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Are Bipartisan Agreements on Health Care Possible?

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By KEN TERRY 

Republicans and Democrats are seen as poles apart on health policy, and the recent election campaign magnified those differences. But in one area—private-sector competition among healthcare providers—there seems to be a fair amount of overlap. This is evident from a close reading of recent remarks by Health and Human Services Secretary Alex Azar and a 2017 paper from the Brookings Institution.

Azar spoke on December 3 at the American Enterprise Institute (AEI), the conservative counterpart to the liberal-leaning Brookings think tank. Referring to a new Trump Administration report on how to reduce healthcare spending through “choice and competition,” Azar said that the government can’t just try to make insurance more affordable while neglecting the underlying costs of care. “Healthcare reform should rely, to the extent possible, on competition within the private sector,” he said.

This is pretty close to the view expressed in the Brookings paper, written by Martin Gaynor, Farzad Mostashari, and Paul B. Ginsburg. “Ensuring that markets function efficiently is central to an effective health system that provides high quality, accessible, and affordable care,” the authors stated. They then proposed a “competition policy” that would require a wide range of actions by the federal and state governments.

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CMS Should Boost the Signal on Social Determinants of Health

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Herb Kuhn, Missouri Hospital Association, Social Determinants of Health

By HERB KUHN 

Historically, the Centers for Medicare & Medicaid Services’ (CMS) stance on the influence that social determinants of health (SDOH) have on health outcomes has been equal parts signal and noise. In April 2016, the agency announced it would begin adjusting the Medicare Advantage star ratings for dual-eligibility and other social factors. This was amid calls for increased equity in the performance determinations from the managed care industry. At the same time, CMS continued to refuse risk-adjustment for SDOH in the Hospital Readmissions Reduction Program (HRRP) despite the research supporting the influence of these factors on the HRRP.

It wasn’t until Congress interceded with the 21st Century Cures Act that CMS conceded to adjusting for dual-eligibility under the new stratified approach to determining HRRP penalties beginning in fiscal year 2019. The new methodology compares hospital readmission performance to peers within the same quintile of dual-eligible payer mix. The debate surrounding the adjustment of incentive-based performance metrics for SDOH likely is to continue, as many feel stratification is a step in the right direction, albeit a small one. And importantly, the Cures Act includes the option of direct risk-adjustment for SDOH, as deemed necessary by the Secretary of Health and Humans Services.

SDOH are defined as “the conditions in which people are born, grow, live, work and age.”  The multidimensional nature of SDOH reach far beyond poverty, requiring a systemic approach to effectively moderate their effects on health outcomes. The criteria used to identify SDOH include factors that have a defined association with health, exist before the delivery of care, are not determined by the quality of care received and are not readily modifiable by health care providers.

The question of modifiability is central to the debate. In the absence of reimbursement for treating SDOH, providers lack the resources to modify health outcomes attributable to social complexities. Therefore, statistical adjustments are needed to account for differences in these complexities to ensure risk-adjusted performance comparisons of hospitals are accurate.

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The Importance of Patient Engagement in Post-Acute Care

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Brian Holzer, patient engagement, post-acute care

By BRIAN HOLZER MD, MBA 

Leaders in hospitals and health systems as well as post-acute care providers such as skilled nursing facilities (SNFs) and Home Health Care (HHC) agencies operate in a complex environment. Currently, the health care reimbursement environment is largely dominated by fee-for-service models. However, acute and post-acute leaders must increasingly position their organizations to prepare for, and participate in, evolving value-based care programs—without losing sight of the current fee-for-service reimbursement structure.

With that said, the call to action for acute and post-acute providers working at both ends of the reimbursement spectrum is real. The time is now to innovate, test and adopt new post-acute care models to support each patient’s transition from hospital to post-acute settings, and eventually home to enable a better care experience for patients and their care teams.

This is especially relevant for Skilled Nursing Facilities (SNFs) and chains that meet the current Medicare requirements for Part A coverage. Increasingly, the SNF industry is under pressure from the Medicare program to improve coordination and outcomes. Medicare’s hospital readmission policy and value-based purchasing program (VBP), bundled payments, and ACOs encourage SNFs, and other post-acute settings, to avoid readmissions. In addition, earlier this year, the Centers for Medicare and Medicaid Services (CMS) finalized a new patient-driven payment model (PDPM) for SNFs, which will go into effect on October 1, 2019. The overhaul of the entire system will require significant staff focus and operational changes.

