It’s open enrollment season—the annual period in which tens of millions of consumers wallow in the misery of health insurance choices and costs. So, let’s pause to reflect on the status of things—enrollment-wise—with employer coverage, Medicare, and the exchanges.
In particular, do consumers have better tools these days to help them choose insurance plans?
For people with employer-based coverage—about 150 million Americans—things are okay and stable, but not great. The latest report from the Kaiser Family Foundation, released last month and based on a detailed survey of 1,900 employers (small, mid-size and large), indicates that premiums rose on average a modest 3% in 2016—to just over $18,000 for family coverage. Workers paid 29% of that.
A similarly small increase in premiums has prevailed for several years and is expected again for 2017.
Almost all firms with 50 or more employees offer health benefits and the vast majority claim their coverage meets the ACA’s requirements for value and affordability. Overall, 56% of employers offer health benefits because hundreds of thousands of small firms either choose not to offer it or can’t afford it—especially the smallest Mom and Pop shops.
Twenty years is a long time to rely on one measurement approach. Imagine if in this technology-centric world we still relied on dial-up to connect to the internet. That’s basically where we are on quality assessment today. But we don’t need to be.
Predictive risk calculations allow doctors to look into the future. A risk score tells doctors how likely their patient is to develop heart disease or have a stroke. Working with their patients, doctors can discuss options for lowering this risk with the goal of preventing such events from happening.
With data from electronic health records, we should be able to create risk profiles for individual patients that actually take into account the different factors affecting their personal health—not just their age and gender, but their family history, whether or not they smoke, what medications and treatments they are receiving, and their own perspective on how they feel.
But right now, a 50 year old woman’s risk of developing heart disease is determined by a threshold set for the entire population of women aged 50-65 across the country. That’s a crude science. Everyone is not built the same. We should create risk profiles that change as patients change: as they reduce their risk by losing weight, quit smoking, or lowering their high blood pressure, thus reducing their chances of a heart attack or other adverse event.
That’s the vision of NCQA’s Global Cardiovascular Risk Score (GCVR). Leveraging the pioneering risk prediction work of Archimedes, it extracts data from electronic health records and uses a sophisticated algorithm to generate a highly sensitive, patient-centric risk profile for each clinician. It works like this: the higher the score the less likely a clinician’s patient will develop heart problems in the next five years.
There’s scant disagreement that a key to transforming the U.S. health system is strengthening its primary care foundation. But there’s no consensus about how.
In last week’s new cycle, evidence of our dysfunction on this central issue was apparent:
Last Monday, the American Academy of Pediatrics fired a volley across the bow at retail clinics, calling them an “inappropriate source of primary care for pediatric patients (1).” Instead, the society that represents the nation’s 62,000 pediatricians encouraged an alternative—the patient centered medical home it originated in 1967.
In its policy statement, while acknowledging the growing popularity of retail clinics, the AAP affirmed its opposition to models that are not physician driven. Never mind that the 1600 retail clinics deliver comparable outcomes for treatment of a dozen uncomplicated medical problems, offer extended hours and cost less than half for a medical office visit. And their caregivers are nurse practitioners.
Then Tuesday, a robust Canadian study was released that cast doubt on the suitability of the patient centered medical home (PCMH) as the transformative model for primary care (2). The Canadian research team compared results from 32 medical home practices in Pennsylvania that had achieved certification from the National Committee on Quality Assurance’ medical home program to 29 non-medical home primary care practices in the same region from 2008-2011.
They concluded “a multi-payer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement (3).”
And the same day, the White House announced it would spend $5.2 billion over 10 years to train 13,000 additional primary care residents and $3.95 billion over 6 years to expand the Health Resources Services Administration (HRSA) program from 8900 primary care providers to 15,000.
The exponential growth in wellness programs indicates that Corporate America believes that medicalizing the workplace, through paying employees to participate in health risk assessments (“HRAs”) and biometric screens, will reduce healthcare spending.
It won’t. As shown in my book Why Nobody Believes the Numbers and subsequent analyses, the publicly reported outcomes data of these programs are made up—often to a laughable degree, starting with the fictional Safeway wellness success story that inspired the original Affordable Care Act wellness emphasis. None of this should be a surprise: in addition to HRAs and blood draws, wellness programs urge employees to go to the doctor, even though most preventive care costs more than it saves. So workplace medicalization saves no money – indeed, it probably increases direct costs with these extra doctor visits – but all this medicalization at least should make a company’s workforce healthier.
Except when it doesn’t — and harms employees instead, which happens altogether too often.
Yes, you read that right. While some health risk assessments just nag/remind employees to do the obvious — quit smoking, exercise more, avoid junk food and buckle their seat belts — many other HRAs and screens, from well-known vendors, provide blatantly incorrect advice that can potentially cause serious harm if followed.
Suppose one day you sit in front of your work computer, click on a link supplied by your employer, and set about the task of answering a hundred or more highly intrusive health questions. Setting aside the issue of financial penalties or rewards for doing the survey, you would trust that the instrument itself, called a health risk appraisal (HRA), would actually have a sound scientific basis, especially since its ultimate goal is to give you purportedly accurate health guidance.
Unfortunately, your trust in the validity of the tool would be quite misplaced.
HRAs are an essential screening tool in workplace wellness programs despite the fact that no body of evidence clearly demonstrates either their fiscal or clinical value and that no health services research has determined which HRA is the optimal tool. Indeed, a recent review of HRAs concluded that they increase spending, not reduce it, and that no one has any idea whatsoever whether taking an HRA has anything to do with the delivery of health value.
