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Category: Health Policy

Men, Women and Health Care Pricing Theory: Speaking Different Languages

• 20

By JEANNE PINDER

flying cadeuciiMen and women in the United States think very differently about health care costs. When I talk about the topic, it’s common for me to see half of my listeners zoning out — the male half. Why? Well, because women make or influence 90 percent of the health care decisions in this country, according to a study by the American Academy of Family Physicians. Of course, men go to the doctor. But they make fewer health care decisions, and they don’t think about pricing the same way women do.

Women are more in touch with health care pricing and more affected by it than men. Women own reproductive health. Women make pediatricians’ appointments and run elder care. Women nag their spouses, be those spouses husbands or wives or none of the above, to get their cholesterol checked, to pick up a prescription, to go to that physical therapy appointment.

So when we talk about shopping for health care, about our business, we’ve grown accustomed to having dudes say “Hm, interesting, can we talk about wearable devices?” or “We have some big data, we’re not really interested in the prices.” At the same time, women tell us how excited they are that we’re attacking opacity in health care pricing.

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About Hastert’s “Known Acts:” The Indifference Is As Disturbing as the Crime

• 3

By DAVID INTROCASO

Screen Shot 2016-06-04 at 8.34.26 AM

This past April 8th federal prosecutors made known former Republican House Speaker, Denis Hastert, sexually molested at least four boys while employed as an Illinois high school wrestling coach beginning in the 1960s.  Prosecutors said there was “no ambiguity” about these abuses.  They were, they said, “known acts.”1 While the news was disturbing sexual and all other forms of child abuse is commonplace.  According to the Centers for Disease Control’s (CDC) Adverse Childhood Experiences (ACE) study, one in four girls and one in six boys are sexually assaulted before they reach the age of eighteen.2  It cannot be a surprise therefore that even a member of Congress molested young boys. 

Also not surprising is how frequently child abuse, if made known, is not revealed until many years later.  Rumors about Hastert’s behavior persisted for years, for example, they were floated during 2006 when Congressman Mark Foley was forced to resign for forwarding soliciting e-mails and sexually suggestive instant messages to teenaged boys.  It was not until last year Hastert’s actions nearly fifty years ago became known albeit accidentally.  What banking officials and eventually the FBI wanted to learn, pursuant to the PATRIOT Act and other federal laws, was why Hastert made multiple $50,000 bank withdrawals over two years.  Hastert initially told officials he was buying vintage cars and stocks.  He then explained he did not think banks were safe and then argued he was the victim of extortion.  None of these explanations were true.  Eventually, the FBI learned Hastert was paying a victim for his silence. 

Like Hastert, Jerry Sandusky was convicted in 2012 on 45 counts dating back to 1994.  It has recently come to light Penn State paid a settlement stemming from Sandusky’s abuse in 1971.  Predatory behavior exhibited by thousands of Catholic priests were also not made known for decades.  Jerry Savile engaged in wide spread pedophilia undeterred for over six decades including abusing boys under hospice care.  The Boy Scouts held “perversion files” for nearly a century.  Abuses at New Your City’s Horace Mann School made known a few years ago date back to the 1960s.  The Boston Globe has recently reported hundreds of children were molested over many decades at at least 67 elite private schools in New England.  USA Swimming’s “Hall of Fame” coach Rick Curl’s 1980s sexual abuse of a female teenage swimmer was, at the time, allegedly made known to his employer, the University of Maryland.  The university never reported the abuse to Maryland state officials.  Curl was not convicted until 2013. 

The Curl case is particularly noteworthy because it did earn the unprecedented attention of one member of Congress, Representative George Miller.  Mr. Miller was the former chair and then ranking minority member of the House Committee on Education and Workforce.  Mr. Miller became interested in the Curl case in part because the committee’s jurisdiction includes student safety.  Though the Committee refused Mr. Miller’s request to hold a hearing, after a lengthy investigation of USA Swimming by Mr. Miller’s staff, the Committee, under Mr. Miller’s sole signature, forwarded an 11-page letter to the FBI in July 2014 requesting the agency “fully investigate USA Swimming’s handling of both past and present cases of child sexual abuse.”  Mr. Miller’s letter stated, “it has become clear that child sexual abuse and sexual misconduct have plagued USA Swimming since its inception in 1980.”  (USA Swimming is the creation of the Congress’s Amateur Sports Act of 1978.)  The letter noted USA Swimming had banned more than 80 coaches for child abuse.  Most were not banned until after 2009 despite “the fact,” the letter stated, “that some of them have engaged in sexual abuse for decades.”  Mr. Miller argued USA Swimming’s banning of coaches was insufficient because coaches continued to coach just elsewhere.  In summary the letter stated, “the FBI’s engagement on these issues is of the utmost importance,” because, “the USA Swimming process allows predators to prey with impunity.” 

