Mar 25, 2014

The Future of Medicine is Now: Can We Afford It?

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“Imagination is more important than knowledge. For knowledge is limited to all we know and understand, while imagination embraces the entire world, all there ever will be to know and understand.” ~ Albert Einstein

Writing about healthcare public policy is never far removed from contention and conflict. It just comes with the territory. So it’s a treat on occasion to share something that can be appreciated and enjoyed without being debated (that being said, stand by). But first, please enjoy these two videos – in order, starting in the late 23rd century with the original crew of Star Trek.

“What is this, the Dark Ages?”

Now fast forward back to the twenty-first century.

InSightec is an Israeli-based company that has pioneered MR guided Focused Ultrasound, which provides a personalized non-invasive treatment that can replace invasive procedures and offer therapeutic alternatives to millions of patients with serious diseases. Jackob Vortman, PdD, the President of InSightec, shares the remarkable advancements he and his colleagues are achieving.

Future of Noninvasive Outpatient Surgery

Policy Implications

The future of medical technology is indeed exciting. As with many innovations over the course of history what once was only imagined is now becoming a reality. At the same time medical technology is recognized as a fundamental driver of healthcare costs and, in turn, affordability. From a social and political perspective what makes this driver so acutely felt today is the demographic impact on escalating demand for core primary care.

Invoking Star Trek again, the relative merits of individual versus social needs pervade several film episodes with the key line being, “the needs of the many outweigh the needs of the few – or the one.” Of course pragmatists will recognize that’s really more a matter of perspective than any metaphysical reality: i.e., depending on whether you are the one or the many and your personal belief system.

To put a finer point on the issue: how can we possibly continue to fund the types of advancements of organizations like InSightec here in the US and allocate sufficient resources to provide a baseline level of care for a dramatically aging population while not being more direct, more candid and more transparent in how medical care is rationed?

There has always been rationing of care. But it has always been a de facto situation that is for better or worse woven into the fabric of our care delivery system. Can we continue that way without anticipating some real tragedies?

Cheers,
  Sparky

Filed Under: Advancements in Medical Technology, In the News · Tagged: , , , , ,
Accountability Without Responsibility?
Mar 13, 2014

Accountability Without Responsibility?

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PHO-10Sep15-267645Earlier this week Rep. Jim Renacci (R-Ohio), together with a bipartisan group of 25 other House members introduced H.R. 4188, the Establishing Beneficiary Equity in the Hospital Readmission Program Act. Text of the bill is not available through the Library of Congress yet, but from what has been discussed publicly its purpose is to provide hospitals with financial relief from Section 3025 of the Affordable Care Act: Hospital Readmissions Reduction Program.

The hospital readmissions program has received a great deal of discussion, but with implementation beginning last year hospitals that exceeded the excess readmission ratio in their 2013 fiscal years are now seeing reductions in Medicare reimbursement of up to 1%. Unless those hospitals are able to improve that ratio the potential payment reduction could increase to 2% next year and 3% the year after. For an organization already struggling with tight margins a 3% reduction in revenue that represents approximately 20% of total revenue without any commensurate reduction in costs has serious clinical and operational ramifications.

Previous PolicyPub posts on Hospital Readmissions:

The Trouble With Avoidable Readmissions ~ February 2012
Is Focus on Hospital Readmissions Misguided ~ May 2012
Update: Hospital Readmissions ~ February 2013

Not unsurprisingly, H.R. 4188 has already garnered rather broad industry support from the likes of hospitals and the trade associations representing them – i.e., anyone standing to benefit from more revenue as opposed to less.

As I understand it H.R. 4188 doesn’t provide blanket relief for hospitals affected by the readmissions program. Rather it is intended to recognize and adjust for the penalty impact of caring for patients who are financially unable to afford post-acute housing, services and care in a manner that would otherwise facilitate their ability to avoid a readmission. And the logic goes that if all those altruistic hospitals are unselfishly willing to open their doors to care for the poor, well then penalizing them for that willingness is grossly unfair.

But hold on. The readmissions reduction program wasn’t thought of, planned or designed in a vacuum. The challenges associated with securing and providing affordable post-acute housing, support services and care has been a widely recognized problem that predates Medicare and Medicaid. The purpose of the program is to provide incentives for hospitals to take a more active and holistic approach to managing patient care post-discharge – regardless of the patient’s wealth and income. No penalties – no incentives.

