An excerpt from Quality vs. Quantity by By MICHEL ACCAD, MD at The Health Care Blog (4 March 2016)
“If we bear in mind that medical care consists of decisions and choices made in the face of uncertainty, then the quality of a decision can only be determined in real time, in a specific context, in light of all its alternatives. A third-party payer—public or private, single or multiple—cannot possibly obtain the needed knowledge to make that determination. For an outsider, the quality chasm is metaphysically impossible to cross. Measuring quality is grasping at straws.”
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.
[News release] Credibility of Evidence: A Reconsideration of the Logic and Strength of Our Healthcare Decisions
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.
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….
[News release] Medicaid Is a Very Good Investment Even If It Does Not Lower Cholesterol, Blood Pressure, or Blood Sugar
Quality-Life Year Gains Average $62,000
March 26, 2015 — Researchers atColumbia University’s Mailman School of Public Health analyzed the results of the Oregon Health Experiment, where eligible uninsured individuals were randomly assigned Medicaid or to stay with their current care. Considered controversial because the experiment found no measurable gains for physical health it did reveal benefits for mental health, financial wellbeing, and preventive screening. In terms of quality-adjusted life years, the researchers showed that Medicaid is an excellent value—a $62,000 gain in quality-adjusted life years. Study findings are online in the American Journal of Public Health.
From the 22 January 2015 post
Of 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.
[Report] Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities | Full Text Reports…
WHY WE DID THIS STUDY
Medicare hospice care is intended to help terminally ill beneficiaries continue life with
minimal disruption and to support families and caregivers. Care may be provided in
various settings, including a private home or other places of residence, such as an assisted
living facility (ALF). Pursuant to the Patient Protection and Affordable Care Act, the
Centers for Medicare & Medicaid Services (CMS) must reform the hospice payment
system, collect data relevant to revising payments, and develop quality measures. This
report provides information to inform those decisions and is part of the Office of
Inspector General’s (OIG) larger body of work on hospice care. While the report focuses
on ALFs, many of the issues identified pertain to the hospice benefit more broadly.
HOW WE DID THIS STUDY
We based this study on an analysis of all Medicare hospice claims from 2007 through
2012. We used Certification and Survey Provider Enhanced Reports data and Healthcare
Cost Report Information System reports for information on hospice characteristics.
WHAT WE FOUND
Medicare payments for hospice care in ALFs more than doubled in 5 years, totaling
$2.1 billion in 2012. Hospices provided care much longer and received much higher
Medicare payments for beneficiaries in ALFs than for beneficiaries in other settings.
Hospice beneficiaries in ALFs often had diagnoses that usually require less complex care.
Hospices typically provided fewer than 5 hours of visits and were paid about $1,100 per
week for each beneficiary receiving routine home care in ALFs. Also, for-profit hospices
received much higher Medicare payments per beneficiary than nonprofit hospices. This
report raises concerns about the financial incentives created by the current payment
system and the potential for hospices to target beneficiaries in ALFs because they may
offer the hospices the greatest financial gain. Together, the findings in this and previous
OIG reports show that payment reform and more accountability are needed to reduce
incentives for hospices to focus solely on certain types of diagnoses or settings.
WHAT WE RECOMMEND
We recommend that CMS, as part of its ongoing hospice reform efforts: (1) reform
payments to reduce the incentive for hospices to target beneficiaries with certain
diagnoses and those likely to have long stays, (2) target certain hospices for review, (3)
develop and adopt claims-based measures of quality, (4) make hospice data publicly
available for beneficiaries, and (5) provide additional information to hospices to educate
them about how they compare to their peers. CMS concurred with all five
Charles Ornstein is a senior reporter with ProPublica in New York. The Pulitzer Prize-winning writer is a member of the Association of Health Care Journalists’ board of directors and past president.
(Editor’s note: This is a revision of the original post, which is available on Ornstein’s Tumblr site.)
The Centers for Medicare and Medicaid Services (CMS) said yesterday that it will soon begin releasing data on payments to individual physicians in the Medicare program.
Why is this such a big deal?
Because it overturns a longstanding agency policy that for more than three decades had barred the release of this very information. And, it follows advocacy for greater transparency by numerous news organizations, including the Association of Health Care Journalists.
