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Above the Fold

Why the SGR Fix Won’t Work and Could Actually Make Things Worse

Feb 7, 2014• 57

By Jeff Goldsmith

Partisan gridlock in Washington regarding health policy has been so pervasive and bitter that any bipartisan co-operation on any important health issue should be applauded by a frustrated public.

That is why the emerging bipartisan compromise regarding the fifteen-year long policy embarrassment known as the Sustainable Growth Rate (SGR) problem needs to be taken seriously.

Remarkably similar solutions — a new hybrid physician “value-based” payment methodology — have emerged from three of the four key committees in Congress, and seemingly the only stumbling block is finding the $115-120 billion to pay for it.

Moreover, key physician interest groups, including the American Medical Association, appear to have signed off on this approach.

This makes it all the more troubling that the approach taken is unsound health policy that will damage practicing physicians in diverse settings: private practice, medical school practice plans, and hospital employment.

This is because the proposed legislation casts in concrete an almost laughably complex and expensive clinical record-keeping regime, while preserving the very volume-enhancing features of fee-for-service payment that caused the SGR problem in the first place. The cure is actually worse, and potentially more expensive, that the disease we have now.

The SGR fix would basically freeze or severely limit future physician fee updates for Medicare Part B (a serious problem for primary care), while permitting physicians to earn modest “value-based” bonuses if they can document quality measure attainment, cost reductions, participation in alternative payment schemes, practice enhancement activities, or meaningful use of EHRs.

Physicians who meet all these standards could expect to supplement their existing Part B fee by about 4 percent in 2016, going to 10 percent in 2020, with the aggregate bonuses subtracted from the pool of total Part B physician payments to preserve budget neutrality. Non-compliant physicians would see corresponding reductions in their updates.

There are sensible opt-outs for physicians who can report in groups, virtual or real, as well as for physicians who participate in as yet unspecified “advanced payment models” (APMs).
Continue reading…

Too Many American Physicians Or Too Few?

Feb 7, 2014• 11

By Robert Pearl, MD

The goal of the Affordable Care Act, also known as “Obamacare,” is to make affordable, quality health care coverage available to more Americans. But how many physicians will America need to satisfy this new demand?

The debate over doctor supply rages on with very little conclusive evidence to prove one case or the other.

Those experts who see a shortage point to America’s aging population – and their growing medical needs – as evidence of a looming dearth in doctors. Many suggest this shortage already exists, particularly in rural and inner city areas. And still others note America maintains a lower ratio of physicians compared to its European counterparts.

This combination of factors led the American Association of Medical Colleges to project a physician shortage of more than 90,000 by 2020.

On the other side of the argument are health policy experts who believe the answer isn’t in ratcheting up the nation’s physician count. It’s in eliminating unnecessary care while improving overall productivity.

The solution, they say, exists in the shift away from fee-for-service solo practices to more group practices, away from manually kept medical records to electronic medical records (EMR), and away from avoidable office visits to increased virtual visits through mobile and video technologies. Meanwhile, they note physicians could further increase productivity by using both licensed and unlicensed staff, as well as encouraging patient self-care where appropriate.

The Doctor Divide: Global And Domestic Insights

Among the 34 member countries of the Organization for Economic Co-operation and Development (OECD), the U.S. ranks 30th in total medical graduates and 20th in practicing physicians per 1,000 people.

Despite these pedestrian totals, there is one area where the U.S. dominates. It ranks first in the proportion of specialists to generalists – and there’s not a close second.

These figures don’t resolve the debate on America’s need for physicians but they do reveal an important rift in the ratio of U.S. specialists to primary care practitioners.

Uber for Health Care?? Not So Much.

Feb 6, 2014• 27

By Khan, Bongiovanni, & Ansary

Let’s get the disclaimer out of the way:

We love Uber.

As physicians with roots in the Bay Area, we use Uber all the time. The service is convenient, (usually) swift and consistently pleasant. With a few taps of a smartphone, we know where and when we’ll be picked up — and we can see the Uber driver coming to get us in real time.

When the vagaries of San Francisco public transit don’t accommodate our varying schedules, it’s Uber that’s the most reliable form of transportation. (It might be that we like having some immediate gratification.)

So when we caught wind of the news that Uber’s founding architect, Oscar Salazar, has taken on the challenge of applying the “Uber way” to health care delivery, there was quite a bit to immediately like. From our collective vantage point, Uber’s appeal is obvious. When you’re feeling sick, you want convenience and immediacy in your care — two things Uber has perfected.

And who wouldn’t be excited by the idea of keeping patients out of overcrowded emergency rooms and urgent care waiting rooms? The concept of returning those patients to their homes (where they can then be evaluated and receive basic care) seems so simple that it’s brilliant.

What the New York Times Got Wrong about Medicare’s Innovation Center

Feb 5, 2014• 2

By Dan Diamond

Since CMS’s Center for Medicare and Medicaid Innovation launched three years ago, its staff have been frequently hailed for undertaking an ambitious research agenda.

