Month: October 2017

MedPAC Sinks Deeper Into the MACRA Tar Pit

Oct 20, 2017• 13

By KIP SULLIVAN, JD

The Medicare Payment Advisory Commission (MedPAC) has done it again. At their October 4, 2017 meeting they agreed to repeal the Merit-based Incentive Payment System (MIPS), an insanely complex and evidence-free pay-for-performance scheme within the larger program known as MACRA. Instead of examining how they made such a serious mistake in the first place (MedPAC has long supported turning fee-for-service Medicare into a giant pay-for-performance scheme), they repeated their original mistake –- they adopted yet another vague, complex, evidence-free proposal to replace MIPS.

MedPAC’s history gives us every reason to believe that when they discuss their “repeal and replace MIPS” proposal at their December 2017 and January 2018 meetings, they will refuse to discuss their “replace” proposal in any detail; they will not ask for evidence indicating their proposal is safe and effective; and in their March 2018 report to Congress they will foist upon CMS the dirty work of figuring out how to make their lead balloon fly. CMS will dutifully write up a gazillion pages of gibberish describing how the new program is supposed to work, it won’t work, MedPAC will return to the scene of the crime years later and, pretending they had no part in creating it, propose yet another evidence-free tweak. And so on.

MedPAC is caught in a trap of their own making. They endorse health policy fads without any evidence and without thinking through the details; then when the fads don’t work, rather than review their defective thought process, they endorse other iterations of the fads, again without evidence and without thinking through the details. The tweaked version of the fad fails, and MedPAC starts the cycle all over again. Two analogies for this trap or vicious cycle occur to me. One is the tar pit where mastodons got stuck and died; struggle only caused the dimwitted creatures to sink faster. The other is the hedge fund that gradually becomes a Ponzi scheme. Investors like Bernie Madoff make bad investments, and when the investments go south, instead of admitting their mistakes, they induce their investors to throw good money after bad.

In this comment I will explain why MedPAC’s MIPS-repeal-and-replace scheme deserves ridicule. In my next comment I will describe the process by which MedPAC built the MACRA tar pit or, if you like, the intellectual Ponzi scheme, that now traps them.

Do Doctors Deserve Mercy?

Oct 19, 2017• 8

By NIRAN AL-AGBA, MD

This past week a video went viral when a woman complained about the lengthy wait time at a clinic. On video, we see the physician asks if the patient still wants to be seen. The patient declines to be seen, yet complains patients should be informed they will not be seen in a timely manner. The frustrated physician replies, “Then fine…Get the hell out. Get your money and get the hell out.” While we do not witness events leading up to the argument between doctor and patient, we do know staff at the front desk called the police due to threats made by the patient to others.

Based on the statement released by Peter Gallogly, MD, he is a humble, thoughtful, and compassionate physician who was very concerned for the safety of his staff, which he considers “family.” Physicians like Dr. Gallogly do their best to serve patients, ease their suffering, and avoid losing ourselves to burnout at the same time. Every human being deserves our compassion, kindness, and clemency. Patients and physicians must accommodate each other when possible.

Do physicians actually deserve our mercy when necessary? Yes, they do. I should know. The kindness shown to me by my patients over the past month has been unparalleled, leaving this physician thankful beyond words.

My father has been a practicing pediatrician in our community for 47 years. As I type these words, he is dying in a hospital bed. We have worked side by side for the last 16 years. It is difficult to make it through the day, desperately hoping to hear his voice one last time in the clinic hallway. He was carrying a full patient load before an unexpected cardiac arrest ended his career. The patient load doubled overnight; it is a burden I am carrying alone.

Could OpenNotes Transform the Analytics Marketplace?

Oct 18, 2017

By MICHAEL MILLENSON

Could OpenNotes help push predictive analytics from paternalism to partnership?

As new payment incentives make it profitable to prevent illness as well as treat it, new technology is offering the tantalizing prospect of accurately targeting pre-emptive interventions.

At the recent Health 2.0 Annual Fall Conference, for example, companies like Cardinal Analytx Solutions and Base Health spoke of using machine learning to find those individuals among a client’s population who haven’t yet been expensively sick, but are likely to be so soon. Companies seeking to make that information actionable touted their use of behavioral theory to “optimize patient motivation and engagement” via bots, texting and other technological tools.

Being able to stave off a significant amount of sickness would constitute extraordinary medical progress. Along the way, however, there’s a danger that an allegiance to algorithms will reinforce a paternalism we’ve only recently begun to shed. A thin line can separate engagement from enforcement, motivation from manipulation, and, sometimes, “This is for your own good” from “This is for my bottom line.” It is here where OpenNotes could play a critical role.

