Questions That Should Be Asked in the Upcoming HHS Secretary Nomination Process

As a public service, the Population Health Blog is pleased to offer up some questions that may or should arise in the course of Senate confirmation process for HHS nominee Ms. Burwell. 

If she can address the inquiries in these key categories, the PHB suggests she'll be more than prepared for the job:

The Clinton years: Supporters of the Affordable Care Act say "it is now the law of the land."  Based on your extensive experience in the Clinton White House, how would you define "is?"

Signing up young people: Do you credit the last-minute surge in sign-ups on the individual exchanges to Mr. Obama, Mr. Galifianakis or to the Two Ferns?  How will you use that insight to increase individual enrollments in 2015?

Use of social media: Since the Population Health Blog began on-line publication more than 5 years ago, health care cost inflation has moderated significantly. Please explain how Medicare's actuaries will factor this into their future projections.

Doing your part for the 2014 mid-term elections: Will you advocate that the "essential health benefit" be broadened to include coverage for global warming?

To test your awareness of the employer mandate: If Peter Baelish hires 47 part-time seasonal service employees in KIng's Landing for more than 120 continuous days in the first quarter of 2014 without a profit sharing provision, what is the number of FTEs and what would the "4980H penalty" be if it were calculated in Gold Dragons?

And finally, tort reform:  Suppose Iva Pannus buys taxpayer subsidized insurance but also participates in a workplace weight reduction program. If Iva's girth paradoxically increases and she develops sore knees, should she sue in state court to recover her out-of-pocket "bronze" plan expenses and should HHS assert a lien if there is a jury award?

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Say Hello to Sylvia Mathews Burwell, the Nominee for HHS

The Population Health Blog is naturally intrigued by the announcement that Kathleen Sebelius is resigning from her position as HHS Secretary, and that the White House will nominate Sylvia Mathews Burwell to replace her.

So, who is she? 

After reviewing a number of reports that are summarized below, it seems Ms. Burwell is a widely-liked and experienced Washington insider. She has a Clinton-Lew-Rubin pedigree and possesses considerable economic/budgetary credentials. Most of all, has the best chance of anyone of getting confirmed by a fractious US Senate.

The bad news is that she doesn't appear to have any significant experience in health care or with health insurance.  Whether her past with McKinsey or as a Met-Life Board member will help her collaborate with the state-regulated commercial health insurance business is an open question.

Onto the summary.....

Ms. Burwell is the current Director of the White House Office of Management and Budget (OMB), where she has served since April of 2013. She's described as genial, a liberal who favors social programs, is willing to take on spending-wary Republicans (with government shut-downs, if necessary) but isn't especially ideological when it comes to managing the budget.  Her nomination to OMB also helped quell criticism that the White House was dominated by males.  She was confirmed by the U.S. Senate 96-0.

Her 96-0 vote getting track record makes it far more likely that Mr. Obama's nominee will survive what will likely be an intensely partisan process.

Here's Ms. Burwell sticking to her Obamacare talking points, even if it means glancing at some notes to make sure she's got it right:

Prior to serving in the Obama Administration, she was President of the Walmart Foundation (dedicated to ending hunger). During her OMB confirmation hearings, she was criticized for not distancing herself from the company's anti-union activities. During this time, she also served on the Board of MetLife, which, during her tenure, was criticized for mishandling mortgage loan foreclosures.

Prior to Walmart, she was at the Bill & Melinda Gates Foundation for about 10 years, where she was President of the Global Development Program; she may have been more willing to leave for WalMart when she was passed over to lead the entire Foundation.

And before Walmart, she was in the Clinton White House, where she served in a variety of roles for all eight years of the Presidency. After leading the economic transition team immediately following the election, she then went on to serve in a variety of roles, including Deputy Director of OMB under Jack Lew, Deputy Chief of Staff to President Clinton and Staff Director of the National Economic Council.  When Robert Rubin left the Council to become Treasury Secretary, she followed him as Chief of Staff. 