By masking essential methodological truths about HRAs, wellness vendors have essentially hustled their employer clients into believing that HRAs, which frequently ask clinical questions best left to primary care clinicians or restate platitudes (gosh, I didn’t know it’s safer to drive while not under the influence), are both probative and predictive of a person’s health future. This is just simply wrong.
Everyone loves prevention. It may seem strange then, to learn that one of the biggest barriers keeping prevention from reaching its full potential is the current set of performance measures that, ironically, were created to promote them. The reason is that current measures are promoting activities that are inaccurate and inefficient. It is as though explorers who are trying to reach the North Pole have been given a compass that is sending them to Greenland.
This problem is being addressed by a new project conducted by NCQA and funded by the Robert Wood Johnson Foundation. The objective is to evaluate a new type of measure of healthcare quality called GCVR (Global Cardiovascular Risk). The new measure will have an important effect on the prevention of cardiovascular conditions.
To understand how, we need first to understand the limitations of current measures. For reasons that were appropriate when they were initially introduced – about 20 years ago — current performance measures were designed to be simple: simple to implement (e.g. collect the necessary data, do the calculations), and simple to remember and explain. This was accomplished in three main ways. One was to create separate performance measures for different risk factors. Thus there are separate measures for blood pressure control, cholesterol control, glucose control, tobacco use, and so forth.
While a performance measure for any one risk factor might take into account a few other risk factors to some extent, none of them incorporate all the relevant risk factors in a physiologically accurate way. A second simplification is that current measures are based on care processes and treatment goals for biomarkers, rather than on health outcomes. Thus a blood pressure measure asks if a patient with hypertension is controlled to a systolic pressure below 140 mmHG. A third simplification is the use of sharp cut points to determine the need for and success of treatment. For example, patients with hypertension are counted as properly treated if their systolic pressures are below 140 mmHG, otherwise not.
Last week I attended the first annual meeting of the Long-Term Quality Alliance and listened to Gregg Pawlson (a geriatrician and executive with NCQA) talk about quality measurement. Right now, quality measurement does too little to drive practice towards quality care because it is based only on things that are “feasible,” or easy to measure—like what gets coded on medical bills. Pawlson observed that while feasibility must be one of the watchwords of quality measurement for now, in the near future electronic medical records should allow us to move beyond billing codes to gather real clinical data for more important quality measurement, including key care processes and outcomes.
I sure hope so. Because those who have looked beyond the dim illumination of current billing-based “quality measures” and searched in the darkness where real processes of clinical care can found have found that the situation is grave. The ACOVE (Assessing Care of Vulnerable Elders) process, while laborious, looks at clinical care where it really happens – in offices and charts – rather than in bills and therefore has a better chance of driving meaningful quality improvement. Readers know that I am a big fan of this work, begun at RAND by outstanding clinician-researchers including Neil Wenger, David Solomon, David Reuben, and many others. I believe that ACOVE is an example of what we need in elder care: high quality evidence about essential clinical practices that are sensibly related to real health outcomes and show how we could (often easily) do better for older people. ACOVE is a blessing.Continue reading…
Peggy O’Kane has been running the NCQA for longer than she might care to remember. NCQA is an independent, non-profit organization whose mission is to improve the quality of health care everywhere, but it’s best known for creating the HEDIS measures that rate health insurer and provider performance. I’ve been a fan of Peggy since I met her in the mid-1990s. Today she shows she’s still fighting the good fight. This is her first contribution to THCB —Matthew Holt
Suppose you’re one of the 22 million Americans living with diabetes and you have to decide where you want to live. Your choices: Providence, Rhode Island, or Houston, Texas. Providence is pretty and you’d have easy access to lobster dinners and weekends at the Cape. But Houston is warmer in the winter and just a hop, skip and a jump from a weekend in Cancun. A hard decision but you’re leaning toward Houston because, let’s face it, you hate shoveling snow!But then you take a look at the 13th annual State of Health Care Quality Report by the National Committee for Quality Assurance (plug alert: I run the place) and you find out the quality of care for diabetics is nearly 11 percentage points better in New England than it is in the South Central region of the U.S. and you begin to reconsider. In fact, you look at the newest data released October 22 and you find that the quality of care in the Texas region of the country is consistently the worst while care in New England is almost always the best. Providence here I come!
Here’s the problem: Most people don’t have a choice of moving from Texas or Oklahoma or Alabama to Massachusetts, Connecticut or Rhode Island. They have to live with the health care system they have. For a diabetic, those 11 points can translate into more kidney problems, loss of vision, toe or foot amputations or, heaven forbid, a shorter lifespan.The thing is, it doesn’t have to be this way. True, care isn’t going to be identical in all parts of the country. And, true, the population of Dallas may have a lot more health problems than the people in Hartford. But 11 points is too big a gap to explain away with demographics.
This post is a bit different from most of the policy points, institutional cases and reports of technical innovations that I’ve been reading on THCB in the past months. I want to pose the above Question to the readers of this blog, since many of you are uniquely positioned help answer it in your comments. And I have a hope that your responses to this Question will help nuance the technical and policy debate over EMR adoption.
First, let’s unpack the Question:
1. THE JOB. In the past several years, a number of public and private initiatives, most recently ABMS’s Improving Performance in Practice (a project with which I am affiliated) and NCQA’s Patient Centered Medical Home, have been making fitful progress toward a new post-reform model of primary care: patient-centered, accessible, care-coordinating, population-focused, prepared, proactive, and the rest. These collaboratives and demonstration projects have all stressed the importance of computerized ‘registry functions’ as the foundation for these progressive capabilities. One, the Health Disparities Collaboratives run by HRSA, went so far as to commission a registry program and provide it free to participating clinics.Continue reading…