AHCJ’s board of directors last September sent a letter of comment to CMS asserting the public’s interest in release of this information. “As long as patient confidentiality is protected, we see no reason why taxpayers should not know how individual physicians are spending public dollars,” said the letter, signed by AHCJ executive director Len Bruzzese.
As this fight has played out, CMS released data to ProPublica on which drugs physicians prescribe in Medicare’s drug program, known as Part D. You can now look up your doctor’s prescribing patterns online.
Open enrollment for the Affordable Care Act Health Information Marketplace, formerly referred to as the “Health Insurance Exchange”, begins October 1, 2013. But did you know that you and your patrons can start collecting information now? According to the HealthCare.gov Marketplace Application Checklist, the following items will be needed for those planning to apply for coverage:
- Social Security Numbers (or document numbers for legal immigrants)
- Employee and income information for every member of your household who needs coverage (for example, from pay stubs or W-2
forms—Wage and Tax Statements)
- Policy numbers for any current health insurance plans covering
members of your household
- A completed Employer Coverage Tool for every job-based plan you or someone in your household is eligible for.
You can see the checklist as well as the complete Employer Coverage online at the following URL:https://www.healthcare.gov/downloads/MarketplaceApp_Checklist_Generic.pdf
To find out more about the Marketplace, see https://www.healthcare.gov/marketplace/individual/. Librarians and other professionals can find marketplace outreach information on the Centers for Medicare & Medicaid Services (CMS) site: http://marketplace.cms.gov/
- Washington & The Affordable Care Act (seattle.cbslocal.com)
- Ohio & The Affordable Care Act (cleveland.cbslocal.com)
- More ACA Delays (cdphphealthcarereform.wordpress.com)
- Texas & The Affordable Care Act (dfw.cbslocal.com)
- ACA Exchange Coverage Notice Due October 1, 2013 (sheakleyhrsolutions.com)
- Education hurdle to implementing Obamacare (onlineathens.com)
- DC & The Affordable Care Act (washington.cbslocal.com)
- NY “Poster Child” for Necessity of Individual Mandate under ACA (hofstrabioethics.wordpress.com)
- In Some Deeply Red States, Figuring Out How To Enroll In Obamacare Is Like ‘Searching For A Unicorn’ (ThinkProgress)
…many states have been busy launching public awareness campaigns so their residents will know how to gain access to Obamacare coverage in the fall. But that’s not necessarily the case in deeply red states that remain stubbornly resistant to President Obama’s health reform law, where Americans may not have any idea what their options are in October.
States had the option of either setting up their own insurance marketplaces under Obamacare, or leaving that work for the federal government to do. Many GOP-controlled states resisted cooperating with the health reform law under any circumstances and refused to set up marketplaces on their own. In Missouri, lawmakers actually went a step further and enacted measures to prevent state officials from providing “assistance or resources of any kind” to the federal government’s effort to establish a marketplace. The New York Times reports that’s essentially encouraged confusion among Missouri residents, who have no idea how to enroll in Obamacare plans….
Across the country, Obamacare opponents have launched a coordinated misinformation campaign about the health reform law, confusing Americans about what the upcoming changes will mean for them. A survey of health care-related advertising in June found that Obamacare critics have outspent its supporters by a nearly five to one margin. And last month, the Koch Brothers poured millions more into a new Obamacare misinformation campaign. Anti-Obamacare groups are now launching grassroots initiatives to actively dissuade people from enrolling in the new insurance marketplaces — telling young Americans to “burn your Obamacare draft card.”
These campaigns could have serious consequences for Americans across the country. There’s a limited enrollment period for the new Obamacare plans in the state-level marketplaces. The initial enrollment period will be extended until March 2014 — but after that, people will only be able to sign up for coverage in between October and December. If they can’t figure out how to do it, or if they’ve been persuaded to simply forgo health plans in the marketplaces, they’ll be forced to go uninsured for the rest of the year even if they end up changing their minds….
Greetings from the National Library of Medicine and MedlinePlus.gov
Regards to all our listeners!
I’m Rob Logan, Ph.D. senior staff National Library of Medicine for Donald Lindberg, M.D, the Director of the U.S. National Library of Medicine.
