Tuesday, June 21, 2016

Problem-Based Wisdom, The Age of Em, Reputation Economics and End of Life Care

The Population Health Blog has been busy with building on the value proposition of IT-enabled care management, helping to plan a 2017 trade show agenda, training for a race, learning about cyber-security, and staying out of the way of the PHB spouse as she plans two family weddings.
 
But that doesn't mean it hasn't been thinking 'bout a lot of stuff. Namely:

End-of-life care: A non-physician colleague asked the PHB why the U.S. can't seem to mitigate the skyrocketing costs of futile treatments for persons who are dying. The PHB's response was that patients and their families are less interested in value than they are in hope, and that "futility" is often discernible in hindsight, not in an ICU at 2 A.M. In addition, as "bundled payments" gain traction, patients and families may have to again wonder about the impact of local economic conflicts of interest. The PHB thinks this will get worse before it gets better.  It wonders if part of the answer may lie in Shared Decision Making, in which an independently derived calculation of the odds of survival with and without disability is provided to patients and families, along with the space to decide next steps.  Think less "defined benefit" and more healthcare financing.

An Interesting Book: Reputation Economics by Joshua Klein builds on the observation that humans ultimately prefer to trade goods with persons they genuinely trust. The invention of money as a medium of exchange may have solved a lot of inconveniences, but it also distanced the seller and the buyer. He suggests that our Information Age is ironically ushering in a return of barter, where many goods and services can be directly exchanged between parties who create a track record of their trustworthiness online. Interestingly, your personal identity doesn't need to be part of that reputation. And if barter isn't available, enter cryptocurrency like Bitcoin, which preserves anonymity but commands trust.

Another Interesting Book: The Age of Em by Robin Hanson suggests that there is less to traditional machine-based artificial intelligence than meets the eye, and that it will be simpler within the next century to image and build a replica (or "emulation") of a human brain. As a result, these super-devices will be capable of self-learning, handle all tasks and oversee a rapidly expanding economy that has little need for (real) humans. If this book is true, the PHB's current and future grandchildren can look forward to a lifetime of pure leisure.  Maybe they can spend part of that time reading PHB's past posts.....

A hot-off-the-presses PHB peer-reviewed publication: This examines how healthcare institutions' boards of directors can leverage the wisdom of crowds, problem-based learning and non-linear generative governance to create insights and unlock competitive value. Traditional governance with fiduciary and strategic oversight is unequal to the task of thriving in a complex and rapidly changing healthcare marketplace. "Problem-based wisdom" occurs when boards step back and ask more questions and seek more options. You can read the paper here.

Friday, June 17, 2016

The Latest Health Wonk Review is Up!

Practically nothing goes unexamined in the latest Health Wonk Review, which is hosted by the Health Affairs Blog.  Chris Fleming does a superb job of summarizing and linking the latest smart bloggery on insurance, healthcare reform, costs, wearables, artificial intelligence, pharma, guidelines, risk adjustment, cancer funding and workers' comp.  Oh, and Theranos too.

Tuesday, June 7, 2016

The Latest Health Wonk Review Is Up

The latest Health Wonk Review is bustin' out and up at David Harlow's erudite HealthBlawg. Dance on over to the latest insights of the top health policy bloggers here

Wednesday, May 25, 2016

Pricing, Product and Audience: Theranos and DTC Blood Testing

Is the Population Health Blog due for a meal of humble pie?

In this prior post, the PHB was "long" on Theranos' prospects.  Since that was written, Medicare has alleged that a company lab was a "jeopardy to patient health and safety," a peer-reviewed study showed troubling test inaccuracies, the Securities and Exchange Commission (SEC) has opened an investigation, higher ups have left the company, years of test results have been "voided"  and founder Elizabeth Holmes faces the prospect of a ban from doing business with Medicare and Medicaid. And to add injury to insult, Walgreens has bailed out.


In this well-written Viewpoint published in JAMA, Stanford's John Ionnidis composes a Theranos requiem that ultimately questions the virtues of the company's low-cost and direct-to-consumer blood testing. He argues that while the solution of self-diagnosis and early treatment only sounds revolutionary. That pales in comparison to the far larger problem of misdiagnosis that leads to the reality of overtreatment.

Good point.  But, while Theranos' prospects are clouded, the PHB is still long on the underlying three point business model.  Theranos got one right, and the other two are within reach.

To wit,

1) The pricing is uncoupled from opaque insurer-based fee schedules and based on rational consumer-driven price points.

2) The product is health insights, not blood testing data.

3) The audience of buyers/regulators need to understand the value-based outcomes  
 
The PHB explains:

1) Theranos stumbles over internal quality control and regulatory compliance issues will play out, and, after a sufficient number of heads roll, will be addressed.  Once that's settled, consumer interest in being able to circumvent insurance and "buy" transparently-priced and OTC blood tests should remain considerable. Medicare's fee schedules are ultimately "cost-plus" which includes the costs of a highly inefficient care system. Think about that $500 stitch and it's little wonder why consumers are so willing to forego the sticker-shock and co-pay hassles to beat a retail path to Theranos' door.