It's unusual for anyone to last two terms with any President in modern day Washington.

She also worked as governor's aide to Massachusetts Governor Michael Dukakis.

She has experience in retail politics, having worked in the Dukakis/Bentson and Clinton/Gore campaigns.

She's also former McKinsey Company employee, where she worked for two years after her college graduation.

She's been criticized for using consultant management jargon in White House meetings.

She received an A.B. Government from Harvard University and a B.A. Philosophy, Politics and Economics from Oxford University, where she was a Rhodes Scholar and a rower. 

She's married to an attorney and has two children. Her family is originally from West Virginia. Her dad is a retired optometrist and her mom was a small town mayor who first ran for the office at age 65.

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Health & Human Services Office of the Inspector General: EHRs Can Facilitate Medicare Fraud

EHR fraud police?

Disease Management Care Blog readers are well aware that it is a nattering nabob of electronic health record (EHR) negativity. It not only has the professional scars from past encounters with these on-screen scourges, the DMCB's literature reviews suggest the impact of the EHR on quality is questionable and its ability to reduce costs is illusory In fact, there's evidence that it can increase costs and hike hospitalization rates.

In addition, the DMCB has repeatedly raised the phenomena of copying and pasting and zombie diagnoses that lead to bloated and inaccurate EHR notes.

Well, readers and detractors no longer have to take just the DMCB's word for it. Things are so bad that even CMS should be worried.

According to this just-released report from the Department of Health and Human Services' (HHS) Office of the Inspector General (OIG), "copy-pasting" and "overdocumentation" are increasing the rates of Medicare fraud.

The former can pepper the EHR with inaccurate information that leads to unnecessary testing and treatment, while the latter makes the work of patient care appear more complicated than it really is.

What's more, the OIG points out that while HHS has been very active (and remuneratively generous) in promoting EHR "meaningful use," it has done little to respond to EHR-enabled fraud. Short of a live human personally comparing multiple notes simultaneously, CMS and its contractors have no ability to systematically audit patient billing records. What's more, there are no consistent internal policies in place or agreement on what to do even if it is detected (such as payment suspensions, overpayment adjustments or referrals to law enforcement).

The DMCB's take:

It remains to be seen if this warning will lead the HHS bureaucracy to catch up with another unintended consequence of health information technology.  If it does, the DMCB is worried that CMS may take its cue from the hostile RAC audits and further alienate physicians. 

Time will tell.

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Dr. Berwick Discovers Toxic Politics Too Late

Dr. Berwick listens to Ms. Sebelius

If you're interested in a post-mortem of Dr. Donald Berwick's failure to be confirmed as CMS Administrator, check out his November 13 JAMA article on "The Toxic Politics of Health Care." 

He identifies six causes of our national discontent, which the social media-minded Disease Management Care Blog has boiled down into 140 character or less tweetable summaries:

Money: there are too many entities making too much money to give up on the status quo. "Reducing costs" means cutting into someone's income.

Unorganized majority latent interests: the majority of Americans can't see or translate their interests into effective political action.

The Silence of Professions: Organized medicine has been all about the SGR and tort reform.  They should advocate for health reform.

Suspicion of Science: public trust in science is eroding because of its elitism. That, in turn, feeds into fear of rationing.

Duality of self interest: a lot of people work in the health care industry. Cutting costs will add to U.S. unemployment woes.

Ambivalence about Federalism: it's difficult to develop a coherent national health policy when power is shared with the states.

Ambivalence about the poor: it's difficult to convince the U.S. electorate that disadvantaged populations deserve public support.

For the record, the DMCB openly supported Dr. Berwick's nomination and still feels that he would have ably served his country as CMS Administrator.  That being said, one cause for his undoing was his failure identify these issues before he was forced to leave Administration. 

