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Coordinating Care Coordination

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By MARGALIT GUR-ARIE

Care coordination is one of the four pillars of Meaningful Use, one of the six NCQA Patient Centered Medical Home (PCMH) standards and one of the main goals of Accountable Care Organizations (ACO). Care coordination, particularly for patients with multiple chronic conditions, is expected to reduce unnecessary repetition of laboratory testing or imaging and the number of avoidable admissions. Other than reducing overall costs, care coordination is also supposed to improve quality of care. According to experts like Joe Flower, “Lack of care coordination is at the core of the mess healthcare is in”, and nobody in their right mind would argue that it is best that medical care remains disorganized and uncoordinated, if it is indeed so. It seems that our fee-for-service, fragmented and fractured (lots of f-words here) health care system is not conducive to care coordination. When patients float around in a sea of hospitals, physicians, nursing homes and other facilities, each care provider gets paid, and is responsible for the piecework performed at their independent entity and nobody is minding the handoff of patients to the next provider of care, and nobody is assembling a comprehensive picture of the entire care process, let alone orchestrating, or coordinating, the progression of patients between stages of care and the overall needs of patients in transit. What would it take then, to see that the bits and pieces of health care we now have, become a safe and affordable continuum of care?

CMS is taking the lead, as it should, in an all-out effort to encourage health care coordination through various carrot-stick initiatives, aligned to ultimately base payment for medical care on value to the patient, as measured on a population level, instead of fee-for-service and no accountability for outcomes. These initiatives fall into three general categories:

  1. Health Information Technology to assist with documentation, information exchange and measurements as required in any coordination effort.
  2. Incentives and penalties for providers based on measures thought to be influenced by care coordination (e.g. preventable hospitalizations, readmission rates, etc.)
  3. Financial and structural encouragement for vertical integration of the delivery system (e.g. ACOs, consolidation, employed physicians, etc.)Continue reading…

Calling All Health Innovators: Health Data Palooza

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By Todd Park

This week the Health 2.0 team will be at Health Innovation Week DC, and the biggest event there will be the Health Data Initiative Forum. One day, 50 demos, mixing more government and private data than you can imagine. We’ve been helping at the periphery of the Health data Initiative and we’ll be be having a special session talking more about the Health 2.0 Challenge, including our upcoming work running Challenges for ONC. We’re incredibly excited and enthusiastic, but no one is as enthusiastic as Todd Park! Here’s the CTO of HHS telling you about his brainchild, Health Data Palooza–Matthew Holt

Almost exactly one year ago, we launched a vital new HHS Open Government effort: The Health Data Initiative (HDI). The Initiative was publicly launched by HHS Secretary Kathleen Sebelius, Deputy Secretary Bill Corr, Institute of Medicine (IoM) President Harvey Fineberg, and White House CTO Aneesh Chopra at a forum held at the National Academy of Sciences.

The Health Data Initiative is an incredibly exciting public-private collaboration that is encouraging innovators to utilize data made publicly available by HHS and others to help fuel applications and services that can help improve health and health care. Over the past year HHS has been working very hard to make our data ever more accessible to the public – both publishing brand new data and making more of our existing data machine-readable, downloadable, accessible via application programming interfaces (APIs), free, and vastly easier to find. We’ve launched major new data and information websites (the HealthData.gov community, the Health Indicators Warehouse; and HealthCare.gov).

Equally importantly, we’ve been energetically publicizing our data, through challenges, code-a-thons, and many sessions with innovators of all kinds – educating folks around the country about what data we’ve made available and its potential to help power health  improvement. Innovators from across America are taking our data and are using it to build and power an amazing and rapidly growing array of applications in creative and powerful ways to help advance health. This movement has included entrepreneurs and change makers from all sectors: startups, major businesses, nonprofits, public health, health care delivery system, federal and local government, and academia.

On June 9th, 2011 at the National Institutes of Health, in partnership with the IoM, we will be holding our 2nd Annual Health Data Initiative Forum (or, as I like to call it, our second annual Health Data Palooza!). Continue reading…

Ryan’s “vouchercare” is a false choice

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Paul Krugman spends time today ripping Paul Ryan once more. Ryan’s plan is to limit government spending way off into the future (starting with people who are now 55) by giving them a flat Medicare voucher and then telling them to try it on for size in the individual insurance market. The joke is that there is a rational way to try to introduce some consumer-choice competition into Medicare. Essentially there are two alternatives to dealing with the mess that is Medicare. One–try to manage Medicare spending both with a global budget (the IPAB) and with specific restrictions on care that’s delivered that’s wasteful or unnecessary (via changes in FFS payment). That’s essentially the route the ACA goes. Two, give recipients a voucher that lets them choose between competing entities that can’t charge more than the value of the voucher and actually are mandated to compete on the correct things (outcomes, service, etc) like they do in Holland and in Alain Enthoven’s theories. That’s rational managed competition under a global budget, and the winners in that would look more like Kaiser and Group Cooperative than today’s insurers. Ryan’s idea is just to subsidize the dysfunctional private marketplace and to repeal the minor restrictions the ACA puts on health insurers while he does it–a sure-fire recipe for disaster.

