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Above the Fold
Protecting the Health of Americans by Improving the Use of Antibiotics
Few appreciate the threat of antibiotic resistance to human medicine more than readers of this blog. You know antibiotics as lifesaving “miracle” drugs that treat sepsis, save victims of burns and trauma, and are crucial to survival of patients receiving transplants and cancer treatment. At the same time, you understand the devastating consequences when these drugs don’t work anymore—when infections become resistant.
The overuse of antibiotics breeds antibiotic-resistant infections that threaten patients, hospitals, and our entire health care system. Resistant infections mean more and longer hospitalizations, increased hospital costs, and higher mortality. As clinicians, it is our job to help our colleagues in the medical community and the American public better understand the risk posed by inappropriate use of antibiotics. Patients and the community benefit from more appropriate antibiotic use, which reduces risks for the individual patient as well as the entire community.
A new, first-of-its-kind analysis of antibiotic use in US doctor’s offices and emergency departments, published in the Journal of the American Medical Association (JAMA), highlights how common inappropriate antibiotic prescribing is. CDC, in collaboration with The PEW Charitable Trusts and other public health and medical experts, found at least a third of antibiotics are given when the patient does not need them. This overuse, largely due to overprescribing for relatively minor illnesses including common colds, sore throats, and ear infections – for which antibiotics are not effective – amounts to 47 million excess antibiotic prescriptions each year.
Fact Checking the Health Reform Debate
Opinions about the U.S. health system vary widely based largely on our individual experiences as users from time to time. And most Americans don’t think of it as a system at all. Rather, it’s a collection of doctors, hospitals, insurers, drug and device manufacturers and others that operate in a complicated, disconnected, expensive industry that’s increasingly difficult to navigate and afford.
Little wonder that opinions about health reform and the Affordable Care Act divide our nation: half see it as over-reach by the federal government that threatens a system best left alone, and half see it as a remedy for systemic flaws. Both argue their positions fervently, and neither is inclined to consider the view of the other. And in both camps, there are widely held misconceptions that run counter to what’s actually known.
For those who oppose health reform and the ACA and are predisposed toward its undoing, the biggest misconceptions are…Continue reading…
ACO 552: The Advanced Class
Lisa Bari, a Master of Public Health candidate at Harvard, attempts to take me to ACO school in her response to a piece I wrote. I welcome the discussion. Game on!
Lisa’s initial point, and the one she ends on, seems to say my argument falls apart because I somehow don’t understand the difference between a commercial ACO and a Medicare ACO. I beg to differ. She states that CMS cannot be held responsible for a commercial non-governmental agreement between a private insurer and a group of health care providers.
I guess you do need to go to Harvard to decipher this stuff. Is the implication that the only ACO model the architect of the ACOs are responsible for is the initial Pioneer model? It makes no sense. To recap: CMS was instructed to create ACO’s. There are 2 programs to do this. The Pioneer model, and Medicare shared savings program (MSSP). As I understand it, the large regional ACO next to me is set up as part of the MSSP. Someone makes a payment to these ACOs when there are cost savings, right? By the end of her first paragraph, one almost has the impression that ACO’s are a renegade program that emerged from thin air between insurers and health care providers. Yes, a commercial insurer decides to make an agreement with an ACO and they set a $4 rate. I guess I am to assume if the govt/CMS did it directly it would be much more. And I do realize that ACO’s are for PCPs, and not designed for specialists. The only reason I think I have any ‘contract’ at all is because I have a PCP I work with. My point with regards to the ACO payment was that I have no clue where that $4 is going – but that compensation for care coordination at that level is inadequate, and would require quite the mix of healthy:sick to make that work. Is there another number you can give me so I can take an opinion on the matter – or should I just continue to trust our fearless leaders?
ACO 101: Koka Completely Misses The Mark on Medicare ACOs
Recently, Anish Koka, MD, a Cardiologist from Pennsylvania, posted his anti-Accountable Care Organization (ACO) manifesto here on The Health Care Blog. Koka argues that ACOs don’t work and are doomed to fail because they were designed by non-practicing physician policymakers and academics in ivory towers. He appears to be basing his judgment on a commercial ACO contract that only pays him $4 per month extra for care coordination and requires that he meet specific quality measures. He is also conflating his experience in a commercial ACO with Medicare ACOs, and interprets the initial results of one Medicare ACO program to mean that all ACOs are a failure. Finally, he relays an anecdote of caring for one of his patients, Mrs. K, a patient with chronic illness who doesn’t want to take her medication.