A month later the FBI responded.  In three brief paragraphs the FBI stated, “representatives recently met with USA Swimming officials and discussed applicable federal violations associated with child exploitation matters,” and “provided information to assist in USA Swimming’s effort to educate their membership regarding the sexual exploitation of children.”4  It appears the FBI took no further action.  In June 2013 Mr. Miller also requested the GAO investigate the abuse of student athletes’ participation in swim clubs.  The GAO report was not published until May 2015, or several months after Mr. Miller retired.  The GAO admitted it “did not assess the effectiveness of any of the selected athletic programs’ policies.”  The report’s conclusion simply stated the “GAO makes no recommendations in this report.”5  It’s worth noting, recently another USA Swimming Hall of Fame Coach, Joe Bernal, was banned for life for sexual misconduct.

Mr. Miller’s efforts stand out as the exception.  Over the past seven weeks, or since Hastert’s offenses were made known, the current House Speaker Paul Ryan has not issued a single press release condemning Hastert.  Senate Majority Leader Mitch McConnell has also been silent, as has Senate Democratic Leader Reid and House Minority Leader Nancy Pelosi.  As was the case during the Sandusky scandal, no Congressional hearings are planned.  Despite the fact they are from the same state and four of the last eight Illinois governors have gone to prison, President Obama as well has been silent.  When asked on April 27th, the day Hastert was sentenced, if the White House had any reaction, Press Secretary Josh Earnest stated, “I don’t have a specific response to that.  Obviously, this is part of our criminal justice system carrying out its mandate.”  When asked in May 2015 after Hastert was indicted, Earnest’s response was equally apathetic.  “Nobody” he said, “derives any pleasure” from Hastert’s “legal troubles.”6     

The failure by senior government officials to condemn Hastert is matched by the health care media and professional health associations’ failure to report the health consequences resulting from childhood sexual abuse.  These consequences are extreme.  Child abuse survivors frequently suffer lifelong, and life shortening, health effects resulting from excessive rates of alcoholism, depression and other psychiatric disorders including the severe trauma disorder, DID, or Dissociative Identity Disorder (previously known as Multiple Personality Disorder), illicit drug use, obesity, sexually transmitted diseases, cancer, heart, lung and liver disease and suicide.  Survivors can also exhibit a constellation of social problems including criminal behavior, dysfunctional parenting including inter-generational abuse, homelessness, prostitution and other at-risk sexual behavior.  Not surprisingly, one of Hastert’s victims died of AIDS in 1995.  In sentencing Hastert on April 27th, Federal District Court Judge Thomas Durkin recognized this reality when he stated, “the abuse was 40 years ago, but the damage lasts today.”  “It’s hard to look at Mr. Cross [one of Hastert’s victims], now in his late 50s, and know,” Judge Durkin stated, “that this [abuse] happened when he was 17 and he is still damaged.”  The CDC estimates the total lifetime estimated costs associated with just one year of confirmed cases of child abuse at approximately $124 billion.7

Despite well documented life-long adverse health effects, when the Chicago Tribune, The New York Times, The Washington Post and others reported Hastert’s “known acts,” one would expect these would be reported by health and health care news organizations.  They have not.  For example, Inside Health Policy, Kaiser Health News, the Morning Consult, Politico Pulse and RealClearHealth, organizations that report daily or twice daily on a wide range of health, health care and public health issues, have made no mention of the health consequences and health care costs.  During the Penn State scandal I asked a Harvard-educated editor of one of the these publications why she was not reporting on  Sandusky.  I was told his behavior was a criminal matter and unrelated to health care or public health.  To further the point, The New England Journal of Medicine, the Altarum Institute, an organization dedicated to “solving complex systems problems to improve human health,” and Health Affairs all refused over the past month to publish versions of this essay.8  Among numerous health care associations, the American Public Health Association (APHA) and the American Medical Association (AMA) have also been silent.  The APHA’s website makes no mention of Hastert and the AMA’s website still notes Hastert as the 2006 recipient of the AMA’s Nathan Davis Award for his “outstanding contributions” “to promote the art and science of medicine and the betterment of the public health.”9    

The indifference by senior federal officials and the health care industry is also the norm.  Over the past  decade Diane Champe, a childhood sexual abuse survivor, cancer survivor and beneficiary of over two decades of DID therapy, and I have worked, unsuccessfully, to interest members of Congress, Congressional committees, the White House, and numerous others in addressing child abuse, or at least discuss the issue publicly.10  I meet Diane in 2007 while doing health policy work for the then House Majority Leader, Mr. Steny Hoyer.  Diane scheduled an appointment with me to ask why the National Institutes of Mental Health (NIMH) at the National Institutes of Health (NIH) was not researching DID, a disorder that frequently afflicts victims of child abuse.  I inquired and learned NIMH was not funding DID research.  NIMH still does not fund DID research.11