Docs like Dr. Berwick - and that includes the DMCB - unfortunately think that all they need are the facts to win the day. Not so: they need to address the money, catalyze coalitions, nudge stakeholders, reconcile multiple interests, cut deals and still do what's right.

He was the wrong guy at the wrong time.

The Health Insurance Death Spiral: Is High Health Insurance Exchange Use An Early Symptom?

According to the White House, the health insurance exchange glitches are a symptom of high demand from a grateful citizenry eager to embrace Obamacare. While articles like this and this suggest that sloppy and amateurish programming is really behind the website crashes, the Disease Management Care Blog is concerned that early high demand - if it exists - could be an early sign of a coming insurance death spiral.

"Death spirals" occur when persons with high levels of risk disproportionately enter an insured population.  When that happens, premiums have to rise to match the increased expenses. That, in turn, causes persons with lower risk to drop their insurance, leading to an even higher proportion of high risk individuals, who drive prices even higher.

The DMCB intuitively doubts that the early high demand described by the White House is the result of healthy latte-sipping millenials and young invincibles having nothing better to do with their web-surfing time.  Rather, the persons most likely to be in a rush to get into the web site are persons who really need insurance.  Those would be the ones facing huge health care bills.
 
Another indication is the relative lack of the standard individual anecdote or "ledes" in media reports that hook the reader into paying attention.  Used by politicians and journalists alike, ledes put a "human face" on a narrative by bridging the personal and the policy.   

Supporters of exchanges would probably like to see something ledes along the lines of...

For years, 25 year old Ivanna Ceeadoc could only lurk outside the local health clinic and watch helplessly as her friends from the coffee shop down the street got free health communications from the nurse practitioners within.  But after using the health insurance exchange....

or

Until he signed up in the health insurance exchange, part-time jazz drummer and retail specialist Hank Erinfersumburgers never had to see a health care provider. Previously unaware of a bleak future of fast food and tight clothes, Hank's zero dollar co-pay now lets him see a dietician and have enough money left over for a lunch......

Young Ivanna and Hank haven't made an appearance in the national health insurance exchange narrative because they probably aren't part of the story.  More likely, it's persons in their 50's and early 60's who have been hold they need a joint replacement, an angioplasty or back surgery....

 Ima Medeesazter was looking at a stack of medical bills a mile high.  Her surgeons' plans included weeks in a hospital costing her hundreds of thousands of dollars. Ima put things off, but now that she used the exchange, she can look forward to getting to know her ICU nurses really well.......

Even more worrisome: this astonishing statement by HHS Administrator Kathleen Sebelius that she "doesn't know" how many have enrolled in health insurance since the October 1 opening date.  If the experts running the shop are unaware the Insurance 101 principle of knowing who and why persons are signing up for health insurance, they have no idea about the spiral threat.

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HHS Assistant Secretary for Planning and Evaluation (ASPE) Report of $1.2 Billion in Savings: Take the Government's Word For It? Why It's Time for Third Party Peer Review of Obamacare Claims of Cost Reductions

Public servants enjoying a good spin

According to this U.S. Department of Health and Human Services: Rate Review Annual Report September 2013 from the U.S. Department of Health and Human Services' Assistant Secretary for Planning and Evaluation (ASPE), the federal government's scrutiny of proposed health insurance rates "saved consumers approximately $1.2 billion" in 2012

In other words, U.S. citizens: 1.  Health insurers: 0.  Or rather, the score is 1.2 billion to zero.

That's a lot of money.  When the DMCB reads the report, it's a credible manuscript that resembles the peer-reviewed medical literature. 

The problem: it doesn't and it isn't.

The DMCB explains.

Disease Management Care Blog readers may recall how Wellpoint's tone deafness turbocharged the inclusion of federal "rate reviews" in the Affordable Care Act.  In addition to hundreds of millions in state grants to bribe strengthen the states' regulation of health insurers, the law also required that proposed increase of 10% or more must be submitted to HHS and "justified."
 