The program wasn’t designed to change the type of patient cared for – but the manner and scope of patient responsibility. What hospitals have argued in return is that they are being held accountable for a scope of services and care for which they have not historically been responsible (accountability without responsibility). CMS’s de facto response is pretty straight forward: then don’t accept Medicare anymore. If hospitals want to continue benefitting from taxpayer dollars, they will have to help find ways to reduce the costs of healthcare subsidized by those taxes – and not just the costs that manifest inside their walls (or more properly, their historical sphere of influence).

We are just now beginning to see the benefits of the readmissions program’s incentives manifested in efforts of hospitals across the country to integrate with post-acute/long-term care provider organizations. That has required their gaining a better understanding of PA/LTC patient care models, understanding the challenging dynamics of care transitioning and working with physicians to better appreciate the post-acute challenges they have wrestled with for generations.

So now that hospitals are finally taking notice of the potential cost and quality benefits of post-acute care integration we want to tell them “ah, never mind – it’s too hard?” Really?

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Hospital Readmission Penalty · Tagged: , ,
Agnes Riolato Will Live to Be 95!
Mar 3, 2014

Agnes Riolato Will Live to Be 95!

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Quentin_Matsys_-_A_Grotesque_old_womanToday the Environmental Protection Agency announced new sulfur emission limits, which they virtually guarantee will add five years to Ms. Agnes Riolato’s life. Don’t believe me? Well okay, maybe that’s stretching things a bit. But they did say this new regulatory requirement would prevent as many as 2,000 respiratory deaths per year without costing refiners and automakers any significant increase in costs.

Of course, as you might expect, the American Petroleum Institute disagreed. Their analysis – no less biased than the EPA’s I am sure – claims the new regulation would raise gas prices while providing little environmental benefit – and could in fact cause interrupted supply lines. House Energy and Commerce Committee Chairman Fred Upton (R-Mich.) expressed concern as well, noting that, "the American people have endured an unprecedented three straight years of gasoline above $3 per gallon. This winter’s cold snap underscores just how vulnerable American families and businesses are to any increases in energy costs, and yet the administration is moving forward to raise prices at the pump … this rule is all pain and no gain."

While that may be true, what about poor Agnes? Is her life worth nothing? Now, I should note that Agnes is a fictitious character – at least as far as my Google search indicated. I am pretty confident out of 7.2 billion people in the world there is at least one person with that actual name, and in the 1 in only slightly less than that amount chance she were to read this blog post, I apologize in advance for any perceived derision.

But what I am driving at here is that I’m not at all sure the EPA’s claim of reducing respiratory deaths by 2,000 a year isn’t just as fictitious as Agnes. I don’t know that it’s fictitious. I have no reason to doubt – but that’s the point. Now stop and think for a minute – no, I mean really stop and think (if you’ve read this far, you’ve already committed more of your life than you had planned, so what’s a few more seconds).

How would you go about projecting a reduction in respiratory deaths (however hundreds of ways that might be defined) attributable to regulatory standards at such a macro level that it would be nearly impossible to predict the many variations in implementation? Just imagine trying to construct a model that would account for those possibilities. Head hurt?

I’m sure there are folks much smarter than me out there who can do that sort of thing. How they convince someone else that doing so produces value sufficient to earn a living is another matter. But even if you can model it, you are still left with making all kinds of assumptions on how things will actually play out. To me, the complexity involved here makes me really question the validity of the assertion: 2,000 lives a year saved. But there you have it.

Let’s face it, we’re living in a sound bite media reality where we toss around portended facts & stat’s as if they were as ingrained in our communicative lexicon as contractions. It’s hard to tell what’s worse: that sound bite reporting does little to build knowledge, awareness and understanding – or that it has been so overused that its effect is now largely ignored (i.e., there is no informing and educating whatsoever going on ).

So I think what we need is a new governmental agency. This is where my conservative colleagues frown and get angry that I was leading them on. But really, why not – who is going to notice one more agency at this point? I want a nonpartisan group of very smart thinking types with strong analytical and mathematical skills (something similar to the CBO) whose responsibility it is to score every official promulgation that comes from another federal agency.

I want them to build the type of model that I described above and understand it in a way that I most certainly could not. And I want them to assess the variability around all of the key assumptions. So, for example, if one of the assumptions used to project the 2,000 lives saved was to assume Agnes would spend 600 hours a month living at her home in the suburbs and 130.5 hours a month in the city (this of course is assuming that’s the only two places she will travel in a month – guess we’d have to assess that assumption as well) I want to know what the probability is of the assertion being made coming true given the variability around those assumptions.

