Can Tech Put the Breaks on Violence?

As if 100+ deaths on U.S. highways every day isn’t horrific enough, we are all too often reading and hearing about cars being intentionally used as weapons and seeing unbelievable images of victims on sidewalks that have been turned into killing fields.

Unfortunately, the list of these instances is growing. The attack Aug. 17 in Barcelona that saw 13 killed was just the most recent; Charlottesville, NC, and Columbus, OH, have been the scene of attacks as well. Since July of last year, vehicle-related assaults have claimed more than 100 lives in Nice, Berlin, Stockholm and London.

It may come as small comfort to know that advanced automotive safety technology, while not eliminating these instances, might be able to reduce the bloodshed. Automatic emergency braking systems monitor what is in front of a vehicle and apply the brakes when collisions appear imminent. This feature already may have saved lives.

The truck used in the attack in Berlin last December had AEB technology. Tragically, a dozen people were killed in the incident, but reports indicate the AEB system stopped the vehicle about 250 feet after initial impact, likely preventing additional fatalities.

These systems will be on more cars in the future. Last year, the U.S. Department of Transportation, the National Safety Council and the Insurance Institute for Highway Safety announced that 20 automakers have committed to making AEB a standard feature on new cars by 2022.

Admittedly, this is a longshot. It will be decades before AEB systems are found on most vehicles on our nation’s roads. And, as AEB is presumably not being designed with this use in mind, many current systems do not detect pedestrians or bicyclists. Finally, at least to this stage of AI development, technology is still not a match for human ingenuity; these devices can be disabled and misused.

But maybe a side benefit of this technology, deployed to shield us against distracted driving and other human errors, is that it might also protect us when more sinister circumstances arise.

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Should We Fear an Amazon Monopoly on Healthy Food? 

 

Two months ago, I wrote about the potential impact of the Amazon purchase of Whole Foods on grocery prices.  Both here and in the Boston Globe, I hoped and predicted that Amazon would use its famed distribution network to drive down prices on the healthy and organic foodstuffs that made Whole Foods famous.

I’m happy to say that I was right. Today, on Day 1 of Amazon’s official ownership of Whole Foods, Americans got to see the first tangible impacts of Amazon ownership and, as predicted, it was lower prices.  As noted by journalists, the chain once derided as Whole Paycheck should now be referred to as “3/4 Paycheck” given deep discounts averaging 25% on a wide range of products ranging from bananas to butter.

Though terrifying for Amazon’s competitors such as Kroger, Walmart and Costco, Amazon’s major foray into brick-and-mortar groceries may end up being a boon for consumers – at least in the short term.  It’s no secret that Amazon retains its web startup mentality in aggressively promoting loss leaders to drive out competition.  And increased competition will better serve consumers who have been squeezed by recovering inflation on food prices.

Soon, Amazon intends to install more of its Amazon lockers into Whole Foods locations, thereby facilitating deliveries for goods bought on the Amazon website while also increasing foot traffic to its stores.  Analysts also speculate that Amazon’s grocery delivery service, Amazon Fresh, may get a much-needed shot in the arm with goods from Whole Foods.  The corporate synergy of this deal is palpable – and just beginning.

This makes people nervous.  Already, journalists and think tanks have sounded alarms about how Amazon’s growing power may make it a monopoly.  They argue that Amazon is an antitrust problem given that it already captures nearly half of U.S. online sales, is the leader in providing cloud computing through Amazon Web Services and has a robust marketing and logistics division.

To bolster their point, it is true that Americans can now spend a large part of their day using Amazon services without even knowing it.  You could wake up on a Saturday, go to Whole Foods for groceries, order supplies off Amazon, read a book with your Kindle, watch TV on Netflix (powered by Amazon Web Services) or catch a movie on Amazon Prime Video.  All of your needs met by Jeff Bezos and company.

It is understandable that this makes people uneasy.  While America has faced more pervasive monopolies, Amazon’s reach is more insidious given that it reaches, and controls, much of our daily lives.

But when it comes to food, does any of this matter?  I would argue, no.

A key responsibility of any government or society is provide a secure food supply to everyone.  And in this regard, America has failed miserably.  As noted in my previous piece, 2.3 million Americans live in extreme food deserts – areas more than one mile from their nearest supermarket and with no access to a vehicle.  And even where food deserts do not exist, eating healthy has progressively become more expensive than eating junk food.

Much of this increase in healthy food prices can be attributed to the increasingly niche treatment of fresh food.  Tack the label of “superfood” on a product and the price seems to mysteriously skyrocket.  A key example is kale, a food blogger favorite, where heightened demand has led to annual price increases of more than 30%.

With Amazon’s purchase of Whole Foods driving prices on fresh foods down in-store, and perhaps online, we might be on the verge of the democratization of fresh and healthy foods.  And that’s a good thing.

It’s time to stop treating healthy eating as a choice.  The truth is that healthy eating has gotten too expensive and too difficult for those in lower income brackets.  And to blame lower-income Americans for failing to eat right, when junk food is fast and ridiculously inexpensive, smacks of out-of-touch elitism.

Instead of fearing the monopoly implications of Amazon-owned Whole Foods, the Trump administration should view it as an opportunity for public-private partnership.  With grocery prices likely to fall in the near to medium future, the administration should be looking to expand the scope of SNAP (formerly known as food stamps) into direct food delivery so that low-income families can get fresh foods delivered directly to their homes.