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Part II | MedPAC’s Proposed “Reforms” Should Be Tested Before They’re Implemented: CMS’s Hospital Readmissions Reduction Program Is Exhibit A

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By KIP SULLIVAN JD 

The Hospital Readmissions Reduction Program (HRRP), one of numerous pay-for-performance (P4P) schemes authorized by the Affordable Care Act, was sprung on the Medicare fee-for-service population on October 1, 2012 without being pre-tested and with no other evidence indicating what it is hospitals are supposed to do to reduce readmissions. Research on the impact of the HRRP conducted since 2012 is limited even at this late date [1], but the research suggests the HRRP has harmed patients, especially those with congestive heart failure (CHF) (CHF, heart attack, and pneumonia were the first three conditions covered by the HRRP). The Medicare Payment Advisory Commission (MedPAC) disagrees. MedPAC would have us believe the HRRP has done what MedPAC hoped it would do when they recommended it in their June 2007 report to Congress (see discussion of that report in Part I of this two-part series). In Chapter 1 of their June 2018 report to Congress, MedPAC claimed the HRRP has reduced 30-day readmissions of targeted patients without raising the mortality rate.

MedPAC is almost certainly wrong about that. What is indisputable is that MedPAC’s defense of the HRRP in that report was inexcusably sloppy and, therefore, not credible. To illustrate what is wrong with the MedPAC study, I will compare it with an excellent study published by Ankur Gupta et al. in JAMA Cardiology in November 2017. Like MedPAC, Gupta et al. reported that 30-day CHF readmission rates dropped after the HRRP went into effect. Unlike MedPAC, Gupta et al. reported an increase in mortality rates among CHF patients. [2]

We will see that the study by Gupta et al. is more credible than MedPAC’s for several reasons, the most important of which are: (1) Gupta et al. separated in-patient from post-discharge mortality, while MedPAC collapsed those two measures into one, thus disguising any increase in mortality during the 30 days after discharge; (2) Gupta et al.’s method of controlling for differences in patient health was superior to MedPAC’s because they used medical records data plus claims data, while MedPAC used only claims data.

I will discuss as well research demonstrating that readmission rates have not fallen when the increase in observation stays and readmissions following observations stays are taken into account, and that some hospitals are more willing to substitute observation stays for admissions than others and thereby escape the HRRP penalties.

All this research taken together indicates the HRRP has given CHF patients the worst of all worlds: No reduction in readmissions but an increase in mortality, and possibly higher out-of-pocket costs for those who should have been admitted but were assigned to observation status instead.

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MedPAC’s Proposed “Reforms” Should Be Tested Before They’re Implemented: CMS’s Hospital Readmissions Reduction Program Is Exhibit A

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By KIP SULLIVAN JD 

Egged on by the Medicare Payment Advisory Commission (MedPAC), Congress has imposed multiple pay-for-performance (P4P) schemes on the fee-for-service Medicare program. MedPAC recommended most of these schemes between 2003 and 2008, and Congress subsequently imposed them on Medicare, primarily via the Affordable Care Act (ACA) of 2010 and the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.

MedPAC’s five-year P4P binge began with the endorsement of the general concept of P4P at all levels – hospital, clinic, and individual physician – in a series of reports to Congress in 2003, 2004, and 2005. This was followed by endorsements of vaguely described iterations of P4P, notably the “accountable care organization” in 2006 [1], punishment of hospitals for “excess” readmissions in 2007 [2], the “medical home” in 2008 and the “bundled payment” in 2008. None of these proposals were backed up by anything resembling evidence.

Congress endorsed all these schemes without asking for evidence or further details. Congress dealt with the vagueness of, and lack of evidence supporting, MedPAC’s proposals simply by ordering CMS to figure out how to make them work. CMS staff added a few more details to these proposals in the regulations they drafted, but the details were petty and arbitrarily adopted (how many primary doctors had to be in an ACO, how many patients had to sit on the advisory committee of a “patient-centered medical home,” how many days had to expire between a discharge and an admission to constitute a “readmission,” etc.).

New rule, new culture

This process – invention of nebulous P4P schemes by MedPAC, unquestioning endorsement by Congress, and clumsy implementation by CMS – is not working. Every one of the proposals listed above has failed to cut costs (with the possible exception of bundled payments for hip and knee replacements) and may be doing more harm than good to patients. These proposals are failing for an obvious reason – MedPAC and Congress subscribe to the belief that health policies do not need to be tested for effectiveness and safety before they are implemented. In their view, mere opinion suffices.