The Alaska-based Nuka system of health care is an alternative approach to clinical practice that is drawing attention as a possible model for other states, and perhaps other nations. I was fortunate to participate in a recent meeting in Anchorage that discussed the Southcentral Foundation’s health care transformation efforts – and introduced Nuka to persons from hospitals and clinics across the U.S. and some other countries.
Nuka is an Alaska Native word that means a strong, living, and large structure. Anchorage’s Southcentral Foundation applies the term Nuka to describe a system of caring for patients (and the community of Alaska Natives Southcentral serves) that prioritizes achieving physical, mental, emotional, and spiritual wellness.
While other health care systems espouse similar wellness goals, Donald Berwick M.D., the recently departed director of the Centers for Medicare and Medicaid Services (CMS) [who attended the meeting], described the Nuka approach as unique and a role model.
What strikes you immediately are Nuka’s and Southcentral’s emphases on a team approach to health care, helping patients improve their quality of life, and a sincere effort to build personal relationships among providers, staff, patients, and the surrounding community.
Incidentally, the Southcentral Foundation calls patients ‘customer owners’ because Southcentral works exclusively for Alaska Natives, who provide extensive advisory roles in the hospital and clinic’s management and policies. The Southcentral Foundation assumed the clinical responsibilities of the Indian Health Service under the Indian Self-determination Act about three decades ago.
Since that time, Southcentral has revitalized what it means to be in a medical clinic for a checkup or routine care. For example, the first Nuka-related surprise occurs when a patient (or visitor) expects to enter a physician’s office for a routine clinic appointment — and instead meets a team of four persons who sit together in an open area.
That’s right – there are no physician’s offices, no nurse’s stations in the clinic. The team who helps you (and whom you are encouraged to know) includes a primary care physician, a doctor’s assistant (who administers some clinical tests during your visit), a nurse (who arranges further care and provides medical instructions), and a person who helps you coordinate future appointments and navigate your way through the medical center. The team’s four members take pride in their ability to work together. Physicians can use a private examination room to treat patients.
If you need to see a specialist, such as a nutritionist, psychologist, or pharmacist, these providers rotate throughout the clinic teams. Other medical specialists, such as cardiologists, are available on referral the same day — within another area of the medical center. Incidentally, the clinical options include Native Alaskan traditional healing, which is available at a person’s request and encouraged as a compliment to western medical treatment.
Have I got your attention? How many clinics linked to a hospital do you know that have a similar approach and level of staff coordination?
Moreover, Nuka’s teams are encouraged to screen patients to enhance their quality of life — in addition to responding to their physical condition. So, Nuka’s screening may include physical fitness, nutrition habits, family and personal relationships, and what is often perceived as social work issues (such as housing quality and access to transportation). In other words, the team is encouraged to react to someone’s needs and boost his or her quality of life parallel to traditional clinical interventions.
Nuka and Southcentral also perceive wellness as individual, family, and community-based. So, the clinics and medical center encourage exercise programs for persons of all ages, and provide community-based counseling to counter ongoing health challenges such as: obesity, alcoholism, drug abuse, abusive family interactions, and learning how to buy and cook nutritious foods.
All of this is based on extensive efforts to train every Southcentral employee how to communicate well with others and how to share stories about one’s personal character and life journey. One of Nuka’s core discoveries is staff members who know each other well function optimally — and understand the importance (and will take the time) to try to know their patients. Southcentral’s employee and patient satisfaction are well above national averages. Southcentral won the prestigious Malcolm Baldridge National Quality Award in 2011.
In a talk during the meeting Dr. Berwick said (and I quote): ‘this is the cutting edge health care system in the U.S.’ (end of quote). Berwick added Southcentral and Nuka were a source of inspiration that influenced CMS’ recent investment in Oregon to encourage a statewide approach to wellness and health care that may serve as a future, national model. Since the Oregon health care experiment has yet to be fully implemented, it is premature to report how well the Southcentral/Nuka model works if adopted within a more diverse patient population in another state.
However, more than 100 participants interested in applying the principles and some specific aspects of Nuka care attended the meeting, including several administrators and physicians from U.S. Veterans Administration medical centers, a multisite federally qualified health clinic in New York City, officers from state departments of health, and a delegation from one of the largest hospitals in Singapore. I was told recent attendees included medical officials from several other nations.