In efforts to meet with members of Congress over the past decade we have either received no response or were told, for example by Representative Elijah Cummings’ office (Cummings is currently the ranking minority member of the House Oversight and Government Reform Committee), that he only meets with constituents.  We did meet with Diane’s representative, Chris Van Hollen, and his staff.  After discussing survivors’ issue over several months we failed to interest his office in any number of a wide range of inter-related issues including the need improve child abuse reporting and data collection, the need to improve related clinical research and treatment including diagnosis and treatment of DID, the need for further protections under the Americans with Disabilities Act and other legal protections for survivors.  Concerning this last issue, Hastert could not be criminally prosecuted as a child molester because the statute of limitations for this crime had expired.  Hastert’s victims could have pursued him in civil court only because Illinois has comparatively liberal “window laws.”  In many states a victim’s “window” to pursue their perpetrator in court closes quickly.  For example, in New York the window closes five years after the victim turns 18.  When the 2013 documentary, “Pursuit of Truth: Adult Survivors of Child Sexual Abuse Seeking Justice,” was released, a film specifically about the inability of survivors to seek and receive justice, we hoped it would serve to stimulate discussion.  We were wrong.  We tried to present the film to relevant Congressional committees, at White House, to Maryland State legislators and, among others, to the American Bar Association’s Commission on Domestic and Sexual Violence.  No one was interested.12  Our only success, or related success, was in attaining pro bono legal counsel from a well-established DC law firm.  Years later we learned the firm supported our efforts largely because the attorney we initially solicited was, while serving as an altar boy, molested by his priest.   

In the federal government’s sentencing recommendation, prosecutors wrote, “He [Hastert] made them feel alone, ashamed, guilty and devoid of dignity.”  “All of them carry the scars [the] defendant inflicted upon them.”  “It is profoundly sad,” prosecutors wrote, the abuse was inflicted by “a man whom they trusted and whom they revered as a mentor and coach.”  In sentencing Hastert to 15 months in prison, Judge Durkin stated, “nothing is more stunning than having the words “serial child molester” and “Speaker in the House” in the same sentence.”13  It is “profoundly sad.”  It is not “stunning.”  With one exception, the fecklessness of the Congress, the White House, the health care media and leading organizations does not disappoint.  The indifference, the ongoing neglect, the failure to even make public comment is exactly what Stanley Tucci’s “Spotlight” character, Mitchell Garabedian, meant when he stated,”if it takes a village to raise a child, it takes a village to abuse one.”  As for Diane’s work she is now dedicating all her time to opening a community center in inner-city Baltimore to provide non-clinical, social support services to adult survivors.    

Notes

1.  An overview of the Hastert case is contained in the “Government’s Position Paper as to Sentencing Factors,” at: https://assets.documentcloud.org/documents/2798113/Hastert.pdf.

2.  Information regarding the ACE study is at: http://www.cdc.gov/violenceprevention/acestudy/prevalence.html.

4.   Mr. Miller’s letter and the FBI’s one page response is at: https://cdn.swimswam.com/wp-content/uploads/2014/10/USASwimming-GMLettertoFBIandFBIResponse-1.pdf.

5.  The GAO report is at: http://www.gao.gov/products/GAO-15-418.

6.  See: https://www.whitehouse.gov/the-press-office/2016/04/27/press-briefing-press-secretary-josh-earnest-4272016 and https://www.whitehouse.gov/the-press-office/2015/05/29/press-briefing-press-secretary-josh-earnest-52915.

7.  See: http://www.cdc.gov/violenceprevention/childmaltreatment/consequences.html.

8.  Searching The New England Journal of Medicine’s website using the phrases, “child sexual abuse” and “childhood sexual abuse” yields no related research articles.   

9.  See: http://www.ama-assn.org/ama/pub/about-ama/awards/nathan-davis-awards-outstanding-government-service/past-recipients-nathan-davis-awards.page.

10.  For information concerning Diane’s work, go to: https://www.edcinstitute.org/.

11.  If you search NIH’s RePORT for “Dissociative Identity Disorder” the response is “did not match any documents.”  See:  http://www.cdc.gov/media/releases/2012/p0201_child_abuse.html and http://www.cdc.gov/violenceprevention/childmaltreatment/consequences.html.

12.  See: http://www.pursuitoftruthfilm.com/.  Lynn Rosenthal, who served up until earlier this year as  the White House Adviser on Violence Against Women, did watch the documentary with a few office colleagues but refused to present the film to a wider White House audience.   

13.  See: http://www.chicagotribune.com/news/nationworld/ct-pdf-transcript-of-sentencing-of-dennis-hastert-20160427-htmlstory.html.