But a New York Times story this week was eye-catching for a different reason: author Gina Kolata mostly assailed Medicare’s researchers for how they’re choosing to do that research.

“Experts say the center is now squandering a crucial opportunity,” Kolata wrote in a front-page article. “Many researchers and economists are disturbed that [CMMI] is not using randomized clinical trials, the rigorous method that is widely considered the gold standard in medical and social science research.”

But many researchers and economists that I talked to at this week’s Academy Health conference say that’s not the case at all. (And some were disturbed to learn that they were supposed to be disturbed.)

“RCTs are helpful in answering narrowly tailored questions,” Harvard’s Ashish Jha told me. “Something like—does aspirin reduce 30-day mortality rates for heart attack patients.”

“However, for many interventions, RCTs may be either not feasible or practical.”

“While RCTs may be the gold standard for testing some hypotheses, it is not necessarily the most effective or desirable model for testing all hypotheses,” agrees Piper Su, the Advisory Board’s vice president of health policy.

CMMI’s ambitious goals

On its surface, Kolata’s article is built around a reasonable conclusion: RCTs offer plenty of value in health care, and we’d benefit from more of them.

As Jha alludes to, think of a double-blinded pharmaceutical study where half the participants randomly get a new drug and the other half get a placebo; that’s an RCT.
The famous RAND study that found having health insurance changes patients’ behavior: An RCT.
The ongoing Oregon Health Insurance Experiment: Also, an RCT.

And it’s fair to examine how CMMI is pursuing its research, too.

Is There Really a Physician Shortage?

Feb 5, 2014• 28

By David Auerbach

Large coverage expansions under the Affordable Care Act have reignited concerns about physician shortages. The Association of American Medical Colleges (AAMC) continues to forecast large shortfalls (130,000 by 2025) and has pushed for additional Medicare funding of residency slots as a key solution.

These shortage estimates result from models that forecast future supply of, and demand for, physicians – largely based on past trends and current practice. While useful exercises, they do not necessarily imply that intervening to boost physician supply would be worth the investment. Here are a few reasons why.

1. Most physician shortage forecast models assume insurance coverage expansions under the ACA will generate large increases in demand for physicians. The standard underlying assumption is that each newly insured individual will roughly double their demand for care upon becoming insured (based on the observation that the uninsured currently use about half as much care). However, the best studies of this – those using randomized trials or observed behavior following health insurance changes – tend to find increases closer to one-third rather than a doubling.

2. A recent article in Health Affairs found that the growing use of telehealth technologies, such as virtual office visits and diagnoses, could reduce demand for physicians by 25% or more.

3. New models of care, such as the patient-centered medical home and the nurse-managed health center, appear to provide equally effective primary care but with fewer physicians. If these models, fostered by the ACA, continue to grow, they could reduce predicted physician shortages by half.

Google Glass: A Paradigm Shift in Assessing Procedure Competency?

Feb 5, 2014• 1

By David E. Stein, MD

I recently had the privilege of becoming a Google Glass Explorer. Basically, this means I walk around with a funky pair of glass frames and look strange – even for an urban hospital setting.

The Glass has a built in camera, and a small display that you can see with numerous apps ranging from GPS navigation to searching the Web. As cool as this the technology is – is there any utility in the healthcare setting?

There is the capability of video chat, where a consulting physician can see what I would be seeing in the operating room, and tell me what I may be looking at and what to do next. Pristine Eyesight, based in Austin Texas, is trialing this use of Glass in University of California, Irvine. Applications for nursing are being developed as well. Yet will this truly impact quality? I am not sure.

Yet one thing that intrigues me about the Glass is the perspective given when using the video function. I recorded some small surgical procedures and reviewed the video afterwards. I watched where I placed my hands, how I held the needle driver, where I took my bites, and in general – what I looked at during the case.

I felt like an NFL Coach reviewing game tape. For the first time in my surgical career, I was able to really see what I did, a perspective that I had never before experienced. This lightweight device with built in eye protection was far more comfortable than any helmet-cam I had used, and the line of sight was right in tune with my visual field. So I began thinking – is there a way this tool can improve outcomes in healthcare?

According to the American College of Surgeons, almost 5,000,000 central venous catheters are placed annually in this country. Complications including placement failure, arterial puncture and pneumothorax range from 15-33% in numerous studies. So how is this common procedure taught?

The classic “watch one, do one, teach one” methodology has been modified over the years. Now, after watching a few lines placed, house staff must perform a certain number of central line placements (usually 5) under the supervision of a senior resident, fellow or attending. Once the appropriate number is reached, the trainee is “competent” to perform the procedure on his or her own. Yet are they truly competent? Perhaps the high complication rates result from a flaw in this classic teaching methodology?

An Urgent Request

Feb 5, 2014• 1

By Michael Painter, MD

“‘Let’s go.’ ‘We can’t.’ ‘Why not?’ ‘We’re waiting for Godot.’” ― Samuel Beckett

For the economists in our midst, demand is a critical but pretty dry idea: the quantity of a good or service a buyer is willing to purchase at a given price. It’s presumed to be part of working health care markets.

