Friday, October 9, 2015

The PHA Forum 2015. the Premier Population Health Meeting

If you have any interest in medical costs, outcomes and consumerism, you really should think about attending the Population Health Alliance Forum November 2-4 in Washington DC.


The PHA is an advocacy and education association dedicated to advancing population health as a component of health reform.  The Population Health Blog likes the PHA because its membership is made up of a wide range of experts who have worked to translate the theoretical and fiduciary interests of insurers, payers, government and other stakeholders into real-world and sustainable programs. 

After rubbing elbows with these guys in meetings, hallways and over beverages, the PHB always walks away a little bit smarter.  If you go, you will too.


Great keynotes that connect policy, theory and reality;

A debate between wellness skeptic Al Lewis and widely published Ron Goetzel.

Instructive case studies that you won't hear about anywhere else;

Insights about monitoring and communication technologies;

Continuing education credits;

You'll get to meet PHA CEO Fred Goldstein and the other outstanding PHA team members;

The PHB will be there!

Registration information here.

The Latest Health Wonk Review Is Up!

Revolving doors at the FDA, anti-Obamacare lawsuits, meaningful use, shared savings, alleged corporate malfeasance, health insurer interest in your Fitbit data and the prognosis of private practice.

Where else can you find linked insights on these topics and more, but at the latest Health Wonk Review hosted by the brainy Joe Paduda


Monday, October 5, 2015

Physician Owned Private Practice Is Still Alive and Well: Here's Why

A death greatly exaggerated...
The Population Health Blog recently broke bread with a Director at the Tucker Advisory Group.  TAG provides professional services to a host of health care entities, including physician-owned provider groups.

The PHB has been skeptical about the death of private practice, and the breakfast did little to change its mind.

What it learned is that there is no shortage of business for outfits like TAG.  A typical private practice client is a group of ten or more physicians with multiple clinics in a multi-county area serving thousands of patients.  These groups range from primary care to pain management to women's service to cardiology.  While their revenues and expenses cannot be taken for granted and payer hassles abound, it's not impossible for a nimble and hard-working group of private practice docs to serve their patient population and still end the year in the black.

In addition, it hasn't been that unusual for individual physicians who are in salaried positions in large hospital-dominated provider organizations to contact TAG to explore the options for going into "private practice."

Anecdotal you say?

Despite the narrative that the death of private practice is "unstoppable," there are plenty of reasons to be contrarian:

1) The latest good information (like this) on physician employment that supports the narrative that private practice is dead is from the AMA's 2012 data base.  While newer data from 2014 indicate that independent primary care practice is dwindling, there are pockets of specialty physician private practice that are remaining strong. In other words, one reason for the growth of salaried physicians is their flight from continuing struggles of primary care, not toward the advantages of employment.

2) Whether they're in a salaried position or in private practice, today's physicians are still demanding autonomy, adequate resources, input and to be rewarded.  Given reports like this and this on getting docs to do what they're told cooperate, is it any wonder that physician entrepreneurship is still alive?

3) And speaking of being rewarded, physician compensation in ACOs don't appear to provide any particular advantages.

4) What about the patients, you ask?  Good question, and you can be sure that the docs are asking it too.

The point?  Large hospital-provider systems relying on salaried physicians are an important option in health care reform.  The PHB suggests that reports of the death of private practice have been exaggerated and it will also remain an important option. 

Stay tuned!

Thursday, September 24, 2015

The Latest Health Wonk Review is Up!

Louise Norris of the Colorado Health Insurance Insider returns with another masterful compendium of wonky insights from the best and the brightest health policy blogs.  There's information here you won't get anywhere else.


Tuesday, September 15, 2015

Physician Participation in Board of Directors: Transcending the Bottom Line

Two quotes:
Healthcare corporate governance in action

One is from Citizen Kane: "Well, it's no trick to make a lot of money... if what you want to do is make a lot of money."

The other is from a long-past Population Health Blog mentor: "Docs can be good at taking care of patients, or at golf.  The problem is that they can't do both."

The PHB had both in mind while it wrote this just released paper appearing in the American Journal of Medical Quality. Somewhere in the nexus of a) patient care, b) having a sustainable enterprise and c) consumerism, all of the health providers, payers, buyers, vendors, systems and business associates need to know that the bottom line is not about making money and being able to afford a country club membership. 

A low handicap is all well and good, but more is needed.

The message of the paper?

During the era of ascendant managed care in the 1990s, researchers examined the association between physician participation in the governance of health entities and their performance.  The result was several peer-reviewed studies that demonstrated that when there was physician participation on a board of directors, measures of profitability, quality assurance and social performance were higher compared to institutions without a doc in the boardroom.

