Tuesday, April 28, 2015

For the Commercial Health Insurers, Winter Is Coming

Fans of HBO's hit fantasy TV series Game of Thrones will recognize the adage. 

In the show, the continent of Westeros has had a long hot summer of breasts, butts and beheadings. Now, it's not only getting colder, but there have been sightings in the North of blue-eyed freeze-dried warrior zombies. Crops are failing, the northern tribes are fleeing and the crows are looking more sinister by the minute. The only thing that separates civilization from catastrophe is The Wall.  That's made of a lot of ice and it is guarded by the Night's Watch.  The Watch is made up of mostly unsavory criminal types who have been given the choices of decapitation or taking The Oath.  Think of them as the Fence Frozen Legion.  Cue camera, raise swords... action!

Naturally, the Population Health Blog is enjoying every minute of it, and so is, inexplicably, the PHB Spouse.  We're both gained valuable insights.  While the PHB ponders her observation that men are untrustworthy swine, it has more constructively responded that Game of Thrones has many lessons that speak to the health insurance market.

To wit:

The Night's Watch may be made up of villains, but they're our villains and they're performing a valuable function.  Commercial health insurers likewise have their knaves, but for years they have been pooling risk and paying claims. 

Unfortunately, times are changing. While we've had a lusty summer of low cost inflation and innovation, Accountable Care Organizations are not as successful as hoped, insurer networks have gone skinny, out-of-pocket expenses are climbing and tax bills are coming due.  While we thought the undead "Medicare for All" was just an unpleasant memory, there have been sightings here and here

Will the Night's Watch of commercial insurers hold the wall?  Cue camera, raise swords.... action!

Image from Wikipedia

Thursday, April 23, 2015

The Latest Health Wonk Review Is Up

The Health Wonk Review is a linked summary of the better insights from smart health policy bloggers.  The latest edition is hosted by Joe Paduda of Managed Care Matters.


Wednesday, April 22, 2015

Curing the Healthcare Digital Divide: There's an App for That

Whither meaningful use?
For better or worse, policymakers, politicians and health leaders in the United States are committed to achieving paperless healthcare environment. Even if there is lack of high quality research and reasonable skepticism over the ultimate cost and quality merits of "e"care, there is no going back.

As a result, visitors to ehospitals and eclinics are increasingly surrounded by monitors that, in turn, are surrounded by providers. To gain their attention, patients need to have internet access to make appointments, update medications, obtain education and communicate with their doctor.

And what if they don't have that access? For the last decade, that worry has been characterized as "the healthcare digital divide. " As recently as 2014, it's been documented that the lack of computer hardware and access can have important healthcare implications for persons with low socioeconomic status.

For the doctors and nurses staring at screens all day, the millions of Americans who are living paycheck to paycheck risk being out sight and out of mind.

But it turns out that that it doesn't need to be that way.

The PHB explains.

Check out this telling report from the Federal Deposit Insurance Corporation on the "unbanked" and "underbanked."  Not having a bank account (unbanked) or using any financial services (underbanked) are linked to persons with low income, being of color, disability and being unemployed.

In other words, these are the very persons at risk of being on the losing end of the health care digital divide.

While there's interesting data on how close to 8% of U.S. households are unbanked and just over 20% were underbanked, there were also these stunning observations:

"Relative to fully banked households (86.8%), underbanked households were somewhat more likely to have had access to mobile phones (90.5%) and smartphones (64.5% of underbanked households compared with 59.0 percent of fully banked households)."

"Notably smaller, but still significant, proportions of unbanked households had access to mobile phones (68.1%) and smartphones (33.1%)" (bolding PHB).

In other words, persons of low socioeconomic status are more likely to have smart phones vs. the "banked" population. They may not have a checking account, but, compared to other segments of the population, they are also more able to use these devices to access and manage their "e"care.

The PHB's conclusions?

1. Not  explicitly fostering heandhelds as a part of the healthcare informatics "ecosystem" may be shutting out persons of low socioeconomic status from the health system. While the Washington DC's "meaningful use" (MU) criteria are not explicitly tilted toward desktop/tower computing, they seem to conspicuously silent on advocating for ease of smartphone use, for example, to manage appointments, medications, education and messaging. 

