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The Inspector General Observes

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By PAUL LEVY

A recent report by the Massachusetts Inspector General raises a thoughtful concern about the implementation of global payments in the state.

In the effort to contain health care costs, much discourse has centered on moving from a predominantly fee-for-service system to one based mainly on global payments to providers organized as Accountable Care Organizations (“ACO”). There is little doubt that fee-for-service reimbursements create incentives for providers to increase utilization of health care services, with obvious inflationary consequences. But moving to an ACO global payment system, if not done properly, also has the potential to inflate health care costs dramatically.

There is nothing inherent in the current marketplace that would cause an ACO-based global payment system to contain health care costs. The evidence, in fact, suggests the opposite conclusion. For the past two years, the primary experiment with global payments in the private insurance market in Massachusetts has been the Alternative Quality Contract (“AQC”) popularized by Blue Cross Blue Shield of Massachusetts (“Blue Cross”). The payments to providers under this contract are made on a global capitated basis. The capitated amounts are determined by starting with the previous year’s experience of the population of lives covered by the specific AQC. That entire amount becomes the base year from which all future payments are derived. Therefore, the AQC embraces and adopts any excessive or wasteful payments in that base year, including all overutilization resulting from over a decade’s worth of fee-for-service provider contracts. Implicitly, the premium increases of that decade, which overall were well in excess of 100%, are made a permanent part of our health care system’s cost structure.Continue reading…

AEI defends Health 2.0 vs the “old guard”

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Not often a lefty like me promotes AEI, but Jon Entine has written a great piece attacking the behavior of the FDA. For the last 3 years the establishment has been attacking the DTC genomics companies for basically allowing people to access their own information. But it’s worse than FDA and others telling the fibs that Entine’s exposed. At a meeting two years ago in DC I asked the regulator from New York state why they were going after Navigenics & 23andMe. Her answer “doctors have power in my state”.

Tele-what?

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By NEIL VERSEL

As a journalist who for the last decade has covered the use of information technology in health care, I’m rather disgusted at some of my brethren in the mass media. I’m none too happy with the medical establishment, either. Both seem hopelessly stuck in the past, refusing to look beyond the status quo. And the public suffers because of it.

This fall, for example, the Los Angeles Times and other news outlets covered a Yale University study that sought to determine whether or not “telemonitoring” heart failure patients recently discharged from the hospital would reduce heart attacks or readmission. The study, published in the New England Journal of Medicine and presented at a November meeting of the American Heath Association, concluded that that telemonitoring, which involved patients calling in their weight measurements and health symptoms after being discharged, made virtually no difference in the outcome. The Times called the trial “a good, commonsense idea that simply didn’t work out.”

Was it, really?

Keeping in touch with one’s physician on a frequent basis after being hospitalized for heart failure is a fine idea, as is monitoring one’s weight. But, as happened in the Yale study, patients generally don’t stick with the program. One in seven study participants never called their doctors, while just 55 percent of patients were making at least three calls per week six months after discharge.Continue reading…

Looking For Quality In the Wrong Place

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By CHRIS LANGSTON

Last week I attended the first annual meeting of the Long-Term Quality Alliance and listened to Gregg Pawlson (a geriatrician and executive with NCQA) talk about quality measurement.  Right now, quality measurement does too little to drive practice towards quality care because it is based only on things that are “feasible,” or easy to measure—like what gets coded on medical bills. Pawlson observed that while feasibility must be one of the watchwords of quality measurement for now, in the near future electronic medical records should allow us to move beyond billing codes to gather real clinical data for more important quality measurement, including key care processes and outcomes.

I sure hope so. Because those who have looked beyond the dim illumination of current billing-based “quality measures” and searched in the darkness where real processes of clinical care can found have found that the situation is grave.  The ACOVE (Assessing Care of Vulnerable Elders) process, while laborious, looks at clinical care where it really happens – in offices and charts – rather than in bills and therefore has a better chance of driving meaningful quality improvement. Readers  know that I am a big fan of this work, begun at RAND by outstanding clinician-researchers including Neil Wenger, David Solomon, David Reuben, and many others.  I believe that ACOVE is an example of what we need in elder care: high quality evidence about essential clinical practices that are sensibly related to real health outcomes and show how we could (often easily) do better for older people.  ACOVE is a blessing.Continue reading…

Not So Fast – Why It Pays to Wait Until FY 2012 on Meaningful Use

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By PROTIMA ADVANI

The registration process and reporting period for the meaningful use incentive program officially commenced on Jan. 3. More than 21,000 health care providers have registered to date and many more are ramping up efforts to meet meaningful use criteria and collect federal incentives in fiscal year 2011. However, rushing out the gates in FY 2011 is extremely risky and not advisable. In fact, the Advisory Board Company strongly recommends waiting until FY 2012 to first demonstrate meaningful use.

