Wednesday, April 16, 2014

The Dichotomy of Medicare’s Data Release Policy: Moral Suasion and the Limits of Mass Data Transparency

The Disease Management Care Blog continues to welcome blog posts from outside authors. This is another one courtesy of Erik Tollefson, who works in the health policy field. He can be reached at erikDOTmDOTtollefsonATgmailDOTcom.

Medicare has had an interesting few weeks: Not only did Congress manage to pass another one-year “fix”  to the (unsustainable) sustainable growth rate reimbursement scheme, but planned Medicare Advantage cuts magically turned into a marginal increase (at least for some insurers) after deftly applied political pressure. This behind-the-scene politicking set the stage for CMS’s second massive release of provider data last Wednesday. Although the data release may further codify extant evidence of some specialists being more richly compensated than their primary care colleagues, coupled with the potential pursuit of fraudulent claims, unfiltered transparency reveals Medicare’s weakness in providing useful transparency for beneficiaries. 

CMS formally released data detailing the 100 most common inpatient services, 30 most common outpatient services, and all physician and other supplier procedures and services performed on 11 more Medicare beneficiaries. The data included information on the doctor who performed the procedure, as well as the city and zip code where the procedure was performed. The biggest related take away seems to be a rather intuitive one: specialists, particularly cardiologists, ophthalmologists, and oncologists, are the biggest recipients of Medicare reimbursements: The three groups of specialists accounted for 7% or $5.6 billion of reimbursements in 2012.

Some in the medical community have responded to the perceived public scorched earth exercise circumspectly: hell hath no fury like scorned ophthalmologists. Valid questions, however, have emerged not only regarding the veracity of released data, but also the lack of context: some individual provider numbers may serve as a pass-through for entire practices, and a longitudinal release of data might allow for a more accurate picture of how service and drug utilization has changed as the country’s demographic profile has grown older. 

In response, CMS and politicians have responded that the benefits of “transparency” would likely drive more cost-effective care with less waste. Putting aside concerns of what transparency actually means in this context, an economist might ask a more apposite question: while the literature shows that public excoriation (in limited doses) may be effective in reducing price variance in an established legislative framework on the supply side, where are equivalent measures to empower consumer (demand–side) decision making?

To perhaps put a finer point on it: while variance in the pricing of procedures by hospitals and providers is certainly a problem, an equal problem is the variance in treatment across patients using non-cost effective treatments and medical devices that add little or no value to outcomes.  On this critical point, CMS and their data are silent. While further data releases may address this critical lacuna in consumer information, it is not likely: statute prevents the agency from making drug and procedure approval decisions explicitly based on costs.  Thus, an odd dichotomy has emerged in Medicare’s transparency campaign: exposure of the downstream cost equation (doctors), while leaving the curtain back on the furtive upstream costs including the RUC committee and other important input prices that would help consumers to make more informed decisions. 

The conflation of releasing big data with transparency is not a fatal error. Numerous useful data products may ultimately be developed as a result of CMS’s efforts.   A bigger problem, however, may be the asymmetrical use of moral suasion to expose doctors to the glare of public scrutiny without giving consumers information on the cost and outcomes related to technology and drugs use. If transparency does not result in more informed decision making, some would argue it is not transparency at all.

Tuesday, April 15, 2014

Seven Things You Need to Know About The Overt Fun and Covert Benefit of Health Gamification

Channeling all this energy for
health and wellness?
The networked Population Health Blog got an alert about this just-published article on the "gamification" of health from the Games for Health Journal

The PHB was only vaguely aware of the growing medical literature that uses humans' love of gaming to promote healthy behaviors, increase prevention and mitigate chronic disease.  And it certainly wasn't aware that there was a entire journal dedicated to the topic.

In this particular article, author Brian Landwehr introduced the PHB to the term "gamification." Using "overt" fun to achieve "covert" benefit, gameplay is combined with virtual or real rewards to engage patients in behavior change. 

Examples include using:

~ videogaming, wireless mats, smartcards and monitors to increase and reward physical activity in children;

~ email/text to remind expectant mothers about appointments and healthy behaviors that are paired with incentives such as gift cards, baby toys and health and safety gear;

~ mobile health apps that track exercise and nutrition choices to earn discounts on merchandise.

What seven things did the PHB learn after reading the manuscript? 

The technology is

1) in its infancy, but it's already being launched in settings that involve thousands of people;

3) utterly scalable, since it can be offered today to entire school districts or fully-insured books of business;

3) very modular, using a surprising amount of "off the shelf" technology that are adapted and combined to build "prototype" products

4) creates products that can also quickly become obsolete thanks to the creation of better and cheaper replacement prototypes;

5) very entrepreneurial, which is one of the drivers behind gamification's surprising growth

6) substitutive when it replaces in-person education, or synergistic when paired with live health coaches

7)  cool because "gamification" is innovation jargon that the PHB cognoscenti can use in meetings and emails to impress their colleagues and stymie their opponents.

Image from Wikipedia

Monday, April 14, 2014

Running for Sheriff and Obamacare

As Washington DC lurches from one partisan skirmish to another, it's only natural that pundits are pining for the good old days of larger than life politicians like Lyndon Johnson.  Despite a recalcitrant Congress dominated by southern conservatives, our 36th President's big-government ideas ultimately prevailed.  

So, while we're looking for ways to ease our national discontent, it's only fair to ask: what would the wily LBJ have done about a vacancy over at Health and Human Services?

The Population Health Blog doubts he would have nominated Sylvia Mathews Burwell.

The PHB recalls the story of the newly minted Vice President soliciting the input of then-Speaker Sam Rayburn about all the brilliant persons that had been tapped to serve the Kennedy's White House.  Mr. Rayburn was less impressed, saying "Well, Lyndon, everything you say may be true, but I'd feel a whole lot better if one of them had ever run for sheriff."

The PHB recalls reading that Mr. Johnson considered that advice when it was his turn to dole out Presidential appointments. As pointed out here, there's something about running for office that instills a better appreciation for the diversity of opinion, the ability to compromise, keeping promises and the risks of public duty.

While Ms. Sebelius was no friend of physicians, the PHB wonders if her past successes in running for public office in Kansas may have partly helped - outside of the debacle - in getting Obamacare passed and implemented.

Despite her Rhodes Scholar and Harvard brainiac chops, Ms. Burwell brings no such experience.  While she's participated in some retail politics, her credentials are essentially that of a high functioning bureaucrat with some worthy, if largely corporate, philanthropic experience.  She's never faced voters.

Combined with her lack of healthcare credentials, the PHB doesn't think Ms. Burwell's Senate nomination process is going to be a slam dunk.  Assuming she prevails and does eventually become HHS Secretary, the PHB doubts her considerable skill set is going to be enough to convince the elected members of Congress to change their minds about Obamacare.

The games will continue.

Thursday, April 10, 2014

Say Hello to Sylvia Mathews Burwell, the Nominee for HHS

The Population Health Blog is naturally intrigued by the announcement that Kathleen Sebelius is resigning from her position as HHS Secretary, and that the White House will nominate Sylvia Mathews Burwell to replace her.

So, who is she? 

After reviewing a number of reports that are summarized below, it seems Ms. Burwell is a widely-liked and experienced Washington insider. She has a Clinton-Lew-Rubin pedigree and possesses considerable economic/budgetary credentials. Most of all, has the best chance of anyone of getting confirmed by a fractious US Senate.

The bad news is that she doesn't appear to have any significant experience in health care or with health insurance.  Whether her past with McKinsey or as a Met-Life Board member will help her collaborate with the state-regulated commercial health insurance business is an open question.

Onto the summary.....

Ms. Burwell is the current Director of the White House Office of Management and Budget (OMB), where she has served since April of 2013. She's described as genial, a liberal who favors social programs, is willing to take on spending-wary Republicans (with government shut-downs, if necessary) but isn't especially ideological when it comes to managing the budget.  Her nomination to OMB also helped quell criticism that the White House was dominated by males.  She was confirmed by the U.S. Senate 96-0.

Her 96-0 vote getting track record makes it far more likely that Mr. Obama's nominee will survive what will likely be an intensely partisan process.

Here's Ms. Burwell sticking to her Obamacare talking points, even if it means glancing at some notes to make sure she's got it right:

Prior to serving in the Obama Administration, she was President of the Walmart Foundation (dedicated to ending hunger). During her OMB confirmation hearings, she was criticized for not distancing herself from the company's anti-union activities. During this time, she also served on the Board of MetLife, which, during her tenure, was criticized for mishandling mortgage loan foreclosures.

Prior to Walmart, she was at the Bill & Melinda Gates Foundation for about 10 years, where she was President of the Global Development Program; she may have been more willing to leave for WalMart when she was passed over to lead the entire Foundation.

And before Walmart, she was in the Clinton White House, where she served in a variety of roles for all eight years of the Presidency. After leading the economic transition team immediately following the election, she then went on to serve in a variety of roles, including Deputy Director of OMB under Jack Lew, Deputy Chief of Staff to President Clinton and Staff Director of the National Economic Council.  When Robert Rubin left the Council to become Treasury Secretary, she followed him as Chief of Staff

It's unusual for anyone to last two terms with any President in modern day Washington.

She also worked as governor's aide to Massachusetts Governor Michael Dukakis.

She has experience in retail politics, having worked in the Dukakis/Bentson and Clinton/Gore campaigns.

She's also former McKinsey Company employee, where she worked for two years after her college graduation.

She's been criticized for using consultant management jargon in White House meetings.

She received an A.B. Government from Harvard University and a B.A. Philosophy, Politics and Economics from Oxford University, where she was a Rhodes Scholar and a rower. 

She's married to an attorney and has two children. Her family is originally from West Virginia. Her dad is a retired optometrist and her mom was a small town mayor who first ran for the office at age 65.

The Latest Health Wonk Review Is Up

If you have some favorite notions, you'll probably NOT want to go over to the Healthcare Lighthouse's latest edition of the Health Wonk Review.  Host Billy Wynne looks at some April Fools style assumptions with a masterful summary of the latest insights from bloggers - like the PHB.


Wednesday, April 9, 2014

Running Amok

With today's horrific Pennsylvania high school knife attack occurring just days after the second Fort Hood shooting, the Population Health Blog naturally sought refuge in the scientific literature.

What's going on?
Here's a highly informative - if somewhat old - article that makes the following observations:

1. "Running amok" (from the Malay word mengamok, meaning to "make a furious and desperate charge") attacks by a single disturbed individual leading to multiple casualties with or without suicide was first reported in the 1700s by European explorers of Southeast Asia.  It was thought that the phenomenon was culturally unique to the indigenous peoples of the Philippines, Laos and Papua New Guinea, but heightened awareness in the 1800's eventually led to the conclusion that this is a rare but worldwide phenomenon.

2. Brooding prior to the episode is common. Attackers who survives often can't recall the event.  This is far more common among males. Suicidal intent is more common among men who are 45 years of age or greater.

3. While culture and the availability of weapons determines how an attack is carried out, an underlying commonality is the presence of one or more underlying psychiatric disorders, including psychotic depression, bipolar disease, a personality disorder, schizophrenia and drug or alcohol abuse.  Those conditions are typically provoked by a personal loss or stress. That leads to combined suicidal and homicidal ideation driven by anger, hopelessness and a quest for revenge.

4. Yet, while practically everyone who "runs amok" has severe mental illness, very few persons with mental illness "run amok."  Health providers should worry about the possibility of it happening if there is a history of violent threats or behavior, a recent stress (job loss, conflicts, loss of a loved one), or paranoia, especially if there are "command" hallucinations.

5. Primary care physicians, employee assistance programs, health insurers and community health clinics are the first line of defense.  Family and social support networks have an important role to play in giving these individuals other options. Yet, other than addressing the social isolation and the treatment of the underlying mental illness, there is no specific treatment for running amok.

The full text of this article is not available, but it says that while school shootings are up, the incidence of running amok has not increased.  The three "prototypes" are 1) struggling adolescents, 2) persons with paranoid psychoses and 3) adults with personality disorders who have experienced a breakdown of a close relationship

Tuesday, April 8, 2014

Doubling Down on Accountable Care Organizations

What happens if CMS' grand experiment in ACOs fails?

There are some good reasons to believe that it could happen:

  • Preliminary results are spotty at best

  • Saving money doesn't mean making a profit

  • inefficiencies, technology shortfalls, culture barriers and inertia abound;

  • bending the curve for sick populations is hard;

  • physician and patient behavior change is difficult;

  • last but not least, it was tried before

  • But note that the Population Health Blog is not asking whether ACOs are going to fail.  That jury is still out.  The question is IF they fail, what happens next?

    While the Population Health Blog Spouse would common-sensically expect the contracts to be cancelled while our national leaders look for the next good idea, the PHB doesn't expect that to happen.  For an example of the thinking behind a far more likely scenario, check out this article by RWJF Advisor and former Health Affairs Editor Susan Dentzer.

    Despite some early bad news, Ms. Dentzer exclaims that she's not about to let any inconvenient facts get in the way of further "improvement" of the ACO model. 

    Among her ideas for doubling down and expanding it:

    1. Tying discounts on Part B premiums "or other financial incentives" to get Medicare beneficiaries to agree to a more narrow network.

    And why, asks the PHB is this any different than managed care?  Or maybe ACOs are destined to be HMOs in "drag!"

    2. Tying discounts or other financial incentives to the use, whenever possible, of the lowest level of care.

    This is another long-used managed care tool that can justify keeping patients out of the hospital.  And the PHB would vote for RuPaul as the ACO National Medical Director. 

    3. Expand the use of multi-disciplinary team-based care for persons with chronic illness.

    A good idea, but teaming of medical home can succeed quite nicely outside of ACOs.

    Hey, says the PHB, if CMS can pull the rug out from under Medicare Health Support, it should be able to do it to ACOs.  Fair is fair.

    Image from Wikipedia

    Monday, April 7, 2014

    For-Profit Meets For-Publication For Big Data

    The "for-profit" research side of health care and the academics have always had a strained relationship. The Population Health Blog witnessed it first-hand when it recruited volunteer participants for an protocol that was sponsored by a pharmaceutical company. It was a good experience, but the company made it abundantly clear who was in charge of the data.

    As "big data" research grows, will large pieces of it be likewise run by self-serving and deep-pocketed healthcare corporations?

    That's the question explored in this JAMA "online first" piece by Sachin Jain et al. Huge electronic health record and insurance claims data sets involving tens of thousands of patients can provide academically (publishable) as well as commercially (profitable) insights on treatment safety and effectiveness in the real world. The JAMA authors use Indiana School of Medicine's Regenstrief Institute's collaboration with pharma giant Merck as an example of how the relationship doesn't have to be anything but collaborative.

    Their 5 year agreement centers on mining a statewide information exchange involving over 11 million patients. Scientists from both companies with similar interests - such as melanoma, heart disease in persons with diabetes, medication adherence, the progression of heart failure, treatment of osteoporosis, natural language processing and vaccinations - are encouraged to jointly present ideas to a steering committee that ultimately okays and funds projects.

    What are some of the lessons learned?

    1. Academics prefer funding that lasts 12 to 18 months, while pharma wants an answer ASAP. The fix was to create sustainable funding "cycles."

    2. Protection of individually identifiable data is a priority; Merck has "arms length" access only to de-identified data, and that's just for starters.

    3. Both institutions have to agree on the release of any research findings into the public domain.  Any disagreements are handled by the steering committee.

    4. A separate operations committee keeps track of all the projects and their timelines.

    5. Some research questions on the natural progression of chronic disease can only be answered over the course of years.  One big data project beats a gold-standard randomized clinical trial.

    The PHB's take:

    This may be a template for population health vendors to follow.

    Because they're interested in the association of multiple risk factors with multiple outcomes, the vendors likewise have a lot to gain from mining big data. The good news is that many already have contracts with health care systems and other entities that are sitting on terrabytes of clinical and claims data. Smart vendors should be asking how to move past their for-profit reputation, leverage these relationships and take big data - with their academic colleagues - to the next level.

    Image from Wikipedia

    Wednesday, April 2, 2014

    Another ICD-10 Delay

    Buried in the U.S. Congress's just-passed sustainable growth rate extension patch is a little known provision that would further delay the HIPAA-mandated implementation of ICD-10. As reviewed years ago by the PHB ("Rough Seas Ahead"), ICD-10's benefit of precise medical billing accuracy was threatened by the considerable provider costs of having to retool their information systems without much impact on patient care or revenue. 

    This was going to be an uphill climb under the best of circumstances.

    While CMS had previously delayed the implementation of ICD-10 from 2013 to October of 2014, continued hospital and physician alarm apparently convinced a majority of U.S. Senators to delay the implementation by another year to 2015.  While many in the health care industry are undoubtedly breathing a sigh of relief, that's small comfort to others who have been diligently working hard and investing a lot of money to be in compliance with the law.

    Is this democracy in action, or further evidence of Washington DC's fickle inability to be a responsible and consistent steward of the health care system?  While readers ponder that, the Population Health Blog was naturally struck by some similarities between the tragic loss of Malaysian flight 370 and the star-crossed travails of ICD-10 roll out:

    Response to heartbroken families and overworked programmers?

    Malaysia 370:   Sorry!               
    ICD-10 Delay:  Sorry!
    Remains only big news only to:

    Malaysia 370:  CNN viewers                
    ICD-10 Delay:  Commercial insurers
    One underlying problem:                   

    Malaysia 370:   Transponding               
    ICD-10 Delay:  Squandering         

    Involving tends of thousands of:

    Malaysia 370:   Square miles               
    ICD-10 Delay:  Diagnosis codes

    How should the public respond?

    Malaysia 370:    Fly less?              
    ICD-10 Delay:   Couldn't care less
    Who really seems to be in charge?

    Malaysia 370:   Astrologers               
    ICD-10 Delay: Senators

    Malaysia 370:   Flotsam         
    ICD-10 Delay:  Bedlam

    Tuesday, April 1, 2014

    What GM's Ignition Switch Travails Can Teach About Concentration of Risk: Implications for Large Integrated Delivery Systems

    CEO Barra not having a
    good day at a Congressional hearing
    Today, the motoring Population Health Blog used its C-SPAN enabled car radio to listen in on the U.S. House Energy and Commerce Subcommittee's grilling of General Motor's CEO Mary Barra.  As the PHB understands it, GM allowed millions of its cars to stay on the road despite awareness among some of its executives of a faulty ignition switch that failed to "meet specifications."  It was deployed in seven GM models for over a decade.

    The PHB can assure readers that when it comes to using "gotcha" yes or no questions on a humbled CEO to plumb the meaning of "specifications," Congressional bipartisanship is alive and well.

    While GM is completing its internal investigation and the PHB is speculating, it's possible that GM's travails are ultimately the result of concentrated risk.  While standardization across automobile manufacturing is a no-brainer, it all came down to a weeny metal spring's inability to hold a plunger in place. That led to a loss in power in moving cars with a catastrophic failure of steering, brakes and airbags.

    Which naturally brings the PHB to health care.

    In a recent chat with a well-connected and savvy colleague, it was pointed out that some health leaders are predicting that, in the years to come, health care in the United States will be delivered by a network of dominant regional integrated delivery systems.  Many policymakers naturally welcome the prospect of "postindustrial care" that is replacing a highly variable and unmeasured cottage industry with guideline-driven science and standardized protocols.  Part of that standardization will almost certainly include uniform treatment pathways and medical devices.

    The problem? 

    Never mind that some guidelines may not work as well as intended.  They can actually cause harm. Medical devices, just like ignition switches, are also not perfect and can lead to (for example) broken pacemaker wires or premature artificial joint failures.  While guideline and device mishaps are infrequent, the rise of "systems" means they're more likely to involve many more people when they inevitably do happen.

    That's because these large regional delivery systems will be favoring single processes and products across all patients and all settings.  Instead of a flawed ignition switch in seven models, think of flawed pacemaker in all seven hospitals serving three states.

    What's more, it's possible that GM decided that a low rate of failure (ultimately only 31 accidents with 13 fatalities) represented an acceptable cost-risk ratio.  The PHB recalls GM was financially ailing during the period in question; could it have decided that retooling a manufacturing process was too expensive?  If future integrated delivery systems also turn out to be financially stressed, will they likewise be tempted to stick with an old pacemaker or metal joint, despite early indications of problems?

    Oh, and if you think it's just a matter of better government oversight, tell that to Acting Administrator of National Highway Traffic Administration, David Friedman .  He was seated next to Ms. Barra and was asked about his decision not to act on switch complaints as far back as 2007.

    Risk is unavoidable.  It's just a matter of anticipating it in all it's many forms.  Assuming these big regional systems turn out to have traction, this concentration of risk will be a feature of them. 

    The PHB leaves it to its readers to decide if it's worth it.