Health and Medical News and Resources

General interest items edited by Janice Flahiff

[Reblog] The Smoking Gun: How U.S. Health Care Came to Cost Insanely More

From the 20 May 2015 post at The Health Care Blog

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Health care that costs more than it needs to is not just an annoyance; it’s a big factor in income inequality in the United States. The financial, physical and emotional burden of disease are major drivers of poverty. At the same time, the high cost of health care even after the Affordable Care Act means that many people don’t access it when they need it, and this in turn deprives large swathes of the population of their true economic potential as entrepreneurs, workers and consumers. People who are burdened by disease and mental illness don’t start businesses; don’t show up for work; and don’t spend as much money on cars, smartphones and cool apartments. Unnecessary sickness is a burden to the whole economy.

How did we get this way? What was the mechanism that differentiated U.S. health care from all other advanced countries? The usual suspects (such as “We have the most sophisticated research and teaching hospitals,” or “It’s the for-profit health insurers” or “Doctors make too much”) all fail when we compare the United States with other sophisticated national systems such as those in Germany and France. Other countries have all of these factors in varying amounts — private health insurers, world-class research, well-paid physicians — and cost a lot, but still spend a far smaller chunk of their economy on health care. Blame has been leveled in every direction, but in reality no single part of health care has been the driver. The whole system has become drastically more expensive over the last three decades.

What’s the Mechanism?

Since the difference between the United States and other countries is so large and obvious, there should be some way we can look at health care spending that would make that mechanism jump out at us. And there is a way.

That first big leap is between 1982 and 1983. What was different in 1983 that was not there in 1982? DRGs, diagnosis-related groups — the first attempt by the government to control health care costs by attaching a code to each item, each type of case, each test or procedure, and assigning a price it would pay in each of the hundreds of markets across the country. The rises continue across subsequent years as versions of this code-based reimbursement system expand it from Medicare and Medicaid to private payers, from inpatient to ambulatory care, from hospitals to physician groups and clinics, to devices and supplies, eventually becoming the default system for paying for nearly all of U.S. health care: code-driven fee-for-service reimbursements.

Cost Control Drives Costs Up?

How can a cost control scheme drive costs up? In a number of ways: In an attempt to control the costs of the system, the DRG rubric controlled the costs of units, from individual items like an aspirin or an arm sling to the most comprehensive items such as an operation or procedure. The system did not pay for an entire clinical case across the continuum of care from diagnosis through rehab; or for an entire patient per year on a capitated basis, which would capture the economic advantages of prevention; or for an entire population. While it is more cost-effective (as well as better medicine) to provide a diabetes patient with medical management, in-home nursing visits and nutritional counseling rather than, say, waiting until the patient needs an amputation, the coding system actually punished that efficiency and effectiveness. Under this system, we got paid for our inefficiencies, and even for our mistakes: Do-overs would often drop far more to the bottom line than the original procedure did.

The system punished, rather than rewarded, spending more time with patients, trying to help patients before their problems became acute, or maintaining a long-term, trusted relationship with patients. Under a code-driven fee-for-service system, getting serious about prevention and population health management would be a broad road to bankruptcy.

If extra items were deemed necessary (an extra test or scan, say), there were codes for that, and reimbursements awaiting. In so doing, the system rewarded doing more (“volume”) rather than whatever would be the best, most appropriate, most efficient treatment path (“value”). It provided a written, detailed catalog of reimbursements which rewarded diagnoses of greater complexity, rewarded new techniques and technologies with new and usually higher reimbursements, and especially rewarded systems that invested in a greater capability to navigate the coding system. At the same time, the reimbursements were constantly open to pressure from the industry. Each part of the industry, each region, each specialty, each part of the device industry, became fiercely focused on keeping those reimbursements up, and getting new codes for more costly procedures.

The business and strategic side of health care became a matter of making money by farming the coding system. Do more of what gets better reimbursement, less of what does not. Make sure every item gets a code and gets charged for. The codes became a manual for success, a handbook for empire.

The Smoking Gun

The smoking gun is right there in the chart, at the big split between the trajectories of the United States and other countries. And today, at this moment, the code-based fee-for-service payment system is still by far the basis of the majority of all revenue streams across health care.

The unifying factor between multiple new strategies unfolding in health care right now, including patient-centered medical homes, pay for performance, bundled prices, reference prices, accountable care organizations, direct pay primary care and others, is to find some way around the strict code-based fee-for-service system, either by avoiding it entirely or by adding epicycles and feedback loops to it to counter its most deleterious effects.

There is no perfect way to pay for health care. All payment methods have their drawbacks and unintended consequences. But the code-based fee-for-service system got us here, and any path out of the cost mess we are in has to get us off that escalator one way or another.