Such programs are not new but they previously faced three major problems: (1) technological, (2) marketing and (3) cost.

Luckily, the technological hurdles to using SNAP online seems to finally have been dealt with.  But the other two questions of marketing and cost remained in the pre-Amazon Whole Foods world.  However, with Amazon’s new pricing and renewed commitment to the food business and marketing prowess, such a program could finally take off and deal with the issue of food deserts once and for all.

Instead of relying on Amazon or its competitors to figure out the online SNAP model, government should coordinate the process and streamline the required elements in a general Request for Proposals, including pricing controls.  Doing so should alleviate concerns about the government enabling the creation of an Amazon monopoly while ensuring that lower-income Americans can get healthy food at reasonable prices.

If, at the end, only Amazon can comply with the RFP then so be it.  More Americans desperately need healthy food, whatever the source.

 

Jason Chung is currently the senior researcher and attorney at NYU Sports and Society, in New York. He tweets at @ChungSports.

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To Promote Health Care Excellence, Let’s Recognize Approaches That Assure Value

A challenge for health care purchasers is choosing vendors whose performance matches their cost and outcomes claims. A 2015 Mercer survey found that only 41 percent of worksite clinic sponsors think that they’re saving money. As Al Lewis and Tom Emerick have detailed, many wellness and disease management companies simply overstate their results. In many cases employers may not realize that they, not the vendor, take the risk for results.

One important answer is the Care Innovations Validation Institute, founded by Intel, that offers health care vendors and purchasers objective validation of vendors’ claims.  The Institute stands behind its work with a money-back guarantee. In the Wild West of the health care marketplace, the Validation Institute is an invaluable resource for purchasers, allowing them to confidently proceed with vendors, knowing that their promises have been vetted by scientists.

With these dynamics as backdrop, World Health Care Congress has partnered with The Validation Institute and The Health Rosetta Institute, another not-for-profit organization dedicated to accelerating adoption of proven fixes to health care dysfunction. Together, they are sponsoring The 2018 Health Value Awards, showcasing health care organizations and programs that demonstrate measurably better health outcomes, costs and/or safety than conventional care.

These awards will recognize health care vendors, brokers, and purchasers who deliver higher value care. They seek to identify high performance organizations that adhere to principles of compassion, evidence, transparency, competition and efficiency, as examples that can be emulated.

The first competition will be held within 11 categories, eight of them formally validated by the Validation Institute: Validated categories cover programming by health plan sponsors (i.e., employers and unions), health plan administrators, and organizations that provide or manage care.

While the awards program’s larger emphasis is on validated high performance approaches, it will also recognize individuals and companies on the basis of more qualitative information. Non-Validated Categories will recognize individuals and firms that are progressive benefits leaders.

Applicants will describe and provide performance data on innovative health benefits programming that has measurably demonstrated significant improvements in health outcomes, patient safety and/or cost Judges will consider not only programmatic impact, but scalability (i.e., ease of program replication in other sites/employers), stickiness (or the durability of impact over time), and the calculation methodology used to demonstrate efficacy.

Online nominations for the 2018 awards competition will be solicited between July 15, 2017 and January 31, 2018. Anyone, including nominees, may submit nominations. Special attention will be given to candidates who receive multiple external nominations.

A multi-stakeholder panel has developed criteria for initial review of the submissions, and an independent panel of experts will review all submissions. Five finalists within each category will be selected and announced by February 28. Final selections will be made by the independent panel.

Health Value Award entrants should plan to attend the 2018 World Health Care Congress unless there are unusual circumstances. Registration for representatives will be complimentary. Finalists will also participate, at a discounted rate, in a validation process developed and managed by The Validation Institute. Stipends will be available to applicants who need support.  Entry is not a guarantee of validation.

The Health Value Award is part of a larger movement to bring health care purchasers clear and transparent value data.  This, in turn, will move competition among vendors to objective, measurable results.  By shining bright lights on those that truly perform, the Award program is an important first step in the right direction.
Brian Klepper is an analyst and Principal in Worksite Health Advisors, which connects health care purchasers with high value offerings.

 

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Think Different about Patient Engagement: Aetna, Apple, and a Vision of Digital Health’s Future, Part 2

By LYGEIA RICCARDI

This is the second post in a series on digital health inspired by Aetna and Apple, whose developing partnership is poised to impact millions of Americans. Part 1 is Mystery Mission in LA.

Getting to Patient Engagement

“Patient engagement” is a popular phrase in healthcare these days, but how do you actually get people to take a greater role vis a vis their own health and healthcare? As the first Director of Consumer eHealth at ONC in the US federal government, I spent several years making the case for strengthening patient engagement with technology, and trying to figure out how to make it happen at scale. With Aetna and Apple working together, I think we’re a step closer.

Using the $36 billion+ federal “meaningful use” program–which catalyzed doctors’ migration from paper files to EHRs—as a hook, we required hospitals and doctors to give patients the capability to access (and use or share) their own health records online. The proportion of healthcare providers who give patients electronic access to their medical records has skyrocketed along with EHR adoption. As of 2015 (the most recent data available from ONC), nearly 70% of US non-federal acute care hospitals enabled patients to view, download, and transmit their health records electronically—up from just 10% in 2013. That’s a huge step in the right direction, but we’re still far from achieving the vision I share with an impassioned community of changemakers: a world in which patients live healthier, fuller lives that revolve around meeting their own personal priorities—supported by doctors/nurses, family members, communities, and digital data and tools.

