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The ACO Information Vacuum

Mar 13, 2016• 4

By KIP SULLIVAN

flying cadeucii In my three-part series on why we know so little about ACOs, I presented three arguments:

We have no useful information on what ACOs do for patients;
that’s because the definition of “ACO” is not a definition but an expression of hope; and
the ACO’s useless definition is due to dysfunctional habits of thought within the managed care movement that have spread throughout the health policy community.

Judging from the comments from THCB readers, there is no disagreement about points 1 and 3. With one exception (David Introcaso), no one took issue with point 2 either. Introcaso agreed with point 1 (we have no useful information on ACOs), but he argued that the ACO has been well defined by CMS regulations, and CMS, not the amorphous definition of “ACO,” is the reason researchers have failed to produce useful information on ACOs.

Another reply by Michael Millenson did not challenge any of the three points I made. Millenson’s point was that people outside the managed care movement use manipulative labels so what’s the problem?

I’ll reply first to Introcaso’s post, and then Millenson’s. I’ll close with a plea for more focus on specific solutions to specific problems and less tolerance for the unnecessarily abstract diagnoses and prescriptions (such as ACOs) celebrated today by far too many health policy analysts.

Summary of Introcaso’s comment and my response

I want to state at the outset I agree wholeheartedly with Introcaso’s statement that something is very wrong at CMS. I don’t agree with his rationale, but his characterization of CMS as an obfuscator is correct.

Feeling the Bern on Universal Single-Player Healthcare

Mar 11, 2016• 37

By JIM PURCELL

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“Elephant in the living room” is an English metaphorical idiom for an obvious untruth going unaddressed. In most political platforms about healthcare and its coverage, there is a most resolutely immovable elephant in our living room. It is there with every single candidate. But with Bernie….

You’ve just got to love Bernie Sanders. It makes me feel like I’m 22 years old in the 1960’s and dumb as all get out about how you pay for things. But let us consider Mr. Sanders’ healthcare proposal. From his own website:

“Bernie’s plan would create a federally administered single-payer health care program. Universal single-payer health care means comprehensive coverage for all Americans. Bernie’s plan will cover the entire continuum of health care, from inpatient to outpatient care; preventive to emergency care; primary care to specialty care, including long-term and palliative care; vision, hearing and oral health care; mental health and substance abuse services; as well as prescription medications, medical equipment, supplies, diagnostics and treatments. Patients will be able to choose a health care provider without worrying about whether that provider is in-network and will be able to get the care they need without having to read any fine print or trying to figure out how they can afford the out-of-pocket costs…[etc.].”

Bernie sure didn’t go half way on this one. All care, whenever, wherever, however. A fundamental right with no filter. OK. So he jumped in with both feet. You’ve got to admire his elan. But what might this mean and how can he ignore what happened in his own home state?

Cancer and Moonshot Economics

Mar 11, 2016• 1

By STEVE FINDLAY

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The Obama Administration’s cancer “moonshot” initiative, announced in January and now being debated in Congress, comes at a time of significant advances in cancer treatment and a spurt of cultural attention to the disease.

A batch of new immunotherapy drugs approved in the last few years, such as Bristol-Myers Squibb’s Opdivo and Merck’s Keytruda, are being widely touted as breakthrough medicines—and aggressively advertised to both doctors and the public. Jimmy Carter’s unexpected remission from melanoma that had spread to his liver and brain is attributed to Keytruda.

At the same time, a cancer memoir (When Breath Becomes Air by Dr. Paul Kalanithi) tops The New York Times nonfiction best-seller list. The Death of Cancer by Dr. Vincent DeVita, a former director of the National Cancer Institute, has also garnered positive reviews and wide attention for its critical assessment of today’s cancer research establishment.

Before these two books, John Green’s 2012 novel The Fault in Our Stars—the touching story of two teens with cancer—was widely acclaimed and read, especially after it was made into a blockbuster movie in 2014.

The administration’s initiative comes at a significant time for me personally, too. My brother, 70, was diagnosed with stage IV lung cancer 10 months ago. Unlike Jimmy Carter, one of the new immunotherapy drugs (Opdivo) did not defeat his cancer. He continues to fight for his life. As with so many families, cancer has stalked ours. My sister died of colon cancer in 2006, age 54. My mother died of lung cancer in 1985, at 65. Like anyone over age 60, I’ve seen friends suffer and succumb, their lives cut short. And I’ve battled two cancers myself, melanoma (localized) and a salivary gland tumor.

The Trump Healthcare Interview: Part 2

Mar 11, 2016• 7

By IAN MORRISON

Donald Trump is leading the Republican delegate count and has the best chance of becoming the Republican nominee and, just maybe, even President. In February, we at THCB asked Scottish-Canadian-Californian healthcare futurist Ian Morrison to conduct an interview with Trump, figuring that Morrison would have an in with Trump given Trump’s praise for Scottish and Canadian healthcare. Fittingly, that interview was published on THCB on President’s Day, February 16th. Since then Donald Trump has racked up impressive victories and more importantly has released some specifics of his healthcare proposal. THCB thought it was time for Morrison to reach out to Mr. Trump again–Matthew Holt

MORRISON: Thanks for making time Mr. Trump, it is a pleasure to have a chance to follow up with you.

