Wednesday, April 20, 2016

Medicare's Comprehensive Primary Care Initiative - A Two Year Report

After all the buzz (for example) around the coming launch of CMS' Comprehensive Primary Care "Plus" program,  the New England Journal of Medicine (or NEJM) just published a "special article" on the original Comprehensive Primary Care (CPC) initiative.

This is important if you think CMS' approach to supporting primary care is the fix for what ails the U.S. health care system.

Population Health Blog readers may recall that two years ago, CMS launched CPC. This is a still ongoing four-year multi-payer study to determine whether primary care that is "turbocharged" with medical home-style capabilities (see here, here and here - see page 8) would increase quality and lower health care costs. 

The term "multi-payer" is important, because CMS recognized that clinics struggled with providing medical home care to some, but not all, patients on the basis of their insurance.  Better to have one standard of care to all patients.

The NEJM article is an analysis of CPC's results after two years. 

To summarize how CPC was set up, 502 clinics (from 978 applicants) across 8 states participated along with a total of 39 other insurers.  In addition to the usual fee schedules, the Medicare and the other insurers paid a per patient severity-based "care management fee" that, on average, ranged from $8 to $40 per beneficiary per month (PBPM). Practices were also promised an additional bonus if, after two years, they reduced health care costs (i.e., shared savings) and improved various quality measures and performed well in surveys about the patients' experience of care.

These CPC practices' outcomes were compared to a propensity matched group of non-participating practices with a similar electronic health record (EHR) infrastructure that cared for a set of patients with similar levels of disease and baseline costs. 30% of these practices had applied but were not accepted in the initiative. The total number of comparison practices was 908.

Results?  Not good.

Aft the end of two years, there was no statistically (p > .05) significant difference in the growth of health care costs between the CPC and control sites.  This was true whether just claims costs were examined (a negligible difference of $11 per patient per month favoring the CPC sites), or whether claims costs plus the additional fees were examined (a difference of $7 favoring the comparison sites).

When patient costs were examined by the burden of disease, there was no indication that more costly patients achieved any savings. 

CPC sites had a statistically significant reduction in outpatient office visits, but not in hospitalizations.

While the difference in claims expense failed to be statistically significant, the total additional fees collected by the participating sites amounted to a financially significant $389,000. This represented a 15% increase in their income

Was quality of care improved?

Patients with diabetes and a high burden of illness were more 3% more (p<.05) likely to receive the recommended follow-up measures to manage their disease. Otherwise, "the initiative did not have significant effects on the processes used as measures of the quality of care for the full sample."

Patient experience of care?

While surveys showed small increases in patient support, "there were no significant effects on other composite measures: ability of patients to obtain timely appointments, care, and information; how well providers communicate with patients; provider’s knowledge of care patient received from other providers; and overall rating of providers by patients."

Yikes. Ouch. Egads.

The authors correctly point out that CPC is a four year program and that it still may be too early to see the impact of the medical home turbocharging.  That was pointed out in the negative one year evaluation.  Maybe something will turn up at three or four years.

In addition, CMS has a lot of other value-based initiatives underway, which may have biased the results.  There may be a "ceiling effect" among the participating sites as well as the control sites, which were already working to reduce (for example) rehospitalizations or pursue the fee schedule modifiers.

It's also important to note that the impact on the other insurers' costs and patient quality was not reported.  It's possible that they saw a benefit.

The PHB's take?

1.  Many care management programs achieve claims reduction with savings (for example) within one to two years.  If CPC hasn't succeeded by now, it probably won't.  And if the just-announced CPC Plus is modelled after this, it's hard to see how that program will turn out any differently.

2. It is possible that, within all the statistical noise, there were some primary care sites with particularly robust approaches to care that did bend the cost curve.  CMS should seek these sites out and find out more about their secret sauce.  More on that in a future post.

2.  If CPC's approach to care is ultimately shown to not bend the curve, what's the problem? 

The PHB continues to believe that one size doesn't fit all and not all patients benefit from care management. Many patients, even those with chronic conditions are quite stable and need minimum attention; some patients are so sick that no intervention will keep them out of emergency rooms and hospitals. As pointed out here, as more and more patients are enrolled in care management, the return on investment can paradoxically go down. Better to focus on patients who are not only at risk, but have "impactable" condition profiles.