Compare MU that with Google's mobilegeddon and the unwillingness of innovative systems (like this and this) to wait for CMS to catch up.  They're loaning handhelds to patients.

What do you know: if you want to increase access to healthcare for the economically disenfranchised, there truly is an app for that.  It was there all along.

2. Yet, smartphones for the economically vulnerable and access to health information technology are not necessarily a slamdunk.  This report reminds us that smartphone contracts are vulnerable to non-payment and that it's not unusual for service to be turned off. 

Health systems that can navigate that reality that will win.

Image from Wikipedia

Friday, April 17, 2015

Some Social Media on the Topic of Social Media

Thanks to this outfit, the Population Health Blog discovered this compelling factcandy video on the topic of social media. 

In the meantime, Fatboy Slim's earcandy has been added to the PHB workout playlist.

Wednesday, April 15, 2015

Reform of Medicare's Sustainable Growth Rate: Be Careful What You Wish For

Be careful what you wish for.  The law of unintended consequences.  I'm from the government and I'm here to help

These were the nostrums that the Population Health Blog considered when the Senate passed House Bill 2 and killed the walking budgetary undead known as the Sustainable Growth Rate or SGR

As PHB readers know, the Balanced Budget Act of 1997 law attempted to use the SGR to substitute medical inflation with general inflation adjustments to the Medicare physician fee schedule.  Since the costs of CAT scans have risen faster than cat food, Congress periodically had to pass catch-up "fixes."

As the PHB understands it, the just-passed "Medicare Access and CHIP Reauthorization Act of 2015" undoes the SGR by substituting 0.5% increases for the next five years.  Medicare payment cuts that were scheduled to kick in immediately have been averted - just in time.

The PHB will review what the bill does.  Then it will look at some downsides.

What does the bill do?

During the five year period, Medicare will transition to two new payment models.

In 2019 the Physician Quality Reporting System (PQRS), Value-Based Modifier and electronic record Meaningful Use (MU) will be consolidated into single program dubbed the Merit-Based Incentive Payment System (MIPS).

Physicians who choose to participate in MIPS will be assessed on a consolidated measure of quality, cost/utilization and electronic record MU.  They will also have to report on participation in quality improvement activities. CMS will offer technical assistance for QI. Medical organizations will be able to provide input into quality. The quality data will be collected and housed in certified registries. More research will be applied to emerging science of risk adjustment for cost/utilization.

The MIPS composite performance score will range from 0 to 100 (it's on page 40 of the Bill). MIPS incentive payments will be adjusted based on change from baseline using the mean as a performance threshold. Physicians who fail to report or participate will automatically be assigned a score of zero.  Physicians participating in a medical home (as defined by Medicare) will automatically be assigned the highest score.

Physicians falling below the mean will experience percentage-based payment cuts.  Payment incentives for the winners will be budget based. Physician-specific data will be made publicly available.

MedPAC will be charged with monitoring MIPS impact on Medicare beneficiary access to care.

There are also incentives for physicians to leave MIPS behind and participate in alternative payment models (APMs). The incentives will be greater than the MIPS program, giving physicians another reason to join an ACO.  If successful, fee-for-service will eventually go away.

The PHB's take on the legislation? 

Something is better than nothing, but the PHB readers need to be aware of the potential downsides:

0.5% increases may not keep up with physician costs.  While the SGR was repugnant, the patches were tied to medical cost inflation. 

As Congress continues to "reform" health care, uncertainty will continue to abound.  Never mind the continued vulnerability of a fifth of our economy to partisan rancor, this particular bipartisan exercise in legislation still went to the wire.  That's success?

Congress - which admittedly knows little about health care - is still outsourcing considerable administrative judgment to the Secretary of HHS. This is a political appointee who presides over a vast and largely unaccountable bureaucracy.  That is, unless, you have pull like this.

