By MICHEL ACCAD, MD

If concepts could get awards, then “risk factor” would surely be a Nobel prize winner.  Barely over 50 years of age, it enjoys such an important place in medicine that I suspect most of us doctors could hardly imagine practicing without it.  Yet, clearly, the concept is not native to our profession nor is its success entirely justified.

A few years ago, on the occasion of the risk factor’s fiftieth anniversary, my colleague Herb Fred and I published an editorial highlighting some of the problem with the use of this concept.  I will summarize here some of those points.

The risk factor concept was developed in the first decades of the twentieth century from within the life insurance industry as it began to systematically apply statistical methods in order to optimize actuarial predictions.  The idea was to identify which baseline characteristics held by individuals would correlate with future risk of death.

The Framingham investigators imported this idea into the public health sphere and introduced the term risk factor in the medical literature in 1961.  From then on, the concept and term have enjoyed an unmitigated success.

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By CECI CONNOLLY

Quality is all the rage in health care these days. It rolls off the presidential tongue and is at the heart of robust targets set by  Health and Human Services Secretary Sylvia Burwell. (No less than half of all Medicare payments to be quality based by the end of 2018!)

“We’re moving Medicare toward a payment model that rewards quality of care instead of quantity of care,” President Obama declared at a March 2015 summit dedicated to alternative payment models that move away from volume-based, fee-for-service payment

Industry is on the rhetorical bandwagon too. A quick search for the word quality on THCB turns up 277 entries – including “Zen and the Quest for Quality,” “An F for Quality” and the very earliest entry dated Aug. 18, 2003, “Performance-based pay in health care?”

Don’t get me wrong.  We at the Alliance of Community Health Plans (ACHP) were into quality way before quality was cool. (We were there at the creation of today’s HEDIS quality measures.)  So perhaps that’s why it’s a little disheartening to see policymakers slow to match the speeches  with action by fixing a glitch in the pay-for-quality movement.

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By NIRAN AL-AGBA, MD

Andy, if you want to fix primary care you must do some field research.  Come spend one day, or even a week at my office or another small primary care physicians’ office.  You need to see what we do on a daily basis and actually understand the view from a small practice perspective. This knowledge deficit is at the core of CMS’s problem.  You cannot repair what you do not comprehend.

Once you understand what we are capable of doing, how we do it, and how it actually SAVES money in the long run, while still providing high quality, then you are ready to tackle Focusing on Primary Care for Better Health.  The bottom line:  you must pay us more for what we are doing if you want to increase our overhead expenses.  Tasking us with additional administrative burden in order to earn extra money is not actually paying us any more for our work.  We would be working harder, not smarter.  Do you understand that?

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By ASHISH JHA, MD

An expert panel convened by the World Health Organization just declared that there is no scientific basis for canceling, postponing or moving the 28th Summer Olympics in Rio de Janeiro in August or the Paralympics in September because of the Zika outbreak. While many of us experts have expressed concerns about how the WHO handled Ebola and other outbreaks, this time the WHO got it right.

There are ample reasons for alarm: The Zika virus continues to spread in Brazil. Zika infection during pregnancy can have devastating effects on developing fetuses, leading to severe brain damage. The risk is so substantial that the WHO has called the Zika outbreak and its effects on pregnant women a public health emergency of international concern. The Centers for Disease Control and Prevention advises pregnant women to avoid traveling to Zika-affected areas if possible.

No wonder, then, that more than 200 medical ethicists and other experts penned an open letter to the WHO, calling for the Olympics to be moved or delayed. They contend that approximately 500,000 people flying into Rio to participate in or watch the Olympic Games would accelerate the spread of the disease as these individuals returned home, leading to a worldwide Zika outbreak.

These arguments seem compelling on the surface, but they don’t stand up to scrutiny.

First, several new studies estimate an exceedingly low risk of travelers getting Zika. One study suggests that there may be as few as 15 new cases as a result of the Games. And because most people infected with Zika suffer only mild symptoms (the real risk is to pregnant women and their babies), these few infections are unlikely to pose a substantial health threat. August and September are cool months in Brazil, when mosquitoes are far less active. Coupled with efforts to keep mosquitoes under control around Olympic venues, that should mean relatively few new infections.

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By ANDY SLAVITT

In the United States, we have historically invested far more in treating sickness than we do in maintaining health. The result of this imbalance is not only poorer health, but more money spent in institutions, hospitals, and nursing homes.

