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Sloppy Risk Adjustment and Attribution Guarantee MACRA Won’t Work

flying cadeuciiI just finished reading the 962-page MACRA rule CMS released late in April. I was prepared for the mind-numbing complexity of the document. What I was not prepared for was CMS’s glib treatment of two fundamental issues: The woeful inaccuracy of the scores CMS will use to punish and reward doctors, and the cost to doctors of participating in ACOs, “medical homes” and other “alternative payment models” (APMs)

These are not peripheral issues. If CMS dishes out financial rewards and punishments based on inaccurate data, MACRA will, at best, have no impact on cost and quality and may well have a negative effect. The second problem – the high cost of setting up and running APMs – may not be as lethal as the inaccurate-data problem, but at minimum it will reduce physician participation in APMs and, therefore, the already slim probability that APMs will reduce Medicare costs and improve quality.

In this comment and two more to come, I will review both of these problems and CMS’s what-me-worry attitude toward them. I begin with a jaw-dropping example of CMS’s reckless indifference to its inability to measure physician “merit” accurately.

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About Hastert’s “Known Acts:” The Indifference Is As Disturbing as the Crime

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This past April 8th federal prosecutors made known former Republican House Speaker, Denis Hastert, sexually molested at least four boys while employed as an Illinois high school wrestling coach beginning in the 1960s.  Prosecutors said there was “no ambiguity” about these abuses.  They were, they said, “known acts.”1 While the news was disturbing sexual and all other forms of child abuse is commonplace.  According to the Centers for Disease Control’s (CDC) Adverse Childhood Experiences (ACE) study, one in four girls and one in six boys are sexually assaulted before they reach the age of eighteen.2  It cannot be a surprise therefore that even a member of Congress molested young boys. 

Also not surprising is how frequently child abuse, if made known, is not revealed until many years later.  Rumors about Hastert’s behavior persisted for years, for example, they were floated during 2006 when Congressman Mark Foley was forced to resign for forwarding soliciting e-mails and sexually suggestive instant messages to teenaged boys.  It was not until last year Hastert’s actions nearly fifty years ago became known albeit accidentally.  What banking officials and eventually the FBI wanted to learn, pursuant to the PATRIOT Act and other federal laws, was why Hastert made multiple $50,000 bank withdrawals over two years.  Hastert initially told officials he was buying vintage cars and stocks.  He then explained he did not think banks were safe and then argued he was the victim of extortion.  None of these explanations were true.  Eventually, the FBI learned Hastert was paying a victim for his silence. 

Like Hastert, Jerry Sandusky was convicted in 2012 on 45 counts dating back to 1994.  It has recently come to light Penn State paid a settlement stemming from Sandusky’s abuse in 1971.  Predatory behavior exhibited by thousands of Catholic priests were also not made known for decades.  Jerry Savile engaged in wide spread pedophilia undeterred for over six decades including abusing boys under hospice care.  The Boy Scouts held “perversion files” for nearly a century.  Abuses at New Your City’s Horace Mann School made known a few years ago date back to the 1960s.  The Boston Globe has recently reported hundreds of children were molested over many decades at at least 67 elite private schools in New England.  USA Swimming’s “Hall of Fame” coach Rick Curl’s 1980s sexual abuse of a female teenage swimmer was, at the time, allegedly made known to his employer, the University of Maryland.  The university never reported the abuse to Maryland state officials.  Curl was not convicted until 2013. 

The Curl case is particularly noteworthy because it did earn the unprecedented attention of one member of Congress, Representative George Miller.  Mr. Miller was the former chair and then ranking minority member of the House Committee on Education and Workforce.  Mr. Miller became interested in the Curl case in part because the committee’s jurisdiction includes student safety.  Though the Committee refused Mr. Miller’s request to hold a hearing, after a lengthy investigation of USA Swimming by Mr. Miller’s staff, the Committee, under Mr. Miller’s sole signature, forwarded an 11-page letter to the FBI in July 2014 requesting the agency “fully investigate USA Swimming’s handling of both past and present cases of child sexual abuse.”  Mr. Miller’s letter stated, “it has become clear that child sexual abuse and sexual misconduct have plagued USA Swimming since its inception in 1980.”  (USA Swimming is the creation of the Congress’s Amateur Sports Act of 1978.)  The letter noted USA Swimming had banned more than 80 coaches for child abuse.  Most were not banned until after 2009 despite “the fact,” the letter stated, “that some of them have engaged in sexual abuse for decades.”  Mr. Miller argued USA Swimming’s banning of coaches was insufficient because coaches continued to coach just elsewhere.  In summary the letter stated, “the FBI’s engagement on these issues is of the utmost importance,” because, “the USA Swimming process allows predators to prey with impunity.” 

