Monday, July 28, 2014

Can Physician Loyalty to Their Profession Be Superseded by Loyalty to their Employer?

Whenever the Population Health Blog heard the "value-not-volume" health policy operatives drone on about "provider alignment of incentives," it wondered.... really wondered.... if this Kool-Aid had completely convinced the ACO Adminosphere's inhabitants that their physicians' loyalty to their profession could be superseded by loyalty to their employer.

Sure, running a private-practice sucks and Obamacare's economics favor consolidation, but that's not necessarily enough to capture hearts and minds.  The PHB recently heard a local ACO executive explain that her long-employed physicians were still (yes, still) challenged with EHR implementation, teaming, shared savings, quality metrics, practice management, joint ventures and the role of patient educators. 

Other than that, Mrs. Lincoln, how was the ACO play?

And then there's a tweet from @VinceKuraitis on how a group of St. Louis cardiologists are "leaving" hospital employment and striking out on their own. Vince asks if this is a random blip or start of a trend.

Good question.

If this does turn out to be the start of a trend, don't be surprised. As someone very wise pointed out millennia ago, people do not live by bread alone.

Image from Wikipedia

Thursday, July 24, 2014

Credble Numbers on Obamacare: And Why is the 16.3% Prevalence of Persons Without Health Insurance Good News?

The signed Affordable Care Act
We finally have some credible numbers on what's happened to insurance enrollment under Obamacare. The paper can be found here.

The authors used the ongoing Gallup-Healthways survey that questions representative samples of the U.S. population about their health insurance status. Since it began, this repeat survey has assessed changes in the coverage of adults 18 to 64 years of age. The authors used these data to assess the trends in insurance status that were associated with the roll-out of Obamacare between January 2012 to June 2014.

For all of 2012 and the first part of 2013, the nation's uninsured rate was 20% to 21%.  Following the star-crossed open enrollment period that began in the fall of 2013, the uninsured rate began to drop.  By April of 2014, it fell to 16.3%. 

Depending on the underlying statistical assumptions, the absolute percent increase in Americans with insurance ranged between 4.2% to 7.1%. States that took the Feds up on their offer to underwrite Medicaid expansion saw a absolute decline of 6%  of low-income Americans having no insurance.

The Population Health Blog predicted that the 2014 outcomes from Obamacare would have something for everyone.  For the news outlets (like this and this) with a reputation of being sympathetic to the Administration, positive spin abounded. In the meantime, more skeptical reporters tried to poke some holes in the data, saying the increase in insurance coverage was really thanks to gains in employment or was in reality a lousy deal thanks to narrow networks.

The PHB's take?

It's struck by the relatively modest decline in the percent of uninsured Americans. Considering the heavy price we've paid, that lingering 16.3% rate is a lot.

That price?  It includes not only the hit to our national fisc, but paralyzing partisan rancor, endless and unpredictable litigation and the precedents of White House 'pen and phone' fiat by regulation. The latter will almost certainly be used by a future Presidents on both sides of the aisle.

And so it goes.

Wednesday, July 23, 2014

Care Management: What a Bargain

They did it again!
Sound familiar?

Patients' intake into the program was initiated with a face-to face meeting with a nurse care manager.  After a physician-approved care plan was in place, the patients were telephoned and engaged in the protocol.  The patients could then use a voice-activated system or a website to report disease status.  Outbound nurse calls were prompted if the patients requested it, reported a problem, didn't have adequate disease control, if the medications were not being taken as prescribed or if there were side effects.  After 12 months, patients in the care management program, compared to a control group, had clinically and statistically significant improvements in the control of their condition .

