One of the big questions since the inception of the Medicare Shared Savings Program has been whether the model would only work in regions with extremely high baseline costs. Farzad’s state-level analysis of earlier MSSP results suggested that ACOs in higher-cost areas were more likely to receive shared savings. It’s one of the questions that Bob Kocher and Farzad received in the wake of the op-ed on Rio Grande Valley Health Providers last week.
So we decided to dig into the data.
We’re still waiting for CMS to make baseline costs for ACOs – and the local areas they serve – public. But in the meantime, we linked each ACO to a Hospital Referral Region using the main ACO address provided by CMS – and took a look at the region’s per capita Medicare costs as a predictor of ACO success.
Continue reading “Why ACO Savings Aren’t About Location.”
Filed Under: Tech, THCB
Tagged: ACOs, CMS, Medicare Shared Savings Program, Rio Grande Valley
Oct 8, 2014
If the federal government’s new Open Payments website were a consumer product, it would be returned to the manufacturer for a full refund.
Open Payments is the government’s site for publishing payments made to doctors and teaching hospitals by drug and medical device manufacturers. It includes 4.4 million payments, worth $3.5 billion, to more than half a million doctors and almost 1,360 teaching hospitals.
In a news release announcing the site’s launch, the Centers for Medicare and Medicaid Services said the goal is “to help consumers understand the financial relationships between the health care industry, and physicians and teaching hospitals.”
Continue reading “Government’s New Doctor Payments Website Worthy of a Recall”
Filed Under: Tech, THCB
Tagged: CMS, open data, Open Payments, ProPublica
Oct 1, 2014
CMS recently announced another change to health IT policy in order to offer healthcare providers greater flexibility. But what will the unintended consequences of this latest change be?
Over the Labor Day weekend, CMS announced that the Meaningful Use Stage 2 deadline will be extended through 2016 in order to offer more options and greater flexibility to providers for the certified use of EHRs. In the interest of full disclosure, I found the timing to be strange— a rule published over a holiday weekend seems an odd choice, particularly when it is being touted as a benefit to the industry and the impact on healthcare provider organizations and clinicians, alike, is monumental.
Unfortunately, I think the additional flexibility allotted by this rule is the latest example of the unintended consequences of health IT regulations. In an effort to make things easier and give healthcare providers more leeway, they have, in fact, made the situation unnecessarily more complex.
Agility is not healthcare’s strong suit
It seems at this point, too many options, or waffling between them (for instance the new ICD-10 transition deadline), can be more crippling than stringent regulations, particularly when there is so much on the line. Healthcare organizations don’t have the wherewithal to vacillate with implementations; they are wrestling with string-tight budgets and constantly shifting rules require large cultural and behavioral changes. As a result, as Dr. John Halamka noted, health IT agendas are being constantly hijacked by regulatory changes, such as Meaningful Use and ICD-10.
It now seems that hospital administrative teams and physicians again must endure constantly shifting rules that they’ve been coping with for years under Meaningful Use. As Dr. Ben Kanter, former CMIO of Palomar Health, so astutely noted “A computer system is a tool, just as a scalpel is a tool. What if a surgeon’s scalpel changed every few weeks? How is it possible to deliver good care if the primary tool you are using keeps changing on an irregular basis?” Continue reading “Sometimes the Best Choice is the Simplest One”
Filed Under: THCB
Tagged: Certification, CMS, EHR, ICD-10, Meaningful Use Stage 2, Washington
Sep 5, 2014
“Drugs don’t work in people who don’t take them.” C. Everett Koop, former US Surgeon General
Cost-based non-adherence, like any lack of medication adherence, leads to further complications and hospitalizations that could have been prevented. CMS appears to have recognized this when they announced that a new ACO measures on whether “providers have educated patients about the cost of medications” in the 2015 fee schedule. Cost and quality conversations between doctors and patients are becoming a cornerstone to value-based care.
The most expensive drugs are the ones that the patient never takes. Nearly one third of prescriptions go unfilled. When patients cannot afford a medication, and only discover the price or out-of-pocket cost at the prescription counter, it’s a big risk to long-term outcomes.