And then I want them to use whatever mathematical techniques are necessary to produce a scoring of the reported assertion. They can play with the reporting language, but I am envisioning something like this using the real life example shared above:

Last year at this time it was reported by the Environmental Protection Agency (I’m just trying to be pragmatic here) that annual respiratory deaths would be decreased by 2,000 through implementation of new emission standards that are just about ready to be released as a first draft. The Agency of Factual Standards and Selective Omissions has determined that there is approximately a 10% chance that between 1,800 and 2,200 lives will actually be saved; that there is a 25 % chance that between 500 and 4,000 lives will actually be saved; that there is a 50% chance that between –2,000 and 10,000 lives will actually be saved . . . etc. You get the point.

If those projections don’t bear out, we would have another agency whose purpose it is to discipline the modelers who made the bad assumptions about the other agency’s assumptions. And then you can see how a scenario similar to the opening credits of Monty Python’s Holy Grail would play out with various, repeated sackings . . .

There is, of course, a more serious side to all this. Today with electronic and social media being what they are, public policy is often discussed and debated with varying amounts of ultimate ability to have any impact in venues like this Policy Pub. And in the passion of those debates it is often overly tempting to pick and choose facts & stat’s that help support our beliefs. That might help the ego through the night – but it really doesn’t do much in the interest of promoting educational discourse.

Okay, lesson over. I’ll have a Macallen 18 y/o neat please, Sam!

Cheers,
  Sparky

Image: Painting by Flemish artist Quentin Matsys around 1513

Filed Under: Editorials & Opinions · Tagged: , , ,
Healthcare & IT: Oil & Water?
Feb 28, 2014

Healthcare & IT: Oil & Water?

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I don’t think it has to be that way, but the history of IT adoption and implementation in healthcare might lead many to believe otherwise. True, there have been major advancements just over the past decade, but from a public policy perspective, have federal policy initiatives helped – or hindered – that progression?

I think most everyone would agree that information technology holds great promise in improving the value of healthcare delivery. And by greater value I mean assisting caregivers and clinicians produce better outcomes at lower cost. Except that in many instances it’s not working that way.

Practical Experience
Courtesy of the healthcare policy-oriented site, KevinMD, I recently came across a blog post by Dr, Christine Sinsky that made me decide it might be a good time to bring this topic up again with you. Dr. Sinsky’s blog post, Hazards of Poorly Designed Decision Support, is an anecdotal yet nonetheless compelling reality of IT utilization in healthcare. The decision support system in question is Trinity Health’s mandatory DVT Advisor.

DVT stands for deep venous thrombosis, which in laymen terms means a blood clot that that forms in a vein deep inside a part of the body. DVTs are most common in adults over age 60 but can occur at any age. If the clot breaks off into the bloodstream, it is called an embolism, which can get stuck in the brain, lungs, heart, or other area, leading to life threatening situations.

DVT Advisor was implemented in response to Meaningful Use requirements. You can read Dr. Sinsky’s post if you would like to understand the practical frustrations she found in using it, but for the purpose of this post I will summarize the key points.

Shortcomings
From her perspective (my interpretation now) there are two key areas of the system that are counterintuitive to facilitating value creation as I describe above: unnecessary input requirements and decision tree logic rigidity that was unable to capture and reflect the patient’s situation (i.e., usability challenges). In essence, the system created more work – and more importantly, introduced a new level of potential risk – than would not have existed without its use. Now that, Pub patrons, is what’s known in laymen terms as, “stupid.”

In the interest of fairness and disclosure I want to note that Dr. Sinsky was complimentary of certain elements of the system; e.g., “the information in the DVT Advisor can be a useful reference if a physician is uncertain about anti-coagulation, but its intrusive and insistent characteristics are based on hope and belief, rather than evidence.”

Policy Issue
And so here’s the policy issue: you have an IT decision support tool that has the potential to add value but for the fact that its design has actually lowered it. Now, I have been an ardent proponent of supporting advancements in HIT as a primary means of improving productivity and efficiency – and thus lowering care delivery costs. I have been less enthusiastic about the top-down approach of HIT policy the federal government has employed to advance those efforts. I have also believed, however, there is the need for an active role of government in helping advance health IT adoption. The what and the how of that role is less certain today.