In addition, CPC is based on a 5 year-old model of care. Things have changed since then: modern population health brings many more resources to the table.  That not only includes in-depth analytics support (for example, to define those patients who are at greatest risk) but mHealth. For example, there is one innovative company (the PHB's Shameless Commerce Dept. over on the right side of your screen) that provides recently discharged patients with an app-enabled handheld configured to provide close follow-up.  And so on.

3. It may be that care management works best in a managed care setting.  CPC is a study of classic fee-fore-service Medicare beneficiaries with access to any participating Medicare provider. In Medicare managed care, the insurers and their providers have an even larger incentive to maximize quality and lower cost.  If that's the case, CMS - despite their commitment to innovation - may want to get out of the care management business, because they just don't know how to do it.

The Latest Health Wonk Review is Up!

Peggy Salvatore of the Health System Ed blog has posted a Spring Edition of the Health Wonk Review.  This brainy compendium offers links to the latest health policy insights on topics that include big pharma, pay-for-performance, the ACA, physician governance on hospital boards, commercial health insurance, extending insurance to undocumented immigrants, ACOs, primary care, and occupational medicine.

Be the early bird and catch this worm here.

Thursday, April 14, 2016

Open Access to Health Care Research: Good Intention, Bad Idea? Thoughts from an Industry Insider

Readers interested in the $25 billion economics of peer-reviewed published research may have seen this article posted in the March 30 issue of The Wall Street Journal. Author Richard Aslin argues that the discoveries from federally supported medical research shouldn't be hidden behind the paywalls or subscription fees of scientific publishers. 

As the volume and scope of funded research has grown, says Dr. Aslin, libraries, medical schools and hospitals are paying more and more for access to study results that are ultimately the property of the U.S. taxpayer. He argues for versions of an "open access" model, in which the authors - and not the taxpayer - ultimately bear the cost of getting their findings into the public domain.
The Population Health Blog contacted a colleague in the medical-scientific publishing industry and asked her for her reaction.  Here's her reply:
Interesting, but frustratingly one-sided.  It leaves out the critical point that someone has to pay for a CRUCIAL service that the publisher is providing - peer-review, editorial expertise, and career-making reputations for authors after the published results appear in a trustworthy, sound, and respected journal.
This is also fueled by complaints from researchers who have benefited for decades from federal subsidies (most notably student loans) who have suddenly found their inner-Reagan and cry foul when the system doesn't suit their needs.
Without the publishing industry to ensure that the science those taxpayers paid for is sound, we'd probably all be drinking Gatorade to cure Alzheimer's, because the incentives would ultimately award sponsorship to the highest bidder. Research misconduct would likely be rampant.

To me this argument sounds like being angry that you pay taxes that the government puts towards highways and then you still have to buy a car from a reputable manufacturer.
Lots of medical journals are Open Access and the publishing industry supports it. But we're also not just slapping it on the internet. Researchers are welcome to do that with their own work, free of charge. And I wish them luck with that. I'm sure they'll need it.

Coda: The PHB - who has authored approximately 50 peer-reviewed publications - tongue-in-cheek offers another potential upside to the status quo: because the ability of mainsteam news media to truthfully and objectively report research findings is highly questionable, lack of open access offers added consumer protections from spin, bias and innumeracy.  If you think it's bad now..... 

But seriously, it's also not unusual for authors to share a copy of manuscript to individual colleagues who, in the interest of advancing scientific knowledge, request it.

Thursday, April 7, 2016

A Presidential Politics-Free Health Wonk Review

Welcome to the Health Wonk Review, a compendium of the latest insights from more than two dozen health policy blogs. Each HWR issue is hosted at a different participant's blog, with topics that include health policy, delivery infrastructure, pharma, insurance and information technology.

