Tag: value-based care

HIPAA RFI Comments: Patient Privacy Rights

Feb 11, 2019• 3

By ADRIAN GROPPER and DEBORAH C. PEEL

Among other rich nations, US healthcare stands out as both exceptionally privatized and exceptionally expensive. And taken overall, we have the worst health outcomes among the Western Democracies.

On one hand, regulators are reluctant to limit private corporate action lest we reduce innovation and patient choice and promote moral hazards. On the other hand, a privatized marketplace for services requires transparency of costs and quality and a minimum of economic externalities that privatize profit and socialize costs.

For over two decades, the HIPAA law and regulations have dominated the way personal health data is used and abused to manipulate physician practice and increase costs. During these decades, digital technology has brought marvels of innovation and competition to markets as diverse as travel and publishing while healthcare technology is burning out physicians and driving patients to bankruptcy.

New Study: Medicare’s Readmission Penalties May Be Killing Patients

Jan 8, 2019• 8

By KIP SULLIVAN JD

On the morning of December 21, I opened my copy of the New York Times to find an op-ed that said almost exactly what I had said in a two-part article The Health Care Blog posted two weeks earlier. The op-ed criticized the Hospital Readmissions Reduction Program (HRRP), one of dozens of “value-based payment” programs imposed on the Medicare fee-for-service program by the Affordable Care Act. The HRRP punishes hospitals if their rate of readmissions within 30 days following discharge exceeds the national average. The subtitle of the op-ed was, “A well-intentioned program created by the Affordable Care Act may have led to patient deaths.”

The first half of the op-ed made three points: (1) The HRRP appears to have reduced readmissions by raising the rate of observation stays and visits to emergency rooms; (2) the penalties imposed by the Centers for Medicare and Medicaid Services (CMS) for “excessive readmissions” have fallen disproportionately on “safety net hospitals with limited resources”; and (3) “there is growing evidence that … death rates may be rising.”

That’s exactly what I said in articles published here on December 6 and December 7. In Part I, I described the cavalier manner in which the Medicare Payment Advisory Committee (MedPAC) endorsed the HRRP in its June 2007 report to Congress. In Part II, I criticized the methodology MedPAC used to defend the HRRP in its June 2018 report to Congress, and I compared that report to an excellent study of the HRRP published in JAMA Cardiology by Ankur Gupta et al. which suggested the HRRP is raising mortality rates. In its June 2018 report, MedPAC had claimed the HRRP has reduced the rate at which patients targeted by the HRRP were readmitted within 30 days after discharge without increasing mortality. Gupta et al., on the other hand, found that for one group of targeted patients – those with congestive heart failure (CHF) – mortality went up as 30-day readmissions went down.

The Importance of Patient Engagement in Post-Acute Care

Dec 19, 2018• 5

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.

Hoarding Patient Data is a Lousy Business Strategy: 7 Reasons Why

Oct 17, 2018• 18

By VINCE KURAITIS & LESLIE KELLY HALL

Among many healthcare providers, it’s been long-standing conventional wisdom (CW) that hoarding patient data is an effective business strategy to lock-in patients — “He who holds the data, wins”. However…we’ve never seen any evidence that this actually works…have you?

We’re here to challenge CW. In this article we’ll explore the rationale of “hoarding as business strategy”, review evidence suggesting it’s still prevalent, and suggest 7 reasons why we believe it’s a lousy business strategy:

Data Hoarding Doesn’t Work — It Doesn’t Lock-In Patients or Build Affinity
Convenience is King in Patient Selection of Providers
Loyalty is Declining, Shopping is Increasing
Providers Have a Decreasingly Small “Share” of Patient Data
Providers Don’t Want to Become a Lightning Rod in the “Techlash” Backlash
Hoarding Works Against Public Policy and the Law
Providers, Don’t Fly Blind with Value-Based Care

Background

In the video below, Dr. Harlan Krumholz of Yale University School of Medicine capsulizes the rationale of hoarding as business strategy.

We encourage you to take a minute to listen to Dr. Krumholz, but if you’re in a hurry we’ve abstracted the most relevant portions of his comments:

“The leader of a very major healthcare system said this to me confidentially on the phone… ‘why would we want to make it easy for people to get their health data…we want to keep the patients with us so why wouldn’t we want to make it just a little more difficult for them to leave.’ …I couldn’t believe it a physician health care provider professional explaining to me the philosophy of that health system.”

Ensuring that the 21st Century Cures Act Health IT Provisions Promotes Interoperability and Data Exchange

Oct 16, 2018• 4

By KENNETH D. MANDL, MD; DAN GOTTLIEB MPA;
JOSH C. MANDEL, MD

The opportunity has never been greater to, at long last, develop a flourishing health information economy based on apps which have full access to health system data–for both patients and populations–and liquid data that travels to where it is needed for care, management and population and public health. A provision in the 21st Century Cures Act could transform how patients and providers use health information technology. The 2016 law requires that certified health information technology products have an application programming interface (API) that allows health information to be accessed, exchanged, and used “without special effort” and that provides “access to all data elements of a patient’s electronic health record to the extent permissible under applicable privacy laws.”

After nearly two years of regulatory work, an important rule on this issue is now pending at the Office of Management and Budget (OMB), typically a late stop before a proposed rule is issued for public comment. It is our hope that this rule will contain provisions to create capabilities for patients to obtain complete copies of their EHR data and for providers and patients to easily integrate apps (web, iOS and Android) with EHRs and other clinical systems.

