Health Affairs

It is increasingly well-known that improper payments cost taxpayers as much as $50 billion each year. These include reimbursements for billing for non-existent patients, falsified diagnoses, non-covered procedures, services not rendered or simply upcoded, as well as billing errors in favor of providers. Steps are being taken to address these issues through increased acceptance of approaches, tools and techniques from private industry and from industries outside of healthcare. More than just technology, some of the most powerful ideas to come along are that incentives matter, decentralization may achieve results faster and better, and stretch goals are crucial.

Scale of the problem

Safeguarding taxpayer resources and maintaining access to healthcare are clear public policy priorities. The Government Accountability Office (GAO) has long designated Medicare as a high-risk federal program due to its vulnerability to waste, fraud and abuse. Conservative estimates by the National Health Care Anti-Fraud Association are that improper payments represent 3 percent of national health care spending. The GAO and others estimate nearly 10 percent of the more than $500 billion in current annual Medicare payments are improper. At the same time, Medicare provides necessary — and often much needed — access to health care for 48 million Americans.

Performance measurement — if done right — can be a core activity to move the health care system to higher value for the American public, while rewarding health professionals and health care institutions for doing the right thing for their patients. Yet, policy makers, private and public, have a duty to the public, patients, and providers to get it right — to measure and report accurately and meaningfully.

Harlan Krumholz and Peter Pronovost have been among the most important contributors to the development of performance measures for quality and safety of health care. At the same time, each has written powerful critiques of particular aspects of the current measurement enterprise with suggested improvements. I work mostly inside the Beltway in a world of policy makers who, despite good intentions, by their actions often display a lack of understanding of the challenges associated with measures, measurement, public reporting, and pay-for-performance. For example, the physician value-based modifier, which was mandated as part of the Affordable Care Act and now must be implemented by CMS, cannot produce a valid snapshot of an individual physician’s “value” but will be imposed nevertheless, unfortunately feeding those within the physician community who resist all efforts to improve accountability and transparency of performance.

With the encouragement of the Robert Wood Johnson Foundation, Harlan, Peter, and I joined in a collaborative endeavor to produce a comprehensive look at the state of play of performance measurement and public reporting — their conceptual underpinnings and limitations, successes and failures, and, perhaps most importantly, recommendations for major steps that are needed now to put the measurement enterprise on track to achieve its potential to improve the value of U.S. health care without doing harm.

“Medical home” has become a term of art within the current wave of health reform. It’s in the medical literature, on the internet and embedded in the Patient Protection and Affordable Care Act of 2010.

There is much debate over what “medical home” means and whether or not it works. The Patient Centered Primary Care Collaborative published an overwhelmingly positive compilation of evidence last year supporting the concept. At almost the same time, the Agency for Healthcare Research and Quality released a review of the literature that was much less positive, suggesting that the impact of practice transformation to the medical home is much less certain. So, in the end, what are we to believe when the messages are so mixed?

Given how the concept has evolved over time, it is not surprising that we are confused. Historically, the term “Medical Home” comes from the American Academy of Pediatrics, which, in 1967, coined the term to describe a repository of records that would offset the dispersal of records between pediatric offices, health departments and hospitals. Over the next 30 years, the concept developed into one of relationship between children, families and pediatricians. Pediatric medical homes were primary care pediatric practices, partnering with families to serve children and youth with special health care needs, and emphasizing the need for care coordination within the many systems that serve the needs of children.

Mark Grube, Kenneth Kaufman and Robert York’s analysis of the decline in hospital utilization rates leads the Health Affairs Blog most-read list for March. Also on the top-ten list are articles on: the human face of hospital readmissions by Risa Lavizzo-Mourey; the impact of the Affordable Care Act by Kathleen Sebelius; the health care workforce by Thomas Daschle; and physician payment reform by Bill Frist and Steven Schroeder.

The most-read list also includes David Muhlestein’s survey of the accountable care organization landscape; Diane Archer’s discussion of the effects of concentration in the health care market, and Jesse Singer’s look at the use of electronic health records by the New York City Primary Care Information Project. Also among the top ten are Tim Jost’s article about the role of federally facilitated and partnership exchanges; and an article by Sara Rosenbaum and Joel Teitelbaum on the impact of the Essential Health Benefits rule on persons with disabilities.

Most experts agree that primary care needs to be re-invented. There are a lot of promising ingredients of practice redesign: better scheduling, electronic medical records with patient portals, redesigned clinician workflow, and work sharing. Linda Green’s intriguing article in the January Health Affairs simulates a strategic combination of these changes and argues if they all happened at once, we would have no primary care physician shortage.

Even if we make much more effective use of clinical time and energy, however, Green’s formula isn’t going to get us far enough fast enough. The baby boom generation of physicians is fast nearing its “sell by” date. In 2010, one quarter of the 242,000 primary care physicians in the US were 56 or older. One in six general internists left their practices in mid-career. Many more hardworking clinicians delayed retirement due to the 2008 financial collapse.