At ONC, we summed up the systemic changes needed to achieve this vision with “the three A’s”:

  • Access—Digital access for patients to information about health, including their own medical records
  • Action—Digital tools including apps and wearables that help patients to take concrete action, informed by data from their medical records and other sources
  • Attitudes—A culture shift from a relatively paternalistic model of healthcare that focuses on “sick care” to one in which patients and families are at the center of their own health and care, and are recognized as taking the lead in daily activities that impact their health, whether through prevention or management.

The partnership between Aetna and Apple could push us significantly toward achieving all three As. In the Access bucket, through health insurance claims, Aetna likely holds the data needed to compile a unified, comprehensive health record for an individual patient from multiple providers. And if Aetna expands use of the Apple watch to all of its 23 million members, that’s a significant swath of the population. In the Action bucket, the Apple watch has its own clean interface and reminders to encourage healthy behaviors, and links to a wide variety of compelling specialized third party apps, devices, and tools.  Finally, the importance of the final A–changing Attitudes, is often underestimated, but it’s here that Apple’s unique brand appeal could turn the tides in how we think about health and healthcare.

My medical records are irrelevant. Or scary. Or boring!

The public is still learning about the online availability of their medical records, though more than a third who have such access still aren’t aware, according to a 2016 survey from Accenture, which also found that people ages 65 to 74 are the most likely to access their EHR data to manage their health, while people 18 to 34 are the least likely. Not surprisingly these “young invincibles” are also among the least likely to buy health insurance under the Affordable Care Act.

Whether young or old, for many of us, not thinking about health at all is the ideal—it means there is nothing wrong—no immediate threat to the body or the wallet. On a deeper level, though, perhaps we fear that poking around in our health records might reveal that we’re not as healthy as we thought. Or even remind us that we’re mortal, a reality most Americans are skilled at avoiding.

And why would anyone choose to engage with the healthcare system unless they absolutely had to? It’s chock full of bad associations beyond illness and mortality—including huge and unpredictable bills and poor customer service. Besides, most people believe their doctor has everything under control… right?

Enter the Most Powerful Brand on Earth

Have a look at the latest ads for the Apple’s watch ? Beautiful, athletic people in cinematic surroundings. These images couldn’t be farther from a dull or preachy public-health PSA or pamphlet urging you to get more aerobic exercise or eat more fiber. Apple has topped the list of the most powerful brands in the world for seven years straight. It represents innovation, creativity, and good design. Think different.

What if Apple, with its brand appeal bolstered by marketing dollars, can help us “think different” about health and healthcare? If Apple can lend its luster to the mundane yet often difficult tasks on which health depends—eating well, moving enough, sleeping well, managing stress—that’s a big win, especially if it can also deliver just-in-time nudges and other tools to help us take the small steps that add up to big change . In partnership with Aetna and its data and scale, Apple may be able to help shift our overall culture to prioritize wellness and prevention.

Yeah, but wellness isn’t equivalent to health. What about people who are seriously ill?

Some argue that the Apple watch is impacting only the most peripheral of health topics—wellness, and that walking a few more steps doesn’t help with cancer or diabetes. Actually, though, I think it does. For one thing, prevention and management of most chronic conditions requires attention to the universally beneficial tasks of healthy living, often while juggling additional tasks including taking medications. For another, the Apple watch already goes beyond wellness, serving as a platform to connect devices such as glucose monitors to address specific health condition needs—and I imagine this trend will continue, particularly if the wearer can give it health record details via Aetna. The watch has already saved lives by detecting early signs of heart trouble.

Yeah, but Apple is only for the rich. What about everyone else?

It’s critical that everyone—especially the poorest and sickest people—benefit from health technologies that can boost health and healthcare. As I see it though, the fact that an Apple watch, which retails at about $350 for the latest model, is too expensive for many people isn’t in itself a problem. For one thing, Apple is a private company, not the government. There is nothing illegal or inherently immoral in creating a luxury product. In the bigger picture it is up to policy makers to figure out how to leverage such tools for everyone, but it’s not Apple’s responsibility. In addition, through their partnership, Aetna may help to bring Apple watches to an economically diverse audience by subsidizing or covering their cost entirely.

In the longer term, though, I think other tech companies will follow Apple’s lead in health to provide lower-cost options to for different demographic groups. The design features of today’s Louis Vuitton purse are clearly recognizable in next season’s knockoff, available in the streets of New York and Hong Kong for a fraction of the price. When the iPhone was introduced in 2017, only 6% of the population had smartphones; today, more than 80% of Americans do—and they’re not all provided by Apple.

Author’s statement of conflict of interest:  I am not employed by Aetna or Apple. While my participation in the event described was paid for by Aetna, I was not required or asked to write about the experience.

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On the Ethics of Accountable Care Research

  • Is it ethical for health policy researchers to claim that a Medicare ACO reduced “spending” by 2 percent if the reduction was not statistically significant?
  • Is it ethical for them to do so if they made no effort to measure the cost to the ACO of generating the alleged 2 percent savings nor the cost to Medicare of giving half the savings to the ACO?
  • Does it matter that the researchers work for the flagship hospital within the ACO that was the subject of their study?
  • Does it matter that the ACO and the flagship hospital are part of a huge hospital-clinic chain that claims its numerous acquisitions over the last quarter-century constitute not mere empire-building but rather “clinical integration” that will lower costs, and the paper lends credence to that argument? 
  • Is it ethical for editors to publish such a paper? Is it ethical to do so with a title on the cover that shouts, “How one ACO bent the cost curve”?

