Author Archives

John Irvine

Why the Potential CVS Acquisition of Aetna is Brilliant, The Law of Unintended Consequences

Oct 30, 2017• 6

By FRED GOLDSTEIN

Many people have been surprised by the announcement that CVS is interested in purchasing Aetna. Why would a PBM want to own a health plan? There has been speculation that the move by Amazon to get into the pharmacy space may be a reason. But there is another more rationale reason and its based upon a flaw in the Affordable Care Act.

The flaw is known as the Medical Loss Ratio requirement and it reads like this from the CMS website

The Affordable Care Act requires insurance companies to spend at least 80% or 85% of premium dollars on medical care, with the rate review provisions imposing tighter limits on health insurance rate increases. If an issuer fails to meet the applicable MLR standard in any given year, as of 2012, the issuer is required to provide a rebate to its customers.

This requirement was put in place as a way to ensure that health plans did not make money by underutilizing medical care. But it had the unintended consequence of insuring that costs never went down and here’s why.

To Achieve Its Goals, Population Health Needs More Specialists

Oct 28, 2017• 15

By VIKRAM REDDY, MD

I attended a Population Health conference this summer where a number of representatives from large health systems and physician organizations convened to discuss common challenges. Many of my healthcare colleagues assume that anything that carries the label “Population Health” must relate to health disparities and food deserts. While we do address these topics, the vast majority of sessions and conversations had one underlying theme: lowering the total cost of care.

In rebuttal to any charges that our group is far too corporate to be considered a fair example of Population Health advocates, even the Institute for Healthcare Improvement addresses the importance of managing costs with the third part of the Triple Aim stated as “reducing the per capita cost of health care”.

Whether it is from Medicare or commercial ACOs, the Efficiency metric in CMS’s Value-Based Purchasing program, or the continued push from commercial payors for bundled payment programs, health systems and provider groups are beset by demands regarding cost. Unfortunately, at this conference, and in most groups trying to meet the demands of Population Health, one key stakeholder group is often absent: Specialists.

If cardiologists, spine surgeons, and hospitalists cannot become engaged with Population Health principles, moving the cost needle will be very challenging, if not impossible. I believe there are ways, however, to engage specialists in providing efficient care.

Is Obamacare Dead?

Oct 27, 2017• 9

By STEVE FINDLAY

“It’s dead. It’s gone. There’s no such thing as Obamacare anymore. It’s no longer – you shouldn’t even mention.”

— President Donald J. Trump October 17, 2017

Not so fast, President Great-Again. First off, this is an obviously and flatly false statement. But also, don’t look now but Congress and the Trump administration itself are haltingly and chaotically moving to enact bipartisan legislation to stabilize the ACA exchange marketplaces for 2018 and 2019.

Importantly, passage of such a measure would get the ACA through the 2018 mid-term elections, although it’s unlikely that any legislation will tamp down the long-running and fierce debate about the fate and future of the law.

The primary aim of the bipartisan effort is to get funding for cost-sharing reduction (CSR) payments on the budget books. The payments, which go to health insurance companies, lower deductibles and co-pays for millions of low-income people.

They are the subject of a long-running legal dispute, which entered a new phase on Oct. 25 when a federal judge in California rejected an urgent appeal by 18 states to compel the Trump administration to continue making the payments as litigation continues. Trump announced earlier this month he would cease reimbursing insurers for the assistance, which insurers are required to deliver.

Super Macranomics

Oct 26, 2017• 1

By KIP SULLIVAN

This is the second of a two-part series on MedPAC’s October 4 decision to recommend the repeal of the MIPS program. In Part One , I gave the MedPAC staff credit for urging the commission to support repeal of MIPS, and I criticized their irrational proposal to replace MIPS. I said MedPAC is stuck in a vicious cycle – they recommend “reforms” without evidence, and when the reforms don’t work, they recommend evidence-free tweaks that don’t work either. I referred to this vicious cycle as a “tar pit.”
In this essay I attempt to explain how MedPAC created this intellectual tar pit. I begin by describing the three most important “reforms” in MACRA – pay-for-performance, ACOs, and “patient-centered medical homes.” Then I review the decisions MedPAC made, starting in 2003, that led them to endorse those “reforms.” We will see a pattern: MedPAC adopts “reform” proposals based on opinion, not evidence, and MedPAC never works out the details of their evidence-free proposals but instead foists that responsibility on Congress or CMS.

The three pillars of MACRA

If I were asked to explain MACRA (the Medicare Access and CHIP Reauthorization Act) to someone who wasn’t familiar with it, I would start like this: “MACRA imposes a pay-for-performance (P4P) scheme on all doctors who participate in Medicare’s fee-for-service program. This program is called the MIPS program. Doctors who want to escape the MIPS program must join either an ACO or a ‘patient-centered medical home (PCMH).’”
Those of you who are familiar with MACRA will have noticed that I left out the handful of small-bore “bundled payment” programs that doctors could enroll in to escape MIPS. But those programs apply to relatively small pools of patients with specific diseases, not patient populations in the tens of thousands as ACOs and PCMHs do.

If you accept my summary description of MACRA, then you must also accept this statement: If P4P, ACOs, and “medical homes” don’t work, MACRA can’t work.