So for me, Dr. Sinsky’s post is not the needle-in-the-haystack that generated an intellectual epiphany on my part regarding the effectiveness of HIT policy efforts. There is more than enough research and literature supporting logical skepticism for the open-minded to consider. Rather it was more of the straw within the haystack that broke the camel’s back. I am looking for some pub patrons that understand this subject-matter much better than me to weigh in here.

There are some of the most brilliant minds in the world working in HIT – in the clinical and nonclinical arenas – but I sometimes wonder if they can’t get out of their own way to understand the pragmatic nature of value creation. And I wonder if federal policy and governmental agencies haven’t been just willing abettors counting more on hope than evidence as Dr. Sinsky points out.

Please, prove me wrong – show me the evidence where HIT public policy has been more effective than not.

Cheers,
  Sparky

P.S. Please click on the hyperlink above associated with Dr. Sinsky’s name. This will take you to her website where there is a wealth of information on HIT based upon her and her husband’s professional contributions.

Filed Under: Editorials & Opinions, Healthcare Information Technology · Tagged: , , , ,
Challenges of Episodic Payment Bundling
Feb 22, 2014

Challenges of Episodic Payment Bundling

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Last week the New England Journal of Medicine included this Perspective: Post-Acute Care Reform—Beyond the ACA by D. Clay Ackerly, M.D. and David C. Grabowski, Ph.D. The article describes the case of what I believe is a hypothetical patient: Mrs. T., an 88-year-old woman who was admitted to the hospital following a trip to the emergency room.

You can read the article to get the specifics of her case. The thrust of what is shared by the authors has to do with how existing Medicare payment methodologies and regulations impact clinical decision making in ways that are not necessarily in the patient’s best interest. And how payment bundling—particularly across acute and post-acute/long-term care providers—faces challenges that simply aligning financial incentives of those provider types will not adequately address.

In theory, the core precept of episodic payment bundling is that if otherwise historically disparate healthcare providers treating the same patient can be financially incentivized to better coordinate care for that patient, the costs attributable to inefficiencies, redundancies, productivity, etc. will be reduced.

Of course, underscoring this precept is the notion that human beings acting in their self interests (i.e., in pursuit of income and wealth ~ Adam Smith’s Invisible Hand) will create valuable external benefits. The counter to this belief could be found in Garret Hardin’s Tragedy of the Commons, which argues that those self interests can lead to depleting common resources to the disadvantage of wider interests – e.g., the community or society.

Economic theory aside, what the authors argue for is additional governmental intervention to remove obstacles they cite as impeding the benefits that payment bundling might otherwise achieve. These include addressing regulations impeding patient transfers between settings (e.g., the 3-day rule); research into various care delivery models that facilitate more effective care transitioning – particularly those elements outside of the clinical setting; and third, increased investment into comparative effectiveness research to help providers better determine appropriate post-acute/long-term care setting for their patients.

So here’s the irony: though many critics of the Affordable Care Act either disbelieve or refuse to accept that it was in many ways an attempt to thwart or at least delay the movement toward a national healthcare system, concepts like payment bundling, insurance exchanges and capitation are theoretically dependent upon market-based solutions. Provide the financial incentive and just watch market-driven forces create valuable solutions.

Now we are being advised in this article that’s not enough. We have to also regulate away the challenges and obstacles that market ingenuity was supposed to overcome. Sorry – but isn’t that somewhat counterintuitive?

Here’s the challenge. We recognize that individuals’ productivity – in terms of being able to create value – is closely correlated with their desire to pursue individual needs and wants (back to basic Economics). And so if we want to maximize value it follows that we need to maximize individual incentive. In a free market that is most effectively accomplished by allowing individuals to make their own choices, unfettered from governmental interference except for ensuring fairness and safety.

What we are trying to do in healthcare—with initiatives such as ACOs—is create hybrid free market models that leverage the value production ability of individuals while at the same time intentionally and unintentionally interfering with their ability to make unfettered choices. So if healthcare shared common characteristics with other industries, it would be easy to argue that government should just get the hell out of the way.

But here’s the rub. Government is already so deeply entrenched in our healthcare delivery system – at a time where demand is just beginning to grow exponentially – that I fear any serious effort to move backward toward market-based delivery would be like throwing a track switch on a runaway train. And beyond that I remain unconvinced that healthcare is not uniquely different than other industries. Thus we plod along.

What do you think?