This has to stop. In this two-part essay I argue for a new rule:  MedPAC shall not propose, and Congress shall not authorize, any program that has not been shown by rigorously conducted experiments to be effective at lowering cost without harming patients, improving quality, or both. This will require a culture change at MedPAC. Since its formation in 1997, MedPAC has taken the attitude that it does not have to provide any evidence for its proposals, and it does not have think through its proposals in enough detail to be tested. Over the last two decades MedPAC has demonstrated repeatedly that it believes merely opining about a poorly described solution is sufficient to discharge its obligation to Congress, taxpayers, and Medicare enrollees.
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The Usefulness and Uselessness of Electronic Medical Records

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By RICHARD REECE, MD

Nothing is so useless as a general maxim.

Lord MacCaulay (1800-1859), On Machiavelli (1827)

I dare say that I have worked off my fundamental formula on you that the chief end of man is to frame general propositions and that no general proposition is worth a damn.

O.W Holmes, Jr. (1809-1904), as quoted in The Practical Cogitator, 1962


The general maxim and general proposition behind the rationale of a national interoperative electronic medical record system in every physician’s office is that you can never get too much information and that government can use digital data to cut costs and improve care.

The Problem

Sounds good, doesn’t it? The problem is that so far, after nearly a decade of advancing this maxim and proposition, perhaps 80% of physicians in independent practice aren’t buying. And this, in face of the reality, that government has proposing spending $27 billion to get EHRs off the ground. And beginning this year, CMS will start offering as much as $44,000 per physician over a staggered five years if physicians make “meaningful” use of “certified” medical records. Many doctors regard such rhetoric as empty talk that will accompanied by unreasonable bureaucratic requirements, as surely as dawn following night.

Why no “buy-in” among doctors? Why have two national IT coordinators appointed by Obama, David Brailer,ND, in 2005 and David Blumenthal, MD, in 2011, resigned in frustration over the failure to persuade doctors that gathering electronic data and measuring care is a good thing? If universal EHRs are such a good thing, why have physicians and hospitals not raced to embrace EHRs?

As Steve Lohr of the New York Times, a leading thinker in health care innovation, says in yesterday’s Times (“Seeing Promise and Peril in Digital Records,”

“What is beyond doubt is that the promise of digital records will be unfulfilled if doctors refuse to adopt them, because they regard the technology as cumbersome, time consuming, and possibly dangerous.”

To date, most doctors, except for enthusiastic early adopters, IT nerds, and those in large organizations, have found EHRs “useless” in their daily work. EHRs cost excess money, show little return on investment, change the very nature of practice, slow productivity, tell no narrative tales, cause conflicts among staff and colleagues, require extensive record keeping, are subject to hacking, and, more often than not, are useless as a tool for communicating to colleagues, hospitals, and other doctors outside your practice.

When the government establishes “usability standards” that work, maybe doctors will come on board the electronic train. Until then, says Dr. Edward H. Shortliffe , a professor at the University of Texas Health Science Center in Houston, “Usability is going to be the single greatest impediment to physician acceptance. “

If EHRs are not made more useful and soon, universal digital records may turn out to be a giant boondoggle rather than a scientific bonanza.

Richard L. Reece, MD, is pathologist, editor, author, speaker, innovator, and believer in abilities of practicing doctors and their patients to control and improve their health destinies through innovation. He is author of eleven books. Dr. Reece posts frequently at his blog, Medinnovation.

HIT Trends Summary for August 2011

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By MICHAEL LAKE

This is a summary of the HIT Trends report for August 2011.  You can get the current issue or subscribe here.

Incentives driving the EMR market. According to a report by Sage Healthcare, most physicians (65%) buying EMRs are doing so because of federal incentives.  The biggest obstacle is still cost with 32% of non-users saying it’s the number one issue.  This is creating a mainstream market, even in solo practices, which report over 30% EMR adoption rates in a new survey by SK&A.

Incentives may also be driving hospital implementation of computerized physician order entry (CPOE).  80% of hospitals still lack CPOE capabilities as of last year.  Meaningful use requires providers to order at least one medication for 30% of unique hospital patients.  In a new KLAS report, CPOE projects have more than doubled, being led by Cerner and Epic.

It is a likely unintended consequence that the incentives are speeding the dominance of market leaders.