ACO 101: Koka Completely Misses The Mark on Medicare ACOs

By LISA BARI

Recently, Anish Koka, MD, a Cardiologist from Pennsylvania, posted his anti-Accountable Care Organization (ACO) manifesto here on The Health Care Blog.  Koka argues that ACOs don’t work and are doomed to fail because they were designed by non-practicing physician policymakers and academics in ivory towers. He appears to be basing his judgment on a commercial ACO contract that only pays him $4 per month extra for care coordination and requires that he meet specific quality measures. He is also conflating his experience in a commercial ACO with Medicare ACOs, and interprets the initial results of one Medicare ACO program to mean that all ACOs are a failure. Finally, he relays an anecdote of caring for one of his patients, Mrs. K, a patient with chronic illness who doesn’t want to take her medication.

In his post, Dr. Koka calls out “well-meaning, hard-working folks that own a Harvard Crimson sweater…[whose] intent is to fundamentally change how health care is provided.” As luck would have it, I do own a Harvard Crimson sweater, and I’d like to respond.

The Affordable Care Act (ACA) of 2010 gave the Centers for Medicare & Medicaid Services (CMS) the authority to create ACOs in two forms. One, the Medicare Shared Savings Program (MSSP), is a large program that does exactly what its name says: it allows physicians and care organizations to share savings with CMS based on their previously-expected health care spending. The other was the Pioneer ACO model run by the CMS Innovation Center (CMMI). This five-year experiment was intended to test if physicians and care organizations could bear both upside and downside risk while still delivering high quality care. The Pioneer ACO program has ended as planned, and CMMI has incorporated its findings from the model thus far into the Next Generation ACO model. Any other ACO program is a non-governmental agreement between a private insurer and group of health care providers that is neither designed nor controlled by CMS or any other part of the government. 

Dr. Koka’s main point of criticism appears to be with the terms of a commercial, non-Medicare, non government ACO with which he contracts. Commercial ACOs tend to have stricter, less-generous terms for physicians; a 2014 study in the American Journal of Managed Care found that commercial ACO contracts were more likely to include both downside risk and upfront payments. CMS cannot be held responsible for the terms of an ACO contract between Dr. Koka and a private insurer, but I’ll leave that aside for now.

Dr. Koka cites a recent Harvard study on the first year and a half of results from the MSSP as evidence for the failure of ACOs. This study looked at Medicare claims data for two cohorts of practices–one starting mid-year in 2012 and one starting on January 1, 2013, through the end of 2013. In short, the mid-year 2012 cohort delivered a small amount of savings per beneficiary, and the 2013 cohort achieved a negligible amount of savings. Additionally, some quality measures showed improved performance, while others were the same as the control group. I do not interpret these results as a “failure” at all. These are early results from a generous program that is easing physicians and care organizations into accountable care by limiting the amount of risk that they must take on at first. Equivalent or better-quality care was delivered, along with small savings.

Leavitt Partners, a health care consulting firm, has been tracking and reporting on Medicare and commercial ACOs since 2010. In their recent report on the early takeaways from the MSSP results, they highlighted that physician group-led ACOs tended to do a better job than hospital-only ACOs, and that ACOs residing in high-cost markets were more likely to generate shared savings. Based on all of these findings, I cannot agree with Dr. Koka that Medicare ACOs are a failure, and I certainly cannot extrapolate from commercial ACOs to Medicare.

The evidence is widespread and irrefutable that our current payment and delivery system has resulted in the highest health care costs in the world, along with some of the lowest-quality care.  We simply cannot continue to pay doctors and hospitals on an unrestricted fee-for-service basis. ACOs are the beginning of a massive shift in how we deliver, pay for, and measure health care in order to address these cost and quality issues.

Dr. Koka also fails to acknowledge a critical point about ACOs: they are generally designed with the Primary Care Physician (PCP) as the central care coordinator versus a specialist. PCPs are best situated to coordinate care for their patients and manage preventive care and population health measures. A more expensive specialist like Dr. Koka should not be the physician responsible for coordinating patient care in an ACO–it makes little sense. One reference point comes from The Accountable Care Guide for Cardiologists from the Toward Accountable Care Consortium. They highlight PCPs and good teamwork as critical central elements in any ACO. [7]

He also does not acknowledge that it takes time to get accountable care and care coordination right. A PCP or primary care organization is not going to have the tools they need or the right contracts in place with specialists and hospitals on day one. The processes and technology for effectively managing an ACO take time. The initial results from the MSSP prove this out.

Let’s say we assume for the sake of argument that Dr. Koka is right; that ACOs don’t work, and they are a colossal waste of time. Even then, his proposed solution is more than a bit ham-handed. There is no agreement among either the American public or the health care system that we should directly ration care. I suggest that we start by making PCPs the gatekeepers to specialists like Dr. Koka rather than asking him to spend many hours coaxing a patient to take her medications. Undoubtedly, this is what his commercial ACO intended. We need to do a better job of delivering the right care at the right time, from the right physician, nurse, or other provider–yes, this is care coordination.