Overall, it was inspiring to watch as medical professionals learned about and tried to embrace a fresh approach to providing care and rethink their primary responsibilities to patients and surrounding communities.
I should add Katherine Gottlieb, the Southcentral Foundation’s chief executive officer, is a member of NLM’s Board of Regents. I thank her for helping me begin to understand the extent of Southcentral’s transformative efforts – and I hope you enjoyed hearing about it. You can read more about Nuka at: southcentralfoundation.com/nuka/
Meanwhile, a helpful guide to choosing a hospital (provided by CMS) is provided in the ‘overviews’ section of MedlinePlus.gov’s health facilities health topic page. A guide to hospital quality indicators (from the Agency for Healthcare Research and Quality) also is available in the ‘overviews’ section of MedlinePlus.gov’s health facilities health topic page.
MedlinePlus.gov’s health facilities health topic page contains links to the latest pertinent journal research articles, which are available in the ‘journal articles’ section. Links to related clinical trials that may be occurring in your area are available in the ‘clinical trials’ section. From the health facilities health topic page, you can sign up to receive email updates with links to new information as it becomes available on MedlinePlus.
To find MedlinePlus.gov’s health facilities health topic page, just type ‘health facilities’ in the search box at the top of MedlinePlus.gov’s home page. Then, click on ‘Health facilities (National Library of Medicine).’ MedlinePlus.gov also has health topic pages devoted to health checkups and nursing homes.
Before I go, this reminder… MedlinePlus.gov is authoritative. It’s free. We do not accept advertising …and is written to help you.
To find MedlinePlus.gov, just type in ‘MedlinePlus.gov’ in any web browser, such as Firefox, Safari, Netscape, Chrome or Explorer. To find Mobile MedlinePlus.gov, just type ‘Mobile MedlinePlus’ in the same web browsers.
We encourage you to use MedlinePlus and please recommend it to your friends. MedlinePlus is available in English and Spanish. Some medical information is available in 43 other languages.
Your comments about this or any of our podcasts are always welcome. We welcome suggestions about future topics too!
Please email Dr. Lindberg anytime at: NLMDirector@nlm.nih.gov
That’s NLMDirector (one word) @nlm.nih.gov
A written transcript of recent podcasts is available by typing ‘Director’s comments’ in the search box on MedlinePlus.gov’s home page.
The National Library of Medicine is one of 27 institutes and centers within the National Institutes of Health. The National Institutes of Health is part of the U.S. Department of Health and Human Services.
A disclaimer — the information presented in this program should not replace the medical advice of your physician. You should not use this information to diagnose or treat any disease without first consulting with your physician or other health care provider.
It was nice to be with you. I look forward to meeting you here next week.
- Graham Leicester: NHS and the Nuka option (scotsman.com)
….An analysis of four years of Medicare prescription records shows that some doctors and other health professionals across the country prescribe large quantities of drugs that are potentially harmful, disorienting or addictive. Federal officials have done little to detect or deter these hazardous prescribing patterns.
Searches through hundreds of millions of records turned up physicians such as the Miami psychiatrist who has given hundreds of elderly dementia patients the same antipsychotic, despite the government’s most serious “black box” warning that it increases the risk of death. He believes he has no other options….
The data, obtained under the Freedom of Information Act, makes public for the first time the prescribing practices and identities of doctors and other health-care providers. The information does not include patient names or the reasons why doctors prescribed particular drugs, so reporters interviewed the physicians to learn their rationales.
Medicare has access to reams of data about its patients, their diagnoses and the medical services they received. It could analyze all of this information to determine whether patients are being prescribed appropriate drugs for their conditions.
But officials at the Centers for Medicare and Medicaid Services say the job of monitoring prescribing falls to the private health plans that administer the program, not the government. Congress never intended for CMS to second-guess doctors – and didn’t give it that authority, officials said.
“CMS’s payments don’t go to physicians, don’t go to pharmacies. They go to plans, which is how our oversight framework has been established,” Jonathan Blum, the agency’s director of Medicare, said in an interview. The philosophy “really has been to defer to physicians” about whether a drug is medically necessary, he said.
Asked repeatedly to cite which provision in the law limits their oversight of prescribers, CMS officials could not do so.
