In my work with healthcare providers and community-based services organizations over the past two years there is one recurring theme that continues to present itself at multiple levels – i.e., personally, professionally and socially: that is the growing awareness of how critically important it is to  integrate mental and behavioral health services with primary care.

Unfortunately, at a popular level mental health in the US has long been synonymous with a disease state – something that needs to be fixed, or at least treated.  The irony of this of course is that we have spent decades worrying about how to fix our healthcare system while all the while forgetting that what we have really had for years is a sick-care system. We care for people when they are ill – we don’t really have an effective system in place to keep them well.

And yet there really isn’t compelling evidence that indicates social investments in health and wellness provide good return on those investments. Education and awareness haven’t had the intended impact. Why?

Could it be that the same underlying drivers impeding the success of health and wellness activities are also manifested as root causes of a variety of physical illness and disease? In other words, in only regarding mental health as a means to cure a problem rather than the promotion of a desired natural state of being are we neglecting a critical element of healthcare reform? I think so.

Admittedly, the policy considerations surrounding mental and behavioral health services are extremely complex, in large part because they interact with so many other policy areas; e.g., Housing, Employment, Criminal Justice and FDA Oversight – just to name a few. Nowhere is this more evident than with one of the most proliferate and threatening elements of mental and behavioral health in America today: addiction.

Rather than try and put forth a meager attempt here to explain the hows and wherefores of addiction, mental health and public policy, I would rather refer Pub visitors to a wonderful post by the One Crafty Mother, Ellie Schoenberger.  In what she titles the most important post she’s ever written, Ms. Schoenberger does a fantastic job of putting a framework around the impact addiction has on society – and how it must be understood from an individual, social and public policy perspective if we are to develop effective policy to address this growing epidemic.

I think it’s a great place to start a discussion, and I hope you will take the time to read it.

Cheers,
  Sparky

Last Friday CMS released a memorandum to state survey agency directors announcing the rollout of electronic assistance and compliance-oriented materials on the QAPI website. HHS/CMS has still not yet published the condition of participation regulation that will provide nursing facilities with compliance guidance (facilities were to have already been compliant in March of this year), but there already exists comparable regulations for other healthcare provider types that will serve as a template. Once that regulation is finally published nursing care providers will have one year to develop an acceptable QAPI plan.

QAPI compliance for nursing facilities is not entirely new. The nursing facility QAPI is based in part on existing Quality Assessment and Assurance (QA&A) regulations. However, the new planning and reporting provision significantly expands the level and scope of QAPI activities that nursing facilities must enact in order to ensure they continually identify and correct quality deficiencies as well as sustain performance improvement.

It is a tad ironic that in promoting a key differentiator between historic, traditional quality assurance – now being coupled with performance improvement – that while quality assurance is to be viewed as a requirement and reactive, performance improvement should be viewed as discretionary and proactive. Never mind that performance improvement is being mandated as part of the QAPI program. Sort of like being able to choose any whole number between zero and two, right?

Anyway, I really fear that for a lot of nursing facilities – particularly smaller and/or single site organizations – this requirement is going to sneak up on them. And the true impact of that reality will not just be the regulatory and economic consequences but the lost opportunity to utilize the QAPI process to drive better quality, higher safety and better outcomes – while lowering the overall cost of care.

There are two ways to view the new QAPI requirement: another onerous regulation designed to burden caregivers with unnecessary compliance requirements at additional cost; or an opportunity to sponsor and embrace a process that – if done strategically and conscientiously – should improve productivity and efficiency while strengthening market position based on quality and outcome characteristics.

So my counsel is don’t wait for the regulation to be promulgated. Start now to learn and understand the tools that have already been made available. CMS has stated that, once provided, the QAPI formal regulation will not contradict the materials that have already been developed and provided.

And for those organizations that are truly interested in taking a strategic approach to developing a continuous quality improvement system that has the complimentary advantage of combining regulatory compliance with value-driven financial performance, please review the white paper that I drafted with colleague Nathan Ives of StraegyDriven Consulting, Aligning Healthcare Organizations: Lessons in Improved Quality and Efficiency from the Nuclear Power Industry.

Cheers,
  Sparky

It is free to join, free to participate – and free to just lurk (read the posts of other contributors). Approval is required to help keep the list free of “junk,” but that is an automated process. Participants receive e-mails only from other registered participants that are discussing US healthcare public policy issues (i.e., no solicitation, no advertising, no spam). To sign up, simply click on the link below. You can unsubscribe just as easily if you determine it’s not for you.