And if all else fails, well, there is one easy, proven way to slow the growth of health care costs: making a blunt cut in reimbursement rates to providers, as we saw in the Budget Control Act of 2011. I am almost certain that Dr. Koka would not welcome another cut like this.

If Dr. Koka would like to avoid this last-ditch option, perhaps it is time to partner with primary care organizations and see how he can help them to be a successful ACO…and allow Mrs. K’s PCP and case manager or health coach to field those Saturday calls.

As avid followers of federal health policy will know, this week CMS released the notice of proposed rulemaking for the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The MACRA encompasses a massive shift in Medicare physician payment. The bad news for Dr. Koka? Accountable, value-based care is not going away anytime soon. The good news is that the proposed payment and delivery system models include more flexibility for physicians and will better reward them for high quality care.

In my opinion, the best news is that the MACRA provides a clear path for our public health care system to move away from fee-for-service once and for all. I hope that Dr. Koka can reconcile himself with a world where care providers, in partnership with patients, are asked to be more accountable for the high cost of health care. At a minimum, I hope that the difference between commercial and Medicare ACOs is now clear.

Lisa Bari is a Master of Public Health candidate at the Harvard T.H. Chan School of Public Health, and previously worked in health IT. She loves primary care health policy, health care payment reform, interoperability, and health data APIs. She never thought she’d own a Harvard sweatshirt. You can find her on Twitter @lisabari.

ACO 101: Koka Completely Misses The Mark on Medicare ACOs

• 9

By LISA BARI

Recently, Anish Koka, MD, a Cardiologist from Pennsylvania, posted his anti-Accountable Care Organization (ACO) manifesto here on The Health Care Blog. [1] Koka argues that ACOs don’t work and are doomed to fail because they were designed by non-practicing physician policymakers and academics in ivory towers. He appears to be basing his judgment on a commercial ACO contract that only pays him $4 per month extra for care coordination and requires that he meet specific quality measures. He is also conflating his experience in a commercial ACO with Medicare ACOs, and interprets the initial results of one Medicare ACO program to mean that all ACOs are a failure. Finally, he relays an anecdote of caring for one of his patients, Mrs. K, a patient with chronic illness who doesn’t want to take her medication.

In his post, Dr. Koka calls out “well-meaning, hard-working folks that own a Harvard Crimson sweater…[whose] intent is to fundamentally change how health care is provided.” As luck would have it, I do own a Harvard Crimson sweater, and I’d like to respond.

The Affordable Care Act (ACA) of 2010 gave the Centers for Medicare & Medicaid Services (CMS) the authority to create ACOs in two forms. One, the Medicare Shared Savings Program (MSSP), is a large program that does exactly what its name says: it allows physicians and care organizations to share savings with CMS based on their previously-expected health care spending. The other was the Pioneer ACO model run by the CMS Innovation Center (CMMI). This five-year experiment was intended to test if physicians and care organizations could bear both upside and downside risk while still delivering high quality care. The Pioneer ACO program has ended as planned, and CMMI has incorporated its findings from the model thus far into the Next Generation ACO model. [2] Any other ACO program is a non-governmental agreement between a private insurer and group of health care providers that is neither designed nor controlled by CMS or any other part of the government. 

Dr. Koka’s main point of criticism appears to be with the terms of a commercial, non-Medicare, non government ACO with which he contracts. Commercial ACOs tend to have stricter, less-generous terms for physicians; a 2014 study in the American Journal of Managed Care found that commercial ACO contracts were more likely to include both downside risk and upfront payments. [3] CMS cannot be held responsible for the terms of an ACO contract between Dr. Koka and a private insurer, but I’ll leave that aside for now.

Dr. Koka cites a recent Harvard study on the first year and a half of results from the MSSP as evidence for the failure of ACOs. [4] This study looked at Medicare claims data for two cohorts of practices–one starting mid-year in 2012 and one starting on January 1, 2013, through the end of 2013. In short, the mid-year 2012 cohort delivered a small amount of savings per beneficiary, and the 2013 cohort achieved a negligible amount of savings. Additionally, some quality measures showed improved performance, while others were the same as the control group. I do not interpret these results as a “failure” at all. These are early results from a generous program that is easing physicians and care organizations into accountable care by limiting the amount of risk that they must take on at first. Equivalent or better-quality care was delivered, along with small savings.

Leavitt Partners, a health care consulting firm, has been tracking and reporting on Medicare and commercial ACOs since 2010. In their recent report on the early takeaways from the MSSP results, they highlighted that physician group-led ACOs tended to do a better job than hospital-only ACOs, and that ACOs residing in high-cost markets were more likely to generate shared savings. [5] Based on all of these findings, I cannot agree with Dr. Koka that Medicare ACOs are a failure, and I certainly cannot extrapolate from commercial ACOs to Medicare.