While the DMCB suspects that rate approvals ultimately belong to the state insurance regulators, HHS' new power is the threat of public humiliation from posting the health insurers' rate requests, their actuarial justification and a determination that the rate is "unreasonable."

It was presumably this threat that led to the initial requests being "reduced or denied" to the tune of $1.2 billion  When the requested amounts were compared to the implemented amounts, there was $311 million in savings in the individual insurance market and $866 million in savings in the small group market.

As the DMCB understands it, the data was from health insurers in 47 states that were submitted on a quarterly basis. Rate submissions had to be "cleaned" to correct "filings that were out of scope, or contained similar or duplicative entries, missing or incomplete filings, or incorrect data on requested and/or approved rate changes."  154 rates were reviewed and 43 were "modified or rejected" in the individual market, while 136 were reviewed and 38 "modified or rejected" in the small group insurance market.

The DMCB's take:

The style and layout of the online ASPE report appears to be taken from the peer reviewed medical literature, such as the New England Journal of Medicine or Health Affairs.  Unfortunately, the resemblance ends there, because everything published in the Journal or in Health Affairs is subjected to external third party review.

While peer review is certainly not perfect, it's the best we got.  As this page shows, Journal editors take the threat of conflicts of interest quite seriously while they rely on external volunteer and expert reviewers as the "lifeblood" of journalistic integrity. As anyone who has submitted a paper for refereed publication knows, medical journal reviewers can be merciless nitpicking critics. While painful and certainly not perfect, the result is greater objectivity, transparency, clarity and trustworthiness.

As far as the DMCB can tell, the ASPE report has not been reviewed by external, unbiased third-party reviewers. While claims of $1.2 billion in savings is credible, the DMCB is worried that the data analysis was consciously or unconsciously configured or manipulated for maximum "spin." Since the folks who run HHS are understandably interested in the success of the Affordable Care Act, it's possible that the unnamed authors of this study configured the numbers to present the most flattering aspect of the rate review process.

Case in point?  At the very end ASPE report at the very end of the Appendix, there's this disclaimer:

"A limitation to this method for estimating savings by state is that it assumes that each affected enrollee in these plans paid the statewide average premium, which may not be likely when small numbers of enrollees are affected.  Another limitation is that the savings are applied to a full year of premiums, even though many rate increases go into effect mid-year.

In other words, there's a possibility that there wasn't $1.2 billion in savings.  Had this report been submitted for peer review, that weakness would have certainly been caught up in peer review and it's likely that another number would have been reported.

Bottom line: Because Obamacare continues to be implemented under ever-increasing levels of scrutiny (for example), it's time for outfits like ASPE to submit reports like this to independent journals for peer reviewed publication.  Just because it's the government doesn't mean we can take its word for it.

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The Affordable Care Act and HHS Oversight of Unreasonable Health Insurance Rates: Is It Good Versus Evil?

Check out this New England Journal July 21 "Truth and Consequences" article that reviews the Affordable Care Act's (ACA) language on the Fed's new oversight of "unreasonable" health insurance premiums. Regrettably, it portrays the folks at Health and Human Services (HHS) as the White Knights come to rescue America from the Black Empire of the Health Insurance Companies. Think of the derring do of a ray-gun toting Princess Leia versus a sociopathic Darth Vader. The good news is that because you read the Disease Management Care Blog, even the Journal's one dimensional storyline can be turned into a short efficient learning opportunity.

If you go online to the ACA and look at Section 1003, you'll see that the HHS Secretary is supposed to establish a "process" to annually review or "monitor" the "justification" for any "unreasonable" health insurance premium increases. This process will not only include the health insurers, but the State Insurance Commissioners. To help them on their way, the Commissioners are invited to dip into a pool of $250 million and, in exchange, give the Secretary their recommendations, including whether an insurer should be listed on their exchanges.

