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Leavitt ACO Report: Overstating or Understating Accountable Care Activity?

Dec 7, 2011• 6

By Vince Kuraitis

Accountable Care Organizations (ACOs) have been likened to:

A unicorn — a fantastic creature that is vested with mythical powers. But no one has actually seen one.

A camel — a horse designed by a committee, one that already has its nose in the tent

With this background, you can begin to appreciate the difficulty of conducting an accurate census of ACO animals in the wilderness. Yet, this is exactly the task undertaken in the excellent Leavitt Partners report measuring ACO activity in the US.

As I will explain, the Leavitt report has the potential both to overestimate and underestimate ACO and accountable care-like activities. In my judgment, however, it’s far more likely to be understating just how much accountable care activity actually is going on.

Findings in the Leavitt Report

The Leavitt researchers “identified ACOs from news releases, media reports, trade groups, collaborations and interviews through the beginning of September 2011. Also included were entities that either self-identified as being an ACOs or specifically adopted the tenets of accountable care.”

The report counts 164 ACOs — 99 that are primarily sponsored by hospital systems, 38 by physician groups, and 27 by insurers.

Here’s how Leavitt summarized their results:

Justice Kagan Should Recuse Herself from Obamacare Case

Dec 6, 2011• 6

By Carrie Severino

This spring the U.S. Supreme Court will decide what may well be the case of the century — the constitutional challenge to Obamacare. But will the case be heard by eight or nine justices?

Before the health care law was even passed, the Department of Justice had been meeting to develop a strategy for defending the law from constitutional attack. Involved in this effort was none other than Elena Kagan, now the newest Obama appointee to the Supreme Court.

Federal law requires Supreme Court justices to recuse from a case if they had earlier “participated as counsel” in the case. Justice Kagan did just that when she was Obama’s solicitor general, but has never explained why she believes she is nevertheless justified in sitting on the case under this standard.

One simply can’t be the coach and referee in the same game. At best, knowing the playbook will color your judgment, and at worst, you’ll be on the lookout for chances to give your former team an advantage.

Here are the facts. It took two lawsuits to get “the most transparent administration in history” to release emails detailing Kagan’s involvement in the Obamacare defense. Those emails show that, in a highly unusual move, she ordered her staff to become involved in the defense before the law was even passed.

Why Three Hospitals Didn’t Hurt My Wife

Dec 6, 2011• 2

By Michael L. Millenson

My wife was lying in the back of an ambulance, dazed and bloody, while I sat in the front, distraught and distracted. We had been bicycling in a quiet neighborhood in southern Maine when she hit the handbrakes too hard and catapulted over the handlebars, turning our first day of vacation into a race to the nearest hospital.

The anxiety when a loved one is injured is compounded when you know just how risky making things better can get. As a long-time advocate for patient safety, my interest in the topic has always been passionate, but never personal. Now, as Susan was being rushed into the emergency room, I wanted to keep it that way. “Wife of patient safety expert is victim” was a headline I deeply hoped to avoid.

In the weeks after the accident, we spent time at a 50-bed hospital in Maine; a Boston teaching hospital where Susan was transferred with a small vertebra fracture at the base of her neck and broken bones in her left elbow and hand; and a large community hospital near our suburban Chicago home. There were plenty of opportunities for bad things to happen – but nothing did. As far as I could tell, we didn’t even experience any near misses.

What went right? After all, though our health care system knows how to prevent errors that kill 44,000 to 98,000 people in hospitals each year, that death toll has remained stubbornly constant. Based on personal and professional observations, I’d simplify the formula that kept Susan safe into three variables: consciousness, culture and cash.

The Promise of Electronic Healthcare Records

Dec 6, 2011• 18

By JOHN HALAMKA, MD

Last week, Don Berwick completed his 17 month tenure as administrator of Medicare and Medicaid. The nation should be grateful that such a visionary was at the helm. The nation should frustrated that he was never confirmed.

In his parting interview with the press, he noted that 20 percent to 30 percent of health spending is “waste” that yields no benefit to patients.

Berwick listed five reasons for the enormous waste in health spending:
*Patients are overtreated
*There is not enough coordination of care
*US health care is burdened with an excessively complex administrative system
*The enormous burden of rules
*Fraud

Certainly regulatory reform is needed, but electronic health records can go far to addressing each of these issues.

Bespoke Limbs and Real Mass Customization

Dec 6, 2011• 1

By MATTHEW HOLT

There’s a new world emerging of customizable materials and it’s being led in health care by designers like my old friend Scott Summit. Scott designed products like an early prototype of the Palm V (yes, there was a life before the iPhone!) and servers for Apple and Silicon Graphics, but in the last five or so years he’s got very interested in the human body—particularly artificial limbs.

Artificial limbs are an interesting challenge for an industrial designer both because mass production doesn’t do a good job at addressing it and because most of them are interested in form as well as function. Scott started doing his first prototypes on real people three years ago when it became possible to use 3D printing relatively affordably to create bespoke parts customized for individual human needs.

Farm Bill Needs a Major Overhaul

Dec 5, 2011• 2

By Marion Nestle

Q: What’s going on with the farm bill? Any chance for improving it?

A: I wish your question had an easier answer. The farm bill has to be American special-interest politics at its worst.

As Stacy Finz has been reporting in the main news and Business sections of The Chronicle, the failure of the recent super-deficit reduction plan also brought an end to a secret committee process for writing a new farm bill. Now Congress must follow its usual legislative procedures. The farm bill is again open for debate.

Advocacy is much in order. The farm bill is so enormous, covers so many programs, costs so much money and is so deeply irrational that no one brain – certainly not mine – can make sense of the whole thing.