“It has been well established that a lack of affordability can drive a lack of adherence to a course of medications. Patients who do not take their medications cost the U.S. healthcare system an estimated $300 billion in avoidable medical spending annually due to poorer health, more frequent hospitalizations and a higher risk of mortality”, according to The Center for Health Value Innovation and the Network for Health Value in Innovation.
A lack of medication adherence drives further costs for the system and suffering for patients. Estimates are that more than a third of medicine-related hospitalizations happen because people did not take medicine as directed, leading to over 125,000 deaths.
Medication non-adherence, of course, can have many reasons: side effects, difficulty in administering the drug, and others, but there is clear evidence that cost is a factor driving non-adherence. 27% of Americans did not fulfill a prescription due to financial hardship in 2012 according to a Kaiser Family Survey. As copays, deductibles and out-of-pocket expenses go up, so, likely, will non-adherence, and value-based care, and value-based benefits must understand the costs related to non-adherence.
Continue reading “The Cost-Response Curve”
Filed Under: Economics, THCB
Tagged: ACOs, CMS, Cost, Cost-Response Curve, Coumadin, does-response, Efficacy, Non-adherence, RxREVU
Jul 11, 2014
Adverse events – when bad things happen to patients because of what we as medical professionals do – are a leading cause of suffering and death in the U.S. and globally. Indeed, as I have written before, patient safety is a major issue in American healthcare, and one that has gotten far too little attention. Tens of thousands of Americans die needlessly because of preventable infections, medication errors, surgical mishaps, and so forth. As I wrote previously, according to Office of Inspector General (OIG), when an older American walks into a hospital, he or she has about a 1 in 4 chance of suffering some sort of injury during their stay. Many of these are debilitating, life-threatening, or even fatal. Things are not much better for younger Americans.
Given the magnitude of the problem, many of us have decried the surprising lack of attention and focus on this issue from policymakers. Well, things are changing – and while some of that change is good, some of it worries me. Congress, as part of the Affordable Care Act, required Centers for Medicare and Medicaid Services (CMS) to penalize hospitals that had high rates of “HACs” – Hospital Acquired Conditions. CMS has done the best it can, putting together a combination of infections (as identified through clinical surveillance and reported to the CDC) and other complications (as identified through the Patient Safety Indicators, or PSIs). PSIs are useful – they use algorithms to identify complications coded in the billing data that hospitals send to CMS. However, there are three potential problems with PSIs: hospitals vary in how hard they look for complications, they vary in how diligently they code complications, and finally, although PSIs are risk-adjusted, their risk-adjustment is not very good — and sicker patients generally have more complications.
So, HACs are imperfect – but the bottom line is, every metric is imperfect. Are HACs particularly imperfect? Are the problems with HACs worse than with other measures? I think we have some reason to be concerned.
Continue reading “Penalizing Hospitals For Being Unsafe”
Filed Under: Tech, THCB
Tagged: Adverse Events, CMS, hospital acquired conditions (HACs), Meaningful Use, To Err is Human
Jun 23, 2014
When CMS approved Solvadi, Gilead’s $84,000 drug for hepatitis C, the stakes were raised in drug price wars. Two opposing forces, one, a financial push toward lower costs came up against an opposing force of public sentiment. The FDA’s goal of getting 90% of patients moved from costly branded prescriptions to generics met with an an large outcry in social and traditional media for providing the best available care, rallying around the story of a patient. The wave of sentiment seems to have won over CMS.
Granted, CMS was likely considering the reversal in its policy on Solvadi, but it was the May 12th coverage by the Kaiser Family Foundation and NPR of the patient who was denied treatment, and the amplification across social media that turned the tide toward coverage.
Solvadi had not been approved by the patient’s prescription drug carrier, so physicians lobbied CMS for coverage of Solvadi and the life of the patient. Solvadi appears to cure liver cancer in 90% of the patients who take it as recommended. CMS agreed. As a single payer, they have the incentive to balance drug costs and benefits with other costs and benefits, and new therapies often win the fight for coverage.
