March is roaring in like a lion, lending itself as the theme for the latest edition of the Health Wonk Review hosted by David Harlow of the HealthBlawg. I know I say it every time, but this one’s really good, and you should read it!
Monthly Archives: February 2014
If you follow your local healthcare marketplace even superficially you have probably noticed that everybody is merging with everybody else. Hospitals, physician groups, and even insurance providers are combining themselves in various ways, ostensibly for the purposes of either making money or helping people, or both. The Affordable Care Act has had something to do with this by agreeing to pay these groups in specific ways, depending on a set of performance measures. There are three broad categories of such groups: Physician Quality Reporting System (PQRS), Group Practice Reporting Option (GPRO), and Accountable Care Organization (ACO).
ACO’s in particular have gotten a lot of attention because the payment system rewards cost-savings and makes the group pay for cost overruns. For example, medicare will pay $X to ACO Y for all their medicare patients. If the total cost for care of all the medicare patients in ACO Y is lower than $X, the members of the ACO keep the change. If the total cost is higher, the members lose money. In order to prevent wily hospital CEO’s from skimping on care and pocketing the dollars, 33 performance measures are followed to ensure care is adequate. Forgive me if all of this is review. I’m getting to my point.
Last Friday the government released performance numbers for five of these measures for 141 ACOs in 2012. The five they chose were, essentially, the easiest to understand and the least controversial. Four deal with diabetes and one with vascular disease. Here are the measures:
1. Controlling blood sugar levels in patients with diabetes
2. Controlling blood pressure in patients with diabetes
3. Ensuring that patients with diabetes do not smoke
4. Prescribing aspirin to patients with diabetes
5. Use of angiotensin-converting inhibitors (ACE-I) or angiotensin receptor blockers (ARB) in patients with diabetes and weakened left ventricles.
According to the Kaiser Family Foundation analysis, ACO’s accomplished these 5 measures satisfactorily 65-75% of the time. OK, not bad. The groups varied widely, however, from 9% on some measures to 97%. The other two types of group payment systems, PQRS and GPRO, did a little better. I’ve been searching around but I can’t find any data on how all individual groups within the ACOs did on these measures before they joined the ACO. That would be nice to know.
The thing is, I’m not sure why consumers need this information, at least on an individual basis. You see, patients don’t choose a specific ACO. Chances are you are in one and you don’t even know. You can’t shop around for an ACO, or a PQRS, or a GPRO. You the patient don’t know how your personal doctor fares on these metrics. What is important to know is how your doctor is getting paid, or not. It’s important because, if you look at those quality measures above, you notice that one of them is a personal behavior that has little to do with your doctor (smoking), and two others require significant patient cooperation (controlling blood sugar and blood pressure). So, in very real way, the behavior of you the patient determines how much the doctor gets paid. Imagine if a group of, say, plumbers got together and persuaded 5,000 customers to pool their money and pay them a set rate for any plumbing problems that occurred in a given year. Say 100 or so of those customers hate all plumbers. Or are just really irresponsible. Those people could, with their behavior (clogging drains, putting hair in the toilet, letting the pipes freeze, etc.), decrease the pay for all the plumbers in the group. Plumbers are smarter than doctors and would never put up with pay being dependent on someone else’s behavior. That’s what your doctor faces. Just so you know.
Transparency in Health Care: Can It Happen?
Most people, regardless of their political leaning, can agree that the market for health care in the United States isn’t really working well. Take one step further, though, and disagreement rapidly ensues. On the left, the common understanding is that a market failure has occurred, and that the proper thing to do is have government intervene to correct that failure–usually by expanding public insurance programs, subsidizing private insurance, and the like. On the right, the common understanding is that the market hasn’t exactly failed, but that it could certainly be improved if we got government out of the way, stopped insulating people from the costs of their care, and made consumers better informed. In other words, take care of the information asymmetry that exists in health care, and the market will right itself.
There are some obvious limitations to health care markets. For example, even with perfect information, someone with a heart attack is highly unlikely to comparison shop for the best doctor or hospital in their area. Yet, just as it’s hard to disagree that the market isn’t working well, it’s hard to argue that there isn’t a problem with information on health care prices and quality that a consumer needs to make rational choices. Moreover, while it won’t solve all of our problems, I do think that increasing people’s access to information about health care prices and quality could help to bring some of our market inefficiencies under control. But the real question is: can transparency in health care happen in the United States?
