The Italics and Dot-Dot-Dot Edition of the Cavalcade of Risk

Welcome to your latest edition of the Cavalcade of Risk.  The Population Health Blog is pleased to offer this linked summary of some of the best and latest bloggery dealing with economic risk.

Knowing how busy readers are, this particular edition wanted to focus on the "bottom line" of each entry. The most important insight is at the end of each paragraph.....

Enjoy!

Auto

Wondering if that non-performing capital assessment called a "parked car" can be addressed by "peer-to-peer car sharing?'  Well, if you think you can grab a portion of Hertz's market share by renting that car, you may want to pause and think about what your automobile insurance has to say about it.  Hank Stern over at the Insure Blog points out that a wreck may not be covered leaving you personally responsible for another party's injuries....

Workers Comp

Did you know that employers can be arbitrary, hostile and vindictive?  That employees can be sullen, suspicious and uncooperative?  Toss in a significant  job injury, and you've got is what AMAXX Blog writer Michael Stack describes as an unwritten part of a workers compensation adjuster's job description: being a peacemaker. Employees ultimately do better if they get to work sooner rather than later, and bosses do better they step back and let the workers comp adjuster deal with any possibility of malingering....

Data Privacy

After Target and eBay, your company's (or, come to think about it, government's) databases may not only be next, that possibility is greater than you realize.  RJ Weiss at the Weiss Insurance Agencies does readers a service by summarizing some of the numbers around the risk of data breaches, including a cost of $195 to $246 per record, an average loss of 2.8% of customers and that having strong preventive measures in place can reduce your cost by $8.98 per record.  Important sources of break-ins include those portable devices and sloppy third parties....

Health Insurance

We'd all like to think that hospitals are working hard to reduce costs and increase quality thanks to the government's value-based purchasing initiative.  Jason Shafrin of the Healthcare Economist summarizes a recent peer-reviewed publication on the topic and the bottom line answer is "not exactly." While results may be more a function of the baseline that was used, there was no discernible impact on clinical process or patient experience performance for Medicare beneficiaries....

Speaking of payment initiatives, your host's Population Health Blog (PHB) takes a look at another recent scientific publication that examines how a statewide bundled payment program stumbled.  The process was stymied by the usual payer-provider tensions, inadequate information technology, regulatory concerns and difficulties on defining just what makes up an "episode of care." It turns out that getting bundled payment off the ground is far harder than it looks.... 

Getting health insurance between jobs should be easy, but it's not. Louise over the Colorado Health Insurance Insider cuts through the noise of Obamacare and the individual market by offering up some useful insights, including the definition of a "qualifying event," the 60-day rule and the option of using Medicaid to trigger a qualifying event to navigate the 60-day rule....

The next host of the Cavalcade of Risk is Paul Dzielinski.  The PHB is looking forward to his hosting debut!

Insights on Health Reform, Courtesy of Medical Home News

Getting more brainy

To the chagrin of the DMCB spouse, the Disease Management Care Blog serves for free on several editorial boards. In its estimation, it's well worth the time.  It's closer to breaking news, has met interesting colleagues, gets to read interesting manuscripts and has one more excuse to take a pass on sharing in the intensely engaging drama of Downton Abbey.

One such publication is Medical Home News, and the latest edition, thanks to a back-page "Catching Up With...." interview with former Deloitte executive Paul Keckley, did not disappoint. The DMCB has seen Dr. Keckley's smarts in person in several venues and the MHN piece did not disappoint. When he opines, the DMCB thinks.

Among his brainy insights....

The struggle to prove that the medical home saves money continues not only because there are many models serving many populations with many metrics.  In addition, "each prominent medical home promotes its model as uniquely effective."  The DMCB saw how pride of ownership and proprietary business models balkanized the early disease management industry.  PCMH advocates, you've been warned.

In "some form" ACOs will survive.  The road from where-we-are to where-we-need-to-be will need to include skills in managing populations on a "risk basis." If that's true, the DMCB provocatively wonders if that means that that ACO "form" will be some sort of HMO, which was very good at manging populations on a risk basis.  Time will tell.

The three things getting in the way of "value-based" care are 1) operational and infrastructure costs, 2) payer-provider agreement on how savings will be shared and 3) "the regulatory framework in the ACA and future laws that will define fair play in value-based purchasing."  At first glance, thinks the DMCB, makes sense until it ponders the irony of that 3rd one.