A month later the FBI responded.  In three brief paragraphs the FBI stated, “representatives recently met with USA Swimming officials and discussed applicable federal violations associated with child exploitation matters,” and “provided information to assist in USA Swimming’s effort to educate their membership regarding the sexual exploitation of children.”4  It appears the FBI took no further action.  In June 2013 Mr. Miller also requested the GAO investigate the abuse of student athletes’ participation in swim clubs.  The GAO report was not published until May 2015, or several months after Mr. Miller retired.  The GAO admitted it “did not assess the effectiveness of any of the selected athletic programs’ policies.”  The report’s conclusion simply stated the “GAO makes no recommendations in this report.”5  It’s worth noting, recently another USA Swimming Hall of Fame Coach, Joe Bernal, was banned for life for sexual misconduct.

Mr. Miller’s efforts stand out as the exception.  Over the past seven weeks, or since Hastert’s offenses were made known, the current House Speaker Paul Ryan has not issued a single press release condemning Hastert.  Senate Majority Leader Mitch McConnell has also been silent, as has Senate Democratic Leader Reid and House Minority Leader Nancy Pelosi.  As was the case during the Sandusky scandal, no Congressional hearings are planned.  Despite the fact they are from the same state and four of the last eight Illinois governors have gone to prison, President Obama as well has been silent.  When asked on April 27th, the day Hastert was sentenced, if the White House had any reaction, Press Secretary Josh Earnest stated, “I don’t have a specific response to that.  Obviously, this is part of our criminal justice system carrying out its mandate.”  When asked in May 2015 after Hastert was indicted, Earnest’s response was equally apathetic.  “Nobody” he said, “derives any pleasure” from Hastert’s “legal troubles.”6     

The failure by senior government officials to condemn Hastert is matched by the health care media and professional health associations’ failure to report the health consequences resulting from childhood sexual abuse.  These consequences are extreme.  Child abuse survivors frequently suffer lifelong, and life shortening, health effects resulting from excessive rates of alcoholism, depression and other psychiatric disorders including the severe trauma disorder, DID, or Dissociative Identity Disorder (previously known as Multiple Personality Disorder), illicit drug use, obesity, sexually transmitted diseases, cancer, heart, lung and liver disease and suicide.  Survivors can also exhibit a constellation of social problems including criminal behavior, dysfunctional parenting including inter-generational abuse, homelessness, prostitution and other at-risk sexual behavior.  Not surprisingly, one of Hastert’s victims died of AIDS in 1995.  In sentencing Hastert on April 27th, Federal District Court Judge Thomas Durkin recognized this reality when he stated, “the abuse was 40 years ago, but the damage lasts today.”  “It’s hard to look at Mr. Cross [one of Hastert’s victims], now in his late 50s, and know,” Judge Durkin stated, “that this [abuse] happened when he was 17 and he is still damaged.”  The CDC estimates the total lifetime estimated costs associated with just one year of confirmed cases of child abuse at approximately $124 billion.7

Despite well documented life-long adverse health effects, when the Chicago Tribune, The New York Times, The Washington Post and others reported Hastert’s “known acts,” one would expect these would be reported by health and health care news organizations.  They have not.  For example, Inside Health Policy, Kaiser Health News, the Morning Consult, Politico Pulse and RealClearHealth, organizations that report daily or twice daily on a wide range of health, health care and public health issues, have made no mention of the health consequences and health care costs.  During the Penn State scandal I asked a Harvard-educated editor of one of the these publications why she was not reporting on  Sandusky.  I was told his behavior was a criminal matter and unrelated to health care or public health.  To further the point, The New England Journal of Medicine, the Altarum Institute, an organization dedicated to “solving complex systems problems to improve human health,” and Health Affairs all refused over the past month to publish versions of this essay.8  Among numerous health care associations, the American Public Health Association (APHA) and the American Medical Association (AMA) have also been silent.  The APHA’s website makes no mention of Hastert and the AMA’s website still notes Hastert as the 2006 recipient of the AMA’s Nathan Davis Award for his “outstanding contributions” “to promote the art and science of medicine and the betterment of the public health.”9    