Across the country, eleven states have indicated that they believe it can, by attempting to increase pricing transparency for health care procedures. The rationale is simple: Tell people what different things cost, and they’ll more likely opt for lower-cost providers, which will lead to an overall reduction in costs as providers begin competing with one another on the basis of price. There are a few problems with this, though. First, it requires a pretty sizable data collection effort. For instance, Colorado has begun work on an all-payers claims database. Second, interpreting the cost data can be a challenge, because the out-of-pocket cost someone pays is largely a factor of their insurance coverage. In other words, if you have excellent coverage, you probably care little about how much your provider charges, and more about what you actually pay. And, finally, we humans can make the mistake that higher priced goods and services must inherently be better goods and services. After all, you get what you pay for, as the saying goes.
Of course, we know that’s not always true. But in health care, measuring quality can also be a rather elusive goal. Sure, we can capture process measures for recommend treatments like administering a beta blocker to a heart attack patient, but is that really what consumers care about? On some level, yes, but they also care about how nice the waiting room is, and how the staff and the providers treat them. We have things like Google Reviews and Yelp for consumer reviews of hotels, restaurants, and other businesses. And, in fact, there are numerous sites out there for reviewing medical providers. The question is: Are they useful?
A recent survey study, just published in JAMA finds that people aren’t really engaged with these sites the way they are with others. In fact, just 5% of respondents indicated that they had reviewed their own provider online, 23% of respondents reported using such reviews when selecting a primary care provider, and only 19% considered the reviews to be very important in their decision. Of course, these types of reviews are only part of ascertaining provider quality, but their limited use raises the issue of whether other efforts at transparency will be more effective. Unfortunately, I don’t have an answer for you, but I’d be extremely curious to hear what you think as an existing or potential consumer of health care.
An Engineering Feat Gives Hearts Extra Life
With the release of their new HeartAssist5 heart pump, ReliantHeart is making real-time, personalized feedback possible for the millions of Americans suffering from heart failure. The new technology allows for real-time, remote monitoring of implantable devices, years of added life for patients, and flexibility to travel without a physician nearby. With a staggering projected 46% growth in heart failure by 2030, advances in heart failure innovation are on the forefront of changing medical treatment, policy, device research and physician reimbursements. Further, with heart failure and disease disproportionately affecting minorities in the US, advances in length and quality of life could be huge strides for medical equality.
Heart Failure In America
Approximately 7.5 million people in the United States currently suffer from heart failure, a figure that is increasing over time as more people survive heart attacks and various other heart conditions. According to the Heart Failure Society of America, an estimated 400,000 to 700,000 new cases of heart failure are diagnosed each year, with deaths averaging 250,000 annually, more than double since 1979. Even worse, an estimated one half of heart failure patients die within five years of diagnosis and 20% within the first year.
With a waiting list for heart transplants at an overwhelming 3,736 at publication, and less than 2,500 hearts donated annually, the need for a bridge between heart failure and transplant is literally life and death.
Left ventricular assist devices (LVAD) are implantable heart pumps that were created to temporarily support patients with advanced heart failure as the bridge between diagnoses and transplant. However, with new scientific advancements, LVADs are becoming a long-term tool for improving heart function without transplant.
The right ventricle pumps blood to the lungs, but the left ventricle is responsible for pumping blood to the rest of the entire body, making it much more susceptible to failure. Therefore, LVADs have been the focus of most modern research to prolong and improve life saving implants.
Reliant’s system acts like your car’s dashboard. “If a patient’s pump has any sign of a challenge, like dehydration or low flow, the remote monitoring system signals the change to a data-collection center that notifies the transplant center as well as the individual,” ReliantHeart CEO Rodger Ford says. This is what makes the HeartAssist5 unique; at the first sign of a problem the right people are notified immediately.
Essentially, if the engine light goes on, the heart center and patient are notified to get the engine checked.
He also notes that the patients can set monitors to send text message notifications, thus making changes in blood flow, speed and power truly personalized. Individual blood flow is collected and transmitted every 5 minutes, making one’s own body the standard comparator.
The greatest importance to Founder and CTO Bryan Lynch is his ability to use his background as an engineer to, “Get involved in a project where you can actually see how you saved a life. While the docs and nurses are the real lifesavers, we give them the tool to make it possible.” He continues that it is vitally important for engineers and innovators to gain a patient-centered approach to get a real reduction in cost burden and improve quality of life.
Sailesh Saxena, CFO, continues highlighting the patient focus of the company by telling about the origination of the design of the VAD pack. “Bryan and I used to go to Schlotsky’s Deli ($BUNZ) for lunch,” he said, “and we used to see this man wearing a coat although it wasn’t cold out. Bryan noticed immediately that he was attempting to hide an LVAD controller and batteries. Well, this happened more than once, and we recognized that he was always concealing the VAD controller. So we decided that we needed to create a unique insert so that our LVAD control system could slip right into a Louis Vuitton ($LVMH) or Gucci ($GUC) bag unnoticed. It’s the small things that make the patient feel like we understand what they really want.”