As PHB readers are well aware, managed care was eventually defanged.  Interest in physician governance waned and the rest is history.

Except things are heating up.  There are millions of newly insured, and healthcare is poised to consume 20% of GDP.  As we look for ways to achieve the Triple Aim, the PHB decided to to dust things off and reexamine the merits of physician governance. 

Here's what it found:

1. Industry Expertise: physicians' broad awareness of health care is just as important financial expertise in the banking sector or educational expertise in university governance.

2. Outcomes: As healthcare organizations participate in public reporting, physicians' familiarity with outcomes data can help their fellow board members provide better oversight of what the numbers really mean and how to improve them.

3. CEO Success: Health care organizations' chief executives don't have to be physicians, but physicians can help them grapple with increasingly complicated marketplace.

4. Diversity: Physicians have been acculturated over their professional lives to skeptically evaluate things for themselves.  While this can be challenging in some settings, the good news is that this independence of thought can be counted on to reduce the risk of corporate "group-think."

5. Credibility: Physicians are still widely admired for their integrity.  This can help set the "tone at the top" as well as diminish the risk that a health care organization is putting profits before patients.

6. Professional Development: physicians' commitment to lifelong learning can act as a role model for lay board members who may be unwilling to commit to the time or the expense of continuing education.

7. Competitive Insights: Physicians are more likely to be aware of the strengths, weakness, turf and politics in their own as well the competitors' organizations.

Given the evidence, it seems that any health care organization without a doc on their board is missing out on an important value proposition that not only adds to, but transcends the bottom line. 

Just sayin'.

One last thought: when any physician ponders participation in governance, he or she will have to deal with three unique barriers: 1) loss of practice income, 2) a time commitment away from the bedside that could erode their clinical skills and 3) the loss of prestige that comes from having a less than 100% commitment to their profession.

More on that in a future post.

Friday, September 11, 2015

The Latest Health Wonk Review is Up!

In our age of expressive individualism. it's only appropriate that we combine brainy wonkiness with our pictorial self-love.  Steven Anderson of the MedicareResources Blog has done just that by posting a "selfie" inspired Health Wonk Review that tackles the latest insights on federal health reform, ACOs, Medicare, the FDA, primary care and public health.


Tuesday, September 8, 2015

The Majority of Medicare ACO Participants Appear to Have Lost Money in 2014

There's no other way to put it.

Like many wonks, the Population Health Blog glommed onto this recent CMS report report on the 2014 performance of the Pioneer and Medicare Shared Savings Accountable Care Organizations (ACOs). 

While there's some quality reporting data, the PHB decided to focus on the economics.

It ain't pretty.

Briefly, as the PHB understands it:

The 20 Pioneer and 333 Medicare Shared Savings Accountable Care Organizations generated a total of $411 million in savings.

Among the Pioneer participants:

15 out of 20 generated savings.  Only 11 of the 15 earned enough savings to trigger a payment from CMS that totaled $82 million.  The PHB calculates that's an average payment of approximately $7.5 million for each ACO. 

Three of the Pioneer ACOs had to provide clawbacks to CMS of $9 million, or an average $3 million each.

Of the 333 Medicare Shared Savings participants:

92 out of 333 saved $806 million in health care costs.  They received checks totaling $341 million.  The PHB calculates that's a payment of $3.7 million per ACO. 

Another 89 of the Medicare Shared Savings reduced costs, but not enough to trigger a payment from CMS.  That also means that the rest of these ACOs didn't even reduce costs.

The PHB's conclusions:

ACOs in the Pioneer program have about a 50% chance of getting some money back.  Assuming that there are from $2 million to $7 million per year in program support costs - in addition to the all of the foregone billable services - it's not clear to the PHB that the business model is sustainable (for example) for many of the Pioneer participants.  To add downside-risk insult to injury, there's a 15% chance a Pioneer ACO would have to pay Medicare.

ACOs in the Shared Savings program have a 75% chance that they won't be able to generate enough savings to cover the lost of income from fewer billable service or their program costs.

That's a majority of the participating ACOs.

Admittedly, there are several advantages to ACOs.  They 1) are an answer to the threat of rising health care costs, 2) are a laboratory for bundled payments, 3) promote care coordination and 4) are linked to medical homes.

But that's all for naught if the majority of the program participants are losing money in a massive exercise in risk transfer involving hundreds of millions of Medicare dollars.

This is health reform?


Coda: The PHB can't help noting that the title of the CMS report is "Medicare ACOs Provide Improved Care While Slowing Cost Growth in 2014."   That may be technically true, but that title is more about spin than about the science. The findings haven't been submitted to the scrutiny of peer-review, and until it is, the PHB won't really know what to believe.

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!"