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Is the ACO DOA? Reasonable Minds Can Improve the Draft Regulations

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By DAVID HARLOW

In the current all-ACO, all the time, health care policy news cycle, we’ve been inundated with declarations that the ACO is dead, because a handful of big boys say they don’t want to play.

Today, CMS announced that it is tinkering with the proposed ACO rules by offering three variations on the ACO theme (link to press release; see also CMS ACO fact sheet).  From the fact sheet:

  • Pioneer ACO Model: The Innovation Center is now accepting applications for the Pioneer ACO Model, which will provide a faster path for mature ACOs that have already begun coordinating care for patients.  The Pioneer ACO model is estimated to save Medicare as much as $430 million over three years by better managing care for beneficiaries and eliminating duplication.  And it is designed to work in coordination with private payers in order to achieve cost savings and improve quality across the ACO, thus improving health outcomes and reducing costs for employers and patients with private insurance.
  • Advance Payment ACO Initiative: The Innovation Center is seeking public comments on whether it should offer an Advance Payment Initiative that would allow certain ACOs participating in the Medicare Shared Savings Program access to a portion of their shared savings up front, helping providers make the infrastructure and staff investments crucial to successful ACOs.  Comments should be submitted by June 17th, 2011.
  • Accelerated Development Learning Sessions: Providers interested in learning more about the steps necessary to become an ACO can attend an upcoming series of Accelerated Development Learning Sessions.  These convenient and free sessions will help providers learn what steps they can take to improve care delivery and how to develop an action plan for moving toward better-coordinated care.

Together with the Medicare Shared Savings Program, the initiatives announced today give providers a broad range of options and support that reflect the varying needs of providers in embarking on delivery system reforms.

CMS has recently hinted that it will be rejiggering the rules to encourage physician-led ACOs, too (an approach I have previously endorsed).Continue reading…

Facebook Misstep Costs RI Physician Fine, Job

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By DAVID HARLOW

In recent years many health care providers and managers have told me, time and again, that the health care world is accustomed to managing confidential patient information, and therefore doesn’t need much in the way of social media training and policy development.  This week brings news that should make those folks sit up and take notice.  A physician in Rhode Island, who was fired for a Facebook faux pas, has now been fined by the state medical board as well.  The physician posted a little too much information on Facebook — information about a patient that, combined with other publicly available information, allowed third parties to identify the patient.  The details of the story are available here and here.

The key takeaway from this story — and the Johnny-come-lately approach to health care social media taken by the Rhode Island hospital in question and the Boston teaching hospital that the Boston Globe turned to for comment — is that prevention is the best medicine.

Facebook and other social media are a fact of life, and cannot be ignored by health care providers and organizations.  They can even be used as a force for good.  As one example, take note of the recently-announced initiative by my colleague, Dr. Val, to start up a peer-reviewed tweetstream, @HealthyRT.  At he very least, health care providers and organizations should be monitoring social media for mentions so that they can reach out, as may be necessary, to address health care and public relations issues.Continue reading…

Who Owns Patient Data?

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By DAVID HARLOW

Walgreens is being sued by customers who are not happy that their prescription information – even though it has been de-identified – is being sold by Walgreens to data-mining companies.

The data privacy and security concerns surrounding the transfer of de-identified data are significant.  To “de-identify” what is otherwise protected health information under HIPAA, some outfits will simply strip data of 18 types of identifiers listed in federal regulations.  However, the relevant regulation (45 CFR 164.514(b)(2)(ii)) also provides that this only works if “the covered entity does not have actual knowledge that the information could be used alone or in combination with other information to identify an individual who is a subject of the information.” Thus, the problem with this approach is that, these days, nobody can disclaim knowledge of the fact that information de-identified by removing this cookbook list of 18 identifiers may be re-identified by cross-matching data with other publicly-available data sources. There are a number of reported instances of this sort of thing happening. The bottom line is that our collective technical prowess has outstripped the regulatory safe harbor.

Is this the basis of the lawsuit brought against Walgreens?  An objection to trafficking in health information that should remain private?  No.  The plaintiff group of customers is suing to share in the profits realized by Walgreens from trading in the de-identified data.Continue reading…

AQC to ACO: As Goes Massachusetts, So Goes the Nation?

By DAVID HARLOW

About four years ago here in Beantown, survivors of the last big ill-conceived or poorly-executed (depends who you ask) wave of health care management and finance innovation were kicking around for a new approach to aligning payor and provider incentives, focusing on quality and cost containment. To hear Andrew Dreyfus, CEO of Blue Cross Blue Shield of Massachusetts, tell the story, the Blues wanted to address both quality and cost, and therefore (after looking in vain for a model elsewhere that could be transplanted to Massachusetts) developed the Alternative Quality Contract, or AQC, which features a global payment model hybridized with substantial performance incentives, plus design features intended to lower the cost of care over time.