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Don Berwick, Martyr for Socialized Medicine

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By Avik Roy

I have a piece up at National Review in which I reflect upon Don Berwick’s controversial tenure as Administrator of the Centers for Medicare and Medicaid Services, the 800-billion-dollar federal agency that dominates the American health-care landscape. Despite White House rhetoric to the contrary, I write, Berwick “wasn’t done in by Republican intransigence. He was done in by presidential cowardice. And therein lies a microcosm of everything that’s been wrong with Obamacare.”

The thing to understand about Don Berwick is that there are really two Don Berwicks. There’s the Don Berwick who, through the Institute for Healthcare Improvement, has focused on apolitical aspects of health delivery reform. Here’s what I wrote about Berwick in April 2010:

First, the good. Berwick is a serious and credible health-care analyst. In his capacities both as a Harvard professor and as founder and CEO of a Cambridge-based think-tank called the Institute for Healthcare Improvement, he has written extensively about health-care policy in all of the leading scholarly journals. His focus, in most of these writings, is on the quality and efficiency of health care: things like avoiding medical errors and unnecessary spending. He was granted an honorary knighthood by Queen Elizabeth for his role in shaping Tony Blair’s (mostly futile) attempts to modernize Britain’s National Health Service.

While he was a big supporter of Obamacare, Sir Donald acknowledges its core failing; in an October lecture, he said, “Health-care reform without attention to the nature and nurture of health care as a system is doomed. It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is, care as our patients, their families, and their communities experience it.” Indeed, if you put Berwick in a room with a leading market-oriented health-care analyst, the two would find broad areas of agreement as to where our health-care system fails patients.

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As Goes the Post Office, So Too Medicare?

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By Dr. Wes

With the announcement that the Center for Medicare and Medicaid Services (CMS) will begin auditing 100% of expensive cardiovascular and orthopedic procedures in certain states earlier this week, we see their final transformation from the beneficient health care funding bosom for seniors to health care rationer:

The Center for Medicare and Medicaid Services will require pre-payment audits on hospital stays for cardiac care, joint replacements and spinal fusion procedures, according to the American College of Cardiology in a letter to members. Shares in both industries fell with Tenet Healthcare Corp., the Dallas- based hospital operator, plunging 11 percent to $4.18, the most among Standard & Poor’s 500 stocks. Medtronic Inc., the largest U.S. maker of heart devices, dropped 6 percent to $34.61.

The program means hospitals won’t receive payment for stays that involve cardiac care or orthopedic treatment until auditors have examined the patient records and confirmed that the care was appropriate, Jerold Saef, the reimbursement chair for the Florida chapter of the American College of Cardiology, wrote in a Nov. 21 letter to members. The review process is expected to take 30 days to 60 days, beginning January 1, Saef said.

This is not at all unexpected. In fact, in our field of cardiac electrophysiology, we have known this day would be coming; our expensive, life-saving gadgets and gizmos are easy targets upon which the government can cut its rationing teeth. And so as it will go for us at first, and then for many other areas of health care.

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Physician Payment Sunshine Act Proposed Regulations Out

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By Kathleen M. Boozang

CMS has published proposed rules for its implementation of the Physician Payment Sunshine Act (SUNSHINE ACT or Act), which was enacted by Congress as part of the 2010 Patient Protection and Affordable Care Act.  In short, the SUNSHINE ACT requires life science companies to report annually to CMS their conferral of anything of value, whether it be payment for services or a dinner, in connection with a particular product of the paying company.  By requiring CMS to post the information on its website, the Act seeks to ensure that interested patients become aware of physicians’ conflicts of interest that could affect their prescription of a branded drug or choice of a specific medical device.

The SUNSHINE ACT represents another example of the transparency movement, which has had varying degrees of success in either changing the behavior of the parties subject to disclosure, and/or enabling consumers to make better decisions based upon their access to the disclosed information.  It is likely that the SUNSHINE ACT will impact physicians and manufacturers’ behavior more than it will enlighten consumers about conflicts of interest.  Some physicians will simply conclude that accepting certain gifts or benefits from pharmaceutical or medical device companies isn’t worth having their names on the CMS website.  Some companies have already discovered that they haven’t necessarily reaped the value of the costs of gifting many physicians, or that the cost of recording certain activities simply isn’t worth the return on investment.  Unquestionably, certain transactions will continue to be valuable to both physician and company, and will continue.

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