In his post, Dr. Koka calls out “well-meaning, hard-working folks that own a Harvard Crimson sweater…[whose] intent is to fundamentally change how health care is provided.” As luck would have it, I do own a Harvard Crimson sweater, and I’d like to respond.
The Affordable Care Act (ACA) of 2010 gave the Centers for Medicare & Medicaid Services (CMS) the authority to create ACOs in two forms. One, the Medicare Shared Savings Program (MSSP), is a large program that does exactly what its name says: it allows physicians and care organizations to share savings with CMS based on their previously-expected health care spending. The other was the Pioneer ACO model run by the CMS Innovation Center (CMMI). This five-year experiment was intended to test if physicians and care organizations could bear both upside and downside risk while still delivering high quality care. The Pioneer ACO program has ended as planned, and CMMI has incorporated its findings from the model thus far into the Next Generation ACO model. Any other ACO program is a non-governmental agreement between a private insurer and group of health care providers that is neither designed nor controlled by CMS or any other part of the government.
Dr. Koka’s main point of criticism appears to be with the terms of a commercial, non-Medicare, non government ACO with which he contracts. Commercial ACOs tend to have stricter, less-generous terms for physicians; a 2014 study in the American Journal of Managed Care found that commercial ACO contracts were more likely to include both downside risk and upfront payments. CMS cannot be held responsible for the terms of an ACO contract between Dr. Koka and a private insurer, but I’ll leave that aside for now.
Dr. Koka cites a recent Harvard study on the first year and a half of results from the MSSP as evidence for the failure of ACOs. This study looked at Medicare claims data for two cohorts of practices–one starting mid-year in 2012 and one starting on January 1, 2013, through the end of 2013. In short, the mid-year 2012 cohort delivered a small amount of savings per beneficiary, and the 2013 cohort achieved a negligible amount of savings. Additionally, some quality measures showed improved performance, while others were the same as the control group. I do not interpret these results as a “failure” at all. These are early results from a generous program that is easing physicians and care organizations into accountable care by limiting the amount of risk that they must take on at first. Equivalent or better-quality care was delivered, along with small savings.
Leavitt Partners, a health care consulting firm, has been tracking and reporting on Medicare and commercial ACOs since 2010. In their recent report on the early takeaways from the MSSP results, they highlighted that physician group-led ACOs tended to do a better job than hospital-only ACOs, and that ACOs residing in high-cost markets were more likely to generate shared savings. Based on all of these findings, I cannot agree with Dr. Koka that Medicare ACOs are a failure, and I certainly cannot extrapolate from commercial ACOs to Medicare.
The evidence is widespread and irrefutable that our current payment and delivery system has resulted in the highest health care costs in the world, along with some of the lowest-quality care. We simply cannot continue to pay doctors and hospitals on an unrestricted fee-for-service basis. ACOs are the beginning of a massive shift in how we deliver, pay for, and measure health care in order to address these cost and quality issues.
Dr. Koka also fails to acknowledge a critical point about ACOs: they are generally designed with the Primary Care Physician (PCP) as the central care coordinator versus a specialist. PCPs are best situated to coordinate care for their patients and manage preventive care and population health measures. A more expensive specialist like Dr. Koka should not be the physician responsible for coordinating patient care in an ACO–it makes little sense. One reference point comes from The Accountable Care Guide for Cardiologists from the Toward Accountable Care Consortium. They highlight PCPs and good teamwork as critical central elements in any ACO. [7]
He also does not acknowledge that it takes time to get accountable care and care coordination right. A PCP or primary care organization is not going to have the tools they need or the right contracts in place with specialists and hospitals on day one. The processes and technology for effectively managing an ACO take time. The initial results from the MSSP prove this out.
