By NELLY GANESAN, JOSH SEIDMAN, MORENIKE AYOVAUGHAN, and RINA BARDIN
With support from the Robert Wood Johnson Foundation, Avalere assesses opportunities to normalize cost-of-care conversations through measurement.
Cost continues to pose a barrier to accessing healthcare for millions of Americans. Research has shown that conversations addressing costs among patients, caregivers, and the clinical team can help build a more trusted relationship between patients and clinicians.
Avalere has partnered with Robert Wood Johnson Foundation (RWJF) since 2015 to work toward normalizing cost-of-care (CoC) conversations in clinical settings, including identifying barriers and facilitators to engaging in conversations about cost. CoC conversations can be defined as discussions that address any costs patients and families might face, from out-of-pocket (OOP) to non-medical costs (e.g., transportation, childcare, lost wages). To that end, Avalere collaborated with the National Patient Advocate Foundation to explore the feasibility of patient-centered measure concepts to support quality improvement, increase satisfaction, and improve outcomes. This issue brief highlights the challenges associated with measurement in this space alongside alternative solutions to encourage CoC conversations in practice.
Alternative payment models (APMs) are a hot topic these days, and everyone seems to agree that we need to transition toward them and away from fee for service (FFS). But how should we do it?
First, let’s think about this task as government policy makers would think about it.
They would probably start by saying, “We need to find a way to give incentives to providers and payers to try out these different APMs.” This would be fairly easy to do through Medicare, so they would create some Medicare APM programs and structure them in a way that makes the benefits of joining large enough that lots of providers will want to participate.
And for the sake of uniform provider incentives, they would also want to encourage private insurer-provider diads to start using APMs, preferably ones as similar to the Medicare APM programs as possible. And so they would probably have to offer private insurers and/or providers money to do so.
I keep hearing the voices of colleagues and friends that have been part of the AIDS epidemic compare it to the current COVID-19 pandemic. In fact Dr. Kathy Creticos, Director of Infectious Disease at Howard Brown Health spoke about the politicization of both the pandemics.
“Here we are in 2020 with this disease that kills people, that we don’t have any treatments for, that we really don’t understand the full manifestation and presentation biology of the virus,” Creticos said In the final segment of an interview with Contagion during International AIDS Society (IAS) AIDS 2020 Virtual Sessions. “We’re really dealing in the same situation as in the HIV epidemic.”
Her words make me reflect on the levity with which the Raegan administration treated the AIDS epidemic and it’s parallel to the Trump administration’s treatment of the current pandemic. However, she makes an important distinction between the two when she says, “I think a lot of it has to do with the fact that COVID affects everybody, but HIV was certainly perceived as not affecting everybody.”
As an Asian American researcher with more than 15 years of experience in this area, whenever, I bring up the issue of the scourge of HIV/AIDS in our community, the common response both from inside and outside the community is “It’s not a problem in this community.”
We need to stop arguing about whether schools should reopen and instead do the work to reopen schools safely. Community prevalence of COVID-19 infection helps to quantify risk, but reopening decisions should not be predicated on this alone. Instead of deciding reopening has failed when an infected student or teacher comes to school, we should judge efforts by our success in breaking transmission chains between those who come to school infected and those who don’t. We should judge our success by when we prevent another outbreak. We should pursue risk and harm reduction by layering interventions to make overall risk of transmission in schools negligible. This CAN be done, as healthcare workers all over the United States have shown us. Unlike politics, we should avoid thinking this is a binary choice between two polarized options. At the heart of these decisions about tradeoffs should be the assumption that the education of our children is an essential, public good.
I advocated for school closures in March. We had little understanding of the risks and transmission of COVID-19 and faced massive shortages of personal protective equipment (PPE). The closures were a blunt force instrument but bought precious time to learn and prepare. Pandemic control, by flattening the curve and buying time for discovery of more effective therapeutics, care and a vaccine, remains a critical tool to save lives. But COVID-19 will not be eradicated. We must come to terms with the reality that COVID-19 will circulate among us, likely indefinitely. Shutdowns slow spread but at a great cost, disproportionately paid by vulnerable groups including children, women, minorities, and those with the least financial resources. Getting children safely back to in-person school should be among our highest priorities.
Hospitals never considered closing. As healthcare workers, we cannot physically distance from patients. We watched in horror as hot spots like Bergamo suffered high nosocomial and staff infection rates as they were quickly overwhelmed. In response, we worked tirelessly and collaboratively to protect one another while continuing to provide care.