The evidence is widespread and irrefutable that our current payment and delivery system has resulted in the highest health care costs in the world, along with some of the lowest-quality care.  [6] We simply cannot continue to pay doctors and hospitals on an unrestricted fee-for-service basis. ACOs are the beginning of a massive shift in how we deliver, pay for, and measure health care in order to address these cost and quality issues.

Dr. Koka also fails to acknowledge a critical point about ACOs: they are generally designed with the Primary Care Physician (PCP) as the central care coordinator versus a specialist. PCPs are best situated to coordinate care for their patients and manage preventive care and population health measures. A more expensive specialist like Dr. Koka should not be the physician responsible for coordinating patient care in an ACO–it makes little sense. One reference point comes from The Accountable Care Guide for Cardiologists from the Toward Accountable Care Consortium. They highlight PCPs and good teamwork as critical central elements in any ACO. [7]

He also does not acknowledge that it takes time to get accountable care and care coordination right. A PCP or primary care organization is not going to have the tools they need or the right contracts in place with specialists and hospitals on day one. The processes and technology for effectively managing an ACO take time. The initial results from the MSSP prove this out.

Let’s say we assume for the sake of argument that Dr. Koka is right; that ACOs don’t work, and they are a colossal waste of time. Even then, his proposed solution is more than a bit ham-handed. There is no agreement among either the American public or the health care system that we should directly ration care. I suggest that we start by making PCPs the gatekeepers to specialists like Dr. Koka rather than asking him to spend many hours coaxing a patient to take her medications. Undoubtedly, this is what his commercial ACO intended. We need to do a better job of delivering the right care at the right time, from the right physician, nurse, or other provider–yes, this is care coordination.

And if all else fails, well, there is one easy, proven way to slow the growth of health care costs: making a blunt cut in reimbursement rates to providers, as we saw in the Budget Control Act of 2011. I am almost certain that Dr. Koka would not welcome another cut like this. [8]

If Dr. Koka would like to avoid this last-ditch option, perhaps it is time to partner with primary care organizations and see how he can help them to be a successful ACO…and allow Mrs. K’s PCP and case manager or health coach to field those Saturday calls.

As avid followers of federal health policy will know, this week CMS released the notice of proposed rulemaking for the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The MACRA encompasses a massive shift in Medicare physician payment. The bad news for Dr. Koka? Accountable, value-based care is not going away anytime soon. The good news is that the proposed payment and delivery system models include more flexibility for physicians and will better reward them for high quality care.

In my opinion, the best news is that the MACRA provides a clear path for our public health care system to move away from fee-for-service once and for all. I hope that Dr. Koka can reconcile himself with a world where care providers, in partnership with patients, are asked to be more accountable for the high cost of health care. At a minimum, I hope that the difference between commercial and Medicare ACOs is now clear.

Lisa Bari is a Master of Public Health candidate at the Harvard T.H. Chan School of Public Health, and previously worked in health IT. She loves primary care health policy, health care payment reform, interoperability, and health data APIs. She never thought she’d own a Harvard sweatshirt. You can find her on Twitter @lisabari.

1 https://thehealthcareblog.com/blog/2016/04/25/the-aco-delusion/

2 http://www.brookings.edu/~/media/research/files/papers/2015/05/12-aco-paper/impact-of-accountable-careorigins-052015.pdf

3 http://www.ajmc.com/journals/issue/2014/2014-vol20-n12/aco-contracting-with-private-and-public-payers-a-baseline-comparative-analysis

4 http://www.nejm.org/doi/pdf/10.1056/NEJMsa1600142

5 http://leavittpartners.com/wp-content/uploads/2016/04/MSSP_ACOs_takeaways_whitepaper_final.pdf

6 http://www.commonwealthfund.org/publications/press-releases/2015/oct/us-spends-more-on-health-care-than-other-nations

7 http://www.ncmedsoc.org/wp-content/uploads/2014/06/ACO-Guide_Cardiologist_052814_reduced-file.pdf

8 http://www.cbpp.org/research/how-the-across-the-board-cuts-in-the-budget-control-act-will-work

9 http://www.politico.com/tipsheets/politico-pulse/2016/04/exclusive-andy-slavitt-on-macra-214014

 

 

 

 

PCMH Fails Natural Experiment

• 9

By AL LEWIS

flying cadeucii

Medical Homes Fail Yet Another “Natural Experiment”

Three “natural experiments,” three failures.  Such is the fate of patient-centered medical homes (PCMH), a well-intentioned but unsuccessful innovation now kept afloat by the interaction of promoter study design sleight-of-hand with customer innumeracy.

By way of review, a natural experiment is an experiment in which the design is outside the control of investigators, yet mimics an experiment.  The first two natural experiments below involve applying the intervention across entire states. The third involves a stimulus-response experiment in one specific community.