Few manpower specialists have noted the cohort effect likely to manifest itself shortly. A continued economic recovery and, more importantly, a recovery in retirement plan and medical real estate asset values will lead as many as 100,000 physicians of all stripes to leave practice in the next few years. We will be replacing a generation of workaholic, 70-hour-a-week baby boom physicians with Gen Y physicians with a revealed preference for 35-hour work weeks. During this same period, we’ll be adding 3 million new Medicare beneficiaries a year and enfranchising perhaps 25 million newly insured folks through health reform. “Train wreck” is the right descriptor of the emerging primary care supply situation.

No one expects a scalpel to perform surgery by itself. Similarly, no one should be surprised by the conclusion of a widely cited article in the January 2013 edition of Health Affairs (“What It Will Take To Achieve The As-Yet-Unfulfilled Promises Of Health Information Technology”) about the unrealized promise of health IT to lower costs and improve care.

Electronic health records (EHRs) are a tool, not a solution. But our experience at the New York City Department of Health and Mental Hygiene with the Primary Care Information Project (PCIP) demonstrates that with the proper support, EHRs can be a powerful tool for improving clinical care and managing population health. Now we are about to turn another corner on our journey, to see if we can use the data we collect from New York City EHRs to paint an accurate picture of the population at large.

Since 2005, PCIP has helped more than 3,200 providers implement EHRs, and we currently provide assistance to more than 7,700 providers in New York City. Our staff members help with everything from choosing an EHR to billing, coding, and documenting workflows, to assisting providers with navigating the federal EHR incentive program, to reviewing their clinical quality measures and helping them with numerous quality improvement (QI) activities. We are the home of New York City’s Regional Extension Center (REC), one of 62 such centers nationwide that are funded to support primary care providers through the transition to an EHR and help them achieve the federal Meaningful Use standards.

Use rates for inpatient and certain hospital outpatient services are declining in many areas of the country, reflecting fundamental change brought by the new business model. Importantly, as evidenced by trends in Chicago and Minnesota, there also appears to be a correlation between the level and pace of a market’s shift toward value-based care and the level and pace of utilization decline.

We believe this trend is here to stay and that it has significant strategic and financial implications for health care providers. Specifically, providers that embrace the migration to value-based care will need to work aggressively to eliminate unnecessary and/or ineffective activities in order to thrive under risk contracts. This requires a fundamental change in mindset, culture, and attitude about volume and activity. It also requires providers to rethink the organization and structure of their delivery networks to avoid supporting unnecessary capacity, and to drive patients into the lowest-possible cost setting in which quality care can be delivered.

The goal will be to manage a population’s health across the care continuum, keeping patients healthy through preventive and primary care services, and out of acute care facilities whenever possible. The right place to provide the right care at the right time with the right quality, cost, and access increasingly will be a setting other than a hospital. By eliminating waste and redirecting patients to ambulatory centers, physician offices, clinics, and online and/or telephonic interactions, less work will be done in the hospital. To reduce well-documented overutilization, tests and services deemed inappropriate or unnecessary based on medical evidence will be eliminated in all settings. (See Note 1) Acute care will be one, and only one, component of the population-centric health management services continuum.

The March issue of Health Affairs, released today, includes a variety of articles revolving around health and wellness, including an examination of mortality rates among American men and women by county. The issue also addresses whether physicians will see a return on investment from the adoption of electronic health records (EHRs), and it raises questions about cost savings from workplace wellness programs and the impact on less healthy workers.

Female mortality rates increased in 42.8 percent of counties in the United States during 1992–2006. Although mortality rates are falling in most counties in the United States, female mortality rates increased in 1,224 counties, compared to an increase in 108 counties for men, write David Kindig, professor emeritus of population health sciences at the University of Wisconsin–Madison, and Erika Cheng, a doctoral candidate there. Their study is the first to examine the relationship between socioeconomic and behavioral factors and mortality at the county level.

The authors found that for both men and women, factors associated with lower mortality included having a college degree, higher median household income, Hispanic ethnicity, and living in a higher population density area. For women, living in counties in the South and West was associated with a 6 percent higher mortality rate than living in the Northeast. Smoking rates were also a key factor in higher mortality rates. The researchers recommend targeted approaches that are suited to the unique needs of a county; they observe that investments in health care, public health, behavioral change, and social and physical environment will be needed to improve mortality rates.

Health literacy is the essential backbone of informed patient engagement, said Howard Koh, Assistant Secretary for Health at the Department of Health and Human Services, at a February 6 Health Affairs briefing. The event was held to unveil the journal’s February issue, “New Era Of Patient Engagement.”