Many of the features put in place under the AQC will allow participating provider networks in Massachsuetts to make the leap to ACO (once the beast is defined by the federales), despite the difference in payment methodology (global cap for AQC vs. FFS for ACO).

I was invited to hear Andrew present the AQC story this week together with Gene Lindsey, CEO of Atrius Health, a Massachusetts multispecialty physician network of some 700 physicians that participates in the AQC.  (Atrius’  largest group is Harvard Vanguard Medical Associates, whose docs used to be employed by Harvard Community Health Plan, the pioneering staff model HMO ’round these parts.)Continue reading…

Geolocate This

By DAVID HARLOWFoursquare screen shot

As health care providers continue to wonder whether and how they should add social media to their mix of communications tactics, new tools — and new uses for those tools — continue to sprout up.

I’m quoted in the current edition of American Medical News in a story that looks at the question of whether and how health care providers should use geolocation services (e.g., Foursquare, Gowalla) as additional channels through which they may communicate with patients, colleagues and referral sources — or through which they may encourage patients and others to communicate among themselves.

I’ve touched on this issue in recent presentations on health care social media, and have noted that even “checking in” on line at an STD clinic — an activity discounted by Mark Scrimshire in the article — is something that people will do for a badge — check out this fall’s MTV/Foursquare Get Yourself Tested campaign.  (Taking it to the next level, targeted sharing of STD test results is the idea behind start-up Qpid.me.)

Health care providers can leverage the general public’s interest in using geolocation services in a variety of ways.  In the the article, Chris Boyer notes that his health system works to ensure that check-in data (addresses and phone numbers drawn from other online services) for each service location is accurate, but doesn’t necessarily encourage check-ins.

There are no HIPAA issues raised by patients “checking in” on line, since it’s a voluntary act by the patient, and doesn’t really involve the provider.  Providers might decide to encourage check-ins (but not repeat visits — we want to keep people healthy, right?) as a way to drive patients to links to targeted health information, or even, perhaps, coupons for coffee or something (as long as we don’t bump up agianst limits on financial incentives … though I think that would not be an issue under most circumstances.

Continue reading…

Facebook Saves Woman’s Life: Newt Gingrich and Reality-Based Healthcare Systems Planning

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By DAVID HARLOW David Harlow

I’ve seen at least half a dozen links to the op-ed coauthored by Newt Gingrich and neurosurgeon Kamal Thapar about how the doctor used information on Facebook to save a woman’s life. (It was published by AOL News. Really.)  In brief, a woman who had been to see a number of different health care providers without getting a clear diagnosis showed up in an emergency room, went into a coma and nearly died.  She was saved by a doctor’s review of the detailed notes she kept about her symptoms, etc., which she posted on Facebook.  The story is vague on the details, but apparently her son facilitated getting the doc access to her Facebook page, and the details posted there allowed him to diagnose and treat her condition.  She recovered fully.

Newt and Dr. Thapar wax rhapsodic about how Facebook saved a life, and sing the praises of social media’s role in modern medicine.  (I’m not sure how this really fits in with Newt’s stance on health reform, within his 12-step program to achieve the total replacement of the Left … but, hey, nobody has the patience these days for so many details anyway.)

Regular readers of HealthBlawg know that I would perhaps be the last to challenge the proposition that social media has a role to play in health care.  However, I think Newt got it wrong here.

Continue reading…

OIG: Imaging pre-authorization may be handled by hospital for referring docs and patients

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By DAVID HARLOW
David Harlow

The OIG released an advisory opinion at the end of last month OK’ing a hospital’s proposal to provide insurance pre-authorization srevices free of charge to patients and physicians. This is an issue that has long vexed folks in the imaging world. Clearly, this is a free service provided to referral sources (to the extent they are obligated by contract with third party payors to obtain the pre-authorization before referring a patient for an MRI, for example), so why is the OIG OK with it?  In the opinion, the OIG blesses the arrangement for four reasons:

  • The arrangement doesn’t target specific referring docs, so the pre-authorization service will be provided for patients of docs who are contractually bound to handle it themselves, as well as for patients of those who aren’t, and thus the risk of using the arrangement to reward referrals is low
  • The hospital will not pay the docs under the arrangement and will not guarantee to docs that the pre-authorizations will be forthcoming (the OIG also notes — not sure why — that the hospital will collect and pass on only such personal health information as may be necessary to secure a finding of medical necessity for the pre-authorization)
  • The hospital staff will be transparent with payors and referring docs, and will have little influence on steering volume, because they get involved only after the hospital has been selected (other situations are distinguished, e.g., where referral seekers provide referral sources with staff like discharge planners)
  • The hospital has an interest in being paid for its services, and thus in ensuring that the pre-authorization process is conducted properly, thus “lower[ing] the risk that the … [a]rrangement is a stalking horse for illicit payments to [the hospital’s] referral sources”

Well, the reasoning here doesn’t really cut it, as far as I’m concerned. Referring docs and their staffs hate having to deal with the pre-authorization process, and if a hospital takes on that headache, that’s a real benefit (remuneration, in the language of the anti-kickback statute). If there are two hospitals in town, and — all other things being equal — one provides pre-authorization services and the other doesn’t, guess where all the docs will refer their patients? It doesn’t really matter that the service is provided to all docs, for all payors. It is still clearly an inducement. If, on the other hand, all hospitals take on this added cost of doing business, then nobody gains a competitive advantage. Finally, to the e xtent physician networks are more and more tightly tied to particular hospital systems (whether through employment or other relationships, post health reform), the potential for steering volume is negligible at best.

Bottom line: I agree with the outcome, but not the reasoning.

David Harlow writes at HealthBlawg:David Harlow’s Health Care Law Blog, a nationally-recognized health care law and policy blog. He is an attorney and lectures extensively on health law topics to attorneys and to health care providers. Prior to entering private practice, he served as Deputy General Counsel of the Massachusetts Department of Public Health.

A Look Inside: The Massachusetts Health Reform Law

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By DAVID HARLOWVintage massachusetts seal

The Massachusetts health reform law Part II, enacted in 2008 – laid the groundwork for cost control and  quality improvement, as a follow-on to the initial legislation’s emphasis on achieving near-universal coverage.  The legislation authorized several studies — including a report published a few months back on global payment strategies — and set the stage for hearings on health care cost containment to be held before the state Division of Health Care Finance and Policy (DHCFP), which are scheduled to begin March 16, 2010.

In anticipation of these hearings, and as required by the law, the Attorney General’s office released a report on health care cost trends and cost drivers on January 29.

While the names of providers and payors are not included in this report, it provides a fascinating level of detail regarding what we already knew, or at least suspected: some providers are paid as much as twice as much as others for the same services, with no correlation to improved quality or outcomes.

The AG’s summary conclusions in full:

[O]ur preliminary review has revealed serious system-wide failings in the commercial health care marketplace which, if unaddressed, imperil access to affordable, quality health care. In brief, our investigation has shown:

A. Prices paid by health insurance companies to hospitals and physician groups vary significantly within the same geographic area and amongst providers offering similar levels of service.

B. Price variations are not correlated to (1) quality of care, (2) the sickness or complexity of the population being served, (3) the extent to which a provider is responsible for caring for a large portion of patients on Medicare or Medicaid, or (4) whether a provider is an academic teaching or research facility. Moreover, (5) price variations are not adequately explained by differences in hospital costs of delivering similar services at similar facilities.

C. Price variations are correlated to market leverage as measured by the relative market position of the hospital or provider group compared with other hospitals or provider groups within a geographic region or within a group of academic medical centers.

D. Variation in total medical expenses on a per member per month basis is not correlated to the methodology used to pay for health care, with total medical expenses sometimes higher for globally paid providers than for providers paid on a fee-for-service basis.

E. Price increases, not increases in utilization, caused most of the increases in health care costs during the past few years in Massachusetts.

F. The commercial health care marketplace has been distorted by contracting practices that reinforce and perpetuate disparities in pricing.

This report is well worth reading, and it is well-illustrated with clear charts.  While the detail is welcome, many have criticized the AG’s office for leaving out identifying information, and for coming to the party a year after the Boston Globe reported on some of the same issues.