Statewide Natural Experiments: North Carolina and Vermont

In North Carolina, a statewide Medicaid PCMH was implemented years ago and steadily expanded until most Medicaid recipients belonged to one.  There was no reduction in relevant event rates (for ambulatory care-sensitive admissions) and costs increased. While the overall Medicaid budgets were routinely exceeded and that should have caused legislators to realize that something in their PCMH was amiss, Milliman fabricated data to pretend the PCMH program was a success.  Milliman got caught making up data (and ignoring other data that quite definitively invalidated its conclusion, and changed their story 180 degrees, a tacit admission that they lied.  And shortly thereafter (at least “shortly” by the standards of state government), North Carolina announced that it is abandoning this failed experiment.

Continue reading…

Does the ACA Actually Mandate Free Checkups?

• 88

By CHRISTIAN GLASON

flying cadeucii“Where in the Affordable Care Act (ACA) does it mandate that every health insurance policy must include a free annual checkup?”

I posed this question to Al Lewis and Vik Khanna in the comments of their recent post entitled: The High Cost of Free Checkups, where they argue against the Affordable Care Act (ACA) provision that requires “free checkups for everyone.” They cite a recent New York Times Op-ed authored by ACA co-architect, Dr. Ezekiel Emanuel, that essentially debunks the link between annual checkups and overall health outcomes.  For Lewis and Khanna the solution is simple, we need to “remove the ACA provision that makes annual checkups automatically immune from deductibles and copays.” But for me there’s an enormous problem with their argument: The ACA doesn’t actually have any such provision.

After raising the issue in the comments section of the post, Mr. Lewis responded informing me that: “It’s definitely there” and “You’ll have to find it on your own, though — I unfortunately have to get back to my day job.” What Mr. Lewis doesn’t consider with his quick dismissal, is that I have already looked.  I’ve combed through the law and other policy guidance, rules and regs; searching for any mention of this required annual wellness exam, physical, visit, or any other linguistic derivative.  It doesn’t exist.

It turns out that while the law does require that an annual wellness visit be covered (sec. 4103. “Medicare coverage of annual wellness visit providing a personalized prevention plan”), this requirement is specific to Medicare beneficiaries and does not apply to individual or group plans. Beyond this particular section you won’t find any mention of a requirement within the ACA.

So what gives?  Lewis and Khanna aren’t the only ones who’ve mentioned this “free” Obamacare benefit. Even when researching this piece I had to engage in a lengthy discussion with a friend who is a healthcare policy advisor, unexpectedly defending my position. This claim has to be coming from somewhere, surely people smarter than me have gotten it right?

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Have Doctors Joined the Working Class?

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Marx und Engels Alexsander Platz Berlin

By Richard Gunderman, MD

On September 28, 1864, exactly 150 years ago this weekend, the first meeting of the International Workingmen’s Association (IWA) was convened at St. Martin’s Hall, London.  Among the attendees was a relatively obscure German journalist by the name of Karl Marx.  Though Marx did not speak during the meeting, he soon began playing a crucial role in the life of the organization, in part because he was assigned the task of drafting its founding documents.

The work of the IWA and Marx is increasingly relevant to the practice of medicine today, largely because of the rapidly shrinking percentage of US physicians who own their own practices.  This moves physicians into the category of what Marx and his associates called, “working people.”  According to data from the American Medical Association, in 1983 76% of physicians were self-employed, a number that had fallen in 2012 to 53%.  And the trend is accelerating.  It is estimated that in 2014, 3 in 4 newly hired physicians will go to work for hospitals and health systems.

To put this change in Marx’s terms, the rapid fall in physician self-employment means that a shrinking percentage of physicians own what he called the means of production.  In his view, this alienates workers – in this case physicians – from other physicians, themselves, the work they do, and from patients.  Whether we agree with Marx on every point, his writings on this topic provides a provocative perspective from which to survey the changing landscape of contemporary medicine.

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Halbig corpus interruptus

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By MATTHEW HOLT

In more stunning proof that America’s 18th century style governing process just doesn’t work, a subset of a regional Federal court ruled against part of Obamacare. The Halbig ruling is certain to be overturned by the full DC court and then probably will stay that way after it makes it’s way through the Supremes–at least Jonathan Cohn thinks so.

But think about what the Halbig ruling is about. Its proponents say that when Congress (well, just the Senate actually as it was their version of the bill that passed) designed the ACA, they wanted states only to run exchanges and only people buying via states to get subsidies. But that they also wanted a Federal exchange for those states that couldn’t or (as it turned out) wouldn’t create their own. But apparently they meant that subsidies wouldn’t be available on the Federal exchange. That would just sail through Logic 101 at any high school. Well only if the teacher was asleep, as apparently most Senators were.

Now two judges interpret what was written down to imply that subsidies should only be available on state exchanges–even though logic, basic common sense and fairness would dictate that if we’re going to subsidize health insurance we should do it for everyone regardless of geography.

Don’t forget that in the House version of the bill there was only a Federal exchange. Continue reading…

How Can Patients on Medicaid Possibly Be Worse Off than Those Who Don’t Have Insurance?