To the Population Health Blog, this narrative has been repeated dozens of times involving numerous chronic health conditions.  In this latest example, Dr. Kroeknke and colleagues randomly allocated 250 patients with three months or more of chronic musculoskeletal pain to either a) state-of-the-art pain care or b) state-of-the-art pain care plus nurse led care management

Twelve months later (and after only one drop-out), patients in the first group rated their pain as having dropped from a baseline of 5.1 to 4.6 out of ten (zero is no pain, 10 is awful), while the second care management group rated their pain as having dropped from 5.3 to 3.6.  Total time spent by the care manager averaged 3-4 hours per patient.

While patients in the care management group were taking more medications, there was no difference between the two groups in narcotic use.  There was also no difference in health care utilization.

The PHB's take:

While the authors credited the care plans that triggered increases in medications that were tailored to patient preferences, the PHB wonders if a greater sense of control combined with the perceived support of a sympathetic listener also contributed to the greater improvement in pain.

Once again, there wasn't hard "savings" or a "return on investment."  However, the expense of only three to four hours of nurse care manager time to achieve a one-point improvement on a 0-10 scale of pain not only seems like a wise investment, it's a comparative bargain.

Monday, July 21, 2014

New Insights on Big Data

Say hello to big data!
This week's The Economist discusses some of the implications of "big data."

Population Health Blog readers may recall the Facebook kerfuffle when it was revealed that the company had been "experimenting" on its users.  While this is another timely reminder that Facebook users are not customers but a product, what's far more interesting is how the company used its vast utilization data to monetize the changes of a hundredth of single percent in its users' behavior. 

These weenie changes can add up to additional ad revenue.  Ditto for the techy Google's search, Amazon's placements and Facebook's ads which, according to Schumpeter, are getting a return on investment from "every pixel" of the monitor screen you're using to read this blog.

Unfortunately, says The Economist, this big data approach has been more difficult for the for the traditional "bricks and mortar" businesses, which have traditionally been fixated on traditional accounting measures.  But, as these businesses tether their infrastructure increasingly to information technology, they're getting there: UPS is monitoring 60,000 delivery vans, retailers are assessing how in-store placements generate the most revenue and businesses are measuring how the mix of different types of employees relates to productivity.

The PHB would rate most health care providers as being in the bricks and mortar category than in the technology space.  They have a way to go.

Two lessons:

1) Big data doesn't replace traditional business monitoring of revenue and expense, balance sheets, averages and standard deviations, it adds to it.  And yes, that ceaseless tinkering adds cost that - in the right hands - should have a return on investment.

2) The "tinkering" has its share of failures in addition to successes.  While The Economist can point to some wins, the landscape is probably littered with losses.

Speaking of the right hands and minimizing losses from big data, the PHB is proud to link this article appearing in the NACD Directorship Magazine.  While a password is necessary, the bottom line is that corporate boards can do ten things to help their companies successfully achieve a big data return on investment:

1. Provide analytic leeway;

2. Be clear on who is responsible;

3. Set realistic budgets;

4. Assess how big data is fitting into the pre-existing culture;

5. Be skeptical;

6. Link it to Enterprise Risk Management;

7. Task the Audit Committee with some oversight;

8. Assure privacy;

9. Reduce inappropriate incentives;

10. Get a big data expert on the Board.

Image from Wikipedia

Wednesday, July 16, 2014

Professional Physician Organizations: A Continuing Necessary Ingredient for Ongoing Health Reform

This JAMA article on "Professional Organizations' Role in Supporting Physicians to Improve Value in Health Care" reminds readers that "organized medicine" continues to have an important role in national health reform.  The Population Health Blog agrees and adds that these doctor professional organizations have not only been underestimated recently, but will continue to be a force to be reckoned with - both a national and state level.

The article points out that groups like the American Medical Association (AMA) along with the various sister specialty physician organizations, along with health systems, practice associations and various non-governmental entities, are critical to the success of the Affordable Care Act.  These doc groups been long-time advocates for health reform, are still trusted by a significant number of providers, collectively represent a majority of docs and bring insights to a complicated health system.