Cheers,
  Sparky

Filed Under: Medicare, Payment Bundling · Tagged: , , ,
Feb 16, 2014

You’re No Prince, Mr. President

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Last week the Administration announced that the Employer Mandate would be again further delayed – at least in part. Businesses with between 50 and 99 employees working 30 hours or more will not be required to make available mandated healthcare coverage until 2016. While businesses with 100 or more employees working at least 30 hours only need offer coverage to 70% of their employees in 2015, rather than 95% (which will not be mandated until 2016).

“Well, isn’t that conveeeeeeeenient . . .”

A little too thinks Senator Mike Lee (R-Utah). On this morning’s Fox News Sunday with Chris Wallace, Lee said that he believes the President is creating a “government of one” by further delaying the mandate – and in his view, ignoring the Constitution in the process.

Sidebar: how much longer do you think Mr. Wallace will be able to withstand Fox’s propaganda machine?

E.g., watch embarrassing exchange between
Chris Wallace and Tucker Carlson.

The premise of Mr. Lee’s position was that the president’s choice to delay the employer mandate was, “a shameless power grab that’s designed to help the president and his particular party achieve a particular outcome in an election. And that’s wrong.”

I think Mr. Lee is right.

Rep. Xavier Becerra (D-Calif.) defended the initiative on Fox News Sunday by claiming, “the president is simply providing small businesses with the flexibility they need.”

Sorry Mr. Becerra, that rings hollow and you should have been embarrassed to even pretend to believe that had anything to do with the delay. I obviously can’t speak for other supporters, but from my vantage Mr. Obama’s renegade approach to policy making has gone too far.

I have been  a pretty ardent supporter of the Affordable Care Act, and I continue to believe that, on balance, it will ultimately bring about necessary and desperately needed changes in the way our healthcare delivery system is designed. I also continue to believe that our failure to address the cost trajectory of our delivery system would have ultimately resulted in fiscal choking from within and ultimately destroy our economy. Finally, because of the unique characteristics of healthcare as an economic commodity – as well as the regulatory infrastructure that has already been in place for decades – I do not believe it is either wise nor prudent to think that a market-based system of healthcare can be successfully compatible with a progressive society. Most of the rest of the developed countries in the world agree.

Those beliefs notwithstanding, the wisdom of Nancy Pelosi grows daily: it’s not just that the ACA had to be passed to find out what’s in it – it’s that clearly the promulgation of regulations implementing the ACA under executive authority has at times supplanted the function of legislative authority. Regardless of how frustrating and demoralizing this Congress has been, there are reasons why certain powers are reserved to the legislative branch and certain powers are reserved for the executive branch.

But the timing of this latest action – whether a tipping point or accumulative – is not only a supplanting of legislative authority but also crosses an ethical line between governing and politics, which of course in Washington requires quite a journey to traverse.  In using what I will term, Obamavellian Authority, the president has repeatedly overstepped executive authority and dared to tread over boundaries that presidents of both parties from the past respected (well okay, maybe not Nixon).

It’s time the president’s supporters call him to account in the interest of democracy and respect for a way of life that transcends political allegiances. Hope you agree, but if not, I would love to hear from you.

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Obama Administration · Tagged: , , , ,
Feb 12, 2014

Medicaid vs Education

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In The Hill yesterday, Dick Morris, one-time Republican strategist and advisor to President Clinton beginning with the 1994 midterm elections, wrote about the looming social battle between state funding of Medicaid v. Education. 

Even in those states that have chosen not to expand Medicaid through the Affordable Care Act’s benefit opportunity Morris believes they will be, “unable to provide decently for education without cutting back on the ambitious Medicaid expansion” as insurance exchanges provide coverage to individuals already eligible for Medicaid without the ACA.

He points out that Medicaid’s recently modest spending trajectory is set to increase substantially with increases in enrollment (spending is projected to rise 12.2 percent in 2014, 7.9 percent in 2015 and 2016, and 6.6 percent per year thereafter). But with state budgets overall not increasing commensurately, that means Medicaid spending must take a bigger share of the budget pie – and something else must get less.

Morris believes that will be education and has issued this dire warning: “we cannot afford both [education and Medicaid]. Of course, states can still raise taxes and join jurisdictions like Detroit into their slow spiral to oblivion.”

What really puts this suggested tradeoff on the razor’s edge is the evidence of failure that Medicaid expansion efforts have generated. Of course the Oregon Health Insurance Experiment is both timely and top of mind here. If you haven’t already, I encourage you to take the time to at least survey that research. In a nutshell, the experiment found that expanding Medicaid resulted, “in no measurable health benefits in the Medicaid group for several chronic conditions, including hypertension, high cholesterol and diabetes.” It did result, however, in a significant increase in ER utilization, where relative costs are substantially higher than primary care settings.