The indifference by senior federal officials and the health care industry is also the norm.  Over the past  decade Diane Champe, a childhood sexual abuse survivor, cancer survivor and beneficiary of over two decades of DID therapy, and I have worked, unsuccessfully, to interest members of Congress, Congressional committees, the White House, and numerous others in addressing child abuse, or at least discuss the issue publicly.10  I meet Diane in 2007 while doing health policy work for the then House Majority Leader, Mr. Steny Hoyer.  Diane scheduled an appointment with me to ask why the National Institutes of Mental Health (NIMH) at the National Institutes of Health (NIH) was not researching DID, a disorder that frequently afflicts victims of child abuse.  I inquired and learned NIMH was not funding DID research.  NIMH still does not fund DID research.11

In efforts to meet with members of Congress over the past decade we have either received no response or were told, for example by Representative Elijah Cummings’ office (Cummings is currently the ranking minority member of the House Oversight and Government Reform Committee), that he only meets with constituents.  We did meet with Diane’s representative, Chris Van Hollen, and his staff.  After discussing survivors’ issue over several months we failed to interest his office in any number of a wide range of inter-related issues including the need improve child abuse reporting and data collection, the need to improve related clinical research and treatment including diagnosis and treatment of DID, the need for further protections under the Americans with Disabilities Act and other legal protections for survivors.  Concerning this last issue, Hastert could not be criminally prosecuted as a child molester because the statute of limitations for this crime had expired.  Hastert’s victims could have pursued him in civil court only because Illinois has comparatively liberal “window laws.”  In many states a victim’s “window” to pursue their perpetrator in court closes quickly.  For example, in New York the window closes five years after the victim turns 18.  When the 2013 documentary, “Pursuit of Truth: Adult Survivors of Child Sexual Abuse Seeking Justice,” was released, a film specifically about the inability of survivors to seek and receive justice, we hoped it would serve to stimulate discussion.  We were wrong.  We tried to present the film to relevant Congressional committees, at White House, to Maryland State legislators and, among others, to the American Bar Association’s Commission on Domestic and Sexual Violence.  No one was interested.12  Our only success, or related success, was in attaining pro bono legal counsel from a well-established DC law firm.  Years later we learned the firm supported our efforts largely because the attorney we initially solicited was, while serving as an altar boy, molested by his priest.   

In the federal government’s sentencing recommendation, prosecutors wrote, “He [Hastert] made them feel alone, ashamed, guilty and devoid of dignity.”  “All of them carry the scars [the] defendant inflicted upon them.”  “It is profoundly sad,” prosecutors wrote, the abuse was inflicted by “a man whom they trusted and whom they revered as a mentor and coach.”  In sentencing Hastert to 15 months in prison, Judge Durkin stated, “nothing is more stunning than having the words “serial child molester” and “Speaker in the House” in the same sentence.”13  It is “profoundly sad.”  It is not “stunning.”  With one exception, the fecklessness of the Congress, the White House, the health care media and leading organizations does not disappoint.  The indifference, the ongoing neglect, the failure to even make public comment is exactly what Stanley Tucci’s “Spotlight” character, Mitchell Garabedian, meant when he stated,”if it takes a village to raise a child, it takes a village to abuse one.”  As for Diane’s work she is now dedicating all her time to opening a community center in inner-city Baltimore to provide non-clinical, social support services to adult survivors.    

Notes

1.  An overview of the Hastert case is contained in the “Government’s Position Paper as to Sentencing Factors,” at: https://assets.documentcloud.org/documents/2798113/Hastert.pdf.

2.  Information regarding the ACE study is at: http://www.cdc.gov/violenceprevention/acestudy/prevalence.html.

4.   Mr. Miller’s letter and the FBI’s one page response is at: https://cdn.swimswam.com/wp-content/uploads/2014/10/USASwimming-GMLettertoFBIandFBIResponse-1.pdf.

5.  The GAO report is at: http://www.gao.gov/products/GAO-15-418.

6.  See: https://www.whitehouse.gov/the-press-office/2016/04/27/press-briefing-press-secretary-josh-earnest-4272016 and https://www.whitehouse.gov/the-press-office/2015/05/29/press-briefing-press-secretary-josh-earnest-52915.

7.  See: http://www.cdc.gov/violenceprevention/childmaltreatment/consequences.html.

8.  Searching The New England Journal of Medicine’s website using the phrases, “child sexual abuse” and “childhood sexual abuse” yields no related research articles.   

9.  See: http://www.ama-assn.org/ama/pub/about-ama/awards/nathan-davis-awards-outstanding-government-service/past-recipients-nathan-davis-awards.page.

10.  For information concerning Diane’s work, go to: https://www.edcinstitute.org/.

11.  If you search NIH’s RePORT for “Dissociative Identity Disorder” the response is “did not match any documents.”  See:  http://www.cdc.gov/media/releases/2012/p0201_child_abuse.html and http://www.cdc.gov/violenceprevention/childmaltreatment/consequences.html.