In a recent article for The BMJ, I proposed a concept called “collaborative health” to describe a shifting constellation of relationships for maintaining wellbeing and for sickness care. Shaped by each individual’s life circumstances, these will sometimes involve the traditional care system, as “patient-centered care” does, but not always.

EHR-Driven Medical Error: The Unknown and the Unknowable

Oct 17, 2017• 5

BY ROSS KOPPEL

Politico’s Arthur Allen has written a useful report on recent findings about EHR-related errors. We must keep in mind, however, that almost all EHR-related errors are unknown, and often unknowable. Why?

The most common errors involved with EHRs are medication prescribing errors. But we seldom find those errors because those type of errors seldom manifest themselves because so many hospitalized patients are old and sick, have several co-morbidities and are taking many other medications. Key organs, like the liver, kidney and heart, are compromised. Bad things can happen to these patients even when we do everything right; conversely, good things can happen even when we do much wrong. We usually miss the results of, say, a wrongly prescribed medication. (Note: these types of ‘missed’ medication errors contrast to leaving a pair of hemostats in the gut or to wrong-site surgery—where most errors soon become obvious).
As the experts referenced (Dr. Bob Wachter, Dean Sittig and Hardeep Singh) noted, very, very few cases make it to litigation, further reducing the numbers examined in the study discussed.
Perhaps worse, few clinicians want to report problems even if they know about them. This is a litigious society and few medical professionals want to spend time in court. Also, as the authors Allen interviewed (all of them my friends and respected colleagues): some of the errors that were known did not result in harm and many were caught by others or by the professional involved in the error before they harmed.

Valuing Value-Based Payment

Oct 16, 2017• 37

By ANISH KOKA, MD

The idea that payment should be linked to the value lies at the heart of most of the transactions we participate in on a daily basis. Yet, value based payment in healthcare has seemingly run into very rocky waters as of late. It is at this precarious time that stakeholders representing large employers and other purchasers of health care’ took to the Harvard Business Review to write in defense of value based payment reform. The authors pepper their article with cherry picked ‘successes’ of the value movement and urge the country to forge ahead on the current path. The picture that comes to my mind hearing this is of the Titanic, forging ahead in dark waters, never mind the warning signs that abound.

One of the authors of the paper – Leah Binder – is President and CEO of the Leapfrog Group – a nonprofit organization founded in 2000 dedicated to triggering ” giant leaps forward in the safety, quality and affordability of U.S. health care by using transparency to support informed health care decisions and promote high-value care”. This is a laudable goal, but it is very much predicated on the ability to measure value. A perusal of the Leapfrog group’s homepage notes a 1000 people will die today of a preventable hospital error.

The warning is explicit – choosing the hospital you go to could be the difference between life or death. I have spent some time in the past about the remarkably weak data that lead to an estimate of 400,000 patients dying per year in hospitals due to medical errors, but suffice it to say the leapfrog group subscribes to the theory that of the ~700,000 deaths that happen in hospitals per year, half are iatrogenic. With no exaggeration, I can say firmly that those who believe this are in the same company as those who believe the earth is flat. If the home page of the Leapfrog group, examination of their claims in their HBR article merits additional concern.

Trump Thinks He Just Blew Up Obamacare With a Stroke of the Pen. Did He?

Oct 14, 2017• 2

By STEVE FINDLAY

If you had illusions, or hopes, that the “Kill Obamacare” reality show starring Donald Trump would settle down to a dull roar, events of the last few days should blow those illusions out of the water.

You’ve heard the news by now and I won’t repeat it here. In addition to your favorite media outlets, see this analysis by ACA legal expert Tim Jost.

Trump has been true to his word and his warnings of the last few months—that if Congress didn’t repeal and replace the Affordable Care Act he’d resort to regulatory and executive branch action.

The words of the day (Friday, Oct. 13) are “sabotage” and “spiteful.” And I agree. But I’ll be curious to hear THCB readers’ views on these extraordinary actions by the President. Bear in mind that every independent analysis of the elimination of the CSR (cost-sharing reduction) payments and reviving long-dead association health plans indicates:

Six Assertions on Knowing the Unknowable Future of Healthcare

Oct 13, 2017• 4

BY JOE FLOWER

Some things never change. Joe Flower is one of those things. Pay attention. Joe was the keynote speaker at Health 2.0 Silicon Valley earlier this month. We’re excited to feature the text of his remarks as a post on the blog today. If you have questions for Joe, you can leave them the comment section. You’ll find a link to a complimentary copy of his report Healthcare 2027: at the end of this post. You should absolutely download and read it. And take notes.