The good news is that we seem to have learned how to prevent in-hospital transmission of COVID-19. A recent study showed that at a large US academic medical center, after implementation of a comprehensive infection control policy, 697 of 9,149 admitted patients were diagnosed with COVID-19. But only TWO hospital-acquired patient infections were detected. COVID-19 is not “just the flu,” but it isn’t Ebola either. I no longer worry that I will become infected with COVID while working in my emergency department. It is not easy, comfortable nor cheap, but a bundle of universal masking and eye protection, appropriate PPE use, sanitation, improved room ventilation, and protective policies have proven effective at preventing in-hospital outbreaks.
We are a group of clinicians, researchers and imaging specialists writing in response to recent publications and media coverage about myocarditis after COVID-19. We work in different areas such as public health, internal medicine, cardiology, and radiology, across the globe, but are similarly concerned about the presentation, interpretation and media coverage of the role of cardiac magnetic resonance imaging in the management of asymptomatic patients recovered from COVID-19.
(This is the sixth in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)
As hospital systems become larger and employ more physicians, healthcare prices will continue to rise and independent doctors will find it harder to remain independent. Hospitals will never fully embrace value-based care as long as it threatens their primary business model, which is to fill beds and generate outpatient revenues. To create a viable, sustainable healthcare system, the market power of hospitals must be eliminated.
Federal antitrust policy is not adequate to handle this task. Even if the Federal Trade Commission had more latitude to deal with mergers among not-for-profit entities, the industry is already so consolidated that the FTC would have to break up health systems involving thousands of hospitals. Such a gargantuan effort would be practically and legally unfeasible.
The government could curtail health systems’ market power without breaking them up. For example, either states or the federal government could adopt “all-payer” models similar to those in Maryland and West Virginia. Under the Maryland model introduced 40 years ago, every insurer, including Medicare, Medicaid, and private health plans, pays uniform hospital rates negotiated between the state and the hospitals.
If you would like to visit the meeting place of America’s two great contemporary pandemics –COVID-19 and structural racism – you need only visit America’s Nursing Homes.
This should come as no surprise to Medical Historians familiar with our Medicaid program. Prejudice and bias were baked in well before the signing of Medicaid and Medicare on July 30, 1965.
President Kennedy’s efforting on behalf of health coverage expansion met stiff resistance from the American Medical Association and Southern states in 1960. Part of their strategic pushback was the endorsement of a state-run and voluntary offering for the poor and disadvantaged called Kerr-Mills. Predictably, Southern states feigned support, and enrollment was largely non-existent. Only 3.3% of participants nationwide came from the 10-state Deep South “Black Belt.”
Based on this experience, when President Johnson resurrected health care as a “martyr’s cause” after the Kennedy assassination, he carefully built into Medicaid “comprehensive care and services to substantially all individuals who meet the plan’s eligibility standards” by 1977. But by 1972, after seven years of skirmishes, the provision disappeared.
Thank you, ONC for the opportunity you gave me to speak in June. Also, thank you for the format of your August meeting where the Zoom chat feature offered a wonderful venue for an inclusive commentary and discussion as the talks were happening. Beats lining up at the microphone any day.
Here is a brief recap of my suggestions, in no particular order:
Episode 24 of “The THCB Gang” was live-streamed on Thursday, September 10th! Watch it below!
Joining Matthew Holt (@boltyboy) were some of our regulars: WTF Health Host Jessica DaMassa (@jessdamassa), patient & entrepreneur Robin Farmanfarmaian (@Robinff3), writer Kim Bellard (@kimbbellard), policy & tech expert Vince Kuraitis (@VinceKuraitis), and guest Mike Magee, a medical historian & health economist (@drmikemagee). The conversation was incredibly wide-ranging and one of the best we’ve had in a while–not the least because Mike Magee gave us a great base with how our non -health system somehow did actually act as a cohesive force in society before tech, then COVID19 broke it up!
If you’d rather listen to the episode, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels — Zoya Khan
Applications for the #COVID19 Symptom Data Challenge close in three weeks!
Amidst #COVID19, using analytic approaches to maximize available information and data is paramount. Hosted by Margolis Center, sponsored by Facebook Data for Good (@academics), and in partnership with the Joint Program in Survey Methodology, Carnegie Mellon University, and ResolveToSaveLives, the Challenge seeks to analytic approaches that utilize COVID-19 symptom data to develop insights into the trajectory of the novel coronavirus.
Have a solution? Finalists can win up to $50k and the winning analytic approach will be featured on Facebook’s (@academics) Data For Good website!
Much, much more information is on the Challenge Website. Apply by 11:59:59 pm ET on September 29!
Much more about the Challenge Background in this interview or in this slack channel.
Farzad Mostashari is CEO of Aledade, former National Coordinator for Health Information technology, and former Deputy Commissioner at the New York City Department of Health and Mental Hygiene. Indu Subaiya is the President at Catalyst @ Health 2.0