12.  See: http://www.pursuitoftruthfilm.com/.  Lynn Rosenthal, who served up until earlier this year as  the White House Adviser on Violence Against Women, did watch the documentary with a few office colleagues but refused to present the film to a wider White House audience.   

13.  See: http://www.chicagotribune.com/news/nationworld/ct-pdf-transcript-of-sentencing-of-dennis-hastert-20160427-htmlstory.html.

Tech VC Answers ‘Will Computers Replace Doctors’ – I Mean VCs

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A constant frustration for many in healthcare is the cognitive dissonance between the elegant, highly anticipated promise of technology solutions and the messy, lived complexity of clinical practice.

In this context, I was fascinated–and feel compelled to share–this unexpectedly revealing excerpt from a recent (and, as always, captivating) a16z podcast, featuring a conversation a16z founder Marc Andreessen and board partner Balaji Srinivasan recorded at Stanford.

Following an extensive conversation about the factors associated with startup success and VC success, as well as about emerging (or re-, re-emerging) trends such as artificial intelligence (AI), an audience member asked whether AI might not select investments better than actual VCs–a VC version of the “will computers replace doctors?” gauntlet that tech VCs have thrown down before the medical establishment.

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What’s the Score?

flying cadeuciiThe Congressional Budget Office (CBO) was created in 1974. Its task is to conduct economic analysis of the budget, and, when asked by Congress, to provide fiscal estimates of the potential impact of any given legislative proposal.  This is commonly known as “scoring.”  Advocates for meaningful and important changes in American domestic policy, even those with major bipartisan and bicameral support, often find themselves running into the CBO wall.  If their legislation “scores high,” i.e: will cost public programs money, hopes of passage are quickly dashed.

The challenge is that CBO is bound by rules that don’t allow them to consider the budget in a dynamic way.  They can only look at black and white estimates rather than how particular programs might cost money but save money on the other side of the ledger. 

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Let’s Be Clear About Transparency

flying cadeuciiTransparency—or its absence—continues to fascinate healthcare analysts and healthcare economists.  A study just published in the Annals of Internal Medicine addresses the effects of public reporting of hospital mortality rates on outcomes.  Its senior author, Dr. Ashish Jha, offered his perspective on the study results and on the topic of transparency in The Health Care Blog.

According to the study investigators, mandatory public reporting of hospital mortality is not improving outcomes.  The result of their analysis surprised them because “the notion behind transparency is straightforward” and the “logic [of public reporting] is sound.”  The conclusion, therefore, is to persist in the effort, but to do it better with better metrics, better methods, and better data.  Says Dr. Jha:

So, the bottom line is this – if transparency is worth doing, why not do it right? Who knows, it might even make care better and create greater trust in the healthcare system.

Now, I have no doubt about the sincere desire of healthcare analysts to improve our lot, but I wonder if they have reflected on a certain pattern that emerges if one studies the history of our healthcare system.

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Making Transparency Work: Why We Need New Efforts to Make Data Usable

Ashish JhaGet a group of health policy experts together and you’ll find one area of near universal agreement: we need more transparency in healthcare. The notion behind transparency is straightforward; greater availability of data on provider performance helps consumers make better choices and motivates providers to improve. And there is some evidence to suggest it works.  In New York State, after cardiac surgery reporting went into effect, some of the worst performing surgeons stopped practicing or moved out of state and overall outcomes improved. But when it comes to hospital care, the impact of transparency has been less clear-cut.

In 2005, Hospital Compare, the national website run by the Centers for Medicare and Medicaid Services (CMS), started publicly reporting hospital performance on process measures – many of which were evidence based (e.g. using aspirin for acute MI patients).  By 2008, evidence showed that public reporting had dramatically increased adherence to those process measures, but its impact on patient outcomes was unknown.  A few years ago, Andrew Ryan published an excellent paper in Health Affairs examining just that, and found that more than 3 years after Hospital Compare went into effect, there had been no meaningful impact on patient outcomes.  Here’s one figure from that paper:

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The paper was widely covered in the press — many saw it as a failure of public reporting. Others wondered if it was a failure of Hospital Compare, where the data were difficult to analyze. Some critics shot back that Ryan had only examined the time period when public reporting of process measures was in effect and it would take public reporting of outcomes (i.e. mortality) to actually move the needle on lowering mortality rates. And, in 2009, CMS started doing just that – publicly reporting mortality rates for nearly every hospital in the country.  Would it work? Would it actually lead to better outcomes? We didn’t know – and decided to find out.