Let’s say we assume for the sake of argument that Dr. Koka is right; that ACOs don’t work, and they are a colossal waste of time. Even then, his proposed solution is more than a bit ham-handed. There is no agreement among either the American public or the health care system that we should directly ration care. I suggest that we start by making PCPs the gatekeepers to specialists like Dr. Koka rather than asking him to spend many hours coaxing a patient to take her medications. Undoubtedly, this is what his commercial ACO intended. We need to do a better job of delivering the right care at the right time, from the right physician, nurse, or other provider–yes, this is care coordination.
And if all else fails, well, there is one easy, proven way to slow the growth of health care costs: making a blunt cut in reimbursement rates to providers, as we saw in the Budget Control Act of 2011. I am almost certain that Dr. Koka would not welcome another cut like this.
If Dr. Koka would like to avoid this last-ditch option, perhaps it is time to partner with primary care organizations and see how he can help them to be a successful ACO…and allow Mrs. K’s PCP and case manager or health coach to field those Saturday calls.
As avid followers of federal health policy will know, this week CMS released the notice of proposed rulemaking for the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The MACRA encompasses a massive shift in Medicare physician payment. The bad news for Dr. Koka? Accountable, value-based care is not going away anytime soon. The good news is that the proposed payment and delivery system models include more flexibility for physicians and will better reward them for high quality care.
In my opinion, the best news is that the MACRA provides a clear path for our public health care system to move away from fee-for-service once and for all. I hope that Dr. Koka can reconcile himself with a world where care providers, in partnership with patients, are asked to be more accountable for the high cost of health care. At a minimum, I hope that the difference between commercial and Medicare ACOs is now clear.
Lisa Bari is a Master of Public Health candidate at the Harvard T.H. Chan School of Public Health, and previously worked in health IT. She loves primary care health policy, health care payment reform, interoperability, and health data APIs. She never thought she’d own a Harvard sweatshirt. You can find her on Twitter @lisabari.
ACO 101: Koka Completely Misses The Mark on Medicare ACOs
Recently, Anish Koka, MD, a Cardiologist from Pennsylvania, posted his anti-Accountable Care Organization (ACO) manifesto here on The Health Care Blog. [1] Koka argues that ACOs don’t work and are doomed to fail because they were designed by non-practicing physician policymakers and academics in ivory towers. He appears to be basing his judgment on a commercial ACO contract that only pays him $4 per month extra for care coordination and requires that he meet specific quality measures. He is also conflating his experience in a commercial ACO with Medicare ACOs, and interprets the initial results of one Medicare ACO program to mean that all ACOs are a failure. Finally, he relays an anecdote of caring for one of his patients, Mrs. K, a patient with chronic illness who doesn’t want to take her medication.
In his post, Dr. Koka calls out “well-meaning, hard-working folks that own a Harvard Crimson sweater…[whose] intent is to fundamentally change how health care is provided.” As luck would have it, I do own a Harvard Crimson sweater, and I’d like to respond.
The Affordable Care Act (ACA) of 2010 gave the Centers for Medicare & Medicaid Services (CMS) the authority to create ACOs in two forms. One, the Medicare Shared Savings Program (MSSP), is a large program that does exactly what its name says: it allows physicians and care organizations to share savings with CMS based on their previously-expected health care spending. The other was the Pioneer ACO model run by the CMS Innovation Center (CMMI). This five-year experiment was intended to test if physicians and care organizations could bear both upside and downside risk while still delivering high quality care. The Pioneer ACO program has ended as planned, and CMMI has incorporated its findings from the model thus far into the Next Generation ACO model. [2] Any other ACO program is a non-governmental agreement between a private insurer and group of health care providers that is neither designed nor controlled by CMS or any other part of the government.
Dr. Koka’s main point of criticism appears to be with the terms of a commercial, non-Medicare, non government ACO with which he contracts. Commercial ACOs tend to have stricter, less-generous terms for physicians; a 2014 study in the American Journal of Managed Care found that commercial ACO contracts were more likely to include both downside risk and upfront payments. [3] CMS cannot be held responsible for the terms of an ACO contract between Dr. Koka and a private insurer, but I’ll leave that aside for now.
