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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

Dec 7, 2018• 4

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.

Health in 2 Point 00, Episode 61

Dec 7, 2018

On Episode 61 of Health in 2 Point 00, Jess and I are still in Tokyo—but this time we’re reporting from a famous whiskey bar. In this episode, Jess asks me about the most important takeaways from Health 2.0 Asia-Japan and the growing health tech market there. We also have two special guest stars today: Yuuri Ueda, the director of Health 2.0 Asia-Japan, tells us how loosening government regulations are opening up opportunities for more and more startups to break into telemedicine, and Fred Trotter explains how Japanese startups can learn from the U.S. in terms of data security and privacy. All this in (exactly) two minutes.

There’s so much more from Health 2.0 Asia-Japan that you all need to see, so keep an eye out on THCB for my three-point takeaway from the conference and be sure to watch Jess’s WTF Health interviews to hear from amazing people in the Asian health tech community —Matthew Holt.

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

Dec 6, 2018• 3

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.
Continue reading…

Iowa Race Questions Logic of Significance of Health Policy Debate

Dec 5, 2018

Joe Molloy, health policy, Congressional gridlock

By JOE MOLLOY

According to the Democrats, their success across the country in the midterm elections has largely been due to the party running on healthcare. Indeed, surveys such as the one conducted by Health Research Incorporated indicated that health was the number one concern for voters during the midterms. In the three states where Medicaid expansion was on the ballot, voters were in favor of it. We’ve been wondering about that, so we took a look at how Iowa voted.

It’s one thing for voters to support healthcare on its own. It’s another for an issue to outweigh all others. Did healthcare really beat every other concern a voter thinks about when picking a candidate during the midterms?

Congressional and Statewide Races

Democrats took 3 of the Iowa’s 4 seats, unseating 2 Republican incumbents. They had a sizeable majority of the votes cast, so things looked good for the Democrats. If the theory holds up, the focus the Democrats kept on healthcare throughout the race would pay off. And it would seem it worked, right?

There’s a big problem here. If Democrats had made gains in Iowa because of healthcare issues, we should expect them to have a pretty resounding victory in the gubernatorial race and in the statehouse.

Integrating in Health Care: 6 Tools for Working Across Boundaries

Dec 4, 2018• 4

By REBECCA FOGG

Today’s health care providers face the formidable challenge of delivering better, more affordable and more convenient care in the face of spiraling care costs and an epidemic of chronic disease. But the most innovative among them are making encouraging progress by “integrating”—which in this context means working across traditional boundaries between patients and clinicians, health care specialties, care sites and sectors.

The impulse to do so is shrewd, according to our innovation research in sectors from computer manufacturing to education. We’ve found that when a product isn’t yet good enough to address the needs of a particular customer segment, a company must control the entire product design and production process in order to improve it. This is necessary because in a “not-good-enough” product, unpredictable and complex interdependencies exist between components, so each component’s design depends on that of all the others.

Given this, managers responsible for the individual components must collaborate—or integrate—in order to align components’ design and assembly toward optimal performance. IBM employed an integrated strategy to improve performance of its early mainframe computers, and this enabled the firm to dominate the early computer industry when mainframes weren’t yet meeting customers’ needs.

In health care delivery, such integration is analogous to, but something more than, coordinated care. It means assembling and aligning resources and processes to deliver the right care, in the right place, at the right time. This type of integration is a core aspiration of innovative providers leading hot-spotting and aging-in-place programs, capitated primary care practices, initiatives addressing health-related social needs, and other care models that depart from America’s traditional, episodic, acute-care model. How are they tackling it? They’re leveraging very specific tools to facilitate work across boundaries. Here are six of the most common we uncovered in our research:

Health in 2 Point 00, Episode 60

Dec 4, 2018• 1

Today on Health in 2 Point 00, Jess and I report from a hedgehog cafe in Tokyo. In this episode, Jess asks me about Bright Health’s $200 million raise and the significance of Amazon’s new EMR product. We also talk about Health 2.0 Asia-Japan, which is happening right now (December 4-5) in Tokyo, showing us the health care market outside of the U.S. Look forward to hearing from some great speakers at the conference, including John Bass from Hashed Health on blockchain, Fred Trotter on security, David Ewing Duncan on the new wellness and personalized medicine, and Adam Pellegrini from Fitbit. And, of course, Jess will be interviewing just about everyone—including a hedgehog—about innovation for WTF Health —Matthew Holt

The Reality of Bush I on Health Care and Its Lessons for Today

Dec 3, 2018• 2

By MICHAEL L. MILLENSON

Former President George H.W. Bush may have been every inch the caring individual portrayed in the eulogies of those who knew him, but when it came to health care reform, two words characterized his attitude: Don’t care.

However, compared to Congressional Republicans, Bush was a profile in conservative courage – a lesson with unfortunate parallels to now.

I covered health policy as a reporter for the Chicago Tribune during the Bush years. One strong memory, confirmed by checking original sources, was the presidential debate on Sept. 25, 1988 between Bush and his Democratic challenger, Massachusetts Gov. Michael Dukakis. When Bush was asked what he’d do for the 37 million people without health insurance – about one in seven Americans – he answered that he would “permit people to buy into Medicaid.”