The future. The Future of healthcare.  Here are the seven words at the core. If you take nothing else away from this, take these:

Everything changes.
Everything is connected.
Pay attention.

— Jane Hirshfield

We are gathered here on holy ground, in Silicon Valley, the home of the startup, the temple of everything new, of the Brave New World.

And healthcare? Healthcare is changing — consolidation, new technologies, political chaos, a vast and growing IT overburden, shifting rules, ever-rising costs, new solutions, business model experiments.

So when I say, “The Future of Healthcare,” what are the pictures in your head? Catastrophic system failure? The dawn of a bright new day of better, stronger, cheaper healthcare for everyone, led by tech? Do we have all the confidence of a little girl screaming down a slide? Do we just say in denial about the future and end up in a kind of chaotic muddling along?

Moving the Needle to Diversify Health Tech

Oct 12, 2017• 4

By SABAH PERVEZ AND ALYX STERNLICHT

There is a dire need for the health tech workforce to keep pace with the changing racial makeup of the nation. According to the Pew Research Center study, from 1960 to 2010, the percentages of Americans identifying themselves as Black, Hispanic, Asian, or “other” increased from just 15 percent of the population to 36 percent of the population:

Black: Increased from 10 to 12 percent
Hispanic: Increased from 4 to 15 percent
Asian: increased from 1 to 5 percent
“Other”: Increased from 0 to 3 percent

The Four Things Keeping Hospital CEOs Awake at Night This Year (Hint: Donald Trump Isn’t One of Them)

Oct 9, 2017• 19

By PAUL KECKLEY

The Center for Medicare and Medicaid Innovation released a Request for Information (RFI) last week– “New Direction for the CMS Innovation Center.” It’s the latest chapter in the unfolding policy framework that will govern the health system for at least the next 3 years.

The RFI, which doubles down on value-based alternative payment models and consumer directed care, coupled with a proposed rule to cancel mandatory bundles by former HHS Secretary Price, the administration’s actions last week to weaken contraceptive coverage requirements in employer-sponsored health plans and Congress’ FY18 federal budget that include cuts in Medicare and Medicaid funding provide a sobering context for hospital and health system strategic planning. But hospital CEOs have adapted to the new normal from DC: uncertainty about the laws governing our health system is standard fare.

Last month, I interviewed 13 hospital CEO’s in preparation for their upcoming Board-Management strategic planning retreats. They lead organizations in 11 states with substantial differences in the scale, scope and strength of their operations and the dynamics in their markets. Two are academic medical centers, six are independent multi-hospital systems and five operate in multiple markets. When I asked “what’s keeping you awake at night” their answers were the same.

Sorry. Health Care Reform Can’t Wait for Quality Measures to Be Perfect

Oct 6, 2017• 28

By BINDER, MARCOTTE, FILDES and THOMPSON

There’s a debate in the United States about whether the current measures of health care quality are adequate to support the movement away from fee-for-service toward value-based payment. Some providers advocate slowing or even halting payment reform efforts because they don’t believe that quality can be adequately measured to determine fair payment. Employers and other purchasers, however, strongly support the currently available quality measures used in payment reform efforts to reward higher-performing providers. So far, the Trump administration has not weighed in.

The four of us, leaders of organizations that represent large employers and other purchasers of health care, reject any delay in payment reform efforts for the following three reasons:

Even imperfect measurement and transparency accelerate quality improvement. One set of measures often questioned is the Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Indicators (PSIs) used by the Centers for Medicare and Medicaid Services (CMS) and others in value-based payment programs. These indicators measure surgical complications and errors in hospitals, which is critical given that one in four hospital admissions is estimated to result in an adverse event.

PSIs remain among the most evidence-based, well-tested, and validated quality measures available. CMS uses many in its value-based purchasing programs. Use and reporting of PSIs through AHRQ’s Medicare Patient Safety Monitoring System has measurably improved quality. For instance, CMS reported a reduction in inpatient venous thromboembolisms (VTEs) from 28,000 in 2010 to 16,000 in 2014, meaning that 12,000 fewer patients had potentially fatal blood clots in 2014.

In addition to using quality measures in payment programs and for quality improvement, making measures public is key to accelerating change. “If transparency were a medication, it would be a blockbuster,” concluded a multi-stakeholder roundtable convened by the National Patient Safety Foundation’s Lucian Leape Institute in 2015. The foundation’s report cited the Leapfrog Group’s first-ever reporting of early elective delivery rates by hospitals in 2010, which galvanized a cascade of efforts to curtail the problem and thus reduce maternal harms and neonatal intensive care unit (NICU) admissions. This was effective: The national mean of early elective deliveries declined from a rate of 17% to 2.8% in only five years.