Thursday, August 27, 2015

"Fusing" Randomized Clinical Trials and Big Data: Another Value Proposition for Population Health?

Randomized controlled trials are the crown jewel of clinical research.  By allocating patients to one of two or more treatment protocols (or "arms"), they can ascertain cause and effect while also eliminating any known or unknown bias from the results.  As a result, they often provide "the" answer to the big questions about the true value of medical interventions.

Unfortunately, they're also difficult, expensive, time-consuming, can only gauge average impact, often exclude many "real world" patients, require patient consent and have made little impact on day-to-day health care. 

Enter Big Data.

Defined as the "rapid analysis of (multiple) data sets using sophisticated machine-learning strategies," it is inexpensive, fast, uses readily available information, can give insight at an individual level, don't necessarily require patient consent, and also have had little impact on day-to-day health care.

So, Derek Angus suggests in the latest issue of JAMA that the two approaches can be fused:

1. Use electronic record based machine intelligence to scour the clinical data bases to find candidates for the trials, prompt the doctors to recruit the patients and then enter them immediately at the point of care;

2. Change the entry criteria as the application of Data to the randomized trial results begin to show that one arm is showing greater promise versus other arms;

3. Tilt the randomization toward one arm of the randomized trial if it begins to show a clinical advantage;

4. Have organizations commit to recruit ALL patients who would meet entry criteria to participation in the randomized trial.

To his credit, the author points out that there would be some challenges. Increased complexity could increase the threat of hacking of electronic health records. Convoluted recruitment, assignment and data analysis could be vulnerable to manipulation.  Without high numbers of participants, heterogeneity could introduce hidden biases and undermine confidence that any observed results are real. Despite assurances that there is increased odds of actually benefitting from participation, physicians and their patients may still be reluctant to cooperate.

While this paper is really about using Big Data to help increase the efficiency of randomized trials, the Population Health Blog finds the concept intriguing. It wonders if large academic centers and traditional research sponsors have the flexibility to change their usual way of doing business.

The PHB makes note of one additional barrier: a small but additional burden on clinical workflows. While it may only take a few more minutes for a physician or nurse to deal with the prospect of a clinical trial, the multiple inefficiencies of the EHR have already added up to a significant burden. While the merits of clinical research are significant, front-line nurses and docs could view this as just one more hassle.

Since Population Health Management service providers already possess expertise in big data and electronic records, applying this to randomized trials may represent a new value proposition for the industry. Now that would be a big impact.

Friday, August 14, 2015

Scaling Mindfulness to Population Health and Tobacco Addiction: The Science Behind the Art

Think about it....
Years ago, the young Population Health Blog was a part of a nurse-led tobacco cessation program.  Hundreds of patients later, we reported the one-year quit rate of over 30%. That seminal research catalyzed the creation of other nurse-based programs in asthma, diabetes and heart failure. The PHB and colleagues didn't know it at the time, but it was the start of an almost 20 year journey in population health that continues to pay dividends today.

The art and science of population health continues to evolve, however.  That's why the PHB is always happy to hear from the leadership of outfits like Craving to Quit.  And this is something different.

As readers may know, "apps" are becoming an important part of the population health landscape, but what the PHB didn't know is that an app could be combined with the science of "mindfulness."

Mindfulness?  Conscious intention was a part of the PHB's martial arts training, but it didn't know that there was a science to it and that could be applied to health care.

Mindfulness can be defined as being attentive to and aware of what is taking place in the present. By consciously stepping back and being aware of the status of your well being, the accompanying cognitive insight enables the "user" to better cope and manage the wide array of emotional states. That can include enhancing a state of wellness or, conversely, combating depression, anxiety, addictions and cravings  The PHB didn't know this, but it's been a subject of intense basic neuroscience as well as clinical real-world research (here and here) for years.  And if you're wondering if there is a Buddhist pedigree in all of this, you're right.

Enter Craving to Quit.

It's seeking to scale one-on-one mindfulness to populations using an app that can be used to combat tobacco addiction.  Users can prompt attentive mindfulness to manage nicotine-withdrawal related cravings.  Add in feedback, access to a community of like-minded users, live expert addiction coaching, plus a library of video-based instructional resources and - boom! - an academic backwater of "mindfulness" turns into a robust population-based intervention.