Expanding healthcare coverage to those who cannot otherwise afford it is both a noble and moral obligation of a progressive society. But making choices to pursue noble pursuits with limited resources is a reality that becomes more urgent every day in the face of what we have seen  happen in other countries due the lack of fiscal responsibility.

Mr. Morris has pointed out an important and challenging debate that states will have to wrestle with in the years ahead. It’s hard to make the argument for defunding children’s educations to support a program that has so far not achieved the desired ROI. But while we’re focused on relative social ROI we might also want to look critically at the success of state investments into educational programs.

Cheers,
  Sparky

Blog image from The Hill ~ Jenny Francis

Filed Under: In the News, Medicaid · Tagged: , ,
Jumping On—And Off—The CBO Report Bandwagon
Feb 10, 2014

Jumping On—And Off—The CBO Report Bandwagon

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In its February 2014 report to Congress, The Budget and Economic Outlook: 2014 to 2024 (see Appendix C: Labor Market Effects of the Affordable Care Act: Updated Estimates) the nonpartisan Congressional Budget Office created quite a stir last week as it reported 2.5 million individuals will leave the labor force by 2024.

A number of the nation’s media intelligencia pounced on the report as an opportunity to provide evidence of the Affordable Care Act’s real, underlying threat to our economy. Trouble is, they got it wrong. Entertainment networks like Fox News had the bandwagon gassed up and ready to roll, so all that Republican candidates and lawmakers had to do was jump on board (see video below). By now most have hurriedly jumped right back off because of the simple practicality that when someone leaves a job the job does not disappear – at least not immediately.

Thom Tillis jumps on the bandwagon . . .

Now, the broader, long-term impact on overall economic growth due to the contraction of personal income is a legitimate debate, but that calls to mind an entirely separate issue: politics aside, has anyone stopped to think how utterly ridiculous it is to try and support that 2.5 million number? How many subjective assumptions had to be made in order to determine who would and would not leave the workforce? And how do you possibly define what it means to leave the workforce anyway in lieu of the inherently transient nature of today’s labor markets?

In the report the CBO states that it was already once way off its “estimate” just a few years ago:

“CBO’s estimate that the ACA will reduce aggregate labor compensation in the economy by about 1 percent over the 2017–2024 period—compared with what would have occurred in the absence of the act—is substantially larger than the estimate the agency issued in August 2010.”

“In 2010, CBO estimated that the ACA, on net, would reduce the amount of labor used in the economy by roughly half a percent—primarily by reducing the amount of labor that workers choose to supply. That measure of labor use was calculated in dollar terms, representing the approximate change in aggregate labor compensation that would result. Hence, that estimate can be compared with the roughly 1 percent reduction in aggregate compensation that CBO now estimates to result from the act.”

In other words, in three years they doubled their estimate. That’s what they call it, an estimate. I would argue you can only estimate that which already exists, so it’s really a projection or forecast – an a pretty meaningless one at that.

Still others have sought to bend the report findings as driving individuals out of the labor force. The ramifications of that of course being more slackers on the dole sucking on the teats of the shrinking middle class rather than working for a living like the rest of us. Right. See the Washington Post’s article, They quit their jobs, thanks to health-care law.

I agree there is reason for deep concern about how to break free of the psychological conundrum we have created with the US welfare state. Personal responsibility should be a mantra of any candidate running for political office – beginning with themselves would be a refreshing change. Working to support yourself and your family should be a socially supported sense of pride – not looked on as being misfortunate you aren’t poor enough for the handouts. But no one should ever have to make the choices that individuals in this country have had to historically because they lack affordable access to quality healthcare. That’s not pushing someone out of the labor force – it’s recognizing the value they have as a human being.

And here’s another sobering thought. The demand for at home services by an aging population with chronic disease and long-term disabilities is going to skyrocket. Since there is virtually no likelihood that additional funding will be available to increase the amount of home care services provided under Medicare or Medicaid, it would be very beneficial to have affordable healthcare in place for the millions of informal caregivers being driven out of the labor force because they choose to provide those services and support to a parent or elderly loved one.