While it's called "APS," it doubles down on ACOs, which still have an uncertain impact on cost and quality. We still do not know how to reconcile the theoretical efficiencies of large provider systems with the real world need for antitrust enforcement.

If - emphasis on the word if - MIPS and APS don't work out, more physicians will flee the Medicare program.  They'll cater to credit-card wielding patients, further reducing access to socioeconomically vulnerable persons who have no other options.  While the legislation charges MedPAC with monitoring access to care, they may not spot problems in time.

As for MIPS:

The economic upside incentives are based on an assumption that the money will be there and that Congress will fund it.

PQRS and MU programs, which are still based on dubious evidence (here and here), are alive and well.

Because there's a mean or median on a 0 to 100 scale, 50% of participating docs are guaranteed to be economic losers.  That information will be in the public domain.  And that's only part of the problem.

Gaming may still be possible. Examples include avoiding high risk patients, questionable links between reporting vs. outcomes and moving the goalposts by changing reporting thresholds

Reporting MIPS data may turn out to be odious; similar tone-deaf hassles and their associated costs led to the rebellion against specialty society maintenance of certification.

Medicare will provide technical assistance? Really?

Wednesday, April 8, 2015

Healthcare Cybersecurity: Lessons for America's Corporate Boards

When this article by the Population Health Blog was published in the prestigious policy journal Health Affairs almost a decade ago, little did it know that it had too little skepticism over what the policy experts were saying about the electronic health record. Since its publication, not only have the interminable cost and quality shortcomings persisted, but hospitals' and clinics' health information technology (IT) has also become a ripe target for hackers.

Who knew?

Which is why the PHB understands the bitter disappointment of directors serving on U.S. boards of directors. IT was supposed to usher in unprecedented levels of innovation, efficiency and consumerism. Little did they know that IT vulnerabilities could also torpedo their company's brands (like this), spawn sovereign criminal gangs, compromise consumers' personal privacy, hollow out their middle class customer-base, lead to a silicon-based robber baron class and propagate Baumol's cost disease.

According to this April 6 Wall Street Journal article, boards are responding to cybersecurity threats by appointing technology committees, making IT a regular part of their meeting agenda, regularly huddling with their company's information officers, monitoring dedicated threat assessment dashboards and recruiting new board members with a background in IT.

The National Association for Corporate Directors (NACD) would agree. This recent report suggests that boards also need to understand the value of their company's information by asking where their data "crown jewels" are and who would want them. They also need to periodically conduct "deep dives" on the topic of e-security, ask their company's executives about response/disaster plans, scrutinize the "tone at the top," assess employee awareness and oversee appropriate hacker stress testing. Last but not least, boards don't necessarily need "expert" members but, rather, members with IT "literacy."

The PHB's physician colleagues have that literacy and feel their pain. Check out this recent article in the New England Journal that describes the travails of health IT. According to the author, 94% of health care institutions have not only been the victims of cyberattacks, but they also have the dubious distinction of sustaining the greatest dollar cost per record-breach. While HIPAA's numerous privacy and security mandates should have given the health care industry a multi-year head start on IT security, hospitals and clinics are still struggling not only with the usual IT challenges, but with the vulnerability of their internet-of(-medical-device)-things and a growing body of antiquated or vague federal and state regulations.

The PHB's take? 

If the healthcare industry is any guide, corporate boards need to know that:

1. Finding the right balance between employee workflows, information "fluidity" and data security is still very much a work in progress.  When it comes to that sweet spot between increasing efficiency and keeping hackers at bay, compromises will be inevitable.

2. Given the experience with HIPAA, intrusive, unwieldy and (sometimes) obsolete laws and regulations are destined to grow. Get used to it, monitor it and manage as best you can.

Image from Wikipedia 

Tuesday, April 7, 2015

You Get What You Pay For in Cancer Care and Insurers Get What They Save With the Medical Home

The latest issue of Health Affairs is out and the Population Health Blog couldn't stay away. 