Your HWR host, the Population Health Blog, uses a skeptical physician's perspective to write about "systems" of care.  Lately, it has focused on mHealth interventions that influence clinical and economic outcomes at a "population" level, as well as the effective governance of health enterprises.
It's also been a proud HWR participant for more than eight years.

The PHB is pleased that NONE of this issue's participants chose to mention any of the appalling lead candidates for U.S. President. Readers could use a break from the campaign cacophony, so the PHB welcomes you to the  Presidential Politics-Free Health Wonk Review.

The Affordable Care Act - What are the numbers?

Charles Gaba of ACASignups has been tracking the progress of the Affordable Care Act. This ongoing labor of love led him to comb through too-numerous-to-count public domain sources to provide an original-sourced summary (with links galore) of the health insurance status for the entire U.S. population in one chart.  He calls it "ambitious."  The PHB calls it gloriously detailed, credible and superb. KHN, you've met your match.


Hank Stern of the InsureBlog reminds us that Medicaid fails to meet the true definition of "health insurance." While beneficiaries get their health bills covered, this payment system is a government program that is ultimately paid for by taxpayers. As this form of income redistribution program expands, the opportunity for the "real" commercial insurance market dims. Ʀєfùsєηíκ indeed!

#mHealth - or the PHB is going to need an app to manage all its patients' apps.....

Peggy Salvatore of the Health System Ed Blog provides a summary of the ePharma Summit 2016 and regales readers with descriptions of how eHealth is helping persons who have gastrointestinal disorders, cancer or complex medication regimens be placed at the center of care.  "eHealth" is reaching critical mass without the help of any government mandates or meaningful use requirements. Imagine that.

David Harlow of the HealthBlawg takes a bite of Apple's CareKit Platform by unpacking the first app entrant from Iodine dubbed "Start."  Start promises to help users to individually manage both the benefits and side effects of anti-depressant medications. The app relies on a validated depression survey to assess progress, promising to take the guesswork out of treatment.


Brad Flansbaum of The Hospital Leader not only summarizes "the best (peer-reviewed) study on (hospital) readmissions to date," but interviews the lead author. As many have suspected, a significant proportion of preventable readmissions are outside the control of the institution and practically all of the current public-reporting measures fail to take that into account. Two insights are that 1) readmission rates will never go to zero, nor should they and 2) innovative interventions to minimize the risk of readmission are just now being developed. The PHB predicts that soon, no at-risk patient will leave the hospital without a dedicated app and telehealth-linked handheld device.  Given the dollars at stake, perhaps those patients without handhelds should be given one.....  

Pharma Misbehavior

Roy Poses from Health Care Renewal pulls aside the curtain and exposes the persons ultimately responsible for the OxyContin fiasco. Members of Purdue Pharmaceutical's C-suite had to pay hefty fines for the company's allegedly misleading advertising, but the upstream owners seem to have escaped scrutiny with their gazillions intact. If any of this is true, we've learned nothing about combatting corporate misdeeds.

Health Savings Accounts

Jay and Louise Norris of the Colorado Health Insurance Insider Blog take a look at some of the arcana and paranoia emerging around health savings accounts (HSAs).  First the arcana: HHS has a BPP about the HSA designation from QHPs that have otherwise been contrived to get around other regulations, likely promulgated in other BPPs. The paranoia is from wary conservatives, who are wondering if the liberals are unable to limit themselves to just "the nine words" by using BPPs to ultimately undermine HSAs.  What could possibly go wrong?  

Dual Eligibles

Tom Lynch of Worker's Comp Blog reviews the history of the successful Commonwealth Care Alliance.  This non-profit HMO currently serves over 17,000 "dual eligibles" in Massachusetts; these persons have significant disabilities and therefore qualify for both Medicare and Medicaid.  Despite huge claims costs, this HMO has been ably served by leadership who understands how money and mission underlie successful health insurance.

A Minimum Wage A Day Keeps the Doctor Away

Drugs: You Don't Get What You Don't Pay For

David Williams of the Health Business Blog has some thoughts for the pharmaceutical industry's efforts to justify its drug pricing policies. He recommends that pharma not only embrace cost-effectiveness, but lead the fight to include that methodology in all things healthcare.  They also need to help the public understand that you don't get good stuff for free: someone has to pay.