Cheers,
  Sparky

Filed Under: ACA Economic Ramifications, Editorials & Opinions · Tagged: , , ,
SGR Repeal & Replacement Act
Feb 8, 2014

SGR Repeal & Replacement Act

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AR-307319997If there was any truth, whether by design or default, to Nancy Pelosi’s infamous quote regarding the Affordable Care Act – i.e., that Congress would have to pass it to find out what’s in it – then she could have been alluding to the reality that the ACA is much more of a framework for creating future policy through regulation than it is prescriptive on the means of enactment.  And for that – and for many of those who did read the ACA – it has taken a fair share of plausible criticism.

Now comes the SGR Repeal and Medicare Beneficiary Access Improvement Act of 2013 (introduced on December 10th of last year).  As of my writing this blog post it has overall received pretty broad support, including from two of the largest and most respected physician trade associations (e.g., the AMA and AMGA) that if you weren’t familiar with the politics behind it would be truly dumbfounding.

Without expressing an opinion on the merits of the legislation, I believe that if you have found core concepts of the ACA unacceptable, then you sure as hell can’t be comfortable with many of the concepts contained in the SGR Replacement bill. I can only guess that most folks know about as much about the latter as they do about the former – and that they take their lead from media interpretations. Or the country is so desperate to have a Congress that works constructively on anything instead of being at war, they read "bipartisan" and jump off the cliff.

My areas of experience and expertise have never included consulting to physician practices, so if I am out of my league here, I apologize in advance. But from what I do understand provided below is a summary of the bill’s key components.  You can decide whether you favor these ideas based upon what’s already been debated regarding the ACA.

Repeal of the Sustainable Growth Rate
This one’s rather easy and hard to imagine will face much controversy. Everyone I have ever met in healthcare wanted to see the SGR formula repealed in favor of a stable, sustainable approach that wouldn’t push uncertainty of physician income to the cliff on a continual basis. Economic uncertainty due to congressional inaction has been the single greatest shortcoming of Congress over the past decade.
Purpose: Create a permanent fix to the Medicare physician payment approach
Risk: It actually fails to control costs and gets debated all over again in five years

Fee Updates
From 2014 through 2018, annual updates will be 0.5%. From 2019 on the 0.5% update would continue – but there would be incentives and potential penalties under a new Quality Incentive Program.
Purpose: Recognize the need to reflect impact of very modest cost inflation
Risk: Medical inflation substantially outpaces 0.5% a year, and the alternative payment models described below fail to provide adequate compensation

Reporting System to Improve Accuracy of Relative Values
Based upon existing data, patient scheduling systems, cost accounting systems, etc., payment incentives would be provided for reporting groups (i.e., physicians across specialties and setting). While this doesn’t appear to be a mandatory requirement, to the extent compensation is available to subsidize cost reductions it will become a de facto requirement.
Purpose: Creation of a data set that can be used to incentivize and reward productivity based upon comparing relative costs and outcomes
Risk: The cost of collecting and analyzing the data far outweigh any long-term cost benefits achieved

Adjustments for Misvalued Physicians’ Services
What will the reporting system above be used for? To identify services whose relative value adjustment would result in a reduction in spending up to 1%. And, of course, this would not be a budget neutral proposition: funds would be removed from the pool of spending for Medicare physician services.
Purpose: To achieve meaningful cost savings where value being produced isn’t commensurate with cost of production
Risks: Historical measures may not be reliable indicators of true cost and methodologies for determining value could be harmfully arbitrary and/or subjective

Quality Update Incentive Program
A new QUIP reporting system would begin triggering payment incentives and penalties beginning in 2019, unless a physician or other eligible professional is already in an alternative payment model. The QUIP quality measures would replace those of the existing PQRS reporting and penalty program, though that program would remain in force. The QUIP would be used to adjust payment rates +/- 1% (or zero) based on scores relative to peer groups, and as an incentive to report there will be a 5% reduction in cost reimbursement for failure to participate.
Purpose: Provide financial incentives to improve quality while reducing costs
Risks: See above

Advancing Alternative Payments Models (APMs)
$2 billion is being advanced from the Medicare Trust Fund for the evaluation, approval and implementation of APMs. A unique bent is the Secretary of HHS must contract with an independent entity to do this rather than CMS (i.e., a privatization of the process – though certainly not beyond the realm of politicization). But the underlying idea is consistent with the ACA’s effort to incentivize innovative new payment models that lower cost and improve quality outcomes, while underwriting the means of education and ability to replicate successful models.
Purpose: To use alternative payment methodologies to incentivize greater provider collaboration and coordination
Risk: Payment incentives become misaligned with provider incentives resulting in practice choices that are not in the patients’ best interest