May 23, 2015 Posted by | health care | , , , , , , | Leave a comment

[Reblog] Value-Based Care’s Data Problem

From the 22 May 2015 post at The Healthcare Blog

I believe the concept of value-based care is good for healthcare. VBC encourages providers to make changes that put the patient at the center of care, so that different services can be provided across providers in a collaborative way. If all went according to the VBC vision, there would be fewer redundant tests, more emphasis on preventative care, and an effort to keep high-risk patients out of the emergency room. It’s also better for costs, something we desperately need in the US, where healthcare spending per capita is more than twice the OECD average.

But Lisa’s story, at the leading edge of the value-based experiment, is not good at all. ACOs and most other value-based models are new, constantly changing, and unproven. ACOs report on 33 metrics that are supposed to represent the quality of care provided by their networks of providers. While still extremely limited in scope, any more than 33 metrics would have made Lisa’s job impossible. So far, few ACOs have reported any savings. Worse — the metrics are unproven. What if they overemphasize standardized process over patient outcomes? And what if efficiency measures result in neglectful and impersonal care? A lot is riding on Lisa’s testing ground.

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The administrative challenge

By engaging with and learning from people like Lisa, I have begun to understand the problems frontier administrators face — the same problems countless others will face if we don’t address the administrative burden early on. Here are a few of the top headaches being rolled out in the name of value:

Selecting metrics

For ACOs, 33 metrics are tracked today. Inevitably, these will expand and change as accountable care evolves. There are also countless other systems of metrics encouraged by other incentive programs: the Physician Quality Reporting System measures, Meaningful Use metrics, Agency for Healthcare Research and Quality Indicators, the Consumer Assessment of Healthcare Providers and Systems for patient experience metrics, indicators for each specialty (Stroke and Stroke Rehabilitation Physician Performance Measurement Set, Endoscopy and Polyp Surveillance Physician Performance Measurement Set, and the Heart Failure Performance Measurement Set, to name a few). The document outlining protocols for the Physician Quality Reporting System is 18 pages long, with a mouthful of a title to match: “The 2015 Physician Quality Reporting System (PQRS) Measure-Applicability Validation (MAV) Process for Claims-Based Reporting of Individual Measures.” Got that? A new piece of legislation that passed the House of Representatives last week — the “doc fix” bill — is about to revamp many of these requirements once again.

Collecting data

Lisa had to fumble through different electronic systems and paper charts to extract the relevant data for each patient in her panel at dozens of different clinics. In many cases, it was clear that care had been provided (e.g. an unstable patient had been upgraded from a cane to a walker), but the documentation wasn’t there (to fulfill the “Screening for Future Fall Risk” metric, documentation must state whether the patient had no falls, one fall without major injury, two or more falls, or any fall with major injury.) Therefore, even though care was provided to prevent future falls, the documentation did not meet the CMS requirement and no credit was given.

For the next reporting year, Lisa is designing her own reporting mechanisms for clinics and doctors. She says that her first reporting experience “was invaluable in learning ways to improve the reporting for year 2015 and beyond,” and she is putting processes in place to facilitate reporting next year. But each clinic is different: some need a page at the front of their paper chart with check boxes, and some have templates in their electronic health records. Her new processes may improve the situation, but additional tracking could also cut into time doctors spend with patients and add to the squeeze they already feel.

Integrating data

Lisa integrated all the data from each clinic manually, and this is a problem for small institutions who are trying to communicate and coordinate with each other. Right now it takes a long time and is not very scalable. Even at larger institutions with leading electronic health record systems, the data is locked away within proprietary databases, often in incompatible formats. Clinical data is rarely integrated with financial and patient-reported data in the way required to tie outcomes and claims to reimbursements in a value-based model.

Reporting

After all of her data collection, Lisa still had to submit her data to a third part to produce reports, and she will wait many months for the results. The CMS websites are comically complex ; the instruction manual for using the CMS metric reporting interface is 127 pages long.


Putting patients at the center

If these problems aren’t addressed, we’re in for a long and painful healthcare reform. Administrative costs will continue to rise, along with another generation of frustrated physicians and admins. Moreover, value-based care could be deemed a failure not because it’s a bad idea but because of poor implementation. Instead of putting patients at the center of care, it could breed more bureaucracy and force doctors to spend more time reporting on metrics and less time with patients.

We can address these issues and we must — to give value-based care a chance at moving the US toward more patient-centered, less exorbitant healthcare.

 

May 23, 2015 Posted by | health care | , , , , , , , , , | Leave a comment

[News release] Credibility of Evidence: A Reconsideration of the Logic and Strength of Our Healthcare Decisions

From the 22 May 2015 HealthCare Blog post

A few days ago, we wrote an editorial for US News and World Reports on the scant or dubious evidence used to support some healthcare policies (the editorial is reproduced in full below).  In that case, we focused on studies and CMS statements about a select group of Accountable Care Organizations and their cost savings. Our larger point however is about the need to reconsider the evidence we use for all healthcare-related decisions and policies. We argue that an understanding of research design and the realities of measurement in complex settings should make us both skeptical and humbled.  Let’s focus on two consistent distortions.