Expanding The Geography Of Care
Remote monitoring, like other methods of telemedicine, is a key to expanding the geography of health care. “As technology matures, with the help of remote monitoring, the cardiologist and patient will feel safer with greater distances between them,” says Saxena.
This growth in telemedicine as a whole, and specifically in heart care, has major implications for the Centers for Medicare & Medicaid Services (CMS) as well as health care policy and reform. Because CMS is beginning to assign reimbursements and penalties based on patient outcomes instead of traditional fee-for-service metrics, it will become more and more important to have reimbursements reflect remote monitoring and its likely benefits.
Reimbursement codes also need to be reworked to genuinely target geographic discrepancies in care, which are fundamentally important for transplant centers. However, at present, CMS is slowly beginning to take growth rates of heart implants seriously based on the agency’s continued increases in payments, including their slight variations in geographic differences.
An Engineering Feat
In a recent study, researchers found that platelets flowing through the HeartAssist5 are exposed to significantly lower cumulative shear stress levels than in competitive devices tested. Ultimately, this means that the ReliantHeart product allows for what the CTO calls “a more physiologically normal cardiac output, including the pulse.”
What Bryan means is that people with failing hearts have low blood flow throughout the body, which is why they are so sick. When an LVAD is implanted, patients return to a more normal flow, but they also need blood flow that is as natural as possible. With the HeartAssist5, blood is not damaged and any pulse that the recovering heart produces is naturally transmitted to the body.
The LVAD and heart now work together to help the patient recover.
Although there are two other continuous flow LVADs on the market (THOR and HTRW), the ReliantHeart team claims their careful design capitalizes on working with the natural ventricle to the benefit of the patient, almost like a gym trainer for your heart.
Their “implantable flow probe” is also a revolutionary aspect of the HeartAssist5. This ultrasonic probe measures the blood flow from the LVAD in real-time providing critical feedback that is a one-of-a-kind technology providing data that makes the aforementioned remote monitoring so valuable. Ford says this ability to see patient-specific trends remotely in real time not only helps all patients improve quality of life, but the longevity of the HeartAssist5 creates a life support system, far beyond the “bridge” that the LVAD was originally created to be.
So this month, for American Heart Month, think about what innovation really is. It might be the ability to prolong and add quality of life for individuals and families across the nation, to share more time with loved ones.
Is there an app for that?
If you ever get access to the inner sanctum of a doctor’s office, besides the dirty scrubs on the floor, the shaving kit on the windowsill, and the remains of Chinese take-out from last week perched on top of the printer, you might notice a rank of post-it’s on a wall somewhere with a bewildering array of numbers and dots. It’s always post-its or some other disposable but never-disposed-of scrap paper tacked to the walls. Those numbers are the diseases your doctors most commonly sees. In numeric form. These are called ICD-9 codes. They allow all billing, essentially. If what you have doesn’t have an ICD-9 code, you aren’t sick, you’re imagining it, go away, no one is going to get paid to see you.
Here’s something I came across while poking around at Health Wonk Review, which will be hosted, by the way, by our own Brad Wright on March 13th. Did you know that this October we’ll be getting a new ICD? No, not an implantable cardiac defibrillator, though some of us may need one of those after we see the size of the Tenth Edition of the International Classification of Diseases. Sarah Kliff, a blogger for the Washington Post, tells us that while ICD-9 had 14,000 codes, ICD-10 has 68,000. So, that’s better. It’s more, you know, numbers.
One of the reasons for the new edition, and the one proponents will tout, is actually a good one. The ICD-9 can’t expand anymore. There are no more qualifiers you can add to, say, Pneumonia NOS (not otherwise specified). The basic diseases have generally been divided by research and innovation into sub-categories based on new microscopic findings, genetic testing, etc. So it’s more specific. It’s also going to be great for moldy researchers and poverty-stricken grad students. Data-mining will be much more fun and informative. You can look up, for instance, how many doctors billed for the ICD-10 code “bitten by large turkey” presumably with a modifier if it was a wild turkey.