There is of course another alternative. Just to let Medicare continue to spiral out of control on both costs and the quality of services it provides, and Ryan’s plan basically does that without a safety net

Some of My Best Friends are in Private Equity

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By PAUL LEVY

Like moths to a flame, private equity investors are quick to pounce on those sectors of the economy that have the potential for higher than average returns. Such investors also have an appetite for the higher risk that accompanies those sectors. In this manner, private equity can serve a useful role in capital formation for the economy. It also helps money managers who want a portion of their portfolio to be in that part of the risk-reward spectrum.

Health care is a fertile field for private equity. You might not think so because of concern about rising costs, but as someone once said, “One person’s costs are another person’s income.” Let’s look at it this way. First, more people will have access to insurance to pay for diagnosis and treatment because they will be newly eligible for private insurance under the national health care reform law. Second, demographic changes in society are producing an ever-increasing demand for health care services. Longer lifespans and the aging population offer a growing number of people with cancer and the other diseases that are more likely to occur with age. The number of Medicare beneficiaries is projected to rise from 46.6 million today to 78 million in 2030. (It was 40 million in the year 2000.)

It is with this background that we should consider the growing interest by private equity in proton beam facilities. You have heard before about my real concern about the cost impact of rapid expansion of the number of such facilities.

I want to expand on that today and give you a sense of how the dollars work in this kind of investment. I have pointed out how the Medicare rate-setting process contributes to its profitability. Let’s look at this in very rough form.Continue reading…

An Obama-Gingrich-Ryan Ticket on Health Policy Reform

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By SENATOR DAVID DURENBERGER

Newt Gingrich has to be one of the most interesting figures in recent political history.  His soul lives at the intersection of public policy, politics and history.  Because he has been on so many sides of history and policy, political insiders greet his entry into the presidential primary campaign as “Harold Stassen-ish.” I am among them, having entered the Senate the same time Newt entered the House 30-plus years ago.  I don’t know Republican House Budget Committee chair Paul Ryan, but I admire his leadership talent and regret his decision not to run for the Senate from Wisconsin.  It would raise the level of health policy discourse substantially in that “august body.”

Barack Obama is undoubtedly making presidential history.  Given the many policy challenges he has had to take on since January 20, 2009, plus the one he chose to take on – health policy reform, aka PPACA, there’s no question he is in a unique place in history today.  But, it is the Republicans – the “Party of No” on Obamacare – that are carrying the day on bringing health policy in line with health reform on the ground in the U.S. today. Obama’s PPACA sets historic national policy goals.  Ryan and Gingrich articulate the policy means to the ends of the new law.

Public health insurance programs like Medicare and Medicaid should begin now to reward success in meeting access, quality, and value goals where they exist in communities and systems across the country.  On their way to converting to private insurance and “premium support” subsidies when, and only if, genuine competition comes to the insurance marketplace. Along with the information consumers of insurance and healthcare need to make value judgments to purchase.

Obama could encourage this now because he has the new law on his side.  He has a budget/debt ceiling impasse which could make it possible. Unfortunately, he doesn’t know it; and it appears those in his administration charged with implementing PPACA, haven’t figured out how to do it. Bogging down in waivers and new rules and regulations which set the new law up for “socialistic” ridicule, and the president for a messy political campaign which will not, as Gingrich suggests, “lead to a national discourse” on the future of health care policy and politics.Continue reading…

What Dr. Oz Learned From His Cancer Scare

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By DAVIS LIU, MD

Dr. Mehmet Oz recently had a piece in Time titled “What I Learned from My Cancer Scare” in which he became the more humbled Mr. Mehmet Oz.  As noted previously here, Dr. Oz last summer had a colonoscopy at age 50 and much to everyone’s surprise had a precancerous colon polyp.  He was advised to follow-up again for a repeat test in 3 months.

As the Time magazine piece noted, he didn’t return for 9 months despite repeated reminders from his doctor.

From this experience, he essentially stumbled upon what has been challenging American medicine and primary care.  How do we enable patients to do the right thing and get the screening tests done and treatments necessary to avoid premature death and maintain a high quality of life?  As a highly trained professional, Dr. Oz knows the risks and benefits of not doing a preventive screening test.  As a doctor, he knows all of the secret protocols and codespeak we use when calling patients or asking them to see us in the office for important matters.  As a doctor, he also understood the importance of a repeat colonoscopy to ensure no more colon growths.

Yet he didn’t return for 9 months.  Why?

None of us want to deal with our mortality.  Having a screening test means there is a possibility that the test may be abnormal and now we must confront it face to face. Skipping the test means to be blissfully ignorant, even if it is the wrong thing to do.

Also, as Dr. Oz noted, many individuals, particularly those who are otherwise healthy with no family history, feel that many of these tests or interventions don’t apply to them.  Trust me, I know.  As a practicing primary care doctor, do you know how hard it is to convince someone to get screened for colon cancer?  Get vaccinated for pertussis, influenza, or pneumonia?