TRUMP: You were a little rough on me last time, but I enjoyed it, I thought I did very well in the interview.

MORRISON: Indeed you did, it was incredible. Mr. Trump before we get to your healthcare plan, let’s just catch up on the race. Since we last talked you have had some impressive victories in a wide variety of states from Hawaii to Mississippi. Why do you think you have done so well?

TRUMP. I’m winning everywhere, everywhere, and with all the groups: vets, high income, low income (we love the low-income). I won Hispanics in Nevada? Hispanics, Trump? They like me because I am a winner, and I’m winning everywhere. I am winning by a lot.

MORRISON: You did particularly well in the South, the so called SEC primaries, where Ted Cruz was expected to do well, particularly with evangelicals. You won by more than 20 points in Alabama for example.

TRUMP: Well they loved me in South Carolina, I won big there and then I did the dog whistle to the Klan and that probably helped, in the South.

MORRISON: You mean being slow to disavow David Duke and the Klan before those southern primaries?

TRUMP: It worked well, we had hats ready: “Make America White Again” but Corey (Editor’s note–He’s referring to Corey Lewandowski Trump’s Campaign Manager who himself made news recently by manhandling a female reporter) told me it probably wouldn’t work in the General, but we trademarked them anyway, I couldn’t believe it was available, so we may use the “Make America White Again” hats later, we’ll see. But now I disavow, I disavow, how many times do I have to say it.

MORRISON: Mr. Trump are you a racist?

TRUMP: Look I told the New York Times Editorial Board the whole story on deep background. Republican primaries are about getting angry, white people to turn up. Those people are tired and angry at the Mexicans, the Muslims, and Obama (we still don’t know if he was born in Kenya). So when we win, we can be nicer in the general election, because I get along with everyone.Continue reading…

A New Federal Agency to Oversee Patient Safety?

Mar 10, 2016• 13

By TEJAL GANDHI, MD

flying cadeucii Patient safety should be a major priority for the United States, and that requires designating a centralized entity or coordinating body to oversee efforts to ensure it. Such centralized oversight is one of the key recommendations of “Free from Harm,” a report published in December by the National Patient Safety Foundation. The report highlights the need to create a safety culture, since preventable medical errors in hospitals are estimated to result in as many as 440,000 deaths annually. That would make it the third leading cause of death – after heart disease and cancer.

A new report by the U.S. Government Accounting Office illuminates the challenges that hospitals face in implementing evidence-based safety practices. One of those challenges – determining which patient safety practices should be implemented – underscores the need for a coordinating entity and resource. The report states: “(Hospital) Officials noted that they face challenges identifying which evidence-based patient safety practices should be implemented in their own hospitals, such as when only limited evidence exists on which practices are effective. For example, officials from one hospital told GAO that the hospital tried several different practices in an effort to reduce patient falls without knowing which, if any, would prove effective.”

What’s more, preventing medical errors in hospitals is only part of the national challenge, as most health care is provided outside of hospital settings: in physicians’ offices and clinics; in outpatient surgical, medical, and imaging centers; and, in long-term, hospice, and home-care settings, among others. There are about 1 billion ambulatory visits each year in the United States, compared to 35 million hospital admissions. Those ambulatory settings are subject to medical errors as well. According to studies cited in “Free from Harm,” more than half of annual, paid, medical malpractice claims were for events in the outpatient setting.

In Defense of Small Data

Mar 9, 2016• 4

By ANISH KOKA, MD

flying cadeucii I read with interest a recent editorial that opined on the poor evidence for screening in cancer trials. The evidence was judged poor because apparently no screening trial has demonstrated a clear reduction in all-cause mortality, only disease-specific mortality. One example discussed in the analysis reviews the data for colon cancer screening and notes that, while there were a statistically significant lower number of deaths related to colon cancer in the screened group, the total mortality in the two groups was no different. The authors posit that the study is either underpowered for total mortality or that the screened patients may have more deaths due to the ‘downstream effects’ of screening. The provocative conclusion by many a tweet and retweet is that cancer screening has not been shown to save lives. Apparently the path to progress in medicine now must be paved by studies with millions of patients. I understand the desire for more and more data, but I see danger in the sanctimonious protestations of those who can only find truth within the confines of a million-person, randomized control trial. This approach ignores the history of advances in clinical medicine, most of which live far outside of the boundaries of million-strong randomized clinical trials.

CMS Approval Another National Nod to the Power of Telehealth

Mar 8, 2016• 1

By KOFI JONES

Screen Shot 2016-03-11 at 3.43.26 PM Approximately 12 million Americans utilize some type of home health care every year. From home health aides visiting the infirmed in their homes, to physical therapy services to aide in recovery, to medical equipment being used to treat the chronically ill, home health has been a critical component of care management for decades.

One of the Medicare payment requirements for these services is for the prescribing practitioner to have a “face to face” encounter with the patient within a reasonable timeframe. This has widely been viewed as a burden on patients, many of whom face mobility issues and other barriers to meeting this obligation. It has also been a barrier for our overburdened physician supply.

