The Health Care Blog – Page 555 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Rate Shock and Awe in California

May 28, 2013• 18

By Robert Laszewski

I have to say I was surprised with the press reports last week that there wasn’t “rate shock” in California when the California exchange offered preliminary information about their new plans and rates.

At least one prominent health actuarial group had predicted a 30% baseline increase in costs for California’s new health insurance exchange plans under the Affordable Care Act (ObamaCare”).

As the director of the California exchange put it, “These rates are way below the worst-case gloom-and-doom scenarios we have heard.”

But a few days later there is lots more information coming out and it would appear we have a case of apples to oranges to grapefruit. And, we have a pretty good case of rate shock.

First, the exchange officials pointed out that we have to be careful to compare apples to apples when looking at 2013 rates and comparing them to the 2014 exchange rates because the 2014 exchange plans have far more generous benefits.

Yes we do, particularly when the California exchange forces us to give up our apple and buy a more expensive orange.

One of the reasons health insurance in the exchange will cost a lot more in most states is because the new health law outlaws many of the existing plans now being offered and requires only those much richer plans to be sold.

Are people going to get more coverage for their money? Yes. Do they want more coverage if the premium costs for those plans is a lot higher? Likely yes if taxpayers are paying for most of it. If not, clearly they didn’t want to pay for it before. Come January, lots of California consumers in the small group and individual market are going to get a letter from their existing insurer telling them their current plan is no longer available and the cost of the new required plans will be a lot more.

Simply, the new law is taking plan design choices away instead of letting the consumer decide what is good for them. Does that matter in California?

7 Burning Questions on Marijuana Legalization

May 28, 2013• 11

By Beau Kilmer

Believe me, I’ve heard all the pot jokes, and some of them are true. Public support for legalizing marijuana use is at an all-time high. Some state-level marijuana laws are going up in smoke. And yes, Washington and Colorado are embarking on a historic joint venture.

Puns aside, discussions about marijuana legalization are getting serious. In November, voters in Colorado and Washington made the unprecedented decision to allow commercial production, distribution and possession of marijuana for nonmedical purposes. Not even the Netherlands goes that far.

Policymakers in both states are confronting some new and tricky issues that have never been addressed. For them, and for anyone else thinking about changing their pot laws, here are seven key decision areas that will shape the costs and benefits of marijuana legalization:

1. Production. Where will legal pot be grown — outdoors on commercial farms, inside in confined growing spaces, or somewhere in between? RAND research has found that legalizing marijuana could make it dramatically cheaper to produce — first because producers will no longer have to operate covertly, and second because suppliers won’t need to be compensated for running the risks of getting arrested or assaulted. After lawmakers decide how it will be grown, production costs will be shaped by the number of producers and other regulations such as product testing.

2. Profit motive. If there is a commercial pot industry, businesses will have strong incentives to create and maintain the heavy users who use most of the pot. To get a sense of what this could look like, look no further than the alcohol and tobacco industries, which have found ingenious ways to hook and reel in heavy users. So will private companies be allowed to enter the pot market, or will states limit it to home producers, non-profit groups or cooperatives? If a state insisted on having a monopoly on pot production, it could rake in a decent amount revenue — but for now, that possibility seems far off in the United States since marijuana remains illegal under federal law.

3. Promotion. Will states try to limit or counter advertisements in the communities and stores that sell marijuana? U.S. jurisprudence against curtailing what’s known as “commercial free speech” could make it tough to regulate the promotion of pot. While a state monopoly system could help control promotion, those advertisements you see for state lotteries should give you pause.

Announcing the Novartis Thalassemia App Challenge

May 28, 2013

By Graeme Ossey

Health 2.0 is excited to announce the launch of the Novartis Thalassemia App Challenge sponsored by Novartis Oncology. There is a critical need to develop an innovative app solution that assists Thalassemia patients and their families in managing the disease, including monitoring/tracking of key parameters, treatment/medication adherence and recording of daily personal facts.

Thalassemia is a diverse family of genetic disorders affecting red blood cell production, causing anemia and consequently, patients suffer significant complications.¹ Thalassemia can range from milder types to severe cases that start in infancy and require regular blood transfusions for patient survival.² Clinical complications can vary by type of thalassemia, and patients also may develop iron overload as a consequence of the disease or because of extra iron absorbed from blood transfusions.³ Most patients with thalassemia are of South and Southeast Asian, Mediterranean or Middle Eastern origin, with immigration broadening the global prevalence.⁴

How UCSF Is Solving the Quality, Cost and Value Equation

May 27, 2013• 11

By Bob Wachter, MD

I sometimes explain to medical students that they are entering a profession being transformed, like coal to diamonds, under the pressure of a new mandate. “The world is going to push us, relentlessly and without mercy, to deliver the highest quality, safest, most satisfying care at the lowest cost,” I’ll say gravely, trying to get their attention.

“What exactly were you trying to do before?” some have asked, in that wonderful way that smart students blend naiveté with blinding insight.