Join the Debate!!
  ~ Sparky

Click here to sign up for the HC Policy Discussion Group

And it has been fascinating to follow the blog stat’s. My number one post continues to be Death Panels Just Won’t Die, which is hit upon most often by folks searching for information on whether knee replacements will be rationed under the Affordable Care Act. It’s for that very reason that post is also my favorite, as I tried very hard in it to combat the misinformation that exists about the Act and how that misinformation has been used to scare our most vulnerable members of society.

So to anyone and everyone who has taken the time to stop by the Pub and read my posts, I want to sincerely thank you for your time and interest. While I find great enjoyment in just having a reason to write, the recognition that comes from knowing someone else finds what I write worth their time to read is very special and very meaningful to me.

I have learned a lot on how to create content that is valuable, interesting and entertaining. I still have a lot to learn, and I am anxious to see where the year ahead will take me – and the Policy Pub.

See you in the Pub!!
  ~ Sparky

On May 8^th the New York Times headlined the article,

It’s not just a non-story but a very old and very tired non-story as well. The cause and effect relationship between the cost of resources that go into delivering care at hospitals and the established charges for that care (i.e, the hospital charge master) bears a weakly causal relationship at best. That reality is a result of the Medicare reimbursement methodology (and, in turn, other governmental programs – e.g., Medicaid – as well as commercial insurers largely adopting very similar approaches).

Healthcare reimbursement in the US is a long and complicated story and one that, from a financial perspective, has seen many winners and many losers – neither of which group represents the individuals that are supposed to benefit from healthcare: the patients. If I can try to sum up the experience of the past half century it would be that effort upon effort has been made to develop systems that fairly reimburse healthcare providers for their costs plus a profit (or income, as it were for the individual).

There are two major problems with cost-based reimbursement: the first is the ability to prospectively allocate overhead costs in a logically consistent manner for a production model that is extremely complicated and constantly changing; the second (and a by-product of the first) is the faulty logic that holds historical production/cost relationships are reasonable predictors of future costs, which belies the effects of innovation, efficiency and productivity improvements.

So why am I jumping on the bandwagon to beat a dead horse. Because I believe the media attention focused on the wide variability in hospital pricing is symptomatic of a much bigger challenge we have in healthcare delivery – and in turn, healthcare public policy: that is, transparency. And in an age of electronic information enlightenment, the public policy issues surrounding transparency both transcend and go well beyond healthcare.

Take for example the two current scandals adding more paralysis to an already ineffective government in DC (as if that were possible).  In the first, the IRS appears to have selectively targeted 501(c)(4) applications based, at least in part, upon political motivations.  In the second, the Justice Department secretly obtained phone records of AP reporters last year stemming from concerns over national security leaks. Information is power – and power easily abused, particularly when the stakes are high as in politics.

The term, transparency, calls up thoughts of truth, honesty, candid, forthright – all terms that are generally consistent with values espoused by the better parts of our nature. So it is a difficult reconciliation that the promotion (or abuse) of transparency can lead to information ending up in the hands of those for whom it was never intended. In other words, as the recording, storage and sharing of electronic information proliferates transparency and privacy are going to increasingly become public policy enemies.

And other than issues of national security nowhere is this confrontation already more acute than in healthcare. Concern over patient privacy has long been one of the primary obstacles to IT adoption in healthcare, and right that it should be. What is more private than our individual health records? But the knife cuts both ways as we know. Under our legal system, quite often the right of privacy is abused as a faux obstacle impeding transparency. This is often manifested in healthcare as over charging third-party payers for services and care not actually provided.

A common theme of the Affordable Care Act is the promotion of transparency with particular emphasis in two areas: patient outcomes and cost data. While the latter faces allocation methodologies and consistency challenges, the former faces the additional challenge of subjectivity in establishing measurements. These are challenges that absolutely must be overcome.

Transparency in healthcare is a necessary prerequisite to patient empowerment, which has the potential to drive organic performance improvement that doesn’t come at the cost of additional regulatory oversight. Transparency is also a prerequisite to determining value (i.e., outcomes divided by costs), which is the basis upon which many employers, commercial insurers and governmental programs are developing new healthcare payment models (i.e., payment for value – not volume).