We doctors are understandably wary of this new edition, and not just because we’ll have to get bigger offices to accommodate all the post-its we’ll have to add to the walls. You see, it’s generally the doctor who generates the code, at least initially. So it’s more work for us. Nothing new there. Most new policies and procedures produce more work for doctors and, even more often, for nurses. But the work increase is greatest for the medical coders. The US has over 186,000 medical coders. That’s 186,000 people who work in the medical field doing absolutely nothing that has anything to do with the actual care of people. Looks like there will be more soon. Wonderful job opportunities out there college graduates!
The AMA, which is of course against implementation of ICD-10, estimates it could cost $50,000 to $8 million dollars for doctors offices to transition, and it would cost a lot of time as the billers would have to slow down until they learned the new codes. Plus there will be more coders. So, not cheap. Now, a major RAND Corporation study in 2004 estimated the potential benefits of switching to ICD-10 outweighed the costs by as much as $4.5 billion. But isn’t it the RAND corp people who said EMR was going to save the health care industry so much money?
So the new ICD codes are not money-saving. They’re not time-saving. They make zero impact on patient care, either in quality or in quantity. They do have the advantage of being more specific and generating better tracking and research data. But what is the mantra for healthcare reform? “Lower Cost, Higher Quality”?
Latest Health Wonk Review
Steve Anderson of HealthInsurance.org hosts the latest edition of the Health Wonk Review. Steve’s gone with a Valentine’s Day–Be Mine edition. Love and health policy are in the air, folks! Check it out here.
ObamaCare and Jobs
A primary criticism of the Affordable Care Act is that it creates incentives for employers to hire fewer full-time employees. One of the House’s attempts to repeal the ACA even referenced it as the “job-killing healthcare law.” It’s true that there are some provisions in the ACA that employers may exploit in order to minimize the cost of doing business. At the same time, it’s also true that the ACA protects employees’ access to health insurance in some very important ways that didn’t exist previously, like mandating large employers with more than 50 full-time equivalent employees to provide affordable insurance to their employees, subsidizing the purchase of insurance for small businesses, and creating other insurance options for employees (besides those their employers may or may not offer) on the health insurance marketplace.
But the latest round of controversy has erupted over the Congressional Budget Office’s February 2014 Budget and Economic Outlook for 2014 to 2024. Buried in Appendix C of that report is a summary of the “Labor Market Effects of the Affordable Care Act.” The report says that “the ACA will reduce the total number of hours worked, on net, by about 1.5 percent to 2.0 percent during the period from 2017 to 2024, almost entirely because workers will choose to supply less labor–given the new taxes and other incentives they will face and the financial benefits some will receive.” (emphasis mine)
The report continues: “The reduction in CBO’s projections of hours worked represents a decline in the number of full-time-equivalent workers of about 2.0 million in 2017, rising to about 2.5 million in 2024. Although CBO projects that total employment (and compensation) will increase over the coming decade, that increase will be smaller than it would have been in the absence of the ACA….The estimated reduction stems almost entirely from a net decline in the amount of labor that workers choose to supply, rather than from a net drop in businesses’ demand for labor, so it will appear almost entirely as a reduction in labor force participation and in hours worked…rather than as an increase in unemployment.” (again, emphasis mine)
Those who think that the ACA is bad for business have seized on this report–specifically the projected decline of 2 to 2.5 million full-time-equivalent workers–to claim that their concerns about the “job-killing healthcare law” have been vindicated. But, as the emphasized portions of the quotes above show, that’s not the real story. The real translation is that the workforce will grow at a slower rate because some people will choose not to work as much. There is more than one reason why that may be an attractive choice.
First, as with any benefit involving a subsidy on a sliding-scale, there can be a disincentive to earn more income. In other words, a low-income person may find that they receive a larger subsidy if they work a few less hours each week. If the increase in the subsidy is larger than the amount of income foregone, it makes sense to work fewer hours. A similar principal is at work for those at or near 138% of the poverty level in states that have elected to expand Medicaid coverage.
Second, some people only continue to work in their current job because they need health insurance benefits. This is the phenomenon of “job lock” that is particularly unique to our American employer-based health insurance system. Under the ACA, individuals now have more choices. They can quit their jobs, change jobs, or switch from full-time to part-time and still access subsidized coverage through the health insurance marketplace. Yes, that’s right. There are employees who, for a variety of reasons, will welcome the opportunity to scale back their hours now that it doesn’t mean losing their health insurance. Maybe they have a child or an elderly parent at home to whom they provide care. Maybe their spouse is the primary bread-winner, but works at a job that doesn’t provide health insurance benefits. There are a variety of possibilities.