Continue reading…

The Summer of Sequels

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By DAVID DRANOVE

I have seen this film before. Folks get all excited about the potential for vertical integration to save our healthcare system, and then the facts emerge.

The results of the first major ACO demonstration project are in and unless there is some hidden meaning behind all the data, it looks like ACOs may not be the magic bullet that the Obama administration had hoped. The demonstration began under President Bush and the specific payment structure and quality incentive differ somewhat from the ACO rules under the Affordable Care Act, but the main features are the same – give an integrated provider organization a share of the savings if it can hold down Medicare spending while also offering some quality bonuses.

Despite the fact that the participants included ten of the nation’s best known physician-led integrated organizations, less than half were able to lower Medicare costs by the final year of the project and only two demonstrated consistent cost savings. And the methods used to achieve savings – nurse call centers and telephone health checkups – are the sorts of thing that don’t exactly require vertical integration.

There are going to be excuses – the ACOs need to be run by hospitals, they need more time to develop their information technologies, the performance incentives need to be strengthened. But that is the kind of ex post rationalizing one hears any time an experiment fails to support a theory. Maybe the theory (that vertical integration is the panacea for our ailing system) is wrong.Continue reading…

Creating Value-Based Incentives For Primary Care

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By BRIAN KLEPPER & DAVID KIBBE, MD

In a remarkable recent interview, Donald Berwick MD, Administrator of the Centers for Medicare and Medicaid Services (CMS), eloquently described his vision of value-based health care.

Paying for value is an incentive…The underlying idea of improvement is that American health care, historically built in fragments, often cannot achieve for patients what it really wants to achieve…Health delivery system reform refers to really reconfiguring care into much more seamless coordinated-care operations so that people, especially those with chronic illnesses, experience continuity of care over time and space.

So when patients come home from the hospital, there is a smooth handoff, and all the necessary information follows them. When they are seeing a specialist, that specialist is coordinating care with their primary care doctor.

This description probably resonates with most health care professionals as a better approach than the current paradigm’s fragmentation and lack of continuity of care. But as with many things in health care, it won’t be easy getting to a value-based health care approach in Medicare and Medicaid. Despite wide acknowledgement that fee-for-service perpetuates our health system’s most undesirable characteristics, the mainstream of American health care seems stuck. One wonders whether CMS can rise above the special interest lobbying, get beyond the interminable pilots and decisively act on payment reform with the conviction required to help save health care from itself.

Still, the idea of value-based reimbursement begs questions. What payment methodology will incentivize the best quality and most efficient care? What path can take us there?Continue reading…

Why Angry Birds Gets More Play Than Health Apps

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By JESSIE GRUMAN


I have been musing about why, despite our fascination with gadgets and timesaving devices, so few of us use the apps and tools that have been developed to help us take care of ourselves.

The range of options is staggering – my iPhone coughed up 52 applications for medication reminders just now – but most of us don’t make use of the (often free) high-tech help available to us.  There are hundreds of websites and portals to help us monitor our diets, physical activity and blood sugar, talk to our doctors by e-mail and understand our test results.  Apps can help us watch for drug interactions, unravel our test results, adjust our hearing aids and track our symptoms.  Devices can monitor whether our mom is moving around her house this morning or continuously monitor our vital signs.

Interesting ideas.  Modest pickup.

In an essay published in the May issue of the American Journal of Preventive Medicine supplement “Cyberinfrastructure for Consumer Health,” I make some observations about why this may be so, based on my experience as a person who daily responds to an exciting variety of chronic and acute conditions that ebb and flow in my body.  My remarks are addressed to those who fund and develop devices and Web-based tools to help those of us with chronic conditions better care for ourselves.Continue reading…

Health Data-Palooza!!!

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Thursday June 9, 2011, 9:00am EDT
Watch the Live Webcast: http://videocast.nih.gov/ or http://www.hhs.gov/live/

Harnessing the Power of Data to Improve Health

Featured Speakers: Aneesh Chopra, US CTO; Tim O’Reilly, O’Reilly Media; Matt Miller, NPR; Harvey Fineberg, IOM President; Todd Park, HHS CTO; and many others

The Health Data Initiative is a public-private collaboration that encourages innovators, entrepreneurs, startups, data geeks, community activists and policy makers to utilize health data to develop products and applications to raise awareness of health and health system performance and spark action to improve health.

On June 9th the Department of Health and Human Services and the Institute of Medicine will hold a second health data forum that will bring together over 500 people in person to showcase how health data can create tools and applications to support more informed decision-making by consumers/patients, health care systems, and community officials.

The innovators presenting are a great example of how data and technology can be harnessed in powerful ways to help provide better care and better health.

Over 40 companies will be featured. This event will be live streamed throughout the day with a series of major announcements (challenges issued, new university programs and partnerships, and new major activity in the startup world).

Follow along on twitter: #healthapps

Sign up for a reminder!

See the Agenda (The full day will be webcast live)

Attend a Viewing Party near you

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