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Evidence-based Medicine (EBM).  Few are opposed to evidence-based medicine.  What’s the alternative? Ignorance-based medicine? Hunches?  However, the real world applicability of evidence-based medicine (EBM) is frequently overstated. Our ideal research model is the randomized controlled trial, where studies are conducted with carefully selected samples of patients to observe the effects of the medicine or treatment without additional interference from other conditions. Unfortunately, this model differs from actual medical practice because hospitals and doctors’ waiting rooms are full of elderly patients suffering from several co-morbidities and taking about  12 to 14 medications, (some unknown to us). It is often a great leap to apply findings from a study under “ideal conditions” to the fragile patient. So wise physicians balance the “scientific findings” with the several vulnerabilities and other factors of real patients.  Clinicians are obliged to constantly deal with these messy tradeoffs, and the utility of evidence-based findings is mitigated by the complex challenges of the sick patients, multiple medications taken, and massive unknowns. This mix of research with the messy reality of medical and hospital practice means that evidence, even if available, is often not fully applicable. 

Relative vs. Absolute Drug Efficacy:

Let’s talk a tiny bit about arithmetic. Say we have a medication (called X) that works satisfactorily for 16 out of a hundred cases, i.e., 16% of the time.  Not great, but not atypical of many medications.  Say then that another drug company has another medication (called “Newbe”) that works satisfactorily 19% of the time. Not a dramatic improvement, but a tad more helpful (ignoring how well it works, how much it costs, and if there are worse side effects).  But what does the advertisement for drug “Newbe” say?   That “Newbe” is almost 20% better than drug “X.” Honest. And it’s not a total lie.  Three percent (the difference between 16% and 19%) is 18.75%, close enough to 20% to make the claim legit. Now, if “Newbe” were advertised as 3% better (but a lot more expensive) sales would probably not skyrocket. But at close to 20% better, who could resist?   

Policy:  So what does this have to do with healthcare policy?  We also want evidence of efficacy with healthcare policies but it turns out that evaluation of these interventions and policies is often harder to do well than are studies of drugs. Interventions and policies are introduced into messy pluralistic systems, with imprecise measures of quality and costs, with sick and not-so-sick patients, with differing resources and populations, with a range of payment systems, and so on and so on. Sometimes, randomized controlled trials are impossible.  But sometimes they are possible but difficult to effect. Nevertheless, we argue they are usually worth the effort. Considering the billions or trillions of dollars involved in some policies (e.g., Medicare changes, insurance rules) the cost is comparatively trivial.

But there’s another question: What if a decent research design is used to measure the effects of a large policy in a select population but all you get is a tiny “effect?”  What do we know? What should policymakers do? Here’s what we wrote in our recent editorial in the US News and World Report….

 

May 23, 2015 Posted by | health care | , , , , , , , , , , , | Leave a comment

[Reblog] Value-Based Care

From the 11 March 2015 post by Cindy Nayer at The Health Care Blog

In recent weeks, the market has reacted to a few noteworthy headlines, all involved with or touching upon value-based discretionary actions, and many with the not-so-hidden question: What’s In It for Me or WIIFM?

  • CMS announced that by 2016 30% of fees in health care should be paid for through a value-based system, moving away from fee-for-service.
  • ACO results have shown ambivalent outcomes.
  • Outcomes-based contracts have permeated the Hepatitis C cost-nado (that’s a cost sharknado, the kind that fiercely defies cost controls and takes over all noise about payment reform and patient preferences).
  • Reference-based pricing is a good/bad troublemaker in the middle of the value-based travails.

The latest rampages have appeared on two national and highly-regarded blogs: The Health Care Blog [Value-Based Reform] and The Health Affairs Blog [Go Slow on Reference Pricing].

As one of the loudest proponents on value-based designs, I lift the curtain again to show the thinking behind the movement from fee for service to value-based designs. All of these items above discuss the message of payment reform, or system alignment, but they are intensely linked to the patient-consumer ability to make the right choices, choose the right sites for care, and pay the right amount for services rendered to achieve health security.

….

March 15, 2015 Posted by | health care | , , , , , , , | Leave a comment

[Reblog] What’s Next For Physician Compare? | The Health Care Blog

What’s Next For Physician Compare? | The Health Care Blog.

From the 22 January 2015 post

Screen Shot 2015-01-23 at 9.33.17 PMOf the many hidden gems in the Affordable Care Act, one of my favorites is Physician Compare.  This website could end up being a game changer—holding doctors accountable for their care and giving consumers a new way to compare and choose doctors.  Or it could end up a dud.