Three interesting articles:

The United States healthcare system has been criticized for spending too much of its treasure for too little in the way of outcomes.  Well, it's not that simple.  Stevens and colleagues in this just published Health Affairs study examined global cancer spending and found that increased spending on treatment correlated with drops in cancer mortality. From 1995 to 2007, the U.S. experienced a growth of $18,000 per cancer patient and dropped mortality among amenable cancers from 55 to 45 per 100,000.  Other than Japan and Finland (which benefit from already low levels of cancer plus sociodemographic factors like this and this), no other country has achieved that level of success.

In other words, you get what you pay for.  And when it comes to cancer, residents of the U.S. are not only paying, but getting a lot.

And speaking of payment, the same issue of Health Affairs has an article on multipayer medical home initiatives. The Population Health Blog didn't know this, but 17 of these initiatives have been launched since 2008.  Most were launched by states, not only because they controlled Medicaid's participation, but because they could blunt antitrust concerns. Challenges included agreeing on the criteria for provider participation, standardizing the payment models, and establishing criteria for success. What's more, the political landscape (health reform) and science (risk stratification, for example) has changed over the years. .

In other words, there is still no single approach to the medical home. When you've seen one statewide medical home initiative, you've seen one medical home initiative.

And speaking of initiatives, Geisinger's medical home program was also featured in Health Affairs. This observational study found that its care management nurses were independently associated with lower health care costs for as many as seven years.  That's good news.

But, the PHB knows that the Geisinger Health System is comprised of provider entities (such as its hospitals and the clinic) as well as a managed care insurance plan called Geisinger Health Plan (GHP). According to the article, "GHP hires, trains and manages the embedded case managers, partly because practices often lack resources to support such capabilities."

In other words, since.....

1) reducing health care costs will only benefit the holder of risk (the insurer) and

2) typical primary care settings lack the resources to change their approach to care,

....the real lesson of Geisinger's ProvenCare is that ownership of the medical home by commercial health insurers is an important option in assuring its success.

Wednesday, April 1, 2015

The Patient Centered Medical Home, Medicare's Comprehensive Primary Care Intiative and Cost Neutrality

Like this, but with snow
Oh my, he was really angry.

Back when the teenage Population Health Blog was living in New York, our family had a small garden tractor that was outfitted with a snowplow. After a particularly heavy snowfall, the PHB's father assigned the son the task of clearing the driveway. When the obliging PHB ran out of space to push the snow, its solution was to eschew use of a shovel and ram piles of snow outward by repeatedly backing up and accelerating forward in 4th gear. Teenage cries of "ramming speed!" seemed like a good idea at the time, but it really mangled the metal struts that held the plow to the front end of the tractor.

In economic terms, any savings the father achieved in outsourcing the snow removal was chewed up by hours of do-it-yourself blacksmithing that weekend. The driveway may have been cleared, but to the PHB father, the entire transaction ultimately ended up being a cost neutral bust.

Which brings CMS' Comprehensive Primary Care ("CPC") Initiative to mind. Thanks to the just-concluded Medical Home Summit, the PHB got to hear one of the authors of a CPC deep-dive analysis speak to the initiative's first-year findings.

 The entire report can be found here.

Very briefly, by October of 2012, CMS got Medicaid and 29 commercial health insurers to agree to ALL align and have everyone - including Medicare - to pay participating primary care sites a fee for Patient Centered Medical Home (PCMH) style care management.

 The rationale for this arrangement was to spare the clinics from having to offer the PCMH to only some of their patients. By imposing a "critical mass of payers" all patients had equal access to the same benefit.  That meant that practices wouldn't have to deal with the variations of different payer-dependent work flows and payment structures.

More than 500 practices (with an average of 4.4 providers) serving more than 2.5 million patients in 7 Medicare regions agreed to participate. In order to do that, the practices had to demonstrate that they had met meaningful-use criteria for their electronic health records (EHRs), had been officially recognized as a PCMH and had experience in quality improvement.

Once they were in the CPC, they were not only paid additional care management fees by CMS, but received quarterly feedback reports and technical assistance in achieving CMS mandated "milestones" (they can be found on page 84)  Over the course of the first year, practices received a median of $226,000 in care management fees.