It is pretty amazing that healthcare has been insulated from the business pressures that everybody from Yahoo! to my father’s garment business have experienced since the days of Adam Smith. We experienced a bit of this pressure in the mid-1990s, when pundits declared healthcare inflation “unsustainable” (sound familiar?) and we invented managed care to slay it. We know how that story ended – the public and professional backlash against HMOs defanged the managed care tiger to the point that it could barely produce a “meow.” The backlash was followed by a 15-year run during which efforts to slash healthcare costs have been remarkably meager.

That run has ended.

Luckily, while we’ve been let off the hook on cost-reduction, we’ve not been given a free pass on improvement. Beginning with the Institute of Medicine reports on safety (2000) and quality (2001), we have been under growing pressure to improve the numerator of the value equation: patient safety, quality of care, and patient satisfaction. Particularly for those of us who work in hospitals, we now feel this pressure from many angles: from accreditors (more vigorous and unannounced Joint Commission inspections, residency duty hour limits), transparency (Medicare’s Hospital Compare), comparative measurement (HealthGrades, Leapfrog, Consumer Reports and many other hospital rankings), and, most recently, payment policies (no pay for “never events,” penalties for readmissions, value-based purchasing, and “Meaningful Use” standards for IT).

These initiatives have created an increasingly robust business case to improve. Hospitals everywhere have responded with new resources, committees, ways of analyzing data, educational programs, computer systems, and more.

7. Task a single entity with defining standards for measuring and reporting quality and cost data.

May 27, 2013

By Berenson, Pronovost & Krumholz

There is a plethora of health care quality data being pushed out to the public, yet no rules to assure the accuracy of what is being presented publicly. The health care industry lacks standards for how valid a quality measure should be before it is used in public reporting or pay-for-performance initiatives, although some standards have been proposed.

The NQF does a good job of reviewing and approving proposed measures presented to it, but lacks the authority to establish definitive quantitative standards that would apply broadly to purveyors of performance measures. However, as discussed earlier, many information brokers publically report provider performance without transparency and without meeting basic validity standards. Indeed, even CMS, which helps support NQF financially, has adopted measures for the Physician Quality Reporting System that have not undergone NQF review and approval. Congress now is considering “SGR repeal,” or sustainable growth rate legislation, that would have CMS work directly with specialty societies to develop measures and measurement standards, presumably without requiring NQF review and approval [30].

Without industry standards, payers, policy makers, and providers often become embroiled in a tug-of-war; with payers and policy-makers asserting that existing measures are good enough, and providers arguing they are not. Most often, neither side has data on how good the contested measures actually are. Most importantly, the public lacks valid information about quality, especially outcomes, and costs.

Indeed, most quality measurement efforts struggle to find measures that are scientifically sound yet feasible to implement with the limited resources available. Unfortunately, too often feasibility trumps sound science. In the absence of valid measures, bias in estimating the quality of care provided will likely increase in proportion to the risks and rewards associated with performance. The result is that the focus of health care organizations may change from improving care to “looking good” to attract business. Further, conscientious efforts to reduce measurement burden have significantly compromised the validity of many quality measures, making some nearly meaningless, or even misleading. Unfortunately, measurement bias often remains invisible because of limited reporting of data collection methods that produce the published results. In short, the measurement of quality in health care is neither standardized nor consistently accurate and reliable.

6. Invest in the basic science of measurement development and applications.

May 27, 2013

By Berenson, Pronovost & Krumholz

The unfortunate reality is that there is no body of expertise with responsibility for addressing the science of performance measurement. The National Quality Forum (NQF) comes closest, and while it addresses some scientific issues when deciding whether to endorse a proposed measure, NQF is not mandated to explore broader issues to advance the science of measure development, nor does it have the financial support or structure to do so.

An infrastructure is needed to gain national consensus on: what to measure, how to define the measures, how to collect the data and survey for events, what is the accuracy of EHRs as a source of performance, the cost-effectiveness of various measures, how to reduce the costs of data collection, how to define thresholds for measures regarding their accuracy, and how to prioritize the measures collected (informed by the relative value of the information collected and the costs of data collection).

Despite this broad research agenda, there is little research funding to advance the basic science of performance measurement. Given the anticipated broad use of measures throughout the health system, funding can be a public/private partnership modeled after the Patient-Centered Outcomes Research Institute or a federally-funded initiative, perhaps centered at AHRQ. Given budgetary constraints, finding the funding to support the science of measurement will be a challenge. Yet, the costs of misapplication of measures and incorrect judgments about performance are substantial.

5. Use measurement to promote the concept of the rapid-learning health care system.

May 27, 2013

By Berenson, Pronovost & Krumholz

Initiatives to promote performance measurement need to be accompanied by support to improve care. Quality measure data should not only be technically correct, but should be organized such that their dissemination is a resource to aid in quality improvement activities. As such, quality measurement should be viewed as just one component of a learning health care system that also includes advancing the science of quality improvement, building providers’ capacity to improve care, transparently reporting performance, and creating formal accountability systems.

There are several strategies to make quality measure data more actionable for quality improvement purposes. For example, for publicly reported outcome measures, CMS provides hospitals with lists of the patients who are included in the calculation. Since the outcomes may occur outside the hospital for mortality and for readmissions that are at other hospitals, this information is often beyond what the hospitals already have available to them. These data give providers the ability to investigate care provided to individual patients, which in turn can support a variety of quality improvement efforts.