Three key reasons hospitals should wait until FY 2012 are outlined below.

Compressed, unreasonable timeline for achieving Stage 2: The final rule states hospitals that first demonstrate meaningful use in FY 2011 will need to achieve Stage 2 by FY 2013 (i.e. Oct. 1, 2012). Furthermore, hospitals must demonstrate meaningful use requirements for the entire year in Stage 2 as opposed to the 90-day reporting period for the first year that a hospital is a meaningful user. Unfortunately, the final rule defining Stage 2 requirements will not be finalized until mid-2012, leaving hospitals that first demonstrate meaningful use in 2011 with less than six months to meet Stage 2 by Oct. 1, 2012. This will be an unattainable leap for health care providers, especially because Stage 2 is being positioned as a step down from Stage 3, not a step up from Stage 1. Stage 2 comprises enhancements to Stage 1 requirements in addition to a host of new, more complex criteria and clinical quality measures. Furthermore, hospitals will be dependent on their vendors’ ability to rapidly develop, test and seek certification for the Stage 2 EHR capabilities, adding another barrier to provider Stage 2 meaningful use achievement in the short time frame available. In contrast, waiting until FY 2012 to first demonstrate meaningful use will afford hospitals nearly 18 months to migrate from Stage 1 to Stage 2 — a more adequate time frame to acquire, implement and adopt the required capabilities for Stage 2.Continue reading…

From Jeopardy! To Your Physician’s Black Bag: Could a Supercomputer Really Assist With Health Care?

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By DAN PELINO


IBM’s Jeopardy-champion computer, Watson, has huge potential for helping physicians and other clinicians work with patients.

The leap from TV game show to physicians’ offices will probably take at least two years. But Watson’s understanding of natural language, vast storehouse of information and ability to keep up with rapidly changing medical research could significantly improve medical care.

The medical faculty at Columbia University and University of Maryland are helping program a Watson-type computer to assist clinicians.

A few years from now, consulting Watson could become a routine part of a clinician’s practice. Caregivers have traditionally resisted computerized assistance in diagnosis and treatment because the technology has been awkward to use and questionnaire-based systems have been too rigid. But Watson can “understand” descriptions of a patient’s symptoms in natural language, and it can even scan years of medical records and doctors’ notes to determine what diagnostic and therapeutic options it might suggest. Doctors can ask it questions using the same terms they would use in an e-mail to a colleague. Continue reading…

Maine Waiver Expected to Increase Insurer Pressures on States

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By ROGER COLLIER

HHS’s bellwether decision of last week to grant the State of Maine a three-year waiver from the medical loss ratio provision of the ACA may lead to new efforts by insurers across the country to persuade states to demand similar waivers.

The HHS decision on Maine was not unexpected. The ACA language clearly allows for waivers when imposition of the MLR 80/85 percent threshold penalties would lead to disruption of a state’s insurance market. Maine, a state with very few major employers, has a higher than average percentage of small group and individual policies which typically provide higher out-of-pocket costs—and consequently higher administrative percentages. HealthMarkets, one of the two dominant insurers in Maine, had threatened to abandon the state’s individual market unless a waiver was granted. (According to a Bloomberg report, HealthMarkets, which is majority-owned by two large investor funds, was recently sued by the City of Los Angeles for selling policies with provisions that allegedly effectively eliminated needed coverage.)

Three other states (Kentucky, New Hampshire, and Nevada) have already filed waiver requests with HHS, and an additional eleven states are reported to be preparing waiver requests.

Almost certainly, every insurer with significant business in the small group and individual markets will be eying the Maine waiver decision with a view to applying pressure to those state insurance regulators who are not yet preparing waiver requests. While Maine appears to have had an unusually strong case for a waiver, the absence in the ACA of any specific measures for “market disruption” may make it difficult for HHS to reject such requests.

Roger Collier was formerly CEO of a national health care consulting firm. His experience includes the design and implementation of innovative health care programs for HMOs, health insurers, and state and federal agencies.  He is editor of Health Care REFORM UPDATE.

Medicaid and (supposed) Welfare Dependence

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By HAROLD POLLACK

Jonathan Cohn has a piece on Medicaid yesterday with which I agree. I want to amplify one related point.