Speaking of Drugs....

Joe Paduda of the Managed Care Matters blog attended the Rx Drug Abuse Summit and has posted some of the more scary data that was presented there. The vast majority of heroin users started with prescription opioid drug abuse and a lot of smart concerned people are mobilizing to address the problem.  Awareness is the first step in addressing this unmitigated disaster.

Food, er Flu Fight

And saving the best for last, in the Health Affairs Blog, Peter Doshi, Kenneth Mandle and Forence Bourgeois scrutinize the CDC's recent recommendations on the treatment of influenza with antiviral drugs. After contrasting the recommendations with the FDA's and others' more detailed analyses on the subject, the authors find the CDC's promotion of a drug of questionable effectiveness to be "problematic."  In academic speak, them's fighting words. This ain't over, so sit back and enjoy while the flu fur flies.  

Your next Health Wonk Review will be hosted by the Health System Ed blog on April 21.

Health Wonk Review Blab

That's right, "Blab."

Plan on joining some of the Health Wonk Review’s “usual suspects” for a live video chat discussion of the latest edition above on Blab – you can watch it live right here next Tuesday, April 12, at 1 pm ET – or you can watch the replay right here if you can’t make it then; you can “subscribe” if you have a Blab account (you’ll need a Twitter account to sign up for one), and you can follow David Harlow (HealthBlawg) on Blab if you want to be automagically notified of future editions.

Friday, March 25, 2016

How the Candidates Can Weigh In on Population Health

Watching March Madness (Go Villanova!) ads and the accompanying Political Silly Season news have alerted the Population Health Blog to the very real possibility that its state's late primary may play a role in the presidential sweepstakes.

While the PHB ponders what to do with its vote, it naturally thought about the candidates' positions on "population health." 

In no particular order and as a public service to the campaigns' search for talking points (and "dog whistles"), the PHB offers the following statements for their consideration, just in case the topic comes up......

Mr. Trump: Believe me, I've studied this far greater than anyone else and population health would have terrible ratings if it weren't for me.

Bonus question on electronic health records (EHRs): We have to EHR how bad it was a disastrous deal amateur hour believe me.

Mr. Cruz: The words "population" and "health" do not appear in the U.S. Constitution and this will end on day 1 when I become president.

Bonus question on EHRs: I cannot find the letters "e," "h" or "r" in the U.S. Constitution either, and it's not just because of the handwriting.

Mr. KasichWe did population health in Ohio when I was governor and while I chaired the Ways and Means Committee in Congress

Bonus question on EHRs: We did EHRs in Ohio and while I chaired the Ways and Means Committee in Congress.

Ms. ClintonWe will build on the success of Obamacare by investing in population health through legislation that offers a tax credit to offset its cost that will be available through the exchange to assure that all families will not exceed a premium threshold under current law while incentivizing expansions of the program through all 50 states with a matching initiative over several years.

Bonus question on EHRs: I never knowingly sent confidential patient information or received anything marked HIPAA protected at any time. But under my plan, physicians will be able to use private email accounts to communicate with their patients.

Mr. Sanders: Population health, like a college education, solar power and frozen yogurt is a basic human right.

Bonus question on EHRs: That too.

Not to be undone, two other recent fixtures in the PHB television universe have weighed in on population health....

Charles Barkley (taking a break from his half-time college basketball commentary): It's turrible that people see that (unintelligible) Krispy Kreme that don't understand how if (unintelligible) people have eaten too much.

Joanna Gains of HGTV's Fixer Upper (a PHB spouse refuge from the TV craziness): Let's face it: Fixer-uppering chronic conditions with population health is possible with the affordable use of vintage twists that accent an existing space and give an illusion of depth with a favorite hue.  Try some mottos, mirrors and oversize remnants that group together and transform drabness to healthiness.

Thursday, March 24, 2016

The Latest Health Wonk Review Is Up!