And what are they doing to help with reform?  According to the authors, they've been serving as "conveners," helping to marshal resources, are creating standards and helping regulators.  While the JAMA article naturally mentions a number of national initiatives (such as Choosing Wisely), the PHB points out the same kind of important activity is occurring at the state level.  A good example can be found here.

Before some PHB readers tut-tut the faux importance of the AMA and its many national and local affiliates by having you believe that docs have transitioned their loyalty from their profession to their employers, the PHB would point to three sentinel events that say otherwise:

1. Even the White House believed that organized medicine was important enough that it sought to circumvent the influence of the AMA by fostering its own professional doctor group called "Doctors for America."  While it hasn't worked so well, imitation is the sincerest form of flattery.

2. The Patient Centered Primary Care Collaborative's Board of Directors has a significant number of members with deep roots in organized medicine.  It's testimony to a vital constituency on which the success of the Patient Centered Medical Home depends.

3. While tort reform has been outside the scope of this blog, an important ballot initiative dealing with California's benchmark Medical Injury Compensation Reform Act (MICRA) will be put before the state's voters this fall.  The lead organization of an impressive coalition of labor, business and consumer groups that has been created to defeat the proposition and preserve MICRA is, you guessed it, a state medical association.

The lesson for population health providers?  Reach out to and work with the physician groups at all levels of reforming the system.

Monday, July 14, 2014

The Medicare Advantage Stars Program: Who Keeps the Money, Is it Evidence-Based and What About Variation?

The Population Health Blog has been practically banished from our living room when the spouse is watching TLC's Say Yes to the Dress.  This reality show follows the travails of young brides as they search for that perfect wedding gown while also dealing family expectations, tight budgets and dubious body art. 

When the PHB stops in and pauses to watch the bridal drama unfold over more than just a few minutes, it naturally wants to share.  Mysteriously, the spouse treats its helpful outreach like some sort of provocation.
Little wonder.  Years ago, the PHB medical director learned that the best way to make itself unwelcome at dreary management meetings dealing with the Medicare Advantage STARS Program was to inconveniently offer various insights, such as:

"If we hit the STARS target, let's not keep the millions in bonus payments; they should be distributed to our enrollees or used to lower premiums in the form of P4P4P."
"Too bad there is no randomized trial that shows that any of this help patients live longer.  Should we tell them that this isn't evidence-based?"

"If there is a small improvement, it could be the result of case mix or statistical variation."

And its innocent Yes to the Dress insights?

"All those dresses look pretty much the same!"

"I hope the groom takes a look at that mom, because if that's what the bride is going to look like years from now, he may want to reconsider."

"Seems to me she's trying to fit 50 pounds of potatoes into a 30 pound bag!"

Wednesday, July 9, 2014

Here Comes Defined Contribution: Implications for Population Health

"Here they come!"
Regular Population Health Blog readers understand that defined benefit insurance plans provide for the future coverage of services (for example, all medically necessary treatment) or income (for example, guaranteed retirement income). 

Failure to account for increasing life expectancy, growing medical demand and technology plus an unwillingness to adequately fund tomorrow's promises with today's dollars have all fueled interest in defined contribution health insurance plans.  They provide financial support before future medical demand occurs. As a result, if the ultimate cost exceeds the available funding, it's up to the beneficiary to make up the difference.

As this timely New England Journal article points out, the defined benefit plans' days are numbered, while defined contribution plans are coming. 

Economists and conservative policymakers like their twin attributes of consumer choice and "skin in the game," while transferring risk away from government and businesses. They also like to point out that employers would be helped by freeing up dollars to hire more individuals and pay them more while also investing in their businesses.  Incidentally, this would also be one solution to the U.S. government's deficit spending.

Past attempts in Congress to translate that logic into a fix for Medicare failed faster than Obama could say "middle class." While the Republicans have proposed that Uncle Sam's rate of defined contributions exceed that of general inflation, opponents pointed out that it wouldn't keep up with medical inflation.