At the end of one year, compared to propensity-matched non-CPC practices, CMS averaged $20 per beneficiary per month in care management fees.  They saved $14 per beneficiary per month in claims expense.  Compared to the non-participating sites, that $6 in additional cost did not achieve statistical significance.  Because the confidence intervals crossed $0, the conclusion was that CPC was cost neutral (the results can be found on page 120).  Some of the regions had statistically significant savings, while other regions had statistically significant losses.

The PHB's take:

Good thing the PHB father isn't in charge. 

This isn't the transformative PCMH break-through, and if CMS is looking to bend the cost curve, these one year results suggest Ms. Burwell et al are going to have to look elsewhere.

That being said, it's possible that years 2, 3 and 4 will show savings.  Even if that's true, the PHB wishes CMS and the health system "good luck" in being able to execute anything outside of fiscal year blocks of time.  We'll see.

The good news? The PHB suspects that the participating primary care sites ended up in the black.  They had already absorbed the costs of their EHRs and becoming PCMHs prior to the start of the initiative, so most of their $226,000 probably flowed right to their bottom lines.

As an aside, some of the $14 PBPM savings were attributed to a reduction in 30-day readmissions.  As the PHB understands it, CMS already has a methodology to claw that cost back from the health care system.  If that's true, the PCMH readmission savings are being double counted.

Image from Wikipedia

Thursday, March 26, 2015

Health Policy Insights from the Medical Home Summit: Wellness, ACOs

The Opening Ceremony of
The Medical Home Summit
The Population Health Blog is back home after attending the intellectually rewarding Population Health Colloquium and Medical Home Summit.  It was great to reconnect with old colleagues and make new friends.

In no particular order, here are some PHB take-aways:

One representative from household-name health insurer spoke in a lofty plenary session on the merits of keeping patients healthy. While the PHB was inspired by the videos of device-wearing joggers, it all seemed eerily reminiscent of the wacky pharmaceutical company value-propositions from years ago. That's when these companies said that they weren't selling "pills" but "cures."  It remains to be seen if Humana's transition from pooling risk to promoting fitness will lead to a similarly unprofitable ending.

More than one smart policymaker expressed skepticism on-stage about the ability of Accountable Care Organizations to reduce costs or increase quality. Wow. The PHB suspects more ACO shoes are getting ready to drop inside the beltway. If that's correct, it seems the expert-class is not only reducing their exposure to the coming stinkbombs, but is retooling to get in on The Next Big Idea gravy train.

One compelling speaker suggested that truly "patient-centric" primary care medical homes should offer timely access, the ability to talk to the doctor by phone at any time and attentiveness to the social dimensions of their patients' needs while richly rewarding docs to provide high-value care to fewer patients.  When the PHB mused out loud that may be what precisely what Concierge/Direct Primary Care practices are doing, the reaction of the audience prompted momentary concern that it might get lynched. 

The looming repeal of the SGR was mentioned only in passing, suggesting that few believe that this latest legislative fix portends a renewed commitment to health care reform.  As the PHB understands it, the current proposal commits Medicare to a .5% increase in physician fees per year over the next five years. This reminds the PHB of a compromise it made when the Spouse countered that a loaded SUV was a better option than a loaded sedan.  We got the loaded SUV.

And the EHR wasn't mentioned at all, which kept the PHB from offering its novel twist on Ms. Clinton's Emailgate tempest. It's clear that the Secretary reasonably concluded that her State Department's email system was unable to meet her personal workflow electronic communication and documentation needs. Our nation's EHR-using physicians feel her pain and salute her for her approach to finding a workable solution. After the American Medical Association gives her a suitable award, they should ask her if they can expect that same commitment to innovative health information technology solutions when she wins the White House.

Image from Wikipedia

Thursday, March 12, 2015

The Latest Health Wonk Review Is Up

The latest Health Wonk Review is being hosted by Brad Wright and the cleverly named Wright On Health Blog.  This is a review of some of the better health policy blogs from about the web.  You Won't Go Rong by checking it out.