Dr. Koka cites a recent Harvard study on the first year and a half of results from the MSSP as evidence for the failure of ACOs. [4] This study looked at Medicare claims data for two cohorts of practices–one starting mid-year in 2012 and one starting on January 1, 2013, through the end of 2013. In short, the mid-year 2012 cohort delivered a small amount of savings per beneficiary, and the 2013 cohort achieved a negligible amount of savings. Additionally, some quality measures showed improved performance, while others were the same as the control group. I do not interpret these results as a “failure” at all. These are early results from a generous program that is easing physicians and care organizations into accountable care by limiting the amount of risk that they must take on at first. Equivalent or better-quality care was delivered, along with small savings.
Leavitt Partners, a health care consulting firm, has been tracking and reporting on Medicare and commercial ACOs since 2010. In their recent report on the early takeaways from the MSSP results, they highlighted that physician group-led ACOs tended to do a better job than hospital-only ACOs, and that ACOs residing in high-cost markets were more likely to generate shared savings. [5] Based on all of these findings, I cannot agree with Dr. Koka that Medicare ACOs are a failure, and I certainly cannot extrapolate from commercial ACOs to Medicare.
The evidence is widespread and irrefutable that our current payment and delivery system has resulted in the highest health care costs in the world, along with some of the lowest-quality care. [6] We simply cannot continue to pay doctors and hospitals on an unrestricted fee-for-service basis. ACOs are the beginning of a massive shift in how we deliver, pay for, and measure health care in order to address these cost and quality issues.
Dr. Koka also fails to acknowledge a critical point about ACOs: they are generally designed with the Primary Care Physician (PCP) as the central care coordinator versus a specialist. PCPs are best situated to coordinate care for their patients and manage preventive care and population health measures. A more expensive specialist like Dr. Koka should not be the physician responsible for coordinating patient care in an ACO–it makes little sense. One reference point comes from The Accountable Care Guide for Cardiologists from the Toward Accountable Care Consortium. They highlight PCPs and good teamwork as critical central elements in any ACO. [7]
He also does not acknowledge that it takes time to get accountable care and care coordination right. A PCP or primary care organization is not going to have the tools they need or the right contracts in place with specialists and hospitals on day one. The processes and technology for effectively managing an ACO take time. The initial results from the MSSP prove this out.
Let’s say we assume for the sake of argument that Dr. Koka is right; that ACOs don’t work, and they are a colossal waste of time. Even then, his proposed solution is more than a bit ham-handed. There is no agreement among either the American public or the health care system that we should directly ration care. I suggest that we start by making PCPs the gatekeepers to specialists like Dr. Koka rather than asking him to spend many hours coaxing a patient to take her medications. Undoubtedly, this is what his commercial ACO intended. We need to do a better job of delivering the right care at the right time, from the right physician, nurse, or other provider–yes, this is care coordination.
And if all else fails, well, there is one easy, proven way to slow the growth of health care costs: making a blunt cut in reimbursement rates to providers, as we saw in the Budget Control Act of 2011. I am almost certain that Dr. Koka would not welcome another cut like this. [8]
If Dr. Koka would like to avoid this last-ditch option, perhaps it is time to partner with primary care organizations and see how he can help them to be a successful ACO…and allow Mrs. K’s PCP and case manager or health coach to field those Saturday calls.
As avid followers of federal health policy will know, this week CMS released the notice of proposed rulemaking for the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The MACRA encompasses a massive shift in Medicare physician payment. The bad news for Dr. Koka? Accountable, value-based care is not going away anytime soon. The good news is that the proposed payment and delivery system models include more flexibility for physicians and will better reward them for high quality care.
In my opinion, the best news is that the MACRA provides a clear path for our public health care system to move away from fee-for-service once and for all. I hope that Dr. Koka can reconcile himself with a world where care providers, in partnership with patients, are asked to be more accountable for the high cost of health care. At a minimum, I hope that the difference between commercial and Medicare ACOs is now clear.
Lisa Bari is a Master of Public Health candidate at the Harvard T.H. Chan School of Public Health, and previously worked in health IT. She loves primary care health policy, health care payment reform, interoperability, and health data APIs. She never thought she’d own a Harvard sweatshirt. You can find her on Twitter @lisabari.