The Office of the Inspector General of the Department of Health and Human Serviceshas repeatedly criticized CMS for its failure to police the program, known as Part D. In report after report, the inspector general has advised CMS officials to be more vigilant. Yet the agency has rejected several key recommendations as unnecessary or overreaching.
Other experts in prescription drug monitoring also said Medicare should use its data to identify troubling prescribing patterns and take steps to investigate or restrict unsafe practitioners. That’s what state Medicaid programs for the poor routinely do.
“For Medicare to just turn a blind eye and refuse to look at data in front of them . . . it’s just beyond comprehension,” said John Eadie, director of the Prescription Drug Monitoring Program Center of Excellence at Brandeis University.
“They’re putting their patients at risk.”
The Part D records detail 1.1 billion claims in 2010 alone, including prescriptions and refills dispensed. ProPublica has created an online tool, Prescriber Checkup, to allow anyone to search for individual providers and see which drugs they prescribe.
Typically in Medicare, the government is responsible for contracting with doctors, reviewing claims for treatment and paying the bills.
But Part D is different: Patients get their drugs through stand-alone drug plans, which cover only drugs, or through Medicare HMOs that also cover medical services.
Medicare pays private insurers a set amount per enrollee to run the program and pay for the drugs. All the insurance plans are supposed to alert pharmacies to potentially harmful drug interactions, query doctors who prescribe high levels of narcotics to individual patients and be on the lookout for fraud, among other things.
Potential for Fraud
Since Part D was launched, the HHS inspector general and the Government Accountability Office have grown increasingly worried that it lacks adequate oversight.
Several reports have found that Part D is vulnerable to fraud. Insurers have paid for prescriptions from doctors who were barred by Medicare. Separately, in 2007 alone, the program covered $1.2 billion worth of drugs prescribed by providers whose identities were unknown to insurers or Medicare, according to a June 2010 report.
The inspector general even found fault with the contractors Medicare hired to dig out fraud: The contractors generated few of their own investigations, relying on outside complaints for direction.
Although many reports focus on fraud, analysts also have found that the program was vulnerable to inappropriate prescribing that put patients’ lives in danger.
A May 2011 report said Medicare has not ensured that Part D paid only for drugs prescribed for FDA-approved and widely accepted off-label indications as federal law requires. About half of the 1.4 million antipsychotic prescriptions made to nursing home patients in the first six months of 2007 “were not used for medically accepted indications,” the report said.
“There’s certainly room for improvement,” Robert Vito, a regional inspector general who has directed many of the reports, said in an interview.
Medicare should, for example, require that prescriptions include a patient’s diagnosis as a way to monitor how Part D drugs were being used, his agency said.
But Medicare officials told the inspector general that neither state boards of pharmacy nor private industry requires this practice, so neither would they.
CMS also has rejected proposals to require insurers to report suspicious prescribing to its fraud contractor. Such sharing is now voluntary.
Medicare’s safeguards lag well behind those of many state Medicaid programs.
Louisiana requires that doctors include diagnosis codes when they write prescriptions for painkillers and antipsychotics. Similar checks have proved effective in other states. Florida found that antipsychotics given to children younger than 6 dropped when specialists reviewed prescriptions.
Even some of Medicare’s top prescribers think the program should do more to research unusual or suspicious prescribing patterns.
Indiana physician Daniel J. Hurley led the country with more than 160,000 prescriptions under Part D in 2010, ProPublica’s analysis shows. In an interview, he said nursing home pharmacies had credited him with prescriptions by other health professionals in his practice, a quirk Medicare should want to address.
It’s unclear how often this might happen, and some nursing home doctors do write lots of prescriptions on their own. Medicare said it recently addressed this issue, but according to Medicare’s own numbers, Hurley’s prescriptions have dropped only slightly.
“Why wouldn’t they call us up and ask us?” Hurley said. “If you hustled, you couldn’t come anywhere near that number, nor should you.”