This HWR is timed with the sixth anniversary of the Affordable Care Act.  Topics include narrow networks, assisted suicide, misprescribing, balance billing, healthcare workplace violence, moonshots and the controversies over morcellation.

No association, or cause and effect?  You be the judge!

Thursday, March 17, 2016

Busting Through the Healthcare Performance Frontier

The costs of business performance - for example, customer delight, reputational excellence, high worker satisfaction, workplace safety, leadership diversity, environmental sustainability or reducing social disparities - are typically viewed through the lens of a zero-sum game. 

In this classic world view, achieving profitability means cutting performance, while pursuing high performance reduces profits. The relationship between the two variables can be displayed as a curve:

Population Health Blog readers can find out more about this here.

Most firms in the real world operate on the "A" curve.  Different firms under different circumstances make dozens, if not hundreds, of decisions on a day-to-day basis involving trade-offs that move them along the curve that extends along the profitability and performance continuum.

Examples of healthcare companies that moved up on the curve at the expense of performance include the Veterans Administration and Turing Pharmaceuticals.  At the other end of the curve, the understandable unwillingness of some hospitals to walk away from their community service obligations may have led them to bankruptcy.

The "B" curve represents the theoretical limit for greater profitability and performance using the current business model.  In other words, as companies maximize all opportunities and minimize all inefficiencies in their existing business models, they can move the curve up and to the right.  That is what all management, executives and boards can define and aspire to.  That "B" curve is known as the "performance frontier."

Examples of healthcare companies that moved toward the "B" curve? You can find more about them here.  If they're hospitals, they fill beds with short lengths of stay and high patient satisfaction.  If they're clinics, they maximize billing revenue and minimize waiting lists.  If they're an ACO, they manage risk by contracting for an actuarially optimum population while pursuing the Triple Aim.
The "C" curve beyond the established frontier is what becomes possible with transformational innovation, superb leadership or both. Examples outside of healthcare include Apple under Steve Jobs and Tesla under Elon Musk. Firms that create value by inspiring employees, new products and innovative processes not only benefit from even greater profitability, but offer enhanced performance

In "C" level healthcare settings, the top-line growth and decreasing costs would be accompanied by better measures of customer/patient well-being, community burden of disease, worker engagement, leadership diversity and improvements in social determinants of health.

While the Population Health Blog eagerly awaits reports of frontier-busting healthcare providers, it offers a few observations:

1. Healthcare organizations have generally not done a good job in defining and measuring their performance metrics.  They've also not made them part of the C-suite's DNA or placed them prominently on their governing boards' agendas. If they did, breakthroughs would become more likely.

2. The EHR's primary functions of billing and documentation will never get healthcare organizations to the C curve.  This is not part of a breakthrough strategy.

3. In contrast, big data, risk stratification, mHealth and machine intelligence have the economic/business potential to identify risk, channel the right care, circumvent high cost service options and rationalize decision-making, but could also increase performance through the engagement of consumers, increasing access to more care options, reducing disparities and minimizing provider busywork.  These are the ingredients for a breakthrough to C-curve level performance that is only just beginning.

4. By the way, another ingredient for high healthcare provider performance can be found here.

5. Last but not least, the leadership of many innovative health technology companies already intuit much of this.  They're looking for partners that are not just looking for "B" level performance, but want to bust through the performance frontier. 

Friday, February 26, 2016

The Personalized Healthcare Ecosystem of the Future: Welcome to the Year 2030

Against your better judgment, you've just checked your contact lens-enabled news feed. You're annoyed, because President Meghan McCain has just used the Trump Doctrine to "fire" Medicare's lead administrator over the botched roll-out of the Agency's block-chain claims payment system.  The mild spike in sweat stress chemicals detected by your clothing sensors prompts a boost in the transcutaneous dosing of the blood pressure pharmaceuticals from the networked skin patch on your thigh. 
It's the year 2030, and personalized "eDxTx" (ecosystems of Diagnosis and Treatment) has arrived for a lucky few who are able to afford it. That has created political headaches for the President and her campaign promise to bring Medicare out of the 20th century. Your decision to opt out of "Medicare for All" (a.k.a "TrumpCare") has been expensive, but worth it because your Geico insurance plan includes eHealth as a covered benefit.  Geico's ability to automate all underwriting and claims handling means high service standards and keeping costs down. Plus, those video ads are still cool.