It’s one of the first things an undergraduate might learn in Econ 100.

There’s no urgency in this demand; it just is.

Of course, nothing—even general economic principles—is simple in health care. Still, you can look longingly at a few nice supply and demand curves and dream about how things might be—if only.

If only health care consumers picked up their role and skittered up and down those demand curves.

If only they helped us find those elusive market equilibriums for this health care service or that. For some time, lots of people have seen that enormous and powerful potential—and drooled over it.

We’ve been waiting a long time for our consumer to show up in health care. We’ve been waiting for the consumer to obtain and use the information she needs to demand great care.

We’ve been waiting for lots of consumers to do that over and over to help us out of our unfortunate health care jam.

It’s that jam where we pay too much for lots of care of marginal quality riddled with safety problems and delivered by a bunch of dissatisfied, demoralized health professionals.

Indeed we have been waiting a long time for our health care consumer. Certainly, there have been and continue to be countless reasons why consumers haven’t arrived to help save us.

“Health care is different!”

“There’s no evidence that consumers will behave like normal consumers in health care!”

Measuring What Matters for ACOs

Feb 4, 2014• 9

By Fisher, Schpero & Corrigan

More than 55 percent of the U.S. population now lives in a local area with an accountable care organization (ACO), in which a group of providers is held accountable by a payer for the total cost and quality of care for a defined set of patients. The spread of ACOs, however, by no means ensures their success.

Significant questions remain about whether the goals of the model—better care at lower costs—will be achieved.

There are some signs that the ACO model—by rewarding provider organizations for implementing high quality mechanisms for care delivery that lower overall costs—is driving innovation in the marketplace. For example, the Montefiore ACO in New York City is using special scales in the homes of patients with congestive heart failure to monitor for changes in weight that could indicate trouble.

Walgreens has formed three ACOs and is using its retail pharmacies as low-cost care centers. In addition, the Beth Israel Deaconess Care Organization created a high-touch care management system in which nurse practitioners visit the ACO’s sickest patients at home to reduce the number of hospital readmissions.

Yet, there are also challenges inherent in the adoption and implementation of the ACO model. There have been several wide-ranging proposals on how to enhance accountable care, especially in Medicare, but we believe that developing policies to standardize measurement is an important first step.

First, we need to promote adoption of a core set of effective measures across payers. Current measures, such as screening for high blood pressure, are limited in scope and fail to incorporate important dimensions, including health outcomes meaningful to patients and the total cost of care for those within the ACO. Proposals for more advanced measures have been developed but not yet adopted, in part because of provider concerns about being held accountable for aspects of performance they do not fully control.

These issues could be addressed by operationalizing the concept of “shared accountability” through patient engagement and partnerships, as with local, multistakeholder community health coalitions, and embracing a core set of more challenging and meaningful metrics, such as functional health and total costs per capita.

The Republican Alternative to Obamacare: Their Aversion to Fixing it May Prove to Be a Political Mistake

Feb 4, 2014• 25

By Robert Laszewski

The Republicans have an alternative to Obamacare and they may have given the Democrats a big political gift.

The proposal was unveiled last Monday by Republican Senators Richard Burr, (NC), Tom Coburn (OK), and Orrin Hatch (UT).

The Republican plan targets many of the most unpopular parts of the Affordable Care Act such as expensive mandated benefits and the resulting lack of choice, the individual mandate, the employer mandate, and age-rating disruptions.

My sense is that most independent voters––the ones that matter in an election-year––don’t want Obamacare repealed; they want it fixed.

The problem for Republicans is that they have such a visceral response to the term “Obamacare” that they just can’t bring themselves to fix it. The notion that Obamacare might be fixed and allowed to continue as part of an Obama legacy and as a Democratic accomplishment is something they can’t get past.

So, the only way Republicans can propose an alternative to Obamacare is to first wipe the health insurance reform slate clean and start over.

Apple Said to Weigh Digital Health Play

Feb 3, 2014• 7

By David Shaywitz, MD

For the last five year or so, digital health has been the Rodney Dangerfield of investment sectors, getting more attention than respect, and garnering more page views than dollars.

However, two important events reported in the last several days suggest all this may be about to change.

First, Fortune’s Dan Primack broke the news on Saturday that Castlight Health — a startup co-founded by U.S. Chief Technology Officer Todd Park in 2008, with the intention of providing increased transparency to healthcare costs – has secretly filed an IPO; an astonishing valuation of around $2B is anticipated.

That’s both impressive growth and serious money, and suggests it’s possible to win – and win big – in digital health.

Second, two complimentary reports from last Friday collectively suggest that Apple is starting to take healthcare very seriously.

For starters, the New York Times reported that Apple executives met with the FDA in December 2013 to discuss mobile medical applications.

In addition, 9to5Mac, a website devoted to “Apple Intelligence,” claimed that the next version of the iPhone operating system, iOS8 – slated for release later this year – will introduce an application codenamed “Healthbook” that is “capable of monitoring and storing fitness statistics such as steps taken, calories burned, and miles walked,” according to 9to5Mac.