Encouraging Care Coordination and Medical Homes
CMS has to develop new HCPCS codes and begin reimbursing for care provided under those codes in 2015 for, “complex chronic care management services.” Of great significance here is that PAs and NPs will also be able to bill Medicare under these codes if they are able to meet criteria equivalent for physicians participating in a medical home model or similar model.
Purpose: to provide a means and mechanism to reimburse the work effort involved in providing care coordination and transitional care services
Risk: The financial incentive to push care coordination onto PAs and NPs results in overburdening and leads to worse overall patient care

Expanding Availability of Medicare Data
The bill increases access and use of Medicare claims data. This allows “qualified entities” to to sell claims data or analyses to authorized users for non-public purposes and allows qualified clinical data registries (QCDRs) access to claims data. Purpose: Streamline access, utilization and analysis of claims data that could provide valuable insights into physician practice patterns
Risk: The wrong type of data ending up in the wrong hands and thus putting patient privacy at risk

Funding
A minor detail. Means of providing revenue to fund provisions of the RSGR haven’t been thought out – or perhaps considered may be more appropriate. One idea being touted is to use the claimed savings from the Better Care, Lower Cost Act, which proponents claim will save as much as $25 billion a year. This bill also has attracted bipartisan support, but the CBO has not scored it yet – so there isn’t anything to hang your hat on there just yet. Short of something like that, however, funding will become another partisan and special interest charged debate that easily threatens to derail the RSGR bill.
Purpose: To provide the revenue need to cover costs of implementation
(HUGE) Risk: In a Robbing Peter to Pay Paul fashion Congress takes even more funding away from post-acute/long-term care providers

Cheers,
  Sparky

Blog Photo: www.modernhealthcare.com

Filed Under: In the News, SGR Repeal and Replacement Act · Tagged: , , ,
Feb 1, 2014

Repeal & Replace Becomes Fix & Embrace

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So we can add the U.S. Chamber of Commerce as one of the ACA’s stalwart detractors dedicated to Repeal & Replace now reluctantly advocating for Fix & Embrace© (you heard that term here first – I Googled it). Last week Chamber President Tom Donohue said, "we’re not going to get rid of that bill [actually, it’s been an enacted law since 2010, Mr. Donohue], and so we’re going to have to devise ways to make it work."

This of course begs the question just how is he hoping to define, “make it work.” How do you make something work that you’re already convinced – at least that’s what you said – absolutely cannot work? Wouldn’t you be better served to just pack up your bags, feel sorry for the country you’ve left behind and head for greener pastures? To a country that isn’t saddled with the weight of a social conscience advocating for equal access and affordability to a basic human right: healthcare.

Having a family history in this country that dates back to the 1670’s (including relatives that fought in both the Revolutionary and Civil Wars) I feel some sense of hosting duties here. I feel compelled to offer some assistance to our departing friends that no longer find this country palatable because of its social largesse. As you depart – besides not letting the proverbial door of fairness and equality hit you in your hard ass on the way out – here are a few countries you probably ought to avoid:

In Africa: Rwanda, Algeria, Egypt, Ghana, Libya, Mauritius, Morocco, South Africa and Tunisia

In Asia: Bhutan, Bahrain, Brunei, China, Hong Kong, India, Iran, Israel, Japan, Jordan, Kazakhstan, Kuwait, Macau, Malaysia, Mongolia, North Korea, Oman, Pakistan, Qatar, Saudi Arabia, Singapore, South Korea, Sri Lanka, Syria, Taiwan, Tajikistan, Thailand, Turkey, Turkmenistan and UAE.

In Europe: Albania, Austria, Andorra, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, the Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Moldova, Monaco, the Netherlands, Norway, Poland, Portugal, Romania, Russia, San Marino, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Ukraine,[and the United Kingdom.

In North America: Barbados, Canada, Costa Rica, Cuba, Mexico, Panama, Trinidad and Tobago.

In South America: Argentina, Brazil, Chile, Columbia, Peru, Uruguay and Venezuela.

Oh, almost forgot – Australia and New Zealand should be avoided too. They, like all of the countries listed above, provide some form of universal healthcare for their citizens. So you couldn’t possibly find happiness there.

But you won’t find North Korea listed above. Happy trails!!

Cheers,
  Sparky

Filed Under: Editorials & Opinions · Tagged: , , , ,
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