In the meantime, more and more employers are embarking on defined contribution plans.  And as the consumer is being forced to deal with a fixed pot of money, many are finding that they can stretch their dollars by agreeing to high deductible plans or narrow networks.  According to one survey, this is now present in close to 40% of employer-sponsored insurance.

The Population Health Blog's take:

Many of the other darlings of health care reform, such as Accountable Care Organizations (ACOs), medical homes, primary care, integrated delivery systems and population health care management providers will need to adjust to the growth of defined contribution plans with a combination of

1) providing enough value that consumers will be willing to personally pay more for their wares;

2) showing once and for all that they can provide health care for a lower price i.e., save money;

3) maintaining enough geographic or niche market dominance that they can insulate themselves from being commoditized.

Thursday, July 3, 2014

The Contraception Mandate: The Supreme Court Hobby Lobby Decision's Five Ironies

Much of the commentariat's dismay over the setback of Obamacare's contraception mandate has been based on the twin principles of women's health and economic justice.  But for an unthinking Supreme Court majority, says critics, the U.S. lost an important chance to link federal health policy to the enlightened science of preventing unwanted pregnancies.

Which leads to five ironies:

1) The Supreme Court Justics would agree that they know little about health or economics: It was the conservative Mr. Scalia who opined in another case involving health care that the issue at hand was not "known to the nine Justices of this Court any better than they are known to nine people picked at random from the Kansas City telephone directory." 

No one should be surprised that the Supremes focused on the law.

2) This isn't about health or economics, but ultimately about Progressivism: In this timely Wall Street Journal essay, Charles Murray distinguishes between classic liberalism and progressivism.  The latter was first championed by President Woodrow Wilson and, decades later, still promotes a reliance on disinterested experts to mold social policy in the interest of collective well-being. One tradition of progressive thought is that the Constitution is ill-suited to the eminently rational work of those experts. 

Progressivists everywhere are going to view the Hobby Lobby decision as a vindication of their long-held beliefs.

3) The Affordable Care Act is untouched: Contrary to popular opinion, the text of the Affordable Care Act makes no mention of contraception. Rather, it outsources the creation of an "essential health benefit" to Health and Human Services. In a classic exercise of modern progressivism, its experts - not Congress - used a regulatory process to determine that significant religious considerations should not stand in the way of women's public health and first dollar coverage of the pill.

Repeat: the Affordable Care Act is untouched.

4) Blame Bill Clinton: As the PHB understands it, the experts in Health and Human Services never contested that Hobby Lobby's owners were deeply religious or that oral contraceptives also prevented implantation of a fertilized egg, i.e., led to an abortion. When that was examined under the requirements of Religious Freedom Restoration Act that was originally signed into law by Bill Clinton, Mr. Alito managed to craft a 5 to 4 majority.

By the way, at the time RFRA was passed, both chambers also had Democratic Party majorities.
5) When It Comes to Experts, You Get What You Pay For: For better or worse, when competiting interests lead to winners and losers, we turn to our court system. Since it's unlikely that the U.S. is going to dismantle its legal system, experts would be best advised to craft compromises that accommodates reasonable constitutional threats to their reasoned planning.

Congress is probably going to step in and do what its outsourced Executive Branch experts should have done in the first place: reconcile the RFRA and access to contraceptives.  We deserve better from HHS.

Wednesday, July 2, 2014

Parallels Between U.S. World Cup Soccer and Health Policy

Like tens of millions of other Americans, the Population Health Blog's productivity nosedived during yesterday's United States versus Belgium World Cup game. Against significant odds, the scrappy American team had advanced to the second stage, only to lose in a heartbreaking nail-biter against a country no bigger than the state of Maryland.

Naturally, that didn't stop the PHB from seeing parallels between World Cup soccer and U.S. health policy:

Waiting for an eternity through normal play, only to lose by one or two points in overtime on a trick play, is what makes the World Cup so exciting. It's also what happened to Obamacare's contraceptive mandate.