These questions were raised by the publication of a paper  by John Hsu et al. about the Pioneer ACO run by Partners HealthCare System, a large Boston hospital-clinic chain, in the May 2017 edition of Health Affairs. Of the eight authors of the paper, all but two teach at Harvard Medical School and all but two are employed by Massachusetts General Hospital (MGH), Partners’ flagship hospital and Harvard’s largest teaching hospital. [1]

Partners has been on a buying and merger binge since it was co-founded by MGH and Brigham and Women’s Hospital in 1994, the year after merger fever broke out across the American health care system following the endorsement of HMOs and “managed competition” by candidate Bill Clinton late in 1992. Partners’ empire-building has been so aggressive it has provoked resistance from antitrust authorities and has probably contributed to the high cost of health care in Massachusetts. [2] 

In this essay I explore the ethical questions raised by Hsu et al.’s article.  I begin with a review of the article.

More bad news for ACOs, some good news for disease management

The paper I am examining is the third that Hsu et al. have published in Health Affairs about Partners’ Pioneer ACO, the second largest of the 32 ACOs that entered Medicare’s Pioneer ACO program in 2012. [3] I described Hsu et al.’s first two papers in an article I posted on THCB last May, Those papers were quite useful (they reported that approximately half of the ACO’s doctors and patients left the ACO over a three-year period).

Hsu et al.’s third paper reported expenditure data at two levels – at the level of Partners’ ACO and at the level of a disease management program within that ACO that enrolled only very sick people. The paper contained good news about the disease management program, a program the authors called the “care management program” (CMP), but bad news for the ACO.

The authors found that the CMP cut Medicare expenditures on “high risk” patients by a statistically significant 6 percent. The authors made no effort to determine what it cost Partners to run the CMP, so they drew no conclusions about the net impact the CMP had on total costs. This conclusion about Partners’ CMP confirms many other studies which found that it’s possible to reduce covered medical costs (usually by reducing hospital utilization) by raising the cost of other services that insurance companies typically don’t cover, typically services provided by nurses to patients with chronic illnesses.

However, Hsu et al. reported more bad news for ACOs. They found that Partners’ ACO cut Medicare’s costs by a statistically insignificant 2 percent. This outcome is consistent with CMS’s data on the performance of Medicare ACOs, as well as the extremely rare studies of total spending by private-sector ACOs (see my discussion of the Blue Cross Blue Shield of Massachusetts ACO here . The only papers seeming to contradict this bad news are two “studies” of simulated ACOs (see my discussion of studies by J. Michael McWilliams and David Nyweide et al. here ). We may infer from the literature that if ACO start-up and operating costs, including the costs of disease management programs, are taken into account, ACOs are raising total health spending.

However, in this third paper, Hsu et al. did not convey to their readers the impression I have just conveyed: Despite their insignificant results, they claimed Partners’ ACO is cutting costs. “Our major overall finding is that participating in an ACO and a care management program lowered utilization and spending,” they concluded (somehow managing to write a sentence with no agent). (p. 881)

Hsu et al. employed two tactics that lulled readers into thinking their data supported their claim that Partners’ ACO “lowered spending.” The first was to treat the statistically insignificant reduction in Medicare spending as if it were statistically significant. The second was to ignore the overhead costs incurred by CMS and Partners’ ACO, a problem that occurs so frequently I have proposed giving it a namethe “free-lunch syndrome.” I ignore for now a third questionable tactic: Rather than use the actual savings data reported by CMS for the Partners ACO, Hsu et al. simulated the impact of Partners’ ACO on Medicare costs. [4]

I examine each of the first two tactics in the following sections.

Questionable tactic No. 1: Celebrating statistically insignificant results

Hsu et al. reported that Partners’ ACO cut Medicare spending on beneficiaries attributed to the ACO by CMS during 2012 and 2013 by a statistically insignificant 2 percent. As the authors put it, “this association was not significantly different from no change” (p. 880). Yet the authors treated this 2 percent difference as if it were significant. Throughout the paper they claimed Partners’ ACO had lowered “Medicare spending.” They did so in the title (“Bending the spending curve….”), the abstract (“ACO participation had a modest effect on spending”), and in the text (see the quote above, as well as, “There were modest overall ACO spending reductions….” and, “This study provides some evidence of how one large … ACO appears to have achieved its stated savings….”). [5]

On May 1, Partners’ flagship hospital, Massachusetts General Hospital (where six of the eight authors are employed) aggravated these sins by issuing a press release about the paper that stated, “Today, researchers at Partners HealthCare published a study showing that Partners Pioneer ACO not only reduces spending growth, but does this by reducing avoidable hospitalizations for patients with elevated but modifiable risks.… The entire ACO population … reduced health care spending $14 per participant per month, a 2 percent decline.” (Note again the confusion caused by the effort to avoid identifying an agent.) It is true that Hsu et al. found that Partners’ CMP program reduced hospital use by a statistically significant amount. It is not true that Hsu et al. found that Partners’ ACO “reduces spending growth.”

Questionable tactic No. 2: Ignoring program costs

Even if the 2-percent savings had been statistically significant, the authors should have subtracted from the claimed savings the cost of the interventions that led to the savings. These costs fall into two categories: Those CMS incurred to run the Pioneer program and those Partners’ ACO incurred attempting to achieve savings. Not reporting these offsetting costs made it easier for Hsu et al. to mislead readers into accepting their statement that Partners’ ACO “bent the cost curve.”