None of this means that employers won’t take measures to scale back their hiring, but that’s simply not the full story. I think it’s a good thing for us to break some of the long-standing ties between health insurance coverage and employment. After all, do we really want to live in a country where losing your job means losing your access to basic health care services? Of course, others disagree with me, and their points are valid. But, the next time you hear someone telling you that the CBO says that ObamaCare kills jobs, you can send them a link to this post and tell them what the CBO report actually says.
The Innovation Center Will Now Demonstrate.
There are many provisions in the Affordable Care Act that people don’t know about. Everybody is familiar with the health insurance part of it, but did you know the Centers for Medicare and Medicaid services (CMS) is giving $10 billion dollars to an organization called “The Innovation Center”? The Innovation Center is charged with researching ways to most effectively deliver health care. Good goal. The center’s website says “The Innovation Center develops new payment and service delivery models”. Oh. Well, still good goal.
Here’s what the definition of a “model” is, according the the free online dictionary: A schematic description of a system, theory, or phenomenon that accounts for it’s known or inferred properties and may be used for further study of its characteristics. So a model is not the thing. It’s a smaller or schematic representation of the thing. So what the Innovation Center is supposed to do is find or come up with schemes of payment and service delivery and try them out. It has been doing this, so far, largely with “demonstration projects”. A demonstration project tests an idea or group of ideas that might improve either payment systems or delivery systems, and then uses some complicated math to determine if things were better or worse before and after the idea is implemented. Therefore, CMS is not looking for proven methods of improving payment or services, but testing ideas that might work.
There’s nothing wrong with this, by itself. My 2-year-old does this all the time. She peers up at the kitchen counter, determines she can’t see, drags a chair over, gets on it, and compares the view with the chair vs. the view without the chair. Over time this has allowed her to develop a policy of always getting a chair if she wants to see what I’m doing. She wouldn’t go get the chair if I just said “be a good girl and go get a chair” and then praise her and give her a cookies if she does it. If you go the the Innovation Center website what you mostly see is incentive programs for good behavior. For example: The Comprehensive Primary Care Initiative is one of the Innovation Center’s projects. This is how CMS describes this program:
“The Comprehensive Primary Care (CPC) initiative is a multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care. Medicare will work with commercial and State health insurance plans and offer bonus payments to primary care doctors who better coordinate care for their patients. Primary care practices that choose to participate in this initiative will be given resources to better coordinate primary care for their Medicare patients.”
Here’s another: The Physician Group Practice Transition Demonstration:
‘The PGP Demonstration was the first pay-for-performance initiative for physicians under the Medicare program. Under the PGP Demonstration, physician group practices continued to be paid under regular Medicare fee schedules, but earned incentive payments for offering patients high-quality, coordinated healthcare that resulted in Medicare savings for the patient population they served.”
Another, the Medicare Health Care Quality Demonstration, goes straight to performance measures. Three hospital/physician care systems in the US are being given money to test ideas that will improve performance measures. Performance measures are not “performance” measures. They are “quality” measures. Doctor’s get up on stage and perform certain things, and judges evaluate whether their performance is a quality one. As I have said before, measures of quality are things that are easily measured, quantifiable, and easy to find in an electronic medical record.
OK, to summarize so far: CMS, i.e the federal government, is funding the Innovation Center, which is supposed to find better ways to pay for and deliver health care, but which is mostly doing pay-for-performance stuff. Fine. There are some people doing some fine work in health care delivery who could use the funding. Some people are complaining that all the studies that the Innovation center are doing are demonstration studies, not randomized controlled trials (RCT). RCT’s are the medical gold standard for proof, essentially. It’s not true until an RCT says it is. Why isn’t the Innovation center doing more RCTs?
I postulate several reasons: 1. RCTs take a lot of time. CMS, under the gun from ACA opponents, wants quicker results. 2. A good RCT has a very narrow research question, usually one or maybe two interventions compared to no change. The researchers have to settle on a promising intervention and follow it up long-term. It’s hard to decide what promising intervention is going to give the best results given how long the question will take to answer. 3. There are so many moving parts in health care. It’s very hard to control for everything. Some large RCTs that have affected national policy, such as the Tennessee study in the 1980’s, which found that smaller class sizes in early childhood translated into better long-term outcomes, changed only one variable and kept everything else the same. Tennessee public schools are a closed system with relatively little short-term variability and relatively predictable human behaviors. An RCT that, for instance, studies the effect of a specific intervention on re-admission rates to hospitals has to deal with the variability of disease process and progression, human behavior, emergency situations, dubious quality measures, record-keeping inconsistencies, the list goes on and on.
So, should the Innovation center be doing RCTs? Absolutely. Is CMS funding the way to get that done? Probably not. But you have to give the ACA an A for effort on this one.