The American goalie Tim Howard made 16 saves against a highly talented Belgian team.  He is among the top-ranked goalies in the world and will have to figure out how to pay U.S. income tax on all those Euros he'll be making next year. This also makes him qualified to make oral arguments the next time anyone has to pull out a long-odds victory at the Supreme Court.

Soccer players periodically collapse on the ground writhing in pain, only to make a miraculous recovery minutes later. That is not only a useful strategy to pause the game and steal the opponent's momentum, it's a demonstration of optimum use of Obamacare's "essential health benefit."  By the way, it is also inspiration for partisan outrage at any adverse decision by the U.S. Supreme Court.

Strangely, cheerleaders are absent at world cup soccer games.  That may be one reason why soccer hasn't captured America's attention, but it's ultimately because the European Union's civil service has yet to issue regulations pertaining to the use of les pom-poms.

Image from Wikipedia

Monday, June 30, 2014

The Contraception Mandate: SCOTUS Quotes

Liberals are outraged and conservatives are overjoyed.  While the Population Health Blog is neither, it was interested enough to go to the Supreme Court's opinion page, read the majority opinion and and pull some of the more telling quotes:

Just where did the contraception mandate come from?

"....the Affordable Care Act requires ... health-insurance coverage to furnish “preventive care and screenings” for women without “any cost sharing requirements.” Congress itself, however, did not specify what types of preventive care must be covered. Instead, Congress authorized the Health Resources and Services Administration (HRSA), a component of HHS, to make that important and sensitive decision. The HRSA in turn consulted the Institute of Medicine, a nonprofit group of volunteer advisers, in determining which preventive services to require.
The [IOM]  Guidelines provide that nonexempt employers are generally required to provide “coverage, without cost sharing” for “[a]ll Food and Drug Administration [(FDA)] approved contraceptive methods, sterilization procedures, and patient education and counseling.”

Rights of corporations vs. the rights of individuals.

"A corporation is simply a form of organization used by human beings to achieve desired ends. An established body of law specifies the rights and obligations of the people (including shareholders, officers, and employees) who are associated with a corporation in one way or another. When rights, whether constitutional or statutory, are extended to corporations, the purpose is to protect the rights of these people. For example, extending Fourth Amendment protection to corporations protects the privacy interests of employees and others associated with the company. Protecting corporations from government seizure of their property without just compensation protects all those who have a stake in the corporations’ financial well-being. And protecting the free-exercise rights of corporations like Hobby Lobby, Conestoga, and Mardel protects the religious liberty."

Religious liberty?

"...we must next ask whether the HHS contraceptive mandate “substantially burden[s]” the exercise of religion. We have little trouble concluding that it does.  [The objecting parties] have a sincere religious belief that life begins at conception. They therefore object on religious grounds to providing health insurance that covers methods of birth control that, as HHS acknowledges may result in the destruction of an embryo. By requiring ... their companies to arrange for such coverage, the HHS mandate demands that they engage in conduct that seriously violates their religious beliefs."

Does this mean coverage of vaccines and blood transfusions are at risk of being litigated?

"HHS and the principal dissent argue that a ruling in favor of the objecting parties in these cases will lead to a flood of religious objections regarding a wide variety of medical procedures and drugs, such as vaccinations and blood transfusions, but HHS has made no effort to substantiate this prediction. HHS points to no evidence that insurance plans in existence prior to the enactment of ACA excluded coverage for such items. Nor has HHS provided evidence that any significant number of employers sought exemption, on religious grounds, from any of ACA’s coverage requirements other than the contraceptive mandate"

What is the way out?

"The most straightforward way ... would be for the Government to assume the cost of providing the ... contraceptives at issue to any women who are unable to obtain them under their health-insurance policies due to their employers’ religious objections. This would certainly be less restrictive of the plaintiffs’ religious liberty, and HHS has not shown that this is not a viable alternative."

Image from Wikipedia