According to the Truth and Consequences article, the ACA is a stand against the insurers' "disproportionate" profits, will buttress the outmatched Commissioners' ability to review rate hikes and provide enlightened and disciplined consistency across the States' regulatory efforts. Yet, the article notes, the ACA ultimately does NOT give the Secretary the power to deny insurance premium increases, which is described as a "lack of regulatory teeth." Another problem is that, now that there's a new HHS sheriff in town, insurers will be tempted to keep premiums down by taking it out on physicians with decreased fees, more administrative hassles, utilization management, a potential return of 1990's style managed care and capitated fees with the inevitable accusations that medical care is being withheld.

The Secretary is now gearing up for this with the announcement that comments are being accepted to help craft the specific regulations that will clarify the "process," "monitoring," "justification" and "reasonableness" language. The DMCB thought it was quite clever when it actually found the web site that is accepting the comments, until it realized that about 230 other groups and individuals have already taken advantage of it.

The DMCB recalls that Ms. Leia could be unpleasant at times. Furthermore, didn't Darth ultimately turn out to be a cuddly saint of a man? Let's look at the world through his black helmet goggles......

The health insurance industry may be making gazillions of dollars but its overall return on investment has been quite anemic. States view the regulation of insurance as one of those powers included in the Tenth Amendment and it still remains how much control they'll cede to the HHS Secretary's potentially intrusive overtures. Critics may charge that health insurers can abandon a State but there are examples of States' wrecking the marketplace with unsustainable demands for low premium levels. The terms "process," "monitor," "justify" and "reasonable" are vague and the final regulations that define them promise to be an overlawyered miasma that will do little to stem our national appetite for more health care. Finally, the insurers were mostly defanged in the 1990's. It'll ultimately be up to the physician community to figure out how to deliver higher healthcare value. If the docs are not up to the task, Plan B won't be the managed care insurers or an evidence-base courtesy of the wise editors of the New England Journal. It'll be the judgment of distant Medicare mandarins holding court in windowless rooms just outside of Baltimore.

Somewhere between all that white and black is a color called grey. To get a sense of that, check out the comments web page mentioned above. The submissions make for interesting reading and run the gamut from pleas to rely on actuarial soundness (the insurers) to demands that they be put out of business (cancer survivors). Hopefully the Obama Administration will put aside its public hostility to the insurers, recognize the Journal's Truth and Consequences article for what it is and steer a middle path.

We'll see.

A Contrarian Nominee Suggestion for the Secretary of Health and Human Services

The DMCB feels sorry for its fellow bloggers who boned up for Czar Dashcle’s reign by memorizing his blueprint or forwarding the minutes from those holiday home-based healthcare confabs. While y’all were getting ‘engaged,’ the DCMB was involved in other far more rewarding holiday pursuits. The silliness is not done, however, thanks to the speculation fever over the identity of the Obama Administration’s ‘Plan B’ HHS nominee. Examples are here, here and here.

Not wanting to miss all the fun, the ever contrarian Disease Management Care Blog would like to present its own favorite candidate:

Gloria James.

NBA sports fans may recognize the name of the mother of the Cleveland Cavs’ superstar forward LeBron James. She’s something else. She had LeBron at the age of 16 and as a single mom moved from one menial job to another while keeping a roof over her head and her son from disappearing into the street violence of Akron, Ohio’s streets. This is a woman of grit, determination and hard work.

So, why is she qualified you ask? Well, says the DMCB, consider the following:

It's not just her mettle, she’s a mom. That is a huge advantage, not only because of her gender (which remains underrepresented in DC) but because of what the Fat Lady teaches us in this story from the 15th Chapter of Matthew: ‘Have mercy on me,’ said this anonymous mother to Jesus, ‘my daughter is grievously vexed with a devil.’ When rebuffed, she repeated her plea, saying ‘Lord, help me.’