The most obvious cost to CMS Hsu et al. should have subtracted was the share of the simulated savings CMS would have had to give to Partners had this been the real-world program. That share would have varied depending on how well Partners’ ACO scored on several dozen “quality measures,” but 50 percent is a reasonable estimate. Cutting CMS’s savings by 50 percent reduces the non-significant 2-percent savings to a non-significant 1 percent.

A less obvious cost to CMS is the cost CMS incurred to administer the Pioneer ACO program. Analysts routinely ignore those costs. A complete accounting of the net impact of the Pioneer ACO program on health care spending should include them.

Hsu et al. also ignored the start-up and maintenance costs Partners incurred to run its ACO and its CMP program. (I discuss these costs in more detail below and in footnote 8.)

Hsu and his co-authors in fact warned readers that they intended to ignore all “program costs” incurred by the ACO, CMS or any other entity, that is, all costs that didn’t require reimbursement by Medicare under Parts A, B or D. They didn’t say why. The only explanation they offered was, “To our knowledge, no other study of ACOs has included program costs in its analysis.” This is true. The vast majority of American health policy researchers think it’s totally appropriate to ignore program costs when analyzing the impact of ACOs. Moreover, they think that if their limited analysis shows the ACO cut Medicare’s gross spending it’s ok to state repeatedly the ACO “bent the cost curve” or “lowered spending.”

How much does the free lunch really cost?

I won’t comment further here on dubious tactic number 1 – treating non-significant results as significant. I’ll focus the remainder of this essay on a question raised by the second tactic: Is it possible Partners’ ACO and CMP program costs were so inconsequential Hsu et al. were justified in ignoring them?

We know woefully little about ACO start-up and operating costs even though the ACO fad is now entering its second decade. We have some ballpark estimates from the staff of the Medicare Payment Advisory Commission (MedPAC), and we have an evaluation of MGH’s CMP program done for CMS in 2010. Both suggest that the interventions Partners’ ACO deploys are very expensive relative to the meager savings Partners’ ACO and other Pioneer ACOs are achieving.

We know that Pioneer ACOs are cutting Medicare’s net spending by no more than a few tenths of a percent on average (and CMS’s MSSP ACOs are raising costs by a few tenths of a percent). According to MedPAC’s staff, ACOs incur costs equal to 1 to 2 percent of their ACO Medicare spending. [6] If we assume 1-to-2 percent is what Partners’ ACO spent to achieve the (statistically insignificant) 2-percent savings reported by Hsu et al., of which Partners would have kept 1 percent, that would mean the ACO would have broken even or lost 1 percent.

This conclusion is reinforced by an examination of the CMP program. It appears that that program costs at least as much to run as it saves Medicare.

According to Hsu et al., the CMP cut Medicare spending by a statistically significant 6 percent. They claimed in both their paper and in MGH’s May 1 press release that it was this 6-percent savings on a small fraction of the ACO’s total assigned population that explains the (non-significant) 2-percent ACO gross savings for Medicare (see the quote above from MGH’s press release).

The press release cited an evaluation of the CMP for CMS by RTI International published in 2010. (The CMP was the subject of a three-year CMS demonstration that began in August 2006.) In RTI’s evaluation, we discover that MGH told CMS its CMP program costs equaled 5 percent of Medicare spending on CMP enrollees. [7]

If CMP’s program costs were still 5 percent of Medicare spending during the 2012-2013 period examined by Hsu et al., that would mean the CMP cut net spending on its enrollees by only 1 percent (the 6 percent reduction reported by Hsu et al. minus the 5 percent program costs). What happens when this 1-percent savings on a few thousand CMP enrollees is spread out over the 50,000 or 60,000 Medicare beneficiaries assigned to Partners ACO? I suspect the savings disappear or turn into losses. In any event, I have made my point: The CMP program costs are not trivial relative to the savings the CMP achieves. Hsu et al. should have investigated those costs, and until they did they should have refrained from claiming that either the CMP or the ACO “lowered spending.”

But MGH’s statement to RTI that its CMP program costs equalled just 5 percent of Medicare spending may have been an underestimate. (RTI’s report contained no data supporting this claim.) In a 2012 report  by the Congressional Budget Office on 34 disease management demonstrations conducted by CMS, including MGH’s CMP demo, the CBO concluded, “On average, the 34 … programs had little or no effect on hospital admissions or regular Medicare expenditures…. To offset the fees they charged CMS, the programs would have had to reduce regular Medicare expenditures by an average of 11 percent.” (pp. 11-12)

That statement that CMS paid out fees averaging 11 percent of Medicare expenditures suggests that the 5-percent-of-expenditures fee MGH negotiated with CMS was not enough to cover MGH’s actual costs of operating its disease management program. Obviously, if the CMP’s real program costs are closer to the average claimed by the other participants in CMS’s disease management demos, Partners’ CMP lost a lot of money during 2012-2013, the period Hsu et al. studied. If, for example, the real program costs for the CMP were 10 percent, the CMP would have lost money (10 percent minus the 6 percent Hsu et al. reported). [8]

Making sense of Hsu et al’s and Partners’ behavior

The data in Hsu et al.’ paper is useful even if it is incomplete. It contributes to a growing body of evidence indicating that ACOs cannot cut total spending, in part because ACOs cannot focus. They are measured on their ability to cut the cost of an entire population by unspecified means rather than on their ability to cut the cost of a clearly defined slice of their sickest “attributees” by clearly defined methods.