Getting Covered: The decision to pay for drug combinations is often quicker than FDA approval of the drug combinations
Objective health policy observers such as KFF note that in the early days of successful antiviral drug treatment for HIV, payers allowed doctors to “mix and match” medications in “off-label” or unapproved combinations as they thought best. Medicare is often slow to approve the physician-driven cocktails, so getting CMS to adopt the strategy was a win for many very sick people in this country, as it sets a precedent for “exceptions.”
One doctor at Beth Israel Health System in Boston has a trial that has shown that combining Solvadi with another high-cost treatment, Olysio (by Janssen, cost $66,000 for a course of treatment) resulted in 90-100% cure rate.
The CMS statement in this case noted that that “the new policy will apply broadly to hepatitis C patients whose doctors prescribe the combined use of the two drugs because they meet certain criteria laid out in January by the Infectious Diseases Society of America and the American Association for the Study of Liver Diseases.” Those guidelines recommend the combined use of the two drugs in patients with advanced liver disease who have failed to be cured by earlier drug regimens – even though the FDA has not yet approved the combination—because Medicare guidelines say a patient must have access to a therapy if his or her condition warrants it.
Continue reading “What’s the Value of a Cancer Cure?”
Filed Under: THCB
Tagged: Cirrhosis, CMS, FDA, Hepatitis B, Hepatitis C, HIV, PhRMA, Solvadi, Value-Based Medicine, value-driven pharmaceuticals
Jun 21, 2014
Five years ago, my mother needed an orthopedic surgeon for a knee replacement. Unable to find any data, we went with an academic doctor that was recommended to us (she suffered surgical complications). Last month, we were again looking for an orthopedic surgeon- this time hoping that a steroid injection in her spine might allay the need for invasive back surgery.
This time, thanks to a recent data dump from CMS, I was able to analyze some information about Medicare providers in her area and determine the most experienced doctor for the job. Of 453 orthopedic surgeons in Maryland, only a handful had been paid by Medicare for the procedure more than 10 times. The leading surgeon had done 263- as many as the next 10 combined. We figured he might be the best person to go to, and we were right- the procedure went like clockwork.
Had it been a month prior to the CMS data release, I wouldn’t have had the data at my fingertips. And I certainly wouldn’t have found the most experienced hand in less than 10 minutes.
It’s been a couple of months since the release of Medicare data by the Centers for Medicare and Medicaid (CMS) on the volume and cost of services billed by healthcare providers, and despite the whiff of scandal surrounding the highest paid providers (including the now-famous Florida ophthalmologist that received $21 million) the analyses so far have been somewhat unsurprising. This week, coinciding with the fifth Health DataPalooza, is a good time to take stock of the utility of this data, its limitations, and what the future may hold.
Continue reading “10 Things You Can Do With CMS Data”
Filed Under: Tech, THCB
Tagged: CMS, Data Dump, Mash ups, Medicare, Outliers, Practice patterns, Quality, specialists, Trending, Value
Jun 9, 2014
Three of the five largest private health insurers in the US – UnitedHealthcare, Aetna, and Humana – have decided to follow the lead of the Centers for Medicare & Medicaid Services (CMS) and release their payment information to the public. According to Bloomberg News, this data will include 5 billion individual medical claims and $1 trillion in spending.
Releasing payment information by governmental and private health insurers is an important step towards transparency. Providing researchers with access to the details of health insurance payments is an unprecedented and long-awaited opportunity to gain insights into the drivers of rising healthcare costs. Although I share the enthusiasm of many other researchers for analyzing this valuable data, I am also concerned with unanticipated consequences that may arise with unrestricted release of sensitive and complicated healthcare insurance data to the public.
Reputation of Physicians
The performance of physicians, as some of the most reputable and highly specialized professionals of our society, cannot be evaluated only based on their insurance billing history. To the untrained eye, the abnormalities in insurance charges may seem unjustifiable. Deep expertise in the medical domain is required to investigate all of the underlying causes of the abnormal prescriptions, medical procedures and equipment utilizations. Accusing physicians of malpractice or misconduct based on hasty analysis of this data and without careful examination of the unique medical context in each case, would be unfair to those who deliver medical care to patients.