National Review and Forbes writer Avik Roy believes that Medicaid is a “humanitarian catastrophe” which is actually worse than no insurance at all. Now Scott Gottlieb has taken up the argument in the Wall Street Journal. I’ve noted before that this is a bad argument. Medicaid should certainly provide better coverage. I’d also like to see the new exchanges provide poor people with better options outside of Medicaid. Yet the claim that people would actually be better off uninsured than they would be with Medicaid—this strains credulity.

I’ve basically said my piece regarding the causal impact of Medicaid in various studies. I want to pick up a different aspect of this debate.

Roy’s response to my initial column includes the following:

Many of the factors Harold raises as flaws of the study are actually flaws of Medicaid. It’s Medicaid that restricts access to the best hospitals and the best doctors and the best treatments. It’s Medicaid, i.e., welfare dependency, that leads to family breakdown and social disrepair. (For those who seek a more extensive discussion of this problem, read Charles Murray’s landmark book, Losing Ground: American Social Policy 1950-1980.)

I took umbrage at that, as indicated below. Roy then took umbrage at my umbrage, writing:

One aspect of Harold’s post is wholly unjustified, and a bit of a cheap shot: his assertion that I am “disrespectful” and “disparaging” to welfare recipients, because I’ve highlighted the corrosive effects of welfare dependency (something Harold dismisses as a “bromide”). We’ll never have a constructive debate on Medicaid policy if we can’t get past this kind of nonsense. The entire point of my series of posts on Medicaid is that Medicaid beneficiaries are the victims of an uncaring and bureaucratic system, and also the victims of those who, for ideological reasons, ignore the very real problems that Medicaid has.Continue reading…

A Speed Bump on the Road to Meaningful Use

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By MARGALIT GUR-ARIE

Meaningful Use has hit a speed bump. It’s of the low, wide and gentle type, not the old raggedy, narrow and mean bump you find in older parking lots. Now that a tentative proposal for Meaningful Use Stage 2 has been published by ONC, and duly commented upon by the public, it just dawned on folks that there isn’t enough lead time between Stage 1 and Stage 2 to allow for an orderly transition, and here is the problem in a nutshell.

Meaningful Use is divided into three, increasingly more demanding, stages, starting in 2011 with Stage 1 and advancing every two years to a higher Stage. So 2013 marks the beginning of Stage2 and 2015 is the start of Stage 3. It seems that ONC and CMS need about a year and a half to define each Stage from start to finish, so if they start working on Stage 2 right after Stage 1 commences, there are only 6 months left for NIST to define certification criteria, EHR vendors to update their wares and certify them, and physician and hospitals to roll the new and improved products out. Oops……

The hand wringing in “industry experts’” circles began immediately after this realization, culminating with an Advisory Board publication advising hospitals in particular to not apply for Meaningful Use incentives in 2011, but instead wait for 2012, which they can do without penalty, and the same advice is applied to ambulatory practices owned by hospitals. They did not recommend anything for physicians in private practice. Continue reading…

A Doctor is Not a Bank

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By KEITH W. BOONE

All too often I’ve heard the comparison between the financial industry and its efforts to make transactions electronic, and the healthcare industry.  But health is not something that I can make deposits on and withdraw later.  We aren’t talking about a case where there are only two organizations completing business transactions on behalf of their customers.

There’s a lot more going on here.  A better comparison would be to automation supporting electronic commerce between multiple businesses.  I’ll use electronic publishing as an example, since I have some history in that space.

Imagine that you had a customer needing a new web page.  You have to understand what the customer is trying to accomplish, and then design a page to meet their needs. Along the way, you have to obtain assets:  Text content, media (pictures or video), put it together, get approvals, and publish the content.  Obtaining the assets might involve negotiating access to content from others, paying someone to provide it, or simply assigning the job of creating it to someone on your staff.  Afterwards, you need to put all those pieces together into a coherent whole, possibly get someone to review and approve it, and then it gets pushed out to the web.  Anywhere along the way you may learn that there are other tasks to perform.  Some of the content may need to be coded in Flash, in which case, you might need to put a flash player download button on the site (which means you need another piece of content), et cetera. Oh, and if you are providing full service, you might also evaluate how people respond to the page, and make any adjustments necessary to improve their response.  Now, consider making that whole process electronic, and you begin to understand the complexity of healthcare. BTW:  There are systems that support this process electronically, but they are proprietary.Continue reading…

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