The outcome depends on how brave and resolute the Centers for Medicare and Medicaid Services (CMS) is over the next few years.  That’s because the physician lobby has been less than thrilled with Physician Compare, and, for that matter, with every other effort to publically report measures of physician performance and quality.

I’d give CMS a C+ to date.   Not bad considering it’s the tough task.  The agency has been cautious and deliberate.  But after the many problems with Hospital Compare, Nursing Home Compare, Home Health Compare, and Dialysis Facility Compare—not to mention the shadow of healthcare.gov’s initial rollout—that’s understandable.  They want, I hope, to get this one right from the get-go.  And competition from the private sector looms.

Congress mandated that CMS establish Physician Compare by Jan. 1, 2011 and that an initial content plan be submitted by Jan. 1, 2013.  CMS met those deadlines, albeit with a rudimentary site that launched in late December 2010.  The agency updated its plans in 2013 and 2014, even as it added more content and functionality to the site.

The law requires the site to have “information on physician performance that provides comparable information on quality and patient experience measures.”  That’s to include measures collected under the Medicare Physician Quality Reporting System (PQRS), Medicare’s main quality reporting vehicle, and assessments of:

  • patient health outcomes and the functional status of patients
  • continuity and coordination of care and care transitions, including episodes of care and risk-adjusted resource use
  • the efficiency of care
  • patient experience and patient, caregiver, and family engagement
  • the safety, effectiveness, and timeliness of care

Notably, Congress set no deadline for the site to meet those specifications or be fully operational.

So what’s posted so far?   The centerpiece of the site is a searchable directory of some 850,000 Medicare providers.  That includes most of the practicing doctors in the U.S. with the exception of pediatricians and other physicians who don’t treat Medicare patients.  This database predates the ACA and Physician Compare but its functionality, reliability and accuracy (a big complaint from physician groups) is being gradually enhanced.

Each doctor has his or her own profile page—a significant foundation that could accommodate quality and patient experience data in the future.

Consumers can also search three additional databases on the site.  They identify doctors and other clinicians who participate in (a) PQRS; (b) the Electronic Prescribing Incentive Program; and (c) the electronic health record (EHR) incentive program (also called the meaningful-use program).  About 350,000 physicians and other clinicians participate in the latter.

The bad news: these databases are separate and their content is not integrated.  That makes searching for information on a particular group practice or individual doctor cumbersome and time consuming.  And the databases aren’t user-friendly.  On the plus side, for researchers and health administrators, the databases are downloadable.

January 26, 2015 Posted by | health care | , , , , , , | Leave a comment

[Reblog] Rewarding Patient Recovery | HealthWorks Collective

Rewarding Patient Recovery | HealthWorks Collective.

From the 6 November 2014 item at HealthWorks Collective

What if we paid for patient recovery rather than just patient services?

What if we paid to treat patients rather than just conditions?

What if we paid to personalize care rather just population health quality measures?

While these questions may sound academic, there is a groundswell of innovative healthcare providers working on the answers.  To realign the healthcare system to overall patient recovery and well-being, it will take physicians and other healthcare providers transforming the entire system. The good news is that this is quietly happening from within, with physicians, healthcare systems and health plans working together.

They include the over 500 Accountable Care Organizations6,500 providers considering bundled payment pilots and providers signing risk sharing agreements with health plans.  Physicians, healthcare systems and insurance plans are sharing data, sharing financial risk and focusing on improving overall patient outcomes and cost.

With little debate or fanfare outside the healthcare industry, Medicare quietly saved $372 million with their versions of the ACO. While some critics predict that ACOs will follow Health Maintenance Organizations (HMOs) demise in the 1990s, ACOs are different.  Patients are assigned to ACOs and remain free to go to any provider.  ACOs can’t limit care or require patients to see providers in their network.  The ACO’s were still able deliver great results even with these two major challenges which they call “churn” (ACO assigned patient turnover) and “leakage” (patients going outside the provider network).

Bundled Payments are just getting started with up to 6,500 providers deciding soon whether to go live Jan 1, 2015 with Medicare’s Bundled Payment for Care Improvement (BPCI) pilot. Provider/Health Plan risk sharing arrangements are expanding rapidly, indicating they are delivering.  This surge began when the Affordable Care Act (ACA) started requiring health plans to write rebate checks if they paid out less than 85% of their premiums in medical claims. This encouraged Health Plans to partner and reward providers for improvements in patient outcomes and cost. Health Plans leaders believe that the “blurring of the lines” between providers and health plans is just getting started.

Patient Recovery vs. Patient Services

 

 

November 25, 2014 Posted by | health care | , , , , , | Leave a comment

   

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