Health literacy is particularly important now as tens of millions of Americans are faced with new choices about coverage and treatment under the Affordable Care Act, said Koh, a physician who also has a master’s degree in public health. Yet only about 12 percent of Americans have the skills necessary to navigate the health care system, leaving the vast majority of Americans at greater risk for unnecessary hospital admissions and readmissions, medication errors, and failure to manage their health conditions effectively.

Physicians and other health care providers often assume that patients understand what they are told unless they indicate otherwise, Koh noted. But the health system has gotten so complex that it challenges the comprehension even of sophisticated patients. The answer is to change the paradigm from a focus on correcting individual deficits in understanding to a systems approach: “The assumption is that everybody is at risk for not understanding, and that we should institute what we call ‘health literacy universal precautions.’”

Proposal

The National Research Council’s Precision Medicine report found that it is imperative to create a new scientific base for biomedical research, clinical care, and public health that accurately reflects the genetic variations in diseases and in individual responses to therapies.

This proposal calls for using the nation’s rapidly expanding capabilities for computerized biomedical research to accomplish this goal as quickly as possible. Research databases and analyses for most diseases would be completed over the next three years (by the end of 2015).

Background

The US-led Human Genome Project was finished ten years ago (2003). In the past several years, key elements for moving forward on a Precision Medicine-type initiative have been coming together.

A goal of Twenty-First Century Healthcare is to establish and enhance the Learning Healthcare System (LHS). As discussed in numerous forums, journals, and social media, the LHS is viewed as critical to improving healthcare. Fundamentally, the LHS converts data about care and operations into knowledge that it translates into evidence-based clinical practice and health system change. In so doing, the LHS utilizes as vehicles health information technology, databases, the electronic healthcare record (EHR) and, importantly, a research infrastructure. The continuing narrow evidence base for clinical care combined with the need for substantial amounts of data to fill large evidentiary gaps, among other factors, have fostered the LHS concept.

To assure the utility and validity of data converted and then translated into improvements by the LHS, we need rigorous research approaches that are also efficient. Research is defined as “a systematic investigation…designed to develop or contribute to generalizable knowledge.” At present, evidentiary inputs to the LHS range from activities not generally considered research (e.g., programmatic and quality improvement evaluations) to various forms of research that are sufficiently rigorous, but for various reasons, can be difficult to employ and translate into the routine workings of the LHS.

For example, the randomized clinical trial (RCT) — considered the cornerstone, or “gold standard” methodology — provides the best data, but by its very nature, is separate from the workings of clinical care in a given healthcare system (HCS). Instead, the RCT functions in an alternate environment precisely controlled for the approach’s particulars. Further, the RCT is costly and time-consuming, and its rather narrow entry criteria may diminish its ability to be generalized to routine patients (e.g., those with comorbidities, or those outside of the entry criteria of age and severity).

As US health care continues down the path of delivery system transformation, January’s Health Affairs explores areas of opportunities and challenges to achieving better health and better care at lower costs. Other articles focus on a range of topics of interest, including the length of time physicians spend with active and unresolved malpractice claims against them.

Seth Seabury at the RAND Corporation and coauthors report that the average physician spends almost 11 percent of his or her career with an open and unresolved medical claim. A major contributor is the length of the process of adjudicating such claims: The typical medical malpractice claim isn’t filed until almost two years after the incident occurred, and it isn’t resolved until 43 months post incident. When dealing with open claims, physicians spend up to 70 percent of that time with claims that never result in a payment.

Among the various distressing factors involved in this type of adjudication, patients and physicians alike may be more troubled by the length of time of the process than the potential damages, the authors say. They recommend exploring policy solutions that can decrease the time to resolution, including tort reform and alternative dispute management tools that can expedite the process and help limit meritless claims.

An extraordinary slowing of growth in the use of health care goods and services contributed to a second year of slow health spending growth in 2010, analysts from the Office of the Actuary at the Centers for Medicare and Medicaid Services reported in the most-read Health Affairs article of 2012. To celebrate the New Year,... Read the rest of this entry »

Health policy devotees of all faiths or none at all will enjoy Hank Stern’s Festival of Lights edition of the Health Wonk Review, posted last week on InsureBlog. Hank’s description of Chanukah and most things Jewish — “sweetness … tempered with bitter reality” — is often a decent description of health policy as well.

Tim Jost’s look at the 2012 election and the implementation of the Affordable Care Act in its aftermath tops the list of most-read Health Affairs Blog posts for November. Jost’s piece is joined on the list by election-related posts by Chas Roades, James Morone, and Jim Capretta.

Second on November’s top-ten list is a look at pay-for-performance through the lens of behavioral economics, by Steffie Woolhandler, Dan Ariely, and David Himmelstein. Other posts on the list discuss regulations issued under the Affordable Care Act; a new effort to promote outcomes measurement around the world; the VA Health System’s new “mega-database” for genomic medicine; and challenges for safety-net institutions in delivering accountable care.

The full list appears below.

Yesterday’s New York Times headline read that “