I remember turning from the TV to my wife and saying, “I have no idea what he’s talking about.” Neither, apparently, did anyone else. A Washington Post story that followed, headlined, “Bush’s Mysterious Medicaid Plan” noted that seeking details from the Bush campaign yielded “answers [that] are contradictory.” The story added that “Bush had never publicly mentioned the idea” until the debate.

Why Narratives Do (and Should) Matter in Bioethics

Dec 1, 2018

By FRANK PASQUALE, JD

There is a fascinating recent decision from the Indian Supreme Court on the Shanbaug case, regarding a woman who has been in a persistent vegetative state (PVS) for over 37 years. A petitioner who had written a book on Shanbaug (Pinky Viranai) argued for a withdrawal of life support. Shanbaug had no family to intervene, but hospital staff resisted, and the Court ultimately sid ed with them. While unflinchingly examining the dehumanizing aspects of PVS, the Court offers a remarkable affirmation of the good will of the staff who have taken care of Shanbaug:

[I]t is evident that the KEM Hospital staff right from the Dean, including the present Dean Dr. Sanjay Oak and down to the staff nurses and para-medical staff have been looking after Aruna for 38 years day and night. What they have done is simply marvelous. They feed Aruna, wash her, bathe her, cut her nails, and generally take care of her, and they have been doing this not on a few occasions but day and night, year after year. The whole country must learn the meaning of dedication and sacrifice from the KEM hospital staff. In 38 years Aruna has not developed one bed sore. It is thus obvious that the KEM hospital staff has developed an emotional bonding and attachment to Aruna Shanbaug, and in a sense they are her real family today.

After a scholarly survey of many countries and U.S. states’ laws on withdrawal of life support, the Court concludes:

A decision has to be taken to discontinue life support either by the parents or the spouse or other close relatives, or in the absence of any of them, such a decision can be taken even by a person or a body of persons acting as a next friend. It can also be taken by the doctors attending the patient. However, the decision should be taken bona fide in the best interest of the patient. . . .Continue reading…

Let Them Depend on Charity

Dec 1, 2018

By MERRILL GOOZNER

Conservative economists writing in today’s Wall Street Journal dismiss the notion that the cost of providing medical care for the uninsured is eventually shifted onto those already insured. Citing an Urban Institute study that appeared in 2008 in Health Affairs, they claim the total cost shift is 1.7 percent at most, or $80 a year for the average plan. They also dismiss as flawed a Families USA study that found there was a significant rise in private insurance premiums to cover the cost of the uninsured.

How did the Democratic-controlled Congress that passed health care reform go wrong by accepting this premise?

Congress ignored the $40 billion to $50 billion that is spent annually by charitable organizations and federal, state and local governments to reimburse doctors and hospitals for the cost of caring for the uninsured. These payments, which amount to approximately three-fourths of the cost of such care, mitigate the extent of cost shifting and reduce the magnitude of the hidden tax on private insurance.

A few paragraphs later, they attack the health care reform law for relying on Medicaid to cover about half the uninsured who will receive coverage under the act:

Medicaid payments to doctors and hospitals are so low that the program creates a cost shift of its own. In fact, a long line of academic research shows that low rates of Medicaid reimbursement translate into higher prices for the privately insured.

So patients who pay nothing or almost nothing do not shift costs because the providers — doctors and hospitals, primarily — get mostly reimbursed for that care by charities and the government. Yet discounted payments through Medicaid are made whole by cost shifting to private plans.Continue reading…

It’s Time to Tango: Impatient With Progress on Patient-Physician Partnerships

Dec 1, 2018

By JESSIE GRUMAN, PHD

The other day I came across this photo of a couple clasping each other in a dramatic tango on the cover of an old medical journal—a special issue from 1999 that was focused entirely on doctor-patient partnerships. The tone and subjects of the articles, letters and editorials were identical to those written today on the topic: “it’s time for the paternalism of the relationship between doctors and patients to be transformed into a partnership;” “there are benefits to this change and dangers to maintaining the status quo;” “some doctors and patients resist the change and some embrace it: why?”

Two questions struck me as I impatiently scanned the articles from 12 years ago: First, why are these articles about doctor-patient partnerships still so relevant? And second, why did the editor choose this cover image?

I’ve been mulling over these questions for a couple days and I think answer to the second question sheds light on the first. Here are some thoughts about the relationship between patients and doctors (and nurse practitioners and other clinicians) evoked by that image of the two elegant people dancing together:

It takes two to tango. Ever seen one guy doing the tango? Nope. Whatever he’s doing out there on the dance floor, that’s not tango. Without both dancers, there is no tango. The reason my doctor and I come together is our shared purpose of curing my illness or easing my pain. We bring different skills, perspectives and needs to this interaction. When in a partnership, I describe my symptoms and recount my history. I talk about my values and priorities. I say what I am able and willing to do for myself and what I am not. My doctor has knowledge about my disease and experience treating it in people like me; she explains risks and trade-offs of different approaches and tailors her use of drugs, devices and procedures to meet my needs and my preferences. Both of us recognize that without the active commitment of the other we can’t reach our shared goal: to help me live as well as I can for as long as I can.Continue reading…