Throughout history strategies of both business and war have often depended upon the advantage gained from having access to information where others do not. Whenever there are two competitors – or world enemies – transparency holds the potential to give an advantage to one over the other. And so as long as the US healthcare delivery system remains positioned someplace between a market-based system and universal system the push for transparency is likely to continue facilitating unintended and undesired consequences.

Cheers,
  Sparky

There was a study published last week in the New England Journal of Medicine that is getting a lot play in the popular media – which as I have written before is the sharpest of double-edged swords where issues of truth and reality are concerned. Nonetheless, the timing of the research reported is well done in light of a number of states still wrestling with whether or not to accept the Affordable Care Act’s Medicaid expansion.

The Oregon Experiment — Effects of Medicaid on Clinical Outcomes

Back in 2008 approximately 90,000 individuals in Oregon signed up for a lottery that would subsequently provide Medicaid coverage to approximately 30,000. In doing so, Oregon created two randomly selected groups that could be analyzed to determine the comparative effects of having access to health insurance via the state Medicaid program there.

Two years later the relative impact of being insured through Medicaid produced what on the surface appears to many as conflicting results. Use of medical services (i.e., physician services, medications and hospital services) by those covered by Medicaid increased 35%, while access to preventative services and screenings increased by 50% or more. The rate of depression incidence in the Medicaid covered population was reduced by 30% compared to the control group. In addition, the financial impact on families was dramatic – e.g., it was reported the probability of having to endure financial hardship to pay medical bills was reduced by more than 50%.

On the other hand, the health impact in terms of outcomes for those individuals covered by Medicaid was less impressive. In fact, while those receiving the Medicaid benefit were more likely to be diagnosed with diabetes as compared to the control group, their blood sugar levels were not markedly impacted. And the same held true for blood pressure and cholesterol levels.

So in a nutshell, what the research shows is that having health insurance can drive higher access and utilization of available medical services. If you provide it, they will use it – a good thing. But it very well may not have a significant impact on health outcomes – particularly outcomes that are largely influenced by chronic conditions such as obesity, diabetes and hyperlipidemia (high cholesterol). Providing it won’t change lifestyle behaviors – a bad thing.

As this research demonstrates, addressing the behavioral elements that impact health outcomes is far more difficult and far more complex than just an access issue. But I think it is certainly shortsighted and faulty logic to fail Medicaid based on health outcome data alone. Improving access and utilization of medical services by the un- and underinsured population is a progressive advancement that has merits independent of outcomes, which is further reinforced when considering the relatively short time period covered by this research.

But the more salient if not subtle point of these results is that chronic disease management requires a coordinated effort of social, educational and medical influences that clearly place expectations of behavior modification beyond the sole responsibility of healthcare practitioners. That reality neither bolsters nor detracts from the arguments being made in support of state Medicaid expansion under the Affordable Care Act despite what you may read or hear otherwise.

Cheers,
  Sparky

From a public policy perspective, the key takeaway underscores a phenomenon common to discussion and debate over how to finance the future long-term care needs of an aging population. At a time in our lives when we are at our peak earning potential we typically also have the highest propensity to spend – quite often as a necessity of family survival. The past half-decade has heightened further that reality for many of us.

Of those interviewed, fully 30% would rather just not think about aging – while an additional 32% were only somewhat comfortable thinking about getting older. Not surprisingly, there was an apparent correlation between being more comfortable (I would posit, willing) to think about and discuss aging and the respondent’s age. Ailments and infirmities tend to be quite effective at breaking down one’s belief in mind over matter as a plausible substitute for the elusive fountain of youth.

In what I interpret as a perceptual vote of no confidence in government’s ability to effectively address the looming cost crisis attendant to long-term care, 51% of interviewees between the ages of 40 and 54 – and 48% between the ages of 55 and 64 – are a great deal or quite a bit concerned about affording the long-term care they may require as they age. This is compared to only 30% of those over the age of 65 (i.e., Medicare eligible) who share the same concern.

Whether that represents a false sense of security or not, it is worth noting the research also highlighted the continuing misperceptions that many individuals have regarding their probability of needing future long-term care, its costs, programs available to provide assistance and how to plan for future needs. For those directly involved in providing long-term care services and support those perceptions are accepted realities.  But for those in positions of public policy influence and responsibility the consequential understanding of those realities is a lot less clear.