- Doctors’ Extreme Prescribing – Footprints of Medicare Fraud? (aarp.org)
- Top Medicare Official: ‘We Can and Should Do More’ to Oversee Drug Plan (gantdaily.com)
- A Rap Sheet For Medicare’s Prescription Drug Program (propublica.org)
- Inspector General Faults Medicare for Not Tracking ‘Extreme’ Prescribers (stateofglobe.com)
- Medicare Has Been Paying for Prescriptions Written by … Art Therapists (newser.com)
- Top Medicare Prescribers Rake In Speaking Fees From Drugmakers (wnyc.org)
- Over 700 US doctors suspected of harmful excessive prescription practices – report (rt.com)
New Database Reveals Thousands of Hospital Violation Reports New Database Reveals Thousands of Hospital Violation Reports
Hospitals make mistakes, sometimes deadly mistakes. A patient may get the wrong medication or even undergo surgery intended for another person. When errors like these are reported, state and federal officials inspect the hospital in question and file a detailed report.
Now, for the first time, this vital information on the quality and safety of the nation’s hospitals has been made available to the public online.
A new website, www.hospitalinspections.org, includes detailed reports of hospital violations dating back to January 2011, searchable by city, state, name of the hospital and key word. Previously, these reports were filed with the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid (CMS), and released only through a Freedom of Information Act request, an arduous, time-consuming process. Even then, the reports were provided in paper format only, making them cumbersome to analyze.
Release of this critical electronic information by CMS is the result of years of advocacy by the Association of Health Care Journalists, with funding from the Ethics and Excellence in Journalism Foundation. The new database makes full inspection reports for acute care hospitals and rural critical access hospitals instantly available to journalists and consumers interested in the quality of their local hospitals.
The database also reveals national trends in hospital errors. For example, key word searches yield the incidence of certain violations across all hospitals. A search on the word “abuse,” for example, yields 862 violations at 204 hospitals since 2011. …
- Series on N.C. hospitals wins national award (charlotteobserver.com)
- Medical execs dispute hospital study (krqe.com)
- Govt. To Publish Data On What Drug & Device Makers Pay To Individual Doctors & Hospitals (consumerist.com)
- Time Magazine Study Reveals Hospitals Hiking up Medical Bills (counselheal.com)
Excessive health care spending is overwhelming America’s economy, but the subtler truth is that this excess has been largely facilitated by subjugating primary care. A wealth of evidence shows that empowered primary care results in better outcomes at lower cost. Other developed nations have heeded this truth. But US payment policy has undervalued primary care while favoring specialists. The result has been spotty health quality, with costs that are double those in other industrialized countries. How did this happen, and what can we do about it.
American primary care physicians make about half what the average specialist takes home, so only the most idealistic medical students now choose primary care. Over a 30 year career, the average specialist will earn about $3.5 million more. Orthopedic surgeons will make $10 million more. Despite this pay difference, the volume, complexity and risk of primary care work has increased over time. Primary care office visits have, on average, shrunk from 20 minutes to 10 or less, and the next patient could have any disease, presenting in any way.
By contrast, specialists’ work most often has a narrower, repetitive focus, but with richer financial rewards. Ophthalmologists may line up 25 cataract operations at a time, earning 12.5 times a primary care doctor’s hourly rate for what may be less challenging or risky work.
These differences in physician worth and payment didn’t just happen. Instead, they have been driven by a 31 doctor – 26 specialists and 5 primary care physicians – American Medical Association panel, the Relative Value Scale Update Committee (RUC), which for 20 years has been Medicare’s sole advisor on the value of physician services. The Centers for Medicare and Medicaid Services (CMS), the federal agency overseeing the program, has historically accepted nearly 90 percent of the RUC’s recommendations with no further due diligence. So the RUC has huge financial impact throughout health care, not only for Medicare but for many commercial health plans that follow Medicare’s lead on payment…
t is clear that it will be impossible to get American health care under control unless we can recapture regulation and reconfigure it to act in the common rather than the special interest. Until that is accomplished, America’s and our children’s diminishing prospects will be directly tied to our failure to stop the health industry’s rapaciousness.
- A Call For a New Primary Care Society (thehealthcareblog.com)
- Will Anyone Listen When Former CMS Chiefs Call For More Objective Physician Payment? (thehealthcareblog.com)
- How can primary care be a policy leader? (kevinmd.com)
- CMS Proposes Payment Increases (!) for Family Physicians and Other Primary Care Practitioners (managemypractice.com)
- Does More Primary Care Increase Healthcare Costs Instead of Lowering Them? (freakonomics.com)
- Health Affairs Study: One-Third of Doctors Won’t Accept New Medicaid Patients (forbes.com)