Thanks to ubiquitous wireless connectivity, cloud-based machine intelligence and mass-personalized medicine, you and your private doctor's team were able to configure a suite of customizable off-the-shelf apps that meet your goals for living well as well as long.  The first step was your $2 psychometric, biomic and genetic testing (the expense of a mitochondrial analysis was offset with an agreement with the laboratory, Theranos, to pool your data with other customers) that spotlighted the optimum mix of nutrition and pharmaceuticals to blunt your risk of Type 15 Hypertension and GAB15a-linked gastrointestinal cancer

As you sit down and use the heads up display in your lens to ponder the short-list of candidates to replace the fired administrator (a well-placed leak suggests it reportedly includes Elizabeth Holmes), the patch modulates your drug dosing to account for the change in body position.

You're hungry and looking forward to your specially tailored evening meal that is being drone-delivered to your patio in.... your contact lens again... 28 minutes. 

This is one of the five days out of the week that you adhere to a configured meal of calories, carbs, proteins, fats, nutraceuticals, probiotics and prebiotics that's adjusted to meet your taste preferences. It will also achieve an optimal body fat percentage, and reduce your risk of cancer and a host of other chronic conditions. The other two days use competitive gamification that is linked to your online preferences to reward you with a real burger for meeting your nutrition goals.  Not for everyone, but your behavioral reward profile suggested that that would help motivate you to stick to the diet. Who knew?

You ponder getting a burger tonight, but fight the temptation by triggering a mindfulness app through your lens.  The lights in your living space also dim and a riff made up of an pleasing artificial jazz-indie chord progression offers a well-placed distraction.

Diet and risk reduction are not the only an ingredients you use to achieve your goal of living 105 years, but also participating in next month's Goggle Spartan Race.  Come to think of it, time to tailor a set of 3D printed sneakers. You look forward to you and your personal life-drone (your spouse suggests it's more evidence of your narcissism; you've named it "Donald" to confirm her suspicions and annoy her) competing in a mix of virtual and real obstacles in a course of that includes real rope climbing and a virtual 3-D avatar obstacle course. The drone and wearables will network, monitor and heads-up display your neuro and cardiovascular dashboard for optimal performance. It will also use the same technology that they used in hospitals to anticipate any medical emergencies that could happen to you.

Naturally, your drone will use artificial intelligence to image, edit and securely post the race video for friends and family to view.

That's what you did last year, when the video also showed you twisting your ankle.  You had to go to a treatment center and be evaluated the old fashioned way, where a doctor treated you.  Some things never change, but avoiding those opaque bills and paying your deductible using virtual currency was so convenient.

As your pour yourself your recommended 1.2 ounces of bourbon (personalized by the distillery with a proprietary combination of esters and lactones to create your preferred finish), you reflect on how healthcare has changed since the days of in-home monitoring and physician teleconferencing. It worked well while it lasted, but was soon eclipsed by the cloud-based technology that combined physician intelligence ("physint") with Watson (artificial intelligence) that "scaled" in an era of fully automated care. 

Sort of like the driverless car that will take you to next month's race.

Speaking of old fashioned cars, that eDxTx medical alert last year reminded you of that old fashioned "check engine" light.  It seems a biochemical marker profile was consistent with the presence of an early stage tumor.  Based on your past medical data, the calculated Bayesian risk that the tumor was real approached 1%.  Watchful waiting using Medicare's IPAB guideline recommendations was raised as an option by your doctor, but you decided to undergo the additional testing to rule it out.  Naturally, your insurance covered most of that cost.

You finish your bourbon after you get an alert that the pizza has arrived.  You silently wish President McCain good luck. Some things never change.

Friday, February 12, 2016

The Latest Health Wonk Review

Here we go again.  While money can't buy love, Steve Anderson over at Medicare Resources looks at money and healthcare reform, and a whole lot more!