"Tranparency about prices means little."  It's all about networks, reference pricing and leveraging them to extract value.  The DMCB cannot disagree and is reminded that's how health care markets really work.

The biggest disappointment in health reform is how disconnected the consumer remains, while the biggest plus has been the advent of data-driven health care.  The DMCB wonders if the biggest disappointment has been the battering of the "big government" brand, while another plus has been the growth of the DMCB readership.  Time, naturally, will tell.

Image from Wikipedia

Medicare's Expenses Increased by 0.4%? Really? And It's All Because of the Affordable Care Act?

If you're the head of Google and you want to teach about the internet, North Korea is a swell place to visit.  If your goal is air travel safety, the 787 Dreamliner is the plane for you.  If you would like to get the puck from an opposing professional hockey player, saying "please" helps.  And if Medicare costs dip, the Affordable Care Act (ACA) obviously deserves the credit.

Writing on an HHS website, Richard Kronick and Rosa Po announce that 2012 Medicare expenditures per beneficiary grew only by 0.4% over the 2011 baseline.  They credit the ACA's value-based payment (VBP) system, attacks on fraud and abuse, reduced payments to Medicare Advantage plans, cutting hospitals payments and "innovation."

The Disease Management Care Blog isn't too sure about that.

1. This Kaiser Health News article notes the VPB program withholds 1% of hospital payments and uses that fund to award bonuses in what is really a zero sum game.  And this Health Affairs article suggests the overall financial impact of VPB on hospitals is quite minimal anyway. 

2. While there have certainly been some big fraud and abuse busts, there's plenty of reason to still be skeptical about the ability of Medicare's ossified bureaucracy to catch up with the sophisticated criminal enterprises that are routinely fleecing billions from the U.S. taxpayer.

3. As for the one-time payment cuts to providers and insurers, the DMCB is confident that they'll figure out ways to get their money back.  They always do.

4. The innovations are in demonstration phase.  It's too early to tell.

In addition, the DMCB is surprised that Medicare's 2012 insurance claims were ready to be rolled up and quantitated in early 2013. Check out this telling quote from the website:

"2010 and 2011 statistics are calculated on a calendar year incurred-basis. 2012 statistics are calculated on a fiscal year cash-basis, because calendar year incurred-basis data are not yet available." (bolding from the DMCB).

Last but not least, the DMCB believes the lackluster economy has probably had the biggest impact on consumers' willingness to use their Medicare benefit.  While Kronick and Ro state" Medigap" insurance benefits have protected the beneficiaries from the financial pain of Medicare's out-of-pocket expenses, the expense of using a hospital or seeing a doctor is more than the sum of all those medical bills.

Is the DMCB being too skeptical?  Perhaps, but this particular HHS spin is built on assumptions that are backed by associations that are biased by partisan loyalty.  Taxpayers deserve better.

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Medicare Pay for Performance for Hospitals May Be Flawed

The Disease Management Care Blog is still waiting to be listed in the CMS' "clear accurate information is essential in times like these" Op-Eds & Blogs web page.  Will the CMS mandarins find favor with this particular DMCB post and include it with the other insightful masterpieces they've linked, like "Health Reform Helps Many" and "Public Service Recognition Week?"

Probably not, says the DMCB.  It's not because the DMCB is again linking this report showing how CMS seems to be incapable of delivering disease management services to its fee-for-service enrollees.  It's not because of this report revealing how Medicare's Hospital Compare isn't having much of an impact on outcomes.

It's because the DMCB is bringing up the inconvenient truth of this independent evaluation of Medicare's Premier Hospital Quality Incentive Demonstration. This demo tested whether pay for performance can increase the quality of care for acute heart attack, chronic heart failure, pneumonia, heart bypass surgery and total knee as well as hip replacements.  33 measures for these conditions were collected from 252 participating hospitals. The hospitals that scored in the top measurement deciles received bonus payments, while those that were underperforming were hit with a payment penalty.

Think of it as "pay-for-performance" for hospitals.

After excluding hip and knee surgery (where mortality rates are very low), the researchers were interested in measuring whether the Premier Incentive Demo was associated with one of the most important outcomes of all: lower death rates. Based on 6 million patients' worth of data from 2002 through 2009, the researchers found that there was no difference in overall 30-day mortality rates for all of the four conditions compared to non-demo hospitals (11.8% vs. 11.7%). In addition, mortality rates for the individual conditions of heart attack, heart failure and pneumonia were no different either. For heart surgery, there was a slight excess of deaths in the Premier group (4.1% vs. 3.3%).