Continue reading “The Side Effects of Releasing Public Health Insurance Data to the Public”
Filed Under: Uncategorized
Tagged: CMS, Comparative Effectiveness Research, Data, Data Transparency
Jun 5, 2014
Recently the Centers for Medicare and Medicaid (CMS) made troves of data publically available. CMS released data on hospital charges, physician utilization, in addition to other data sets. Journalists and academics were excited to potentially confirm their theories on healthcare spending.
We at The Engelberg Center hosted an event, Hacking America’s Health where experts from the Brookings Institution and the government spoke to participants regarding the impacts of data transparency on the nation’s healthcare system. The purpose of the festival is to focus on “innovators from around the world and their transformative solutions to global challenges.”
Out of this discussion emerged a consensus that data transparency could spur disruptive innovation in the health sector but overcoming several key barriers was essential to maximizing the benefits to the public.
Benefits of Data Transparency
1. Help Consumers Make Informed Decisions
Open data offers numerous benefits to consumers. The CMS data unveils the enormous variation in the cost of different treatments. Enabling consumers to find high value care providers improves the efficiency of the market. Price transparency can also uncover providers that charge unusually high prices and puts pressure on them to lower those charges. Finally utilization can reveal if a doctor uses a rare treatment with regularity. All of these data empower health care consumers to choose wisely.
2. Identify Vulnerable Patients
CMS has used open data for numerous projects to help patients. One project involves collaboration with local and state governments. Using Medicare claims information they identified specific patients who could be in special danger in the aftermath of a natural disaster. Without electricity it’s impossible to operate a lifesaving device like a ventilator or nebulizer. The claims data allows emergency officials to notify such individuals about the locations of shelters.
3. Data Mashups
Combining together data sets could help identify bad actors in the health system. For example merging data from the Sunshine Act which describe payments and items given to physicians combined together with utilization data from CMS. This could identify doctors who were using a drug or procedure due to a financial relationship rather than best practice. Other data mashups could also uncover unexpected patterns.
Continue reading “Upgrading the Value of Data Transparency in the Health Sector”
Filed Under: Uncategorized
Tagged: CMS, Darshak Sanghavi, Hacking America, Health Data, Informed Decision Making, Joshua Bleiberg, Transparency
Jun 2, 2014
Did you hear the one about the CMS administrator who was asked what it would take to delay the 2014 ICD-10 implementation deadline? An act of Congress, he smugly replied, according to unverified reports.
Good thing he didn’t say an act of God.
So, now that CMS has been overruled by Congress, who wins and who loses? Who’s happy and who’s not?
The answers to those questions illustrate the resource disparity that prevails in healthcare and, mirroring the broader economy, threatens to get worse. The disappointed Have-a-lot hospitals are equipped with the resources to meet ICD-10 deadlines and always felt pretty confident of a positive outcome; the Have-not facilities were never all that sure they would make it and are breathing a collective sigh of relief.
First off, it is necessary to recognize that ICD-10 is far superior to ICD-9 for expressing clinical diagnoses and procedures. Yes, some of the codes seem ridiculous … “pecked by chickens,” for example. But people do get pecked by chickens, or plowed into by sea lions, so I believe the intent is positive, as will be the results.
An example: I saw my physician this past week at a Have-a-lot health system in San Francisco and I asked what she thinks of the ICD-10 extension.
“We’re already using (ICD-10) in our EHR and it is much better than ICD-9,” she said. “When I want to code for right flank pain, it’s right there. I don’t have to go with back pain or abdominal pain and fudge flank in. It’s easier and more accurate.”
“If I was still on paper and not our EHR, which I like,” she added, “my superbill would go from 1 page to 10. SNOMED works.”
Continue reading “The ICD-10 Extension: For Whatever Reasons, Congress Did the Right Thing.”
Filed Under: Tech, THCB
Tagged: CMS, Edmund Billings, EHR, HIT, Hospitals, ICD-10, ICD-10 Delay, Physicians
Apr 23, 2014