And credit to the leadership at CtoQ for committing the resources to precisely measure their outcomes for the scrutiny of peer review.  They're conducting an Institutional Review Board - approved randomized clinical trial to further document the impact of mindfulness. As the PHB has written here, without a disciplined approach to documenting outcomes, population health service providers are putting themselves and the industry at significant risk.

Being mindful of an attitude of plenty, this is good news for the art and science of population health.
No wonder it caught CNN's attention. It's worth paying attention to.
Their success is our success.

Friday, August 7, 2015

Channeling the Fox News Rebublican Debate for Health Care Reform

Last night, the Population Health Blog secured a suitable beverage supply, pulled up a chair and tuned to the Republican Party debate. As predicted, there was little substantive attention to health reform.

That won't stop the PHB.   Lacking specifics, it's offering an important public service by channeling the debate's bombast to a hypothetical question:

"Specifically, what is the first thing you would do on the first day of your administration, as the next U.S. President, to control the growth of health care spending?"

Chris Christie - "I'd do hugs, not drugs!"

Scott Walker - "Since they've hacked all our medical records anyway, let's outsource it to China."

Rand Paul - "Stop the outsourcing of how we pay for it to China!"

Ben Carson - I've done brain surgery on conjoined Siamese Twin health policy specialists; one lost their brain and when I was done, I couldn't tell the difference between the two!"

Donald Trump - "You're stupid for even asking that, but I'd build a wall around every hospital."

Jeb Bush - "If everyone ate some milquetoast everyday like I do, they'd be calm and healthy, like me!"

Ted Cruz - "I'd shut down the government."

John Kasich - "If all Americans would only go to Ohio hospitals, costs would go down."

Marco Rubio - "I had a $100,000 in educational loans, and I look forward to $100,000 in loans to pay for my health care bills."

Mike Huckabee - "The purpose of health care is not not kill people or break things!"

Thursday, August 6, 2015

The Gap Between Rank and File Physicians and Their Leaders

Awaiting our orders
Talk about a study in contrasts.

According to this Commonwealth Fund and Kaiser Family Foundation survey, only a minority of "front-line" primary care providers (including a sample of non-physicians) believe that the major linchpins of health reform such as value-based payments, Accountable Care Organizations (ACOs) and medical homes are having a "positive impact on medical care."

The survey relied on a representative national sample of 1,624 primary care docs and 525 nurse practitioners and physician assistants who were working in primary care practices.  64% and 87%, respectively, were compensated with a mix of salary and/or capitation and 55% of the docs' had incentives that were based on quality, patient surveys or cost. Just under 30% were participating in some sort of ACO arrangement.

Only 33% of the physicians and 40% of the non-physicians believed medical homes are beneficial. 

26% of the physicians also viewed ACOs negatively.  Among the physicians who were in an ACO, "three of 10 said ACOs are having a positive impact, one-quarter said their impact is negative, and 20 percent said they have no impact."

What's more, 50% and 40% of physicians and non-physicians believe quality incentives are having a "negative" impact on the quality of care.

And how bad is it? 47% and 27% of physician and non-physicians are considering retirement "earlier than they thought they would."

And then there is this separate report by the "American Association for Physician Leadership."  According to partner "Navigant Center for Healthcare Research and Policy Analysis," this survey of 2,398 of the Association's members shows that "55%" believe the Affordable Care Act has "more good than bad," that "69%" felt that physicians should be held "accountable for costs of care" and that 57% agreed that ACOs will "be a permanent model for risk sharing."

And just was is the AAPL?  The Population Health Blog didn't know this, but it's the rebranded American College of Physician Executives (ACPE).  Being a member of AAPL doesn't necessary mean that a doc occupies a position of leadership in a hospital or clinic, but the credential suggests a strong interest in that career path.

Why the disconnect between physician leaders and rank and file primary care physicians

It could be argued that their vantage point enables the leaders to be better aware of the realities of health reform and that those realities have yet to be communicated or accepted by primary care physicians.  Cue the narrative about education, aligning incentives, letting the malcontents quit and questioning whether physicians should even be in charge.