2) Consumer insights about screening blood tests come from combining the test results with pre-test odds, sensitivity and specificity.  While a smart physician can certainly help patients navigate an abnormal liver function test or a high cholesterol, distance technology combined with consumer-friendly machine intelligence (here's a simple example) can also. It's simply a matter of industrializing and democratizing what we've known for decades. And once consumers can understand tests' imperfections, things will rationally equilibrate between under and overtreatment

3) For many reasons, healthcare is a different business. Among the many reasons for that is that "success" is particularly dependent on the need to understand the short and long term outcomes and costs (i.e. value) of any new care model. That means committing considerable resources to study, document, internalize and publicly report what was achieved at what price. An audience of scientists, regulators, providers, insurers, buyers, politicians, physicians and bloggers want to know: does open-range testing for Hepatitis C paired with education on true and false positive test results reduce the incidence and costs of cirrhosis or liver cancer?  Does consumer self-ordering blood glucose levels combined with post-test odds reporting increase awareness of otherwise undiagnosed diabetes and increase claims expense? Does DTC pregnancy testing.... oh, wait, we know that one. You get the picture.
 
If not Theranos, then some other company will profit from putting patients in at the center of lab testing.  The genie is out of the bottle.

Since first posted on May 25, there have been update modifications.

Tuesday, May 17, 2016

19th Hedda Gabler's Lessons for 21st Century Health Information Technology

It's the 17th of May, which means it's Norway's Constitution Day.  Sort of like July 4th.  Which reminds the Population Health Blog.....

If you are in D.C. in the coming weeks and have an interest in health information technology (HIT), you may want to check out the Studio Theatre production of Norwegian playwright Henrik Ibsen's Hedda Gabler. 
 
The Population Health Blog explains.

In the two and a half hour production, Hedda struggles to reconcile her human dysfunctions with the rigid etiquette of an aristocratic age. As her dilemmas unfold, her academic husband George delights in analyzing societal trends while being unable to see the disaster unfolding in his own home. George ironically delights in knowing more, but is aware of less and less. 
 
There's far more to the play, but what can this 19th century masterpiece teach about HIT?

While Hedda has her issues, she's still being victimized by a complex set of external social determinants.  The PHB suspects playwright Ibsen was intrigued by the impact of rigid social norms in late 19th century Europe.  His play examines their implications for otherwise smart people who can't and/or refuse to adapt. 

Is Hedda's resistance to be reviled, or admired?

Sound familiar?  Instead of a mansion decorated with dying bouquets, we have hospitals filled with the fading economics of piecemeal work. Physicians are working harder than ever to help their patients, but a new technocracy is advancing a new set of expectations.  And the mainstream HIT Georges are so fascinated by making meaningful use meaningful, they are likewise unable to see the forest past all the trees. 


Thursday, May 5, 2016

The Latest Health Wonk Review Is Up

"If elected, I'll....."
Wright on Health pivots to an excellent "general election edition" of the Health Wonk Review.  After reading it, you'll be better informed than either Hillary or The Donald about health policy. 

Too bad you can't do anything about it, but enjoy, eh?


Wednesday, May 4, 2016

Governance Advice for Hospital Boards: Population Health

"For 60 or 90 days of post-discharge care?"

As income shifts from fee-for-service to global payments, the insurance risk transfers that underlie much of "population health" are an important threat to these enterprises' viability.

After a compact and well-written summary of the growth of population health, he offers six suggestions for these boards:

1. Plan on having "forthright discussions" about the difficult tradeoffs between still-remunerative fee-for-service activities (such as high-dollar imaging, lucrative surgical services) and having to invest in the Triple Aim (care coordination personnel, improving quality measures for persons with chronic illness).

The Population Health Blog suspects most boards will ask why they can't have both the FFS cake and the global payment icing. If that's the case, these boards need to plan on having forthright and very lengthy discussions. It's organizationally difficult to have one mission on the 4th floor of the hospital and another in the emergency room.

2. If the organization's employees are enrolled in a "self-insured" health plan, bring them into a population health program sooner rather than later.

Not only is this an important opportunity for a board to understand the revenue versus savings versus expenses involved in driving the clinical and care experience outcomes of population health, its only right to take this for a personal test drive before subjecting your patients to it.

3. Look for common ground between old fee for service and new global payment arrangements.  The author suggests reducing readmissions is a good start.

The PHB suggests boards ask their management teams to also pursue the care coordination "chronic care management" payments offered by CMS.

4. Start demanding population health metrics from your management team, "such as details of total medical expenditures."

More details on the work of measurement can be found here.  The PHB has also humbly suggests here that health organizations should be prepared to invest significant resources - and discipline - into the process.

5. Invest in primary care, care coordination teamwork and pursue "population health pilot programs."

Since the PHB believes well-intentioned CMS' programs are star-crossed (see here and here), it suggests working with local commercial insurers for starters.  As it reviews resources like this, they seem to have a better track record. 

6.  Ask your management team to be open population health contracting.

Hear hear, says the PHB.  But it also cautions that the board needs to have individuals with the kind of industry knowledge necessary to provide oversight of these contracts.  

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.