It is all trees, no forest. The current bill, passed in 2008, is 663 pages of mind-numbing details about programs – hundreds of them – each with its own constituency and lobbyists.

The farm bill was designed originally to protect farmers against weather and other risks. But it grew piecemeal to include programs dealing with matters such as conservation, forestry, biofuels, organic production and international food aid.

Medical Injustice – Contracts That Suppress Patient Comments About Their Doctors or Dentists

Dec 5, 2011• 21

By Paul Alan Levy

Last week we filed a class action complaint on behalf of the patients of a New York dentist, Stacy Makhnevich, over a form agreement that she imposes on all new patients to try to suppress any online comments on her work that she finds disagreeable. In the form, Makhnevich promises not to evade HIPAA’s patient privacy protection in return for patients’ commitment not to disparage her, not to post any comments about her publicly; if the patient writes anything about the dentist, the patient assigns the copyright in those comments to Makhnevich. Relying on the form, Makhnevich sent one of her patients invoices purporting to bill him a daily hundred-dollar fine for having posted comments about her on Internet review web sites.

The copyright assignment aspect of the agreement is especially dastardly. It is intended to enable the dentist to send a DMCA takedown notice to the host of any web site where the criticism is posted. Because the DMCA protects site hosts from liability for copyright infringement, but only if they act expeditiously to remove infringing material once they receive notice of its presence on their servers, hosts generally respond like Pavlov’s dog to such notices. In theory, copyright could be asserted regardless of whether a comment is true or false, and regardless of whether it is an opinion that is constitutionally protected from libel claims; copyright can also be used as a basis for seeking awards of statutory damages even if there are no real damages.

End of life “care” redux

Dec 4, 2011

There ‘s an excellent article by physician Ken Murray at Zocalo Public Square suggesting that few (or no) doctors would put themselves through routinely practiced end of life care. Let’s face it. The system is on automatic for reasons that are lost in professional medical culture and propagated by the Jerome Groopman meme that we must keep practicing new stuff to find out what works, and if lots of people suffer on the way….well that’s the cost of progress. The result is a medical system that does massively excessive care of everyone–especially the nearly dead. As the old joke goes, they really do put nails in coffins to keep the oncologists out. Yes there are cases when intensive treatment does work, but I suggest everyone looks at the engagewithgrace.org site in order to start the conversation with their own families and providers. At least take the system off automatic for you and your loved ones.

Should Doctors Make House Calls?

Dec 4, 2011• 2

By Sanjay Basu, MD

In the olden days, doctors would travel from house to house when community members fell ill. Now, we usually expect patients to come to our office-based clinics. The modern model of care is certainly more efficient for us as physicians. But it’s also a barrier for patients to receive medicine; the highest-risk people usually make it to our clinics after being discharged from their first or second hospitalization, well after high blood pressure or diabetes has already taken its toll on their bodies. Our latest research suggests that we can statistically predict which people are most likely to end up having chronic diseases five or ten years from now. We can pinpoint these people right down to which house they live in. Such predictive models present a new opportunity to prevent disease before it becomes costly or deadly. In this week’s post, we look at a new idea for community-based disease prevention in medicine: the geographical mapping of chronic disease risks, and preemptive visits of healthcare workers to households where people are likely to become ill in the future.

The physician Jeffrey Brenner became famous for piloting a model of healthcare that would attempt to simultaneously improve services while reducing healthcare costs in his city of Camden, New Jersey. His model, recently profiled in Atul Gawande’s popular New Yorker article “The Hot Spotters”, was based on a simple observation: that sick people with poorly-treated diseases tend to be clustered in certain parts of the city.

The Last Six Months of Life

Dec 3, 2011• 17

By David M Sack, MD

This discussion was inspired by the two women I owe my life to: my mother and my wife.

I cannot identify the citation for this factoid, but the assertion has become engrained in the lore of medical urban myth: “50% of healthcare costs are incurred in the last 6 months of life.” (or some similar figure) There are other less arresting but more concrete statistics to be found. For example, according to Health Affairs, July 2001 vol. 20 no. 4 188-195, one quarter of Medicare outlays are for the last year of life. Another more recent discussion concerned the various factors that influence that spending in the last 6 months. An article in the Annals of Internal Medicine for February 15, 2011 vol. 154 no. 4 235-242 describes determinants of healthcare spending and points out that regional variation in medical care does not account for as much variation as is sometimes pretended.

A concise summary of that article by one consulting firm states “Individual characteristics such as black or hispanic race, severe functional impairment, having Medicare Supplement coverage, suffering from certain chronic diseases or from four or more, were associated with higher spending. Others, such as having a relative live nearby or having dementia, are associated with lower spending. And some, such as having an advance directive, sex, marital status, education, net worth, or religiosity, appeared to have no relationship. Altogether, patient characteristics account for 10% of the variation in spending in the last 6 months of life.” (Quoted from Kevin Roche at vitaadvisors.com) Yet even with all this taken into account, patient and regional factors accounted for only 15% of the variation.There seems to be a major subtext to all of this discussion about the last six months of life, whether the topic is cost, ethical issues, quality of life, or whatever. The unstated message is “WE ARE WASTING MONEY ON FUTILE CARE!”. The implication seems to be, “couldn’t we devote these scarce medical resources to more beneficial use?” and “Why are we prolonging suffering and poor quality of life at such great expense to so little gain?” I ask myself these same questions whenever I walk down the corridor of the ICU to see a consult, past room after room of people on ventilators, bloated, mittened and tubed beyond our ability to recognize them as the same individuals seen in the photos I sometimes see pasted to the wall opposite the bed. “Don’t we know”, I ask, ”when to cease and decist?