These results are quite a contrast from this Premier press release that estimates that the Demo "saved an estimated 6500 heart attack patients." The DMCB suspects that that particular number was derived and extrapolated from prior studies linking less tobacco cessation or greater aspirin use to improved death rates.

It seems the math may have been wrong. And it was that same math that led the architects of the Affordable Care Act to establish the Medicare Hospital Value-based Purchasing Program ("Hospital VBP"). As the DMCB understands it, it's just now getting underway.

Egads.

Go to this particular HHS web page and you'll find that the Department....

"...monitors and evaluates programs to assess efficiency and responsiveness and to ensure the effective use of information in strategic planning, program or policy decision making, and program improvement."

Hopefully, the leaders at HHS will be doing precisely that by reexamining its assumptions and it's ability to achieve real value with the Hospital VBP.

Should Health Insurer Coverage Be Conditional On Participation In Disease Management?

Standing between patients
and outcomes?

The unsophisticated Disease Management Care Blog used to think the answer was a simple yes. 

Its rationale was twofold:

1. The patient impact of the medical and pharmacy benefit, i.e., medications and other treatments, will be greater if there's a link to concurrent care management services that promote self care and increase doctor-patient engagement, and

2. The gateway to accessing the medications and treatments could be used to incent enrollment in care management programs which, depending on the circumstances, increase quality and lower costs.

Both factors undoubtedly underlie the decision of many insurers to combine disease management and coverage of certain services.  For example:

Many Medicaid programs won't cover tobacco cessation medications unless the patient is participating in "counseling services."  That's because much of the original research on the drugs showed they work if they are linked to concurrent behavioral support.  By the way, the same is true when it comes to drugs for the treatment of obesity (page 53), which showed up in this coverage document.

In addition, consider the example of "external insulin pumps."  These are battery powered, small and discreetly wearable devices that provide a highly tailored course of insulin to persons with diabetes.  They are are also complex and expensive, which is why many commercial health insurers rely on guidelines that require participation in a diabetes program before they'll be approved.

There are exceptions to the rule.  For example, while asthma treatment guidelines (page 60) recommend 'instruction, demonstrations and frequent reviews' along with the prescription of peak flow meters, coverage of these devices is not conditional on participation in an education program.

Upon further reflection, however, it occurred to the DMCB that having to enroll in disease management - whatever its merits - could be viewed by patients as a barrier which could, in turn, paradoxically reduce medication possession ratios, participation in tobacco cessation programs or use of insulin pumps.

In mulling this over, the DMCB turned to the topic of Value Based Insurance Designs. While VBID can be defined as the explicit setting of patient out-of-pocket-cost (such as co-pays or co-insurance) to the underlying value of any medical service,the DMCB thinks it can be broadened to include the removal of any barriers that stand between the patient and high value services.  The highly regarded University of Michigan's Center for Value-Based Insurance Design, in this excellent review, doesn't think of disease management as a barrier but as an incentive.

Incentive or not, the good news is that it's possible to combine VBID and disease management that together achieve outcomes that are better than either one alone.  Unfortunately, the DMCB fears those outcomes are limited to patients willing to enter the programs in the first place: there may be a larger unseen population outside the disease management intervention who aren't included because they don't want the hassle.  In other words, good outcomes for a few known participants doesn't make up for the potentially bad outcomes for the many non-participants.

If any readers have an answer, the DMCB would appreciate hearing from you.  In the meantime, the DMCB cautions that the population health management suppliers need to be aware of the downsides of linking insurance coverage to their services.  They also need to do everything they can to avoid being viewed by patients as a barrier.

Image from Wikipedia

Free Drugs For Heart Attack Patients: The Analysis Behind the Analysis of the MI-FREEE Trial

Assuming drugs are not free, should all patients in an insurance plan that covers medications get the same coverage at the same price?

While that may seem to be a no-brainer, there's plenty of research (for example) that demonstrates that out-of-pocket costs can reduce persons' willingness to take their pills as prescribed.  While that may be the price of doing business, why not give persons who really need a particular life-saving medication a price break?  While that may seem unfair, suppose everyone in the risk pool benefits from lower health care costs?