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By Saurabh Jha, MD

“Extraordinary claims require extraordinary evidence,” said Carl Sagan.

The claim that health insurance improves health outcomes is hardly ground breaking. Studying whether insurance affects health status is like wondering whether three meals a day lead to a higher muscle mass than total starvation.

Well that’s what I thought. Until I read the study on Oregon’s Medicaid program by Baicker and colleagues in the NEJM earlier this year and, more recently, Avik Roy’s short treatise “How Medicaid Fails the Poor”.

Baicker et al found that Medicaid enrollees fared no better in terms of health outcomes than those without insurance. That is, no insurance no difference.

The study is an exemplar of policy research laced with regression equations, control of known confounders and clear separation of variables. There is only so much rigor social science can achieve compared to the physical sciences. Yet this is about as good a study as is possible.

The one thing the study did not lack was sample size. It’s useful to bear in mind sample size. Large effects do not need a large sample size to show statistical significance. Conversely, if study with a large sample size does not show even a modest effect, it means that the effect probably does not exist.

There are several interpretations of the Medicaid study, interpretations inevitably shaped by one’s political inclination. The ever consistent Paul Krugman, consistent in his Samsonian defense of government programs against philistines and pagans, extolled critics of Medicaid as “nuts” and asked, presumably rhetorically, “Medicaid is cheaper than private insurance. So where is the downside?”

Unlike Krugman I am not a Nobel laureate and am about as likely to win a Nobel Prize as I am of playing the next James Bond, so it’s possible that I am missing something blatantly obvious.  Could the downside of a government program paying physicians, on average 52 cents, and as low as 29 cents, for every dollar paid by private insurance in a multiple payer system be access?

Indeed, it’s darn impossible for patients on Medicaid to see a new physician.  As Avik Roy explains “…massive fallacy at the heart of Medicaid….It’s the idea that health insurance equals healthcare”.

But wait. It gets better.

I am accustomed to US healthcare throwing more plot twisters than Hercule Poirot’s sleuth work. But one I least expected was that patients on Medicaid do worse than patients with no insurance (risk-adjusted, almost). I am not going to be that remorseless logician, which John Maynard Keynes warned us about, who starting with one mistake can end up in Bedlam, and argue that if you are for Medicaid that is morally equivalent to sanctioning mass murder. Rather, I ask how it is possible that possessing Medicaid makes you worse off than no insurance whatsoever.

To some extent this may artifactually appear so because poverty correlates with ill health, and studies that show Medicaid patients faring worse than uninsured, cannot totally control for social determinants of health.

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The Email I Want to Send To Our Tech Guys But Keep Deleting…

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By Shirie Leng, MD

Dear Tech Guys:

So today I’m doing anesthesia for colonoscopies and upper GI scopes. Nowadays we have three board-certified anesthesiologists doing anesthesia for GI procedures every single day at my institution. I’ll probably do 8 cases today. I will sign into a computer or electronically sign something 32 times. I have to type my user name and password into 3 different systems 24 times. I’m doing essentially the same thing with each case, but each case has to have the same information entered separately. I have to do these things, but my department also pays four full-time masters-level trained nurses to enter patient information and medical histories into the computer system, sometimes transcribed from a different computer system. Ironically, I will also generate about 50 pages of paper, since the computer record has to be printed out. Twice.

No wonder almost everyone I know hates electronic medical records! I don’t know anything about computers, and I don’t know what systems other hospitals have. I may be dreaming of a world that doesn’t exist or that world is here and I haven’t heard about it. Nevertheless, here’s my wish list for a system that doctors would actually want to use:

1. Eliminate the User Names and Passords: You can’t tell me that in this day of retinal scans and hand-held computers that there isn’t a better way to secure data. What if each person had their own iPad that you only have to sign into ONCE a day that automatically signs your charts. If you’re worried about people leaving them sitting around use a retinal scan or fingerprint instant recognition system.

2. Eliminate the Paper: If you’re going to have full-time people entering data for you, why print it out? It’s on the computer for anyone to access.

3. All Data Systems Must Be Compatible: You can’t have patient data entered in one place that doesn’t automatically import into another place. If my anesthesia record can’t talk to the hospital OMR, I have to RE-TYPE everything in, which is completely ridiculous.

4. Everybody Has to Use the Same System: Everybody, state-wide. Right now, electronic records from a nearby hospital are not available at my hospital, even though the two hospitals are right across the street from each other.

5. Don’t Make Me Turn the Page All the important information about a patient should be on the first page you open when you look up a patient. I shouldn’t have to click six different tabs. Specific to anesthesia, all the relevant data about the patient including what medications they have received during the case should be automatically displayed on the screen when you start a case. Specific to primary care, all the latest labs and data, recent appointments with specialists, current med list and anything else the doctor wants to see commonly should be right on the first screen.

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