Curious, isn’t it? The child is ill but it is the mom that is personally suffering and is begging for mercy and help for herself. The DMCB finds this story once again demonstrates the Bible’s special insights about the human condition: mothers feel their children’s pain. What’s more, they understand other moms’ pain and they’ll (and in this example, literally) move heaven and earth to fix it. The DMCB asks: wouldn’t this special skill of selflessness for others’ suffering be a refreshing ingredient inside the beltway? Go to ANY home and school association meeting, any school sports game or Sunday school and you’ll find qualified candidates for the job. You’ll find Ms. James.

Speaking of moving heaven and earth, Ms. James would be a tireless and energetic advocate. There is no better demonstration of this than this clip of Ms. James rigorously debating the finer points of NBA officiating with a referee during a Boston-Cleveland game. The DMCB thinks our President and his team of rivals would benefit from having a person like this who won’t be afraid to tell the Big Man the way it is. By the way, Mr. Obama’s love of basketball will only further cement their mutual respect.

Last but not least, Ms. James has allegedly amply demonstrated her preference to not to take advantage of limo rides at the taxpayers’ expense, expressed by kicking out car a window, if necessary, to make her point. No last minute tax issue surprises here: with Ms. James, what you see is what you get.

But she has no background in healthcare policy you reply? Well, it’s not just the DMCB that thinks it’s possible to have too many economist/PhD experts cluttering up the White House. What’s more, just because you are one doesn’t mean you’ll be very successful. Secretary Ms. James can surround herself with her own team of rivals. What’s more, if common sense and hard work don’t allow her to understand what’s being proposed, I think we can count on her to keep our healthcare laws regulations from being gummed up by even more gobbledygook.

But she has no chance you think? Well, she has about as much of a chance of being named as this guy does.

You GO Ms. James!

A Crisis-Driven Reorganization of Health and Human Services?

Remember when, in response to a large crisis, the Federal government reorganized over 20 separate agencies into a new Department called ‘Homeland Security?’ How about the recent meltdown-driven foray of the U.S. government into banking and insurance? Now that there is growing consensus that there is a healthcare crisis, think the Department of Health and Human Services (HHS) will go unchanged? How can Congress resist?

And here's its cover for it to do something. The Institute of Medicine has released a report to Congress at the request of the House Committee on Oversight and Government Reform. Recall that HHS is a cabinet level Department that includes not only Medicare and Medicaid, but the National Institutes of Health, the Food and Drug Administration, the Centers for Disease Control, the Indian Health Service, the Agency for Healthcare Research and Quality (AHRQ) and a host of others. It occupies about a quarter of the entire Federal budget. Think the one-time $700 billion bailout is a lot of money? That’s HHS’ yearly budget. Given the coming Administration’s appetite for ‘change’ and the leading role of HHS in leading that change, the IOM report could catalyze crisis-style reorganization the Department.

You can access a ‘brief’ of the IOM report here. That’s free. For a full report, you’ll need to go here. That's not free, but the DMCB suspects members of Congress won’t need to pay for it.

Here’s a quick summary of the brief for you.

HHS needs to define a modern ‘vision, mission and goals’ to help persons inside and outside of the Department to understand its work. The IOM recommends the number of individual department heads within HHS be reduced and that the remainder be ‘re-aligned’ to fulfill the new mission and goals. In addition, the office of the Surgeon General needs to be revitalized and AHRQ needs more dependable budgeting. When there is overlap with outside Federal agencies (an example being food safety), it should be brought entirely within HHS. HHS also needs to begin studying and reporting on the comparative effectiveness of medical interventions and procedures. It should also invest in its own workforce recruitment and professional development. Congress should increase HHS’ accountability by getting regular reports but allow greater flexibility to fulfill a ‘new compact.’

The Disease Management Care Blog likes what it’s reading. If that sprawling bureaucracy known as HHS can be even slightly more efficient, mission driven, attentive to outcomes and modeled after entities in the private sector, patients and their providers might be better off for it. Of course, the devil is in the details of the enabling legislation. Let’s hope that Congress follows through on the IOM Report.