Of course, I am thinking of the Commission on Long-Term Care, which pursuant to Section 643 of the Taxpayer Relief Act, is charged with developing, “a plan for the establishment, implementation, and financing of a comprehensive, coordinated, and high-quality system that ensures the availability of long-term services and supports for individuals in need of such services and supports, including elderly individuals, individuals with substantial cognitive or functional limitations, other individuals who require assistance to perform activities of daily living, and individuals desiring to plan for future long-term care needs.”"

There is widespread belief that a key element of any successful plan should include efforts to create greater awareness and education surrounding the individual realities of long-term care. The research shared above serves to underscore that belief. What is largely unknown, however, is whether such investments are worthwhile. We have so far seen the relatively disappointing results of investments in health and wellness (as an aside, I wonder whether Senator Harkin has seen that research).

Sometimes things that seem to be intuitively correct are disproved by empirical evidence. The failure of long-term care insurance to gain greater traction may be an indicator that education and awareness regarding the need to plan for long-term care will have a limited ability to overcome the strong human inclination to stay in the moment.

Since it is also true, however, that intuition often bears fruit only through successive efforts to overcome obstacles, I do believe education and awareness, along with wellness and prevention, should continue to be encouraged from a healthcare and long-term care public policy perspective.  In making those investments, however, programs with tighter feedback loops that help measure relative effectiveness are not only prudent but will help accelerate the desired outcomes of those investments.

Cheers,
  Sparky

According to an ABC Washington Post-ABC News Poll, over 90% of Americans are in favor of universal background checks as a prerequisite to gun ownership (as are 85% of NRA households by the way). That was still not quite enough to convince more than 46% of the US Senate to accept the will of the American majority over the metaphorical bags of gold being dangled in front of them by the NRA (or rather, being taken away).

I’m not going to beleaguer Pub visitors with a diatribe on the pure idiocy of turning a blind eye to even legitimately considering what was a common sense and widely accepted gun control policy measure. I rather refer you to former Representative Gabrielle Giffords’ editorial in the New York Times, A Senate in the Gun Lobby’s Grips.

I have long held that the political realities are such that we can expect no change until being elected becomes more like being chosen to serve jury duty than winning the lottery. The addiction to political power in this country is now so strong that with few exceptions elected officials have become whores to the status, fame and fortune attendant to public office. They achieve through Congress that which they would never be able to achieve through any other legal means of personal industry.

And the greatest irony I find in this is mockery of democracy is that those who most ardently oppose any encumbrance upon gun acquisition and ownership do so under the auspices of individual rights and liberties. I wonder whether they really trust a sitting body of government to protect those rights and liberties when that body has clearly and blatantly demonstrated its ability to ignore the will of a strong majority in favor of the political influence bought and paid for by business interests. Be careful what what you wish for Daniel Boone . . .

Cheers,
  Sparky

Separating the caregiving related costs attributable to dementia is challenging, if not impossible, because of the prevalence of comorbidity in individuals having dementia and because of the lack of quantifiable data reflecting the financial burden associated with informal caregiving. Using data from the University of Michigan’s Health and Retirement Study, the study’s authors sought to adjust for such phenomena by parsing out data that is believed to reflect the marginal costs associated with dementia.

Their methodology looked at how these costs could vary over the spectrum of probability within a given population that an individual would be afflicted with dementia. Costs were stratified according to:
     Out of Pocket Spending
     Spending by Medicare
     Net Nursing Home Spending
     Formal and Informal Homecare

If the intuitive concern that the economic impact of an aging society will be dramatic, the aggregate cost projections from this research certainly reinforces that concern. With a prevalence rate of 14.7% of the US over the age of 70 having dementia, the current (2010) cost of care (not including the valuation of informal caregiving) is $109 billion. By 2040, if prevalence rates and utilization of non-informal services and care are held constant, that amount is projected to more than double.

The authors note that dementia is one of the most costliest diseases to society, yet 75% to 84% of attributable costs of dementia are related to institutional care (e.g., a nursing care facility) or home-based long-term care – i.e., as opposed to medical care. Healthcare providers in that space should recognize the challenges and opportunities of that consequence.

I think it is important to remember that the inherent subjectivity of the dataset – and the data elements represented – is a reality that cannot be overlooked. In addition, even if there wasn’t the inherent subjectivity, I’m not really sure of the article’s value, nor whether it is deserving of the attention received in the press. Perhaps there’s something there I missed.