My criticism of Hsu et al. is their misuse of their data. They implied statistically insignificant results were significant, and by stating over and over that Partners’ ACO cut “spending” they misled readers into thinking they had measured total costs when they hadn’t. 

We badly need research on the cultural and financial incentives that induce health policy analysts to misuse data and to avoid studying issues (such as the start-up and maintenance cost of ACOs) that risk contradicting reigning managed care doctrine. This problem occurs at epidemic levels. Let me suggest two incentives worth further study.

First, Hsu et al. work for one of the nation’s pre-eminent hospital-clinic chains that has long acted like a cartel, and like all cartels, it stands to benefit from research that seems to prove that the cartel is doing the Lord’s work (it is “clinically integrating” all parts of the cartel for the betterment of humanity, we are told) and, therefore, anti-trust authorities should not object to the cartel’s next acquisition. The Department of Justice, state attorneys general and other anti-trust enforcers must weigh the benefits to society of mergers against the damage mergers may do to competition. Partners’ lawyers will no doubt brandish the paper by Hsu et al. the next time an acquisition by Partners is challenged on anti-trust grounds.

The second incentive worth study falls into the category of incentives created by culture or the expectations of one’s peers. Hsu et al. work within a culture that arose in the 1970s, roughly simultaneously with the rise of HMOs and the establishment of health services research as a separate discipline. One of the norms of that culture is to treat the managed care diagnosis (overuse due to the fee-for-service method) and the managed care solution (shifting risk to doctors and micromanaging them) as articles of faith, not hypotheses to be tested. We need research on how this casual attitude toward a basic rule of science became so widespread among people with degrees in the medical and social sciences. [9]

[1] According to Massachusetts General Hospital’s website , “nearly all” of MGH’s physicians are on the Harvard Medical School faculty.

[2] Massachusetts had the nation’s second-most expensive per capita health care cost as of 2014 according to CMS’s latest report on state-level spending.

[3] The five-year Pioneer ACO program ended in 2016.

[4] I have criticized the conflation of simulated with real ACO results by the authors of two other papers – one by J. Michael McWilliams (also at Harvard) and the other by David Nyweide et al. (employed by CMS). I have chosen not to discuss Hsu et al.’s decision to study a simulated version of Partners’ ACO in this article because the version Hsu et al. simulated closely resembled the real version. Hsu et al. did not use a different experimental group from the one CMS used (which was the case in the McWilliams and Nyweide studies), and the method Hsu et al. used to create a control group was less vulnerable to distortion by differences in patient health and income than those used by McWilliams and Nyweide et al.

[5] Hsu et al. applied a double standard to statistically insignificant results. While they repeatedly celebrated the non-significant 2-percent reduction in gross Medicare costs achieved by Partners’ ACO, they did not celebrate a statistically insignificant 2- or 3-percent increase in hospitalizations among Medicare beneficiaries assigned to the ACO.  In fact, Hsu et al. didn’t even report the percent by which hospitalization rates increased; I had to eyeball a graph in Exhibit 3 to make the 2-to-3-percent estimate. Instead, Hsu et al. merely noted, “There was no significant association between overall ACO participation and hospitalization rates” (p. 879). After that, they never came back to the subject.

[6 ] At the September 11, 2014 MedPAC meeting, commissioner David Nerenz asked MedPAC staffer Jeff Stensland if “we know anything about” ACO “overhead.” Stensland replied, “[P]eople we talk to and the data we have seen, it looks like maybe 1 to 2 percent of your spend, that that’s what they’re spending on their ACO to operate it….” (p. 133 of the transcript of the meeting). Stensland also reported, “[I]f you averaged everybody [that is, all ACOs] … the share of savings … that they get is going to be less than their administrative costs of being in it….” (p. 144)

[7] I calculated the CMP’s program cost to be 5 percent of Medicare expenditures on CMP participants based on data reported in the RTI evaluation of the CMP. RTI stated, “MGH negotiated a [per enrollee per month] management fee of $120 for the original and refresh intervention groups through the duration of the demonstration.” (p. 4). RTI also reported that the CMP cut Medicare’s costs by $288 “per beneficiary per month” (PBPM) and that this constituted 12.1 percent of PBPM Medicare spending. (p. 14) This allowed me to determine that the $120 monthly fee thus amounted to 5 percent of Medicare spending on the CMP patients. (The $120 fee paid by Medicare is 41.7 percent of $288, and 41.7 percent of 12.1 percent is 5.0 percent.)

[8] I encourage readers to peruse RTI’s evaluation of the CMP to get a clearer view of the complexity and expense of Partners’ CMP program. To give you just a taste of the resources Partners is investing now for the 4,000 CMP enrollees examined by Hsu et al., consider these excerpts from RTI’s report describing elements of the program for the 2,000 CMP enrollees during 2006-2009:

  • “Eleven nurse case managers [each of whom worked with about 200 patients] who received guidance from the program leadership and support from the project manager, an administrative assistant, and a community resources specialist” (p. 7);
  • “a social worker to assess the mental health needs of CMP participants” (p. 6);
  • “a mental health team director, clinical social worker, two psychiatric social workers, and a forensic clinical specialist (M.D./J.D.), who follows highly complex patients with issues such as legal issues, guardianship and substance abuse” (p. 10);
  • “a pharmacist to review the appropriateness of medication regimens” (p. 6);
  • “home delivery of medications five days per week” (p. 7);
  • “a nurse who specialized in end-of-life-care issues” (p. 7);
  • “a patient financial counselor who provided support for all insurance related issues” (p. 7);
  • “The clinical team leader provided oversight and supervision of case managers” (p. 8);
  • “The medical director provided oversight and day to day management of MGH’s CMP….” (p. 8);
  • “MGH developed a series of clinical dashboards using data from the MGH electronic medical record …, claims data, and its enrollment tracking database” (p. 8);
  • “MGH provided [200] physicians with a $150 financial incentive per patient per year to help cover the cost of physician time for [CMP-related] activities” (p. 8);
  • “a designated case manager position to work specifically on post discharge assessments to enhance transitional care monitoring” (p. 9);“ and
  • “a data analytics team to develop and strengthen program’s reporting capabilities” (p. 10).

In addition to all these goods and services, a true accounting of the cost of the CMP would include numerous housing, transportation and other “support services” and “community services” (p. 6) that RTI described only vaguely. The cost of these additional “non-clinical” services obviously show up on someone else’s books but might well have a positive impact on medical costs.

We must remember that all these goods and services were provided to patients who cost Medicare about three times the cost of an average Medicare beneficiary. Nevertheless, this long list of goods and services clearly cost a pretty penny, and should have received serious attention from Hsu et al. before they announced to the world that Partners’ ACO “bent the cost curve” and it was their CMP that did it.

[9] On July 7, 2017 I sent an email to Dr. John Hsu, the lead author of the Health Affairs paper, at the address listed in the paper. I asked him if I was correct in interpreting the 2-percent savings as non-significant and why he treated those results as significant. I also asked whether he knows what Partners’ ACO and CMP overhead costs are. I have not received a reply as of August 24, 2017.

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How To Prevent Burnout: A Case in Point. Frederick This One.

By MARTIN A. SAMUELS

I posted an essay on The Health Care Blog (entitled The Prevention of Physician Burnout: A Nine Step Program. Here is an example of how this works. Recall the wonderful children’s book by Leo Lionni, Frederick. Let me remind you of it.

A family of mice begins to store away food and supplies for the long winter ahead.  Most are practical and gather corn, grains, and straw. One of the mice, Frederick, instead collects rays of sun, colors of the rainbow, and words to remember.  When winter arrives the family begins to use up their practical supplies.  They become irritable and angry and don’t have anything to talk about.  In other words, they become burned out. Frederick shares his stores of sun rays, colors, and a poem which enlivens their spirits and saves their lives.

Ever since reading this story to my own children I have used Frederick as a verb. When a wonderful event occurs, I try to remember to Frederick it…….and save it for a tough day.

About a month ago, a 20 year old woman, previously completely healthy, began to experience twitching of her left hand. Over several days this involuntary jerking worsened and spread to involve the left side of the face as well. Her parents told us that her personality had dramatically changed in that she lost her usual ebullient nature and became almost inert and unreactive. She came to us where it appeared that she was suffering from epilepsia partialis continua (continuous partial seizures).

The MRI was very abnormal in that it showed a very bright signal on T2 weighted images in the basal ganglia bilaterally. An EEG was abnormal in that it was quite slow, but there were no definite cortical correlates to the jerking. Her spinal fluid was acellular under normal pressure with normal protein and glucose measurements. We were very concerned that she was suffering from a form of encephalitis, either viral or autoimmune and, if autoimmune, whether it could be paraneoplastic or benign.

It seemed that an infectious encephalitis was very unlikely given the normal spinal fluid and the absence of systemic signs such as fever. A broad batter of auto-antibodies, known to cause various autoimmune encephalitides were ordered, all of which were ultimately negative. She underwent a whole body PET scan and pelvic ultrasound to exclude a malignancy or ovarian teratoma. Both were normal. A definite diagnosis could not be made, so it was decided to treat her empirically.

First a brief course of high dose intravenous steroids (methylprednisolone) was tried with no obvious improvement. The was then given a course if intravenous immunoglobulin. On the day of the third infusion, her family said that she reacted more normally when friends visited her, but her movements seemed unchanged. A trial of intravenous lorazepam was given which stopped the movements promptly but left her unacceptably drowsy. So levatiracetam, an anti-epileptic drug was started. It also had a negative effect on her level of consciousness, so it was replaced with oxcarbazepine, a newer anti-epileptic drug related chemically to carbamazepine. Having improved slightly, she was discharged with follow up planned in a month.

Yesterday, I saw her in my office. She was bright and happy. She and her family said she was now greater than 90% back to normal and was continuing to improve day by day. Her exam showed only the slightest irregular twitching of the left fingers, but this barely affected her ability to use the hand. She is planning on going back to college right after Labor Day. She and her family left a box of cookies that they asked me to give to the doctors and nurses who had helped in her care while in the hospital and they gave me a handwritten note which said:

To Jane Doe’s team of Doctors:

Mere words simply cannot express how grateful we are for the care you gave and the compassion you showed to our daughter during her week stay at Brigham and Women’s. Truly, how do you thank someone for giving you back your child?

Each one of you was an intrinsic link in a chain of care, that got her to where she is today. If any of those links had been missing, she could be in a much different place right now. You may feel like you were just doing your job, but to us, you are all angels on earth.

Thank you not only for the care you gave to her, but for the patience and compassion you showed to us during a most difficult time. Because of all of you, she will be starting her junior year at college on time, and as far as we can see, participating fully (albeit under some very watchful eyes).