But the PHB isn't sure that quite explains everything.

The recent controversy over maintenance of certification (MOC) is a telling example of how easy it is for otherwise smart and respected physician leaders who are advancing quality and value to get it really wrong.  Thanks to all the publications, webinars, meetings, PowerPoints in the closed-information loops of health reform, it's too easy for well-meaning leaders to recycle Washington DC's value-based nostrums.  The PHB is running into many of them, and the group-think is getting both boring and alarming.

In other words, just because "leaders" are championing change doesn't mean the rank and file "get it."  There is also no guarantee that there won't be inconvenient raising of ethical concerns, a reprise of the anti-managed care backlash, a strike threat or even acts of civil disobedience.

Based on the input of physicians who are at the front lines and are seeing the impact first hand, health reform remains very much a work in progress.  And maybe it's the physician leaders that don't get it.

Stay tuned.

Image from Wikipedia

Thursday, July 30, 2015

Health Care Cost Inflation Returns

True, that....
Call it the return to the old normal.

With the slow recovery of the U.S. economy, the advent of some blockbuster drugs and the entry of more than 8 million newly-insured persons, healthcare cost inflation is ticking back up. Writing in Health Affairs, CMS' actuaries are projecting a 5.8% year-over-year rate of inflation that reminds them of the years prior to the Great Recession. This rate is projected to grow faster than the Gross Domestic Product (GDP), which means that by 2024, the U.S. will be devoting 19.6% of its economy to healthcare.

Some eye-catching observations:

1) If it weren't for consumer cost-sharing, the inflation rate would be even higher;

2) Drug treatment for a single disease - Hepatitis C -  is driving prescription drug costs "sharply higher" and adding to the overall 5.8% rate;

3) No mention of the impact of the administration's innovations, like accountable care organizations;

4) Substantial uncertainty.

The Population Health Blog's take:

In a highly competitive global economy, even single point increases in healthcare costs underlying the manufacture of items that make up the GDP, automobiles or washing machines, is bad news.  If the projections are true, business leaders could reconsider the merits of overseas outsourcing or start dropping employer-based health insurance.

Costs in 2015 and 2016 will be lower than the 5.8% rate, which means it won't hurt enough to make healthcare a big factor in the 2016 elections.  While the Affordable Care Act remains a rhetorically rich target environment, the PHB expects politicians on both sides of the partisan divide to find better red meat elsewhere, like building thousand-mile walls or buying hundreds of millions of solar panels.  So, if you're an investor in healthcare stocks, continue to go long.

Any good news in other sectors of the economy could paradoxically make healthcare costs look comparatively worse. As energy and housing costs creep along at a lower rate, consumers are going to see a greater percent of their income going toward healthcare - either in the form of health insurance premiums or out-of-pocket cost-sharing.  If (and that's a big if) the U.S. economy can return to its efficient cost-cutting ways, expect the healthcare debate to heat up and for calls for a government-sponsored option to increase. 

The mean increase of 5.8% is an average.  Some segments of the insured population will see higher costs and others will see lower costs "around" the mathematical mean.  Which voter block "loses" by paying more than the 5.8% could drive the coming debate as it shifts from insurance coverage to affordability and access.  Case in point: the PHB's spouse is registered to vote and she's not happy with the guesswork behind our pricey monthly insurance premium.

While Americans have reasons to be reluctant to travel overseas for cheaper surgery, they'll be far less so for access to a course of just-as-good medications that are under foreign price control.  Call it medication tourism.

And finally.... uncertain abounds.  No one saw that Hepatitis C would have such a near-term impact.  Who knows what else is out there?  A new epidemic?  Another cure?

Stay tuned!

Thursday, July 23, 2015

A Primer on Population Health

If you need to help a colleague who is clueless about cost-saving potential  of population health, the Population Health Blog recommends you refer him or her to this efficiently written primer from The Health Care Transformation Task Force's High Cost Patient Work Group.

Basically, if the small number of patients who are destined to be high cost can be prospectively a) identified and b) helped, a lot of money could be saved.  By focusing resources on a small fraction of insured people, the costs for the entire risk pool can be decreased.

In the meantime the majority-remainder of the population can be aided with other lower-cost resources that include, but are not limited to wellness and prevention.

Who are the small numbers of people?

1) patients with a) advanced illness who are nearing end of life who may benefit from b) hospice.

2) patients with a) high spending patterns who may benefit from b) coordination of care by a dedicated health provider (such as a nurse or a lay community care worker).

This population does not include:

3) high cost patients with a) any illness who b) are destined to get better all by themselves or c) unlikely to derive any benefit.

Algorithms to spot that small number of patients use diagnosis codes, treatment codes and medication utilization data from the electronic record or insurance claims databases.  Other useful insights can be gained from patient surveys (and a number are available), using public data to ascertain socioeconomic status (zip codes are destiny), asking physicians to refer patients who are at risk and the design of insurance benefit (patients may not be aware that certain services are covered).

The science behind the use of these inputs is imperfect but getting better, and the more inputs, the better.  Don't let the perfect be the enemy of the good, however, because simple algorithms based on readily available data will get you started.

One of the advantages of this approach is that the cost of coordination of care is variable.  It can start small and be flexed up as expertise grows and opportunities arise

The Population Health Blog couldn't have said it better.

Wednesday, July 22, 2015

Are Primary Care Physicians (PCPs) Important to ACO Success? Payment Arrangements Say Otherwise

Long ago, the Population Health Blog learned that when it comes to health insurance, capitation or bundled payments brakes, while fee-for service payments are gas. Too many physician office visits?  Use "capitation" brakes. Want to increase physician visits?  Apply a payment for each encounter with some FFS gas. 

Health care organizations can pass this arrangement onto their physicians. They can pay them with a salary (a form of capitation), or a variable "productivity" compensation (seeing more patients is compensated with a form of FFS) or with a combination of both.
Simple, right?  To figure out this ying-yang of utilization management, just follow the money.

That's why the PHB was interested in this just-published Annals of Family Medicine paper on how primary care physicians are being paid by Accountable Care Organizations (ACOs). If you believe more primary care visits translate to savings in other parts of the ACO, then you'd want to apply gas. If you believe primary care visits are a cost that doesn't necessarily save money, you'd want to apply the brakes.

The authors used data from the 2012-2013 "National Survey of Physician Organizations" to compare primary care physician (PCP) compensation in ACOs with non-ACOs. 1,398 organizations were in the original database; after excluding solo practitioners and specialist physician organizations, 632 were left. 

Three groups were compared:

1) Medicare ACOs (21.1%) with exposure to some financial risk related to total health care utilization;

2) Non-ACOs (2.8%) with contracted financial risk for primary care costs (2.8%);

3) No ACO and no risk (76.1%).

Results?  PCPs in.....
Medicare ACOs got 49% of their income from a flat salary and 46% tied to productivity. 3.4% was tied to quality;
Non-ACOs at primary care risk got 66% of their compensation from salary, 32% tied to productivity and .8% from quality;

No ACO arrangements with no risk had compensation that was similar to the Medicare ACOs.

The PHB's take-aways?

Based on the non-ACOs, health care organizations are prepared to use salary to influence physician behavior.  If you believe PCP visits are a cost and you are at financial risk for utilization, apply more brakes than gas.  The model is still out there.


The leaders running Medicare ACOs don't know what the right balance of FFS and capitation for PCPs, and are mirroring a status quo that is indistinguishable from business as usual.  Despite the fanfare about the critical role of primary care in health reform, the Medicare ACOs have decided otherwise. If they ultimately succeed or fail, it won't be because of any special innovation involving their PCPs' compensation.

Image from Wikipedia

Thursday, July 16, 2015

The Latest Health Wonk Review is Up!

Hank Stern of the InsureBlog has posted the latest version of the Health Wonk Review.  Titled Hot Summer Nights, Cool Summer Drinks, this compendium of posts is sure to quench any thirst for health policy braininess.


Wednesday, July 8, 2015

Three Downsides to Commercial Health Insurer Consolidation

Writing in The Wall Street Journal, Scott Gottlieb argues that the Aetna-Humana and the Anthem-Cigna combinations are evidence of waning insurer competition that is the direct result of Obamacare.  Not only are ACOs not a panacea, but the Affordable Care Act's insurance mandate to limit administrative costs is forcing Aetna et al to spread their costs over a larger base.  Dr. Gottlieb fears that the oligopolies won't be able to deliver on innovation and will limit consumer choice   

Too bad The WSJ didn't give him more print space.  If they did, Dr. Gottlieb may have also pointed to three other potential downsides to commercial insurer consolidation:

1) The concentration of risk: While having a small regional health insurer go bust is a big problem for hundreds of thousands of insurance enrollees, having a for-profit national insurer with tens of millions of enrollees go bust would be a national catastrophe. Think Lehman Brothers, Black Swans and Too Big To Fail.

2) Cronyism: Politicians and C-Suite executives no longer blush at the prevalence of the revolving door between government and all industry.  Health insurance will likewise be too regulated and complicated to leave to anyone other than insiders, who will naturally be unable to discern the line that separates their interests from the patients'.
3) Political Power: Will Washington DC and 50 states really be able to stand up to a handful of companies that dominate a fifth of the national economy?  Years ago, the commercial insurers remained silent while they were called "Fat Cats." The Population Health Blog bets that the next time a While House blames the insurers for rising costs, they won't remain so deferential.

Image from Wikipedia

Friday, June 26, 2015

The Potential of Community Health Workers (CHWs)

He was among the highest.

Utilizers of healthcare services, that is. 

I had the pleasure of talking to a physician who is leading a group of community health workers (CHWs) assigned to taking care of dozens of patients like this.  Burdened by decades of multiple chronic conditions, patients like him are typically struggling with myriad complications of chronic illness, side effects from numerous medications, mental illness, extreme poverty and homelessness.  The result is an endless cycle of emergency room visits, admissions, discharges and more emergency room visits.

According to the physician I talked to, these highest utilizers don't need more physician care; us docs can only do so much with an office visit. They also don't need health insurance, because they already have it. 

What these patients really need are resources that can help bridge the aspirations of health reform and the reality of the street.

The Population Health Blog agrees. In its professional career, it saw plenty of insured people with access to health care who were still unable to get better.  They didn't need more of the PHB, they needed..... help, in the form of monitoring, education, coaching, encouragement and advice.

Enter this timely article by Dr. Kangovi and colleagues appearing in the June 11 issue of the New England Journal.  It's a good primer on the long history of CHWs and the work that will be necessary to mainsteam them into health reform.  
CHW-based programs in the U.S. have been around since the 1960s. They typically focus on the indigent, are modest in scope, and have been funded "hand-to-mouth" by community organizations.  However, they've also been used to facilitate insurance enrollment, support "Medicaid Health Homes" and provide preventive and screening services on a regional basis. 

The PHB believes, however, that their greatest value proposition may be in supporting interventions for high utilizing patients under Medicaid waiver arrangements or in managed care programs. By coordinating alternatives to the emergency room revolving doors, CHWs can save taxpayers a lot of money.

Dr. Kangovi et al describe five barriers to the widespread adoption of CHWs:

1) Insufficient integration with traditional providers - But the good news is that CHWs can now use the shared data and remote electronic communication of health information technology to extend the reach of the non-physician (e.g. nurses, social workers) members of a medical home.

2) Fragmented health care systems - But the good news is that health care organizations are slowly being forced out into the communities that surround them. CHWs are waiting.

3) Lack of treatment protocols - But the good news is that this is an emerging science. Some on-line resources already exist.

4) High worker turnover - the authors cite one Harlem program that lost a third of their workers over a matter of months.  The good news is that there are ways to identify "keepers" who will find the CHW career to be satisfying.

5) Low quality published evidence - But the good news is that the volume and the quality of published research is going up.  Even better news is that that will help inform accreditation programs.

That high utilizer mentioned above?  The PHB learned that his last encounter with the health care system was in a primary care provider's office, in the company of a CHW.

Image from Wikipedia