4. Measure patient experience with care and patient-reported outcomes as ends in themselves.

May 26, 2013

By Berenson, Pronovost & Krumholz

Performance measurement has too often been plagued by inordinate focus on technical aspects of clinical care—ordering a particular test or prescribing from a class of medication—such that the patient’s perspective of the care received may be totally ignored. Moreover, many patients, even with successful treatment, too often feel disrespected. Patients care not only about the outcomes of care but also and their personal experience with care.

There is marked heterogeneity in the patient experience, and the quality of attention to patients’ needs and values can influence their course, whether or not short-term clinical outcomes are affected. Some patients have rapid recovery of function and strength, and minimal or no symptoms. Other patients may be markedly impaired, living with decreased function, substantial pain, and other symptoms, and with markedly diminished quality of life. It would be remiss to assume that these two groups of patients have similar outcomes just because they have avoided adverse clinical outcomes such as death or readmission.

In recommending a focus on measuring outcomes rather than care processes, we consider surveys or other approaches to obtaining the perspectives of patients on the care they receive to be an essential component of such outcomes. When designed and administered appropriately, patient experience surveys provide robust measures of quality, and can capture patient evaluation of care-focused communication with nurses and physicians [24]. And while patient-reported measures appear to be correlated with better outcomes, we believe they are worth collecting and working to improve in their own right, whether or not better experiences are associated with improved clinical outcomes [25].

3. Measure quality at the level of the organization, rather than the clinician.

May 26, 2013• 1

By Berenson, Pronovost & Krumholz

Historically, the physician has been viewed as the leader of medicine, with responsibility for the care and outcomes of patients; in iconic photographs and paintings, the physician is seen as a lone, heroic figure. Such a view has led to natural interest in the measurement of individual physicians’ performance. It is therefore not surprising that some information brokers, including the U.S. News and World Report and many city magazines like the Washingtonian, provide ratings of “top doctors,” often based mostly on reputation, warranted or not.

However, this focus on the individual is flawed for most measures of quality and presents substantial technical challenges. Systems-based care is emerging as a key value within health care and a vital component of high-quality care, while the notion that an individual health professional can be held accountable for the outcomes of patients in isolation from other health professionals and their work environment is becoming an outdated perspective. For example, better intensive care unit staffing sometimes mitigates the evidence that surgeons who perform more procedures achieve better outcomes [21].

The communication and coordination of services across providers is required to ensure that patients, many of whom have multiple conditions, are assisted through various health care settings [22]. For some aspects of care, such as diagnosis errors and patient experience, measuring at the individual physician level might be considered. Nevertheless, focusing measurement on an individual runs counter to our goals in promoting teamwork and “systemness” as core health care delivery attributes.

2. Use quality measures strategically, adopting other quality improvement approaches where measures fall short.

May 26, 2013

By Berenson, Pronovost & Krumholz

While working to develop a broad set of outcome measures that can be the basis for attaining the goals of public accountability and information for consumer choice, Medicare should ensure that the use of performance measures supports quality improvement efforts to address important deficiencies in how care is provided, not only to Medicare beneficiaries but to all Americans.

CMS’ current focus on reducing preventable rehospitalizations within 30 days of discharge represents a timely, strategic use of performance measurement to address an evident problem where there are demonstrated approaches to achieve successful improvement [6]. Physicians and hospital clinical staff, if not necessarily hospital financial officers, generally have responded quite positively to the challenge of reducing preventable readmissions.

CMS has complemented the statutory mandate to provide financial incentives to hospitals to reduce readmission rates by developing new service codes in the Medicare physician fee schedule that provide payment to community physicians to support their enhanced role in assuring better patient transitions out of the hospital in order to reduce the likelihood of readmission [7]. CMS recently announced that after hovering between 18.5 percent and 19.5 percent for the past five years, the 30-day all-cause readmission rate for Medicare beneficiaries dropped to 17.8 percent in the final quarter of 2012 [8], simplying some early success with efforts to use performance measures as part of a broad quality improvement approach to improve a discrete and important quality and cost problem.

However, this Timely Analysis of Immediate Health Policy Issues 3“CMS’ current value-based purchasing efforts, requiring reporting on a raft of measures of varying usefulness and validity, should be replaced with the kind of strategic approach used in the national effort to reduce bloodstream infections.”approach is not without controversy.

Improvements have been modest, and some suggest that readmission rates are often outside the hospital’s control, so CMS’ new policy unfairly penalizes hospitals that treat patients who are the sickest [9]. And while readmission in surgical patients is largely related to preventable complications, readmissions in medical patients can be related to socioeconomic status. Also, some have questioned the accuracy of CMS’ seemingly straightforward readmission rate measure, finding that some hospitals reduce both admissions and readmissions—a desirable result—yet do not impact the readmission rate calculation [10]. And one of this paper’s authors (R. Berenson) has suggested a very different payment model that would reward hospital improvement rather than absolute performance, thereby addressing the reality that hospitals’ abilities to influence readmission rates do vary by factors outstside of their control [11].