Counting the number of teeth a shark has and noting their regenerative capabilities is a fascinating exercise, but it’s the shark that can kill you – not its teeth.

Cheers,
  Sparky

Special Note: last summer I shared with Pub visitors a webinar, Emerging Trends and Drivers in Dementia Care, presented by my Artower colleague, Lori Stevic-Rust, PhD ABPP, Board Certified Clinical Health Psychologist and nationally recognized authority on Alzheimer’s disease. Another plug here seems appropriate.

As an example, Dr. Elliott Fisher and colleagues were sharing their research findings on hospital readmissions back in 1994 in the New England Journal of Medicine. Using Medicare claims data they studied discharge patterns in Boston and New Haven between October 1987 and September 1989. What they found was that, “hospital-specific readmission rates varied substantially …” and that “no relation was found between mortality (during the first 30 days after discharge or over the entire study period) and <sic> either community or hospital-specific readmission rates.”

In their conclusions they noted that, “regardless of the initial cause of admission, Medicare beneficiaries who were initially hospitalized in Boston had consistently higher rates of readmission than did Medicare beneficiaries hospitalized in New Haven. Differences in the severity of illness are unlikely to explain these findings. One possible explanation is a threshold effect of hospital-bed availability on decisions to admit patients.”

In other words, despite what is  understandably a popular media association, identification, concern and debate over whether and how reducing hospital readmissions represents a prudent means of lowering healthcare expenditures without impacting quality or outcomes is not a phenomenon borne of the Affordable Care Act. More importantly for my purpose here, understanding the history of hospital readmissions as a policy topic is to understand and accept the challenges associated with developing public policy intended to incent reductions.  And of course, the primary case in point here is Section 3025 of the Affordable Care Act, the Hospital Readmissions Reduction Program (HRRP).

I believe there is justifiable concern with the HRRP, particularly in the realm of unintended consequences. But I also believe those concerns have thus far tended to be self-serving and inflated when compared to the potential benefits. I addressed these points just about a year ago in the post, Is Focus on Hospital Readmissions Misguided? That was in reaction to another article published in NEJM, Thirty-Day Readmissions – Truth and Consequence. Now fast forward to an article published this past week in the NEJM, A Path Forward on Medicare Readmissions. Are you getting the sense that the hospital readmissions topic is nothing if not complex and contentious?

In this latest contribution to the subject, authors Drs. Karen Joynt and Ashish Jha identify two recent developments that provide insights into how HRRP implementation appears to be playing out.  The first was a MedPAC report evidencing a decrease in national rates of readmission for all causes, from 15.6% in 2009 to 15.3% in 2011. The second is an emerging recognition, based on CMS reports, that hospitals most susceptible to financial penalties under the HRRP are also those most likely to provide care for individuals with complex and/or expensive healthcare needs. In other words, this suggests that HRRP implementation has the potential to provide a financial disincentive leading to disparities in care availability.

Rather than chucking the HRRP as a policy failure, however, the authors suggest an approach that is quite admittedly conceptually foreign to a government characterized by intransigence and stubbornness: they suggest modifying the program in reaction to what is learned during implementation. Specifically, they first suggest adjusting readmission rates for socioeconomic status. Second, they suggest weighting the HRRP penalties according to the timing of the readmission to better recognize the potential causes of that readmission. And finally, they suggest an offsetting credit be given for comparatively lower mortality rates in recognition of hospitals – e.g., large teaching hospitals – where readmission rates are more likely to be an expected consequence of keeping their sickest patients alive.

The authors correctly point out that, “no policy is ever perfectly designed at inception, and policies should be changed as new evidence emerges.” At the same time, we should be cognizant where policies reach too far or are impractical in their design. For example, the UK’s National Health System (NHS) Medical Director, Bruce Keogh, announced this past Friday that hospitals there will face future reduction in fees for failing to follow the latest clinical guidance (i.e., quality standards).

In my thinking, there is both a philosophical as well as practical difference between policies that provide financial incentive through measuring health outcomes versus measuring the means and methods of achieving those outcomes. But if our aim is to develop a healthcare system that leverages the productivity and efficiency advantages of market-based solutions, while guarding against the market failures inherent to healthcare, we will need to be vigilant in avoiding the slippery slope of policy dysfunction.

Cheers,
  Sparky