At the end of last week, DHCFP released a series of three reports on health care cost trends as well.  The DHCFP reports are summarized here; they really serve to describe the baseline facts on the ground and explore trends form 2006 through 2008.  Here’s the summary of key findings:

  • The Commonwealth’s health care system is a key employer and driver of economic growth for the region. However, personal health spending per capita is higher in Massachusetts relative to the nation and continues to rise.
  • Some characteristics of the Massachusetts health care marketplace that may be contributing to the high levels of cost growth, include:
    • Most of a health insurance premium goes toward spending on health care services as opposed to administrative and other non-medical services. On average, in Massachusetts more than 88% of premiums are spent on health care expenses (compared to less than 84% nationally).
    • Average monthly health insurance premiums increased 12% from 2006 to 2008.  If employers and individuals had purchased comparable benefits each year, the growth in premiums would have been larger.
    • Premium trends, benefit levels, and trends in health care spending vary across different-sized employer groups.  Small group premiums were higher and grew faster on average than mid-size and large group premiums, when adjusted for differences in benefits, demographics and location.
  • Health care spending in the Commonwealth increased 7.5% per year from 2006 through 2008, a growth rate that is higher than the nation.  The increased spending can be attributed to several factors:
    • Price was an important factor contributing to rising health care spending across all service types.
    • One area of particular concern (and opportunity) is the variation in prices, which was typically greater for facility charges than professional charges.
    • In addition to price increases, care is being provided in more expensive settings over time—more inpatient care is being provided in academic medical centers and there is a decline in the provision of care at stand-alone outpatient facilities.   Much of the growth in outpatient hospital care occurred at academic medical centers located in the metro Boston area.
    • High concentration of physicians (especially specialists);
    • Greater availability and use of academic medical centers for both inpatient and outpatient hospital based-services, and use of outpatient hospital-based facilities for some services that could be provided in less costly settings;
    • Richer health insurance benefits compared to the nation; and
    • Use of payment methods that are not designed to incentivize efficiency and coordination of medical care.

Again: no surprise here — Massachusetts health care costs are higher than national averages, and are growing at an unsustainable rate.The challenge before Massachusetts policymakers is clear:  They need to put together these puzzle pieces of data, learn from the past, model potential solutions, and plan for the future.  Even the national mainstream media acknowledges that, in the face of health reform meltdown, doing nothing is not an option.  (Where were they six months ago?)

In the midst of this challenge, Governor Deval Patrick seems to be distracted by health reform’s implications for his political future. Instead of waiting for a reasoned outcome of the deliberative process set in motion two years ago (well, as reasoned as possible, given the heavy-duty political and economic interests at stake here), he has leapt into the fray with what looks like an ill-conceived bit of political grandstanding: a bill that would give the state insurance commissioner the authority to cap health care price increases.

The Boston Globe reports:

Rates hospitals and other health providers charge insurers would be “presumptively disapproved as excessive’’ if they increased faster than the level of medical inflation, and they could be rejected after a public hearing.

Similarly, for health insurance plans sold to employers with 50 or fewer workers, premium increases that exceed one and a half times the level of medical inflation would be considered excessive and could be turned down.

The legislation would also impose a two-year moratorium on lawmakers’ mandating any new health benefits that must be covered by insurance plans, a practice that employers have said drives up their health insurance premiums. Small businesses have been hit with double-digit rate increases in recent years.

This proposal brings us back to the future here in Massachusetts:

Twenty years ago, Patrick’s presumptive GOP challenger in the fall, Charlie Baker (who, thanks to some of his views being out of step with GOP orthodoxy, will likely draw many of the significant number of independent voters in Massachusetts, as well as some Democrats), was largely responsible for the dismantling of the Massachusetts health care rate setting system during his tenure in budget and health policy roles in the Weld administration.  (In fact, some of us who have been around long enough still refer to DHCFP as “the agency formerly known as Rate Setting.”)  (As a second aside: For those of you tuning in from afar, Baker’s most recent position was CEO of Harvard Pilgrim Health Care, one of the three dominant payors in the Commonwealth.)   Is Patrick trying to stake out a position in opposition to Baker’s legacy?  What constituency is going to buy into this vision of the future?  Other local observers have also questioned the wisdom of this approach, including fellow health policy bloggers Evan Falchuck and Paul Levy.  (Taking a cue from Paul’s musings on blogger disclosure in connection with this issue, I’ll just say that as a life-long registered Democrat, I have voted for a Republican maybe just once.)

Deregulation was successful twenty years ago because we were collectively convinced that payors could do a better job of holding providers’ feet to the fire.  We later framed this in terms of holding providers accountable, and have employed a variety of tools over time to try and make this private-sector arrangement work: capitation, discounted fee-for-service payments, quality incentives, global payments, etc., etc.  Patrick’s proposal is one version of the general acknowledgment that the market approach has essentially failed.

Instead of going back to the future, Governor Patrick ought to let the health reform process play out.  The legislature should hold the Governor’s bill pending the DHCFP hearings and the subsequent deliberations that will — we hope — yield a more data-driven and sustainable approach to the problem of health care costs and quality.

And who knows?  The national debate may continue to be informed by what comes out of Massachusetts.

David Harlow blogs at the HealthBlawg.

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