P4P must work at the level of the individual doctor if MIPS is to work, and it must work at the group level if ACOs and “homes” are going to work as advertised. [1] And ACOs and PCMHs must work if doctors are going to have some place to run to escape MIPS, and if Medicare is going to save money on the ACOs and PCMHs that doctors are expected to run to. Not one of the three nostrums essential to MACRA’s success – P4P, ACOs, and PCMHs – has worked (they do not lower costs and have mixed effects at best on quality). Yet MedPAC enthusiastically endorsed all of them.

My 14 Year Old Cancer Patient May Be Addicted to Opioids. What Do I Do?

Oct 25, 2017• 7

By JULIE KIM, MD

I’m a pediatric oncologist, but cancer is not always the most serious problem my young patients face. Currently one of them, a 14-year-old boy, his mother, or both may be opioid addicts. I may be enabling their addiction.

Tragically, their situation is not unique. Adolescent patients are at risk for addiction from opioid pain medications just as adult patients are. But pediatric patients are overlooked in this war against opioid addiction. No policies protect them or those caring for them.

Usually pain is short-term, and only limited opioids are needed. Most providers, including those caring for children, are trained in acute pain management. Patients and providers are also protected by policies limiting the prescribed amount of opioids for acute pain.

ACOs: An Act of Faith, Theory, Hope, or Evidence? What Do the Data Say?

Oct 25, 2017• 1

By ROSS KOPPEL and STEVE SOUMERAI

The recent Health Affairs Blog piece by Chernew and Barbey (October 17, 2017) provides a helpful theoretical summary of the various ways ACOs might achieve savings—even if modest or still latent. But their analysis of the empirical literature, including the CMS innovations, gives us little confidence that even these small savings are real or will emerge. It is astonishing there is little or no critique of ACO studies’ limitations that generally bias the findings toward the apparent (but miniscule) savings.

Two Critical Methodological Flaws:

ACOs generally volunteer to participate based on their pre-existing capacity to “manage” care. These organizations are then compared to non-volunteer organizations that are less likely to game the system and are destined to perform worse than volunteers.
These studies fail to incorporate the costs of forming and maintaining ACOs. These creation and maintenance costs alone would alter the calculations and may sink them.

It is no wonder the majority of Pioneer ACOs have dropped out of the program. It seems clear they were not saving money. In fact, the arrangement put Dartmouth Hitchcock—associated with the developer of the ACO concept—at financial risk.

Other, similar studies (such as the Massachusetts’ Blue Cross/Blue Shield reports on alternative payment models), have similar methodological limitations, including volunteer bias and significant shifts in the participant population over time.

I Refuse to Tell You What to Eat

Oct 24, 2017• 11

By MICHEL ACCAD, MD

A recent tweet from JAMA, the journal of the American Medical Association, urged me andother doctors to “include nutrition counseling into the flow of [our] daily practice.”

Along with the tweet came a link to an article that outlines “relatively small” dietary changes, based on the latest Dietary Guidelines for Americans, that can “significantly improve health.”

My response to the tweet was swift and knee-jerk. I will not do it. I simply will not. I refuse to follow dietary guidelines or recommend them to my patients.

“What are you saying?!” “Are you the kind of self-interested doctor who only treats disease and cares nothing about prevention?!” I imagine my outraged critics erupting in a chorus of disapproval.

Is my reaction unwarranted? After all, the recommendations themselves seem sensible enough: Eat fast food less often; drink fewer sugary sodas; consume more fruits and vegetables. What’s not to like?

Unhealthy guidelines

I don’t know. Perhaps it’s dietary guideline fatigue.

For more than 40 years, the nutrition experts have instructed us with guideline after guideline, food pyramid after food pyramid. But what have they got to show for? The obesity epidemic followed the introduction of dietary recommendations, and some doctors even blame those recommendations for causing the epidemic!

The blame may be far-fetched, but there’s something un-natural and perhaps even unhealthy about dietary guidelines.

Take the recommendations in the JAMA article. Even though the authors claim that only “small steps” need be taken, the whole message occupies 2 pages of fine print. What’s more, the doctor is supposed to start the process by asking patients to fill out a questionnaire. Who has the appetite for yet another questionnaire?!

The recommendations themselves come in the usual manner of adding or subtracting “servings:” increase vegetables by one serving per day; decrease sodas by one serving per day; replace one serving of crackers with one handful of nuts, etc…

But why think about meals in terms of discrete servings of food and beverage stuff? A meal is one thing, one experience. To break it up into physico-chemical or caloric components makes sense for laboratory animals, and perhaps for patients with serious metabolic disorders. But does it really work for most human beings in their natural environment?

Price Transparency Tools Are Still Struggling. We Offer Advice

Oct 23, 2017• 7

By PETER, BELL & FINDLAY

The potential of price transparency tools to help consumers with high out-of-pocket medical expenses remains largely untapped, according to two recent studies published in Health Affairs and other recent research by Consumer Reports and Public Agenda.

One study found that while more than half of the nearly 3,000 patients surveyed said they would use a website to shop for healthcare if they knew of one, only 13 percent actually looked for information on future healthcare spending and only 3 percent compared prices and costs across providers.

In the second study, patients with access to a price transparency tool focused on “shoppable” services did not experience overall lower spending on those services, and only 12 percent used the tool to begin with. On a positive note, patients who compared prices for imaging tests decreased spending an average 14 percent.

Research by us at Consumer Reports and a survey by Public Agenda (publicagenda.org) signals additional cautious hope for consumer’s use of price transparency tools in the future. Both projects were sponsored by the New York State Health Foundation (nyshealthfoundation.org) and received additional funding from the Robert Wood Johnson Foundation (rwjf.org).

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.