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.

Medicaid

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.

Outcomes

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

California's Anthony Wright of the Health Access Blog is not only unapologetic about his home state gradually increasing the minimum wage to $15, he argues that that level of income correlates with better insurability, out-of-pocket affordability, higher health status, improved social determinants and less need for Medicaid.  What's there not to like, especially since the 48 other states can see how this ultimately works out.

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.

How To Provide Care for the Medicare-Medicare Duals: The Population Health Management Playbook

The Care Continuum Alliance (CCA) has come out with an important report on how to improve the care of the 9 million persons who are "dual eligible."  These individuals are among the most economically vulnerable and sickest Americans.  They simultaneously qualify for both Medicare and Medicaid and their health care costs are staggering.

The CCA recommendations for the care of duals on a regional or state basis should not be unfamiliar to regular readers of the Disease Management Care Blog: collect the necessary data, risk-stratify the individuals, maximize coordinated care for those at greatest risk, work with the docs, measure outcomes, lather, rinse repeat.

No knowledge base on disease and population health management and dual eligibles is complete without this download.  Check it out and you'll learn that....

Data on this population should be centralized, comprehensive and interconnected: This means pooling insurance claims, electronic records, labs and pharmacy and making the data available in health information exchanges.  How else will program planners understand the dual's needs, plan programs, foster communication among providers and evaluate outcomes?

The population should be risk stratified.  Health risk assessments are a good option because these persons may drift in and out of dual eligibility.  Incentives should be offered to increase the likelihood that the HRA surveys will be completed.

Professional care planning should be used to to best "position" patients in a coordinated, patient centered and streamlined manner.  This coordination should include providers, pharmacy, behavioral health and long term care to maximize mental health support, rehab, end-of-life care, additional counseling needs and referral to community-based programs.

Provider incentives should use all possible options including capitation, shared savings and bonus payments.  Training and tools should be made available.

Goals for the dual population should be defined and there should be measurement of progress toward those goals.

Care Coordination: The Way Forward For The Dual Eligibles

Hot on the heals of the Disease Management Care Blog's bus tour of the problematic "dual eligibles"  comes this AHIP sponsored report from Emory health economist Kenneth Thorpe on how the Feds could save the taxpayers some serious money.   Recall that there are close to 9 million duals costing in excess of $230 billion per year and that the President's recent cost reduction proposal is curiously devoid of any mention of this group.

So what is Dr. Thorpe's recommendation?  It can be summed up in two words:

"Care coordination."  The report can be found here.

 As the DMCB previously noted, the duals are being victimized by a perfect misalignment storm of Medicare and Medicaid.  Dr. Thorpe recommends that they be automatically enrolled (on an "opt-out" basis) in State-regulated managed care plans that would finance 24-7 centralized team-based care that, in turn, would be required to offer three key evidence-based services:

1. Transitional care or comprehensive planning and follow-up as patients move from the hospital to the community, which is led by dedicated full-time nurses.

2. Coaching and education using motivational interviewing and behavior change theory that is designed to prompt changes in life-style and greater self-care.

3. Medication management under the direction of a full-time pharmacists who make sure that the right medicines are being taken at the right time.

Based on a host of papers that have examined the impact of the interventions described above, Dr. Thorpe estimates, depending on the number of opt-outs, that the savings could exceed a whopping $125 billion over ten years.

The physician-DMCB endorses Dr. Thorpe's recommendations:

While critics may charge that it gives too much power to the insurers, it thinks that the States and the Feds can ensure that there are consumer protections.  Witness the preliminary good work of the Special Needs Plans.

The report avoids drinking the "physician-centric" Kool-Aid that assumes some combination of electronic records and financial incentives will enable primary care docs to take this on.  They can't.

While the Patient Centered Medical Home (PCMH) is certainly an option, report capitalizes on the more important elements of the PCMH and discards the rest. 

Finally, it's the health plan that has the accountability - and the downside financial risk - for making this work in a high cost and particularly needy population.

The Budget Battle and the Dual Eligibles

$315 billion?

While it digests the details behind the Prez's $320 billion health care budget-cutting proposal, the Disease Management Care Blog toured an unfamiliar corner the health care universe called the "dual eligibles" a.k.a. "duals."

Two good up-to-the-minute summaries are here and here.  For a program that is so poorly run and an Administration that is so willing to spend money, the DMCB is surprised the duals haven't garnered more attention.

According to the Kaiser Family Foundation, there are 8.9 million disabled young persons (40%) or low income elderly (60%) who are "dually" enrolled in both Medicare and Medicaid.  Under this system, Medicare is the primary payer, while Medicaid is "secondary." Depending on the beneficiary's income level, Medicaid can be limited to paying for the duals' Medicare Part B premiums, cost sharing deductibles and co-pays (about a third of the duals), or it can cover other services that are not otherwise covered by Medicare (two thirds of the duals).  Two examples of services that are picked up by Medicaid is long-term care in a skilled nursing facility and home-based services. 

Duals had combined Medicare and Medicaid spending of almost $200 billion in 2005 and it's projected to go to a whopping $315 billion in 2011.  While this population on average accounts for only 15% of a state's Medicaid beneficiaries, these patients account for almost 40% of a state's Medicaid budget, mostly for long term care services.

The DMCB learned that these patients are the canaries in the health care coal mine.  They are vulnerable, the sickest of the sick, low income, have multiple conditions and are notorious users of hospitals, emergency rooms and nursing homes.  While some benefit from being in managed care style "special needs plans," 80% of the duals are stuck in a patchwork of overlapping state and federal fee-for-service programs, financing and rules that result in haphazard and poorly organized care.  What's more, since Medicare is the primary payer, any efforts by states to reduce the health care costs of their duals go to the fed's bottom line. 

That's why the Affordable Care Act established a "Duals Office" that is providing grants to states to develop proposals based on either 1) capitated payments to plans that achieve savings for both Medicare and Medicaid or 2) state-run 'managed fee for service" options like "ACOs" or "health homes" that allow states to gainshare in any savings.  The Office will also be monitoring consumer protections, such as preserving choice, maintaining an adequate provider network and ensuring that some of the savings are directed toward care management, coordination and community-based services.  It's too early to tell if they've had any meaningful successes.

In looking at President Obama's latest proposal, the DMCB can't quite discern what the budget cuts will do to the duals.  Cost shifting to the states won't help, but in the long run, the DMCB believes the states are better positioned - despite some bumps in the road - to rely on well-run special needs plans to serve this population with expanded population health and care management programs.

Stay tuned!