Modern software systems use APIs to interact with each other and exchange data. APIs are fundamental to software made familiar to all consumers by Google, Apple, Microsoft, Facebook, and Amazon. APIs could also offer turnkey access to population health data in a standard format, and interoperable approaches to exchange and aggregate data across sites of care.

Aetion raises $36m, Carolyn Magill interview

Apr 11, 2018

BY MATTHEW HOLT

It’s not every day that an analytics firm focusing on improving the efficacy and value of drugs has a big raise in the health tech world–especially one I don’t know much about. This morning Aetion raised $36m to add onto $11m they raised last year. Their new round is led by famed venture firm NEA and includes Amgen Ventures. I spoke to CEO and part-time extreme skier Carolyn Magill to find out what Aetion does and why big pharma and major payers need their help in the brave new world of value-based care.

CMS Quietly Launches an Offensive Against Direct Primary Care

Feb 19, 2018• 14

By NIRAN AL-AGBA, MD

Our healthcare system is self-destructing, a fact made more obvious every single day. A few years ago, a number of brave physicians who were fed up with administrative burden, burnout, and obstacles to providing care for patients started a movement –known as Direct Primary Care (DPC.) This is an innovative practice model where the payment arrangement is directly between a patient and their physician, leaving third parties, such as insurance or government agencies, completely out of the equation.

The rapidly growing number of DPC physicians have organized into a group called the DPC Coalition (DPCC); suddenly, the Centers for Medicare and Medicaid (CMS) is paying attention. As of February 2018, there are 770 DPC practices across the United States with new clinics opening each week as brave physicians leave the “system” behind, never looking back. Breaking free from the chains of insurance and government, this group is restoring the practice of medicine to its core, a relationship between a physician and their patient.

CMS understands there is a problem with the way Medicare services are being delivered to tax payers; it turns out their idyllic version of “high quality” care is not as affordable as they predicted. All evidence indicates the DPC model is not only capable of generating significant cost reduction, but also saving the federal government billions if administered on a large-enough scale. As fewer physicians accept Medicare and convert to DPC practices, CMS wants a piece of the pie.

On Data and Informatics For Value-Based Healthcare

Feb 15, 2018• 3

By SALLY LEWIS, MD

Introduction

Value-based healthcare is gaining popularity as an approach to increase sustainability in healthcare. It has its critics, possibly because its roots are in a health system where part of the drive for a hospital to improve outcomes is to increase market share by being the best at what you do. This is not really a solution for improving population health and does not translate well to publicly-funded healthcare systems such as the NHS. However, when we put aside dogma about how we would wish to fund healthcare, value-based healthcare provides us with a very useful set of tools with which to tackle some of the fundamental problems of sustainability in delivering high quality care.

What is value?

Defined by Professor Michael Porter at Harvard Business School, value is defined as a function of outcomes and costs. Therefore to achieve high value we must deliver the best possible outcomes in the most efficient way, outcomes which matter from the perspective of the individual receiving healthcare and not provider process measures or targets. Sir Muir Gray expands on the idea of technical value (outcomes/costs) to specifically describe ‘personal value’ and ‘allocative value’, encouraging us to focus also on shared decision making, individual preferences for care and ensuring that resources are allocated for maximum value.
This article seeks to demonstrate that the role of data and informatics in supporting value-based care goes much further than the collection and remote analysis of big datasets – in fact, the true benefit sits much closer to the interaction between clinician and patient.

Bigger is Not Always Better: How Consolidation in Health Care Hurts Patients

Jan 30, 2018• 2

By TIMOTHY HOFF

The recent news that U.S. retail giant CVS Health will purchase insurance giant Aetna, in part to gain millions of new customers for its prescription drug and primary care businesses, is another ominous sign for patients. Patients should worry about all the continued consolidation in the health care industry, whether it is Walgreens buying Rite-Aid to increase their pharmacy clout; Anthem’s ill-fated attempt to purchase Cigna to become an insurance monopoly; or hospital systems like Partners Healthcare in Boston trying to buy the hospitals and physician networks in and around its service area to control patient flow and increase market share. Consolidation often limits competition, and when that happens in market-based systems especially the result, says good research, is often that the cost of health care goes up. This does not benefit patients, who increasingly are paying more out of pocket for their insurance and for the services they receive from doctors, hospitals, labs, and drug companies.

The Affordable Care Act did little to encourage greater competition in the health care marketplace. That was probably by design, since those creating the legislation held an implicit assumption that the bigger players in each of the different industry areas like insurance, pharmacy, and hospital care could deliver given the size of the insurance expansion the ACA would promote. As we see from the existing premium inflation on the exchanges across the country and with prescription drugs, and the continued long delays in people’s ability to access care, this assumption was not accurate. To the contrary, the ACA’s focus on new and unproven structures like accountable care organizations; new payment models that reward scale and resource investment in things like information technology; and rewarding those organizations that have the most comprehensive performance measurement infrastructures has encouraged the kind of profit-oriented consolidation in the industry that does less to improve the overall system. Also, given the increased squeeze by payers like Medicare on payments to hospitals, for example, mergers and acquisitions are a natural yet dysfunctional corporate response to higher levels of uncertainty in the external health care environment.