The road to a better health care system means correcting this imbalance. We should reinvest in what we value — primary care — as a practice, as a profession, and as an abundant resource for patients. In recent years, we have begun taking a number of meaningful steps to begin this reinvestment process. Today, we are proposing significant actions to improve how we pay primary care physicians, mental health specialists, geriatricians, and other clinicians. By better valuing primary care and care coordination, we help beneficiaries access the services they need to stay well. In addition to keeping people healthy, health care costs are lower when people have a primary care provider and team of doctors and clinicians overseeing and coordinating their care.

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By JEANNE PINDER

Summary: Watching cash prices in health care, as we have for the past five years, we have noticed a few trends. Here’s one: cash prices vary across a fairly narrow band, in most cases, for most things. Another: More and more providers are quickly able to quote cash prices than were able to do so when we started doing this in 2011. Yet another thing: Prices charged by providers to insurers and others can vary a lot, and prices paid by insurers to providers can also vary a lot. And finally: the intermediation of the insurance system (a third-party payer) can really affect what you’re charged and what you’ll pay.

Some of our observations come from a recent exercise: updating some of our Texas data. We update annually, though sometimes it slips to 1.5 years.

In truth, quite often the prices do not change all that much. Unless they do.

Do insured prices change more than cash ones?

When the prices do change, it’s sometimes the result of the current wave of mergers and acquisitions in health care.

Here’s one story about that and a passage from The New York Times:

“Imagine you’re a Medicare patient, and you go to your doctor for an ultrasound of your heart one month. Medicare pays your doctor’s office $189, and you pay about 20 percent of that bill as a co-payment. Then, the next month, your doctor’s practice has been bought by the local hospital. You go to the same building and get the same test from the same doctor, but suddenly the price has shot up to  $453, as has your share of the bill.”

Here’s a clip from  a Stat  News (Boston Globe) story about that: “The cost of visiting the doctor is climbing as hospitals scoop up a growing number of physicians’ groups, according to a Harvard Medical School study.”

Here’s an Association of Health Care Journalists overview: WSB-Atlanta recently explored what happens when hospitals buy physician practices, which has been happening all over the Atlanta area. Prices for patients go up. The same physicians – in the same offices, with the same treatments – start charging more.”

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By JOHN HALAMKA, MD

Some have suggested that my comments over the past few months about the Meaningful Use program, MACRA/MIPS, and Certification imply that we should just give up – throw out the baby with the bath water.

That’s not what I’ve written.

Here’s a clarification.

I believe MACRA/MIPS is the right trajectory – create a set of desirable policy outcomes, then enable clinicians to choose technology, quality measures, and process improvements that are relevant to their practice.

Although the current MACRA formula is overly complex, it’s the right idea and I’m confident that CMS will revise the notice of proposed rulemaking appropriately.   My metric for MACRA’s success is simple – can a clinician keep three goals in mind while seeing a patient and be rewarded if successful i.e.:

1. Ensure care is delivered in the most appropriate location in the community (urgent care, home care, rural hospital)

2. Focus on wellness/prevention

3. Avoid redundant and unnecessary testing, medications, and procedures

My issue is that MACRA currently “inherits” the flawed 2015 Certification Rule that is a kitchen sink of immature standards and a black hole for developers.   Overly zealous regulatory ambition resulted in a Rule that has basically stopped industry innovation for 24-36 months since it has listed every use case for every purpose including those unrelated to Meaningful Use and MACRA.

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By PAUL TAYLOR, MD

As a practicing internist, I have followed the gamut of the sturm and drang surrounding interoperability, and have experienced its pros and cons first hand.

What’s important now is that interoperability must evolve into population health management and value-based care use cases to match where healthcare delivery and payment is quickly going. Along with the approaching permanence of alternative payment models, population-based payments, either condition-specific or comprehensive, are on the ONC/CMS roadmap.

The FHIR API can can advance how the healthcare industry exchanges data, and not just for EMRs. All healthcare information technology products—from lab systems to HIEs, and even population health management tools—will have the opportunity to leverage the new framework.

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By JOHN HALAMKA, MD

Boston Physician Atul Gawande wrote The Checklist Manifesto in 2009  stressing that medicine should adopt “pilot’s checklists” to ensure that operating room teams are “ready for takeoff” before a scalpel is ever opened.

Here’s the “Time Out” done among all OR team members before a case beings – it includes a list of staff participating in the timeout, the agreed upon procedure, the verification of consent, appropriately marked operative site, patient identity verification, and best practices for prophylaxis.

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