We hope that you all are blessed with good health now and always, because we have learned through this experience that without your health, nothing else really matters.

Keep working miracles every day! With our love and deepest gratitude,

The Doe Family.

Frederick that one

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Healthcare As a Moral Universal

In mid-July 3 Quarks Daily posted an essay written by Umair Haque, a London-based consultant and frequent contributor to the online Harvard Business Review, that argued “the American experiment is at an end.”   This is because unlike every other rich country the US lacks, Haque stated, essential moral universals defined as “sophisticated, broad and expansive public goods that improve by the year.” These include higher education, a responsible media, transport, welfare and healthcare. Democracies depend on these moral universals available to everyone because these benefits educate, inform and allow us to lead healthy lives. Absent these civilizing mechanisms we are left unable to act morally, democracy breaks down and we are left with our best universities churning out hedge fund managers, are economy recording paper profits and our media, when it bothers, debating climate change. We are left with perverse inequality, a declining middle class and falling life expectancy. Instead of our society producing a sense of “people cooperating by voting to give each other greater prosperity,” we have, Haque wrote, one that takes “prosperity away from one another.”

Though she does not frame her work in these terms, that health care is far from a moral universal in this country is documented at length in Dr. Elisabeth Rosenthal’s recent, “An American Sickness, How Healthcare Became Big Business and How You Can Take It Back.” Dr. Rosenthal, Kaiser Health News’ Editor-in-Chief, makes clear what poses as US health care is neither a moral universal nor actually health care. Instead, what purports to be health care is a profit maximizing industry with possibly at best only an incidental interest in actually improving our health. The “American health system,” Rosenthal states in her very first sentence, “attends more or less single-mindedly to its own profits.” Commercial forces “stole our healthcare.” It is therefore “rigged against you.”

Arguing we have monetized health care delivery beyond recognition or that we have moreover medical commerce posing as health care, is not a difficult argument to make. Beyond ongoing efforts to sabotage coverage expansion under the Affordable Care Act (ACA) and the still unaddressed opioid epidemic (annual drug overdose deaths now roughly approximate the total number of US military fatalities over the 16 years we were involved in Vietnam), there are still over one-in-ten Americans without health care coverage, our country is without a long term care policy, integrating social service supports and dental care for the elderly are either completely, or largely, ignored, we care for a large number of the mentally ill by torturing them (see my THCB February 7 blog post), we have made at best nominal progress in reducing medical errors and/or in measuring quality improvement, we appear to have no interest in correlating quality and spending; and, because health care is so inefficiently delivered we are forced to pay unnecessarily an additional $1 trillion annually causing us to both drown in medical debt and ironically forgo necessary care.

Over the first two-thirds of her work, Dr. Rosenthal explains how the health care “industry” is designed such that “at every point there’s a way to make money,” or where “everything is monetized to the maximum, without much regard for the implications for patient health.” She does this using a ten rule framework. Rosenthal’s rules include: more and more expensive treatment is always better; there is no free choice; there are no economies of scale and no competition; there are no fixed prices nor price transparency; no billing standards; and, prices are whatever the market will bear. Rosenthal illustrates these rules via a long list of examples, many, if not most, of these will be familiar to the THCB reader. These include for example, service overuse, risk adjustment coding creep or upcoding, exploitation of medical residents, obscene pharmaceutical and medical device marketing and pricing practices, billing practices, physician entrepreneurialism, hospital consolidation, and profiteering by not-for-profit medical societies, “hospital conglomerates,” charitable foundations and venture philanthropists.

The latter third of Rosenthal’s book addresses how patients or consumers “can take back” their health care or presumably subvert or mitigate industry profit taking. She proposes several long-debated structural reforms, for example, negotiated drug pricing, price transparency and FDA drug and medical device regulatory reforms, anti-trust and tax exempt status reforms, medical school curriculum reform, payment reform including reference pricing and bundled payments and medical liability reform. All of these, except with possibly the exception of the last, appear likely off the table at least in the near term. Rosenthal, moreover, proposes patients or consumers essentially challenge providers and payers by, for example, asking your physician why he/she is ordering a particular test, asking what is the price tag for care before hand, vetting your hospital, shopping around for medications and requesting bill itemization and/or negotiation. She makes these suggestions and related others because, she argues, “we patients have allowed this heist of our healthcare by commercial factors.” Leaving aside the accuracy of our “allowing,” as other reviewers have noted these remedies are, to be polite, naïve, particularly since reconciling her ten rules with being an informed patient is likely impossible. For example, concerning the absence of free choice, both my mother and wife had surgical procedures over the past eight months. When I attempted to learn more about both procedures, both surgeons as if reading from a script immediately responded by stating if I was not “comfortable” with them or their protocols they would be happy to refer me to another surgeon. (The first surgeon initially refused to physically examine my 85-year-old mother before surgery and the second refused to ensure my wife with prescription pain medication after surgery.)

The relevance of Rosenthal’s work, particularly in light of Haque’s criticism (and similar criticisms by Benjamin R. Barber, among others), forces one to question how perverse or morally bereft the just concluded seven-month debate over repealing the ACA has been and more productively forces us to wonder how going forward health policy reform should be debated. Health care is not, cannot, simply be a cost or a tax paid at the expense of profit taking but instead be a public good, something that protects us, uplifts us, civilizes us, allows us dignity.

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