1 https://thehealthcareblog.com/blog/2016/04/25/the-aco-delusion/
2 http://www.brookings.edu/~/media/research/files/papers/2015/05/12-aco-paper/impact-of-accountable-careorigins-052015.pdf
3 http://www.ajmc.com/journals/issue/2014/2014-vol20-n12/aco-contracting-with-private-and-public-payers-a-baseline-comparative-analysis
4 http://www.nejm.org/doi/pdf/10.1056/NEJMsa1600142
5 http://leavittpartners.com/wp-content/uploads/2016/04/MSSP_ACOs_takeaways_whitepaper_final.pdf
6 http://www.commonwealthfund.org/publications/press-releases/2015/oct/us-spends-more-on-health-care-than-other-nations
7 http://www.ncmedsoc.org/wp-content/uploads/2014/06/ACO-Guide_Cardiologist_052814_reduced-file.pdf
8 http://www.cbpp.org/research/how-the-across-the-board-cuts-in-the-budget-control-act-will-work
9 http://www.politico.com/tipsheets/politico-pulse/2016/04/exclusive-andy-slavitt-on-macra-214014
Measuring Hillary
Hillary Clinton is now the presumptive Democratic nominee and the odds-on favorite to be our next president.
For healthcare, that could be a very good thing, not just compared to a Trump (or Cruz) presidency but for the following reasons:
(1) Hillary knows and cares deeply about healthcare.
Even if you don’t support or like her, she’s been a tireless advocate for reform and coverage expansion for decades. She worked, for example, in the 1980s with the Children’s Defense Fund and other groups to enhance coverage for children.
As first lady, of course, Bill put her in charge, in 1991, of developing a health reform plan. Though the process had its flaws, she was steeped in the subject for over a year and learned it inside and out.
Famously, the legislation failed in 1993-94 due to staunch Republican opposition (and, yes, a bungled legislative strategy by the White House). A widespread impression still exists that Hillary slunk back from the issue after the Clinton reform failed. Not true. Continue reading…
The Angry Physician
I think I speak for most physicians when I say that we did not choose to go into medicine to shape health care policy. Medicine is a calling, and I treated it as such. I immersed myself with taking care of patients, and keeping up with the ever changing knowledge landscape that is medicine. I left the policy making to the folks I voted for the last 8 years. These were the adults, the intellectuals – they would take care of the task of taking out the bad elements of our healthcare system and leaving the good. I truly believed. I eagerly began the ehr/meaningful use saga believing this would result in better care for patients.
It took me two years to realize the meaninglessness of meaningful use. I still can’t believe how long it took me to realize that creating a workflow in my office to print out and deliver clinical summaries to patients didn’t do anything other than fill the trashbin. I still held out hope. I thought – this was a first draft, improvements would come. What came instead were positively giddy announcements of the success of the meaningful use roll out. The administration was actually doubling down. There was no acknowledgment for the mess that had been created – onward and forward on the same road we must continue to march. Except the road would no longer be paved and we would be walking uphill.
You Won’t Believe What Medicare Just Did on Patient Engagement!
Sure, I’ve always wanted to write a clickbait headline that sounds like a promo for the bastard child of Buzzfeed and the Federal Register. But, seriously: you will not believe what Medicare just did about patient engagement in a draft new rule dramatically changing how doctors are paid.
And, depending upon the reaction of the patient community, you definitely won’t believe what happens next.
Engaging Responsibly In the Health Care Debate
With no apology offered, I will be venturing into a very subjective realm, namely, a characterization of today’s healthcare dialogue and what, in my opinion, might be an improvement.
I would suggest we have fallen into the trap that was partly enhanced by email and blogs, namely, that we can say outrageous things impolitely and without consequence. With email we tend to be much blunter and impolite than we would be face to face. On blogs, we can be positively toxic. It’s like driving in a car with a tinted windshield that no one can see through. You are anonymous and therefore can act less responsibly.
Another vignette. I grew up in a very small upstate New York town where everyone knew everyone else. You used your car horn to beep “hi” or to warn, and not in anger, ever. When you waved at someone, it was with all five fingers. And so on. I think you get my point.
The healthcare debate always has stoked emotions like almost no other. It is intensely personal, and the stakes are high. We’re all involved and engaged.
As I’ve written in the past, I first earned my stripes as a lawyer representing my local Blue Cross plan in rate hearings. These rate hearings always started with “public comment.” The comment ranged from pure outrage to controlled anger to discontent coupled with suggestions. What did we pay the most attention to? Of course, the latter.