Just recently, CMS published a new rule extending this requirement to states – stating that home healthcare matching Medicaid funds will be linked to this same requirement. But, there’s another component of the rule which mirrors Medicare and will have a tremendously positive impact on the home health care community – the face-to-face requirement can be met through telehealth.

Optimistic Skepticism About the Future of Consumer Healthcare

Mar 8, 2016• 9

By GABRIEL GONG-LEI LU

Screen Shot 2016-03-08 at 9.23.41 AM Healthcare options are changing dramatically. Technological and market developments give people the power to take control of their own health and wellness, now more than ever before. Companies are constantly creating new consumer applications that seek to solve problems across the full spectrum of the healthcare lifecycle. These products include everything from contact lenses that measure blood glucose levels to an application that lets me chat with a psychiatrist at a moment’s notice. But despite recognizing the added convenience and personalization, I’m surprised by how frequently I ignore the sheer variety of products at my disposal in favor of doing things the old-fashioned way. Just this past week, I had to schedule my yearly checkup. Instead of booking my appointment through a service like ZocDoc or DocASAP, I instinctively grabbed my phone and tried to call a doctor. Why?

One reason is that just knowing about the existence of those services didn’t mean they immediately came to mind. Companies in other sectors such as entertainment or e-commerce can habituate customer behavior because their products cater to consumer needs that reoccur on a daily, or at least weekly, basis. This means that, if you can routinely provide a better user experience than your competitors, you establish customer loyalty. This is why when I want to binge watch TV shows, I immediately go on Netflix. Or when I need to buy a new pair of shoes, I always use Amazon. However, changing customer behavior regarding health is challenging because the nature of the behavior is infrequent and sporadic. Most people don’t get sick that often and, when they are healthy, it’s hard to convince them to remember to use app X, Y, or Z in preparation for the future. For a healthcare product to successfully disrupt the status quo, the added benefit or user experience has to be so formative that the person will remember the product the next time around, which could easily be months.

Empathy and Shame

Mar 7, 2016• 2

JOHNATHON TOMLINSON, MD

flying cadeucii How we respond to patients who are feeling, or at risk of feeling shame can make or break a therapeutic relationship. This is about how I try to respond.

Shame is a negative moral judgement about oneself. Unlike guilt or embarrassment where someone thinks that fundamentally they are a reasonable person who has done a bad thing, someone who feels shame thinks that they have done a bad thing because fundamentally, they are a bad person.

Guilt is when, for example, you feel bad that you forgot to call your mum on her birthday, but you might reasonably conclude that this doesn’t make you a bad person and so you decide to make up for it and call her the next day. Shame is when you conclude that you are (and have quite likely always been) a hopeless son or daughter who is always forgetting the important things in life and feel too despondent even to call the next day.

We should suspect shame in the following situations. A patient misses an appointment because they are afraid of being judged on the basis of their blood tests . Another fails to attend a follow-up appointment after having disclosed a history of child sexual abuse. The mother who took her child to an A&E department takes them to a different department the next day with the same feverish symptoms in order to avoid the clinician who said they were time-wasting the day before.

Situations where patients blame themselves for their perceived failure to take responsibility either for themselves or their dependents can arouse shame. Healthcare professionals have, in addition to their clinical authority, a moral authority and consciously (or more often not) and intentionally (or not) pass moral judgement on their patients’ behaviour if they do not acknowledge shame and self-blame.

Why We Know so Little About ACOs: The Managed Care Culture at Work

Mar 6, 2016• 11

By KIP SULLIVAN

flying cadeucii This is the third essay in a three-part series in which I explore the answer to that question. In the first installment I blamed this problem on the flimsy definition of “ACO.” ACO proponents “defined” the ACO in terms of their hopes for it, not in terms of the mechanisms ACOs would use to accomplish those hopes.

In the second installment I reviewed a paper published by the Center for Health Care Strategies (CHCS) to document my statement that we have no useful information on ACOs and to illustrate the quandary the hope-based “definition” of “ACO” creates for researchers. I criticized the CHCS paper as well for its cavalier attitude about evidence. The paper relied heavily on press releases and anonymous sources, and ignored the costs providers and insurers incur to set up and maintain ACOs.

In this last installment, I explore the role that culture – the culture of the managed care movement and the larger health policy community – played in elevating the ACO to the status of national health policy and, at the same time, thwarting the production of useful research on what it is ACOs do for patients.

The ACO isn’t the only example of hope-based health policy

If the ACO were the only example of an undocumented and poorly defined health care “reform” that was flogged from obscurity to fame by a few well-placed health policy entrepreneurs, we might dismiss the problems created by the flabby definition of the ACO as an aberration. But the ACO is not the only example of such “reforms.”

To the contrary, the ACO illustrates the norm, not the exception. It is an excellent illustration of how health policy has been made in America since the modern health care reform debate began circa 1970. Over the last half-century, every managed care “reform” that was eventually unleashed on all or large portions of the American populace followed the trajectory of the ACO: