Thursday, April 24, 2014

The Latest Health Wonk Review Is Up

Louise Norris hosts a wide ranging Health Wonk Review at her smartly-written Colorado Health Insurance Insider. Like prior HWRs, Louise summarizes and links the best health policy bloggers on topics like the high price of Hepatitis C treatment (follow the money), Medicaid (does it really save lives), how the competition in Mexico is taking a bite out dentists' fees... and so much more.


Wednesday, April 23, 2014

Questions That Should Be Asked in the Upcoming HHS Secretary Nomination Process

As a public service, the Population Health Blog is pleased to offer up some questions that may or should arise in the course of Senate confirmation process for HHS nominee Ms. Burwell. 

If she can address the inquiries in these key categories, the PHB suggests she'll be more than prepared for the job:

The Clinton years: Supporters of the Affordable Care Act say "it is now the law of the land."  Based on your extensive experience in the Clinton White House, how would you define "is?"

Signing up young people: Do you credit the last-minute surge in sign-ups on the individual exchanges to Mr. Obama, Mr. Galifianakis or to the Two Ferns?  How will you use that insight to increase individual enrollments in 2015?

Use of social media: Since the Population Health Blog began on-line publication more than 5 years ago, health care cost inflation has moderated significantly. Please explain how Medicare's actuaries will factor this into their future projections.

Doing your part for the 2014 mid-term elections: Will you advocate that the "essential health benefit" be broadened to include coverage for global warming?

To test your awareness of the employer mandate: If Peter Baelish hires 47 part-time seasonal service employees in KIng's Landing for more than 120 continuous days in the first quarter of 2014 without a profit sharing provision, what is the number of FTEs and what would the "4980H penalty" be if it were calculated in Gold Dragons?

And finally, tort reform:  Suppose Iva Pannus buys taxpayer subsidized insurance but also participates in a workplace weight reduction program. If Iva's girth paradoxically increases and she develops sore knees, should she sue in state court to recover her out-of-pocket "bronze" plan expenses and should HHS assert a lien if there is a jury award?

Image from Wikipedia

Tuesday, April 22, 2014

Discovering What We Don't' Know About Risk-Adjustment for Hospital Readmission Rates in Medicare

Something like this?
When the Population Health Blog agreed with the spouse that it was time to replace the living-room gas fireplace insert with something more sleek and modern, it then turned its attention to changing the surrounding mantle. The PHB favored something heraldic, featuring partially-garbed warrior babes, sporting shields and sandals. Cherubs too.  Preferably oak.

After some counseling from the PHB spouse, it came to realize that its wayward tastes in interior design may be a function of going sans helmet during its childhood bicycle riding, its deepening appreciation of bourbon's mysteries and pausing too frequently on Fox News' The Kelly Files

Naturally, the PHB wants to know the relative influence of each. Increasing exposure will help it propose some ideas for the unfinished basement.

Hospital administrators are dealing with a similar problem when it comes to readmissions.

Approximately 20% of discharged Medicare beneficiaries come back within 30 days. In response, CMS financially penalizes hospitals with high readmission rates for heart attack, heart failure and pneumonia. To reduce that penalty, hospitals have asked about the quality of their care, discharge planning and follow-up outpatient care. 

But, what is the relative impact of each? Where should administrators focus their corrective actions? 

Or, like the PHB and interior design, are readmissions ominously outside of anyone's control?

According to some interesting research, it turns out that more than half of the variation in readmissions may be outside of hospitals' control.  What's worse, CMS doesn't account for that in its calculation of the penalty that uses patient factors, such as age, gender and illness burden.

That's the conclusion of this recent article appearing in HSR Health Services Research.

Herrin and colleagues correlated CMS's Hospital Compare readmission data with each hospital county's socioeconomic data (rural vs. urban, persons living alone, employment status and educational level), access to care (the per capita density of primary care and specialist physicians as well as hospital beds) and nursing home number and quality (the number beds and the number of high-risk, long-term patients with bed sores).

Based on risk-adjusted rates from 4,079 hospitals in 2,254 counties, the authors found that more half of the variation in hospital readmissions was statistically explained by the counties' data.  That included persons living alone, low educational attainment, urban setting, a higher number of Medicare beneficiaries, fewer primary care physicians, fewer nursing home beds, higher numbers of nursing home patients with bed sores.  More beds and more specialist physicians were also independently associated with higher readmission rates.

The Population Health Blog's take?

As it noted previously, much of the vituperation around the unexplained variation in health care has been less a function of an inefficient health care system and more a function of our inability to identify the underlying drivers of utilization.

And now we're getting better. The HSR article shows that when it comes to readmissions, much of that variation is a reflection of the poverty in our neighbors' homes as well as the strength of the primary care network and the ability of nursing homes to act as a cushion.

Hopefully the mandarins at CMS will take these findings into account as they continue to financially sanction hospitals for readmissions. A more sophisticated approach to risk adjustment could help lessen the budgetary impact of county-level factors that are outside the hospital administrators' control. 

And since hospitals' bottom lines typically reflect the populations they serve, better risk adjustment could also lessen the disparate impact on the nation's poorest hospitals.

Image from Wikipedia

Monday, April 21, 2014

I'm From CMS and I'm Here to Help

Writing in JAMA "online first," CMS Administrator Tavenner and colleagues offer a payment reform "framework" that includes "multipayer collaboration."  The article is wonky, so the Population Health Blog dons its universal adminispeak translator so us normal humans can better understand what CMS is up to.

According to the writers, CMS has a history of innovatively implementing reforms that were later adapted by other insurers. The most famous example is the hospital "DRG" system that, starting in 1983, paid for a diagnosis in lieu of a daily room rate.  Suddenly, hospitals had an incentive to shorten hospital stays, which is precisely what happened in the years that followed.

Buoyed by this success, the authors describe the merits of championing Medicare's transition from "category 1" fee-for-service without any link to quality to "category 4" population-based payments that are linked to quality. And, as CMS embarks on this excellent payment journey toward accountable care, they'll get other commercial insurers to mirror their efforts by:

"Being conveners" as in "working with" other insurers in a region or a state to implement large payment reforms.  Working with may include grants;

"Incentivizing," as in requiring the participation of other payers prior to funding any large pilot programs.

"Working with states" to implement additional reforms, when the state has sufficient influence over the health insurance or delivery system.

The Population Health Blog's take:

"Category 4 population-based payments" are a form of capitation that are ultimately designed to transfer insurance risk from CMS to providers. The PHB hopes the bureaucrats at CMS are aware of the risk re-introducing some 1990s-style managed care abuses. 
What also goes unmentioned by the JAMA article are examples of CMS payment reform unintentionally gone awry, including RVUs, regional payment variation and the SGR with lingering fraud. While CMS has had its successes, it's also had more than its share of problems.  Time will tell which track record will apply to population-based payments.

Convening was an art developed by Medicaid programs.

Ms. Tavenner implies that population-based payments (a form of capitation) are intrinsically linked to quality.  Nothing could be further from the truth, since it's possible to reward quality while also relying on a FFS methodology

Accountable population-based care remains a large experiment.  Ms. Tavenner implies that there is an aura of inevitability.  The PHB learned long ago that the sign of a good plan is an exit strategy in case things go south.  The PHB didn't read that here.

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