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Fast Medicine

Screen Shot 2016-05-31 at 9.00.10 AMA diversion into the world of high fashion in this week’s post… It’s an area that everyone who knows me would admit I know nothing about. Nevertheless, here we go…

Martin Schulte, a Partner at Oliver Wyman management consultants, recently posted a fascinating article on, of all things, fashion industry supply chain management. It contains some interesting nuggets for healthcare.

Background: before the 1980’s, couture was customized, reserved for the wealthy, and slow to diffuse into popular culture from biannual fashion shows.

Two disruptive changes shook up the fashion industry in the 1980’s and 1990’s:  The first was a move to what is called the “fast-fashion business model” where couture was “translated” from the runways and quickly mass-produced.  The second disruption was the emergence of discount realtors like H&M and Topshop, which offered extremely fashion-sensitive clothing (at cut-rate prices) to the masses.   These two trends quickly democratized fashion.

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Getting Better Outcomes From Outcomes-Based Healthcare

Screen Shot 2016-05-31 at 9.43.38 AMOutcomes-based healthcare is a popular topic of conversation in healthcare today. But despite its popularity, there isn’t a standard outcomes-based healthcare definition. One possible explanation is outcomes-based healthcare’s scope; it encompasses a vast spectrum of strategies used to transition from fee-for-service (FFS) to value-based care.

Although the industry lacks a standard, industry-accepted outcomes-based healthcare definition, there is something healthcare leaders can agree on: health systems need to embrace outcomes-based healthcare in order to survive the transition to value-based care. But healthcare organizations are up against seemingly endless challenges as they attempt to make the switch to this new, value-based approach to care delivery. While many of these organizations are slowly but surely (and successfully) making the transition, just as many feel overwhelmed by the inevitable challenges associated with changing the way they do business.

This article takes a closer look at outcomes-based healthcare and what it really entails. It describes the importance of making the transition, three challenges health systems are up against, and key success factors when it comes to moving away from an FFS model. A Texas Children’s Hospital success story shows these success factors in action and proves that making the transition, although difficult, is not only achievable, but also an absolute necessity.

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America’s New Drug War

Screen Shot 2016-05-31 at 6.43.03 AMEarlier this month an 86-year old man in Florida killed his 78-year old wife.  He called 911 and when the cops arrived he confessed.  When asked why he did it, the man told authorities that the couple could no longer afford her medications.  She’d been sick for 15 years, the man said, and was often in pain. 

News sources reported that the couple filed for bankruptcy in 2011.  At the time, they had $53,900 in liabilities, most in medical bills put on their credit card.   They lived primarily on social security.    

There’s very likely more to this sad story, and it’s unclear why Medicare didn’t cover most of the couple’s drug costs.  He told authorities he shot his wife (while she slept, by the way) because they had “run out of options.”   

Related, a few months back a Massachusetts Institute of Technology economist and a Harvard oncologist proposed that banks create a new kind of long-term loan—pegged somewhere between a car loan and a home mortgage—that would let people borrow money to pay for expensive medicines.   For example, a loan for a $100,000-a-year drug might require pay back in 9 years at an annual 9% interest rate, they suggested.     

With a nod towards value-based payment, they proposed that a borrower would not have to repay a loan if the therapy didn’t work or if the patient died.  Andrew Lo, of MIT’s Sloan School of Management, and Dr. David Weinstock, an oncologist at the Dana-Farber Cancer Institute, told news outlets they agreed that good insurance would be a much better option. “This is a private sector stopgap way to deal with [the drug price/cost problem] right now,” said Lo.

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How Radiologists Think

flying cadeuciiDiagnostic tests such as CAT scans are not perfect. A test can make two errors. It can call a diseased person healthy – a false negative. This is like acquitting a person guilty of a crime. Or a test can falsely call a healthy person diseased – a false positive. This is like convicting an innocent person of a crime that she did not commit. There is a trade-off between false negatives and false positives. To achieve fewer false negatives we incur more false positives.

Physicians do not want to be wrong. Since error is possible we must choose which side to err towards. That is we must choose between two wrongness. We have chosen to reduce false negatives at the expense of false positives. Why this is so is illustrated by screening mammography for breast cancer.

A woman who has cancer which the mammogram picks up is thankful to her physician for picking up the cancer and, plausibly, saving her life.

A woman who does not have cancer and whose mammogram is normal is also thankful to her physician. The doctor does not deserve to be thanked as she played no hand in the absence of the patient’s cancer. But instead of thanking genes or the cosmic lottery, the patient thanks the doctor.

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