Enter the Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) trial. 

Too long to read at one sitting you say?  The Disease Management Care Blog at your service!

The study involved Aetna beneficiaries who had just been discharged from a hospital following a heart attack.  While the trial was randomized and prospective, the randomization occurred at the level of the insurance plan. Various employer, union, local government or other association groups (and their patients) were randomized to one of two arms:

1) an intervention group where patients had no out of pocket cost sharing or co-pays for brands or generics in four classes of drugs that have been shown (go to page e227) to reduce the risk of death after a heart attack: 1) statins, 2) beta blockers, 3) ACE inhibitors and 4) ARBs, or

2) the usual co-pay for statins, beta blockers, ACEs and ARBs.

2845 persons were placed in the "no-cost" arm of the study and 3010 were in the "usual cost" arm of the study.  The mean age was 53 years and 75% were men.  About 34% and 27% of both groups had diabetes and heart failure, respectively.  Over time, the percent of persons that were fully compliant with their medications became different: 31% in the usual cost vs. 41% in the no-cost group.  The median duration of follow-up was 394 days.

And what happened?  When the number of first-time fatal and nonfatal cardiovascular events were grouped in and counted with heart surgeries (that included angioplasties, stenting or open bypass), there was no statistical difference between the two study arms: 18.8 events per 100 person-years "usual cost" vs. 17.6 per 100 person-years in the "no-cost" group.  There was no difference in the cardiovascular death rate either: 2.0 vs. 1.7 deaths per 100 person years.

However, there was some good news.  The combined endpoint similarity was largely driven by a high equal number of heart procedures in both groups (which seemed to involve more than 10% of the entire study cohort).  If the surgery patients are backed out, there were fewer first time fatal or non-fatal vascular events and strokes in the "no-cost" group. 

There is even more good news. Some patients had more than one event (a patient could have a heart attack, a stroke and then open heart surgery, for example). When the total number of events was added up, there was a difference and it was statistically significant: 329 per 100 person-years in the "no-cost" group vs. 406 per 100 person years in the "usual cost" (p=.03).

Did the insurers save any money?  Yes and no.  Average total spending in the "no-cost" group tallied up to $18,254, while the "usual cost" group averaged $20,238.  While that's a $2000 difference per patient, it failed to achieve statistical significance. However, when the DMCB multiplies those savings by the number of persons in the no-cost treatment arm, it calculates $5,690,000 in total savings. That sure sounds financially significant. 

DMCB criticisms:

1.  Heart procedures - which may be prone to factors other than clinical need - may have diluted the results in this trial, especially if a significant proportion of them were not evidence-based.

2.  The secondary prevention benefit of drugs for heart attack patients extends beyond 394 days.  If this study had gone longer, the difference may have expanded over time and achieved statistical significance.

3.  While a cost difference of $2000 did not reach statistical significance, that may have been because insurance claims follow a non-Gaussian distribution, making their analysis very tricky.  In addition, the DMCB thinks that a real world savings potentially exceeding $5 million is very noteworthy.

DMCB questions:

1. It'd be nice to know if patients with a higher burden of disease (for example heart failure or diabetes) and therefore more vulnerable benefited more than persons with less disease burden.  If so, would it make sense to limit the "no-cost" option to heart attack patients at the highest level of risk? 

2. There is no information on the level of out-of-pocket costs in the usual-pay group. As co-pays increase, medication adherence goes down. We don't know if Aetna's pharmacy benefit is typical of the rest of the market.

DMCB insights:

1. The possibility of $5 million (or more if compliance can be increased beyond 41%) in savings may make paying patients to take their pills seem reasonable.  Silly you say?  Think again.

2. Since $5 million in cost reductions that can result from just a 10% swing in medication compliance, readers should gain a better appreciation on the stakes behind disease management.  If nurses can talk patients into taking their pills, the downstream savings can be potentially huge.  And why stop there, why not combine no out-of-pocket costs with disease management?

Summary:

While the authors dutifully report that the primary outcome of the study (the number of first non-fatal or fatal heart attacks or some type of heart procedure) was the same in both groups, the DMCB remains impressed that free drugs for heart attack patients may be worth it and that Oncle Karl may have been right and that the University of Michigan VBID folks are on to something.  That's because the total number of events achieved statistical significance and there were some specifics that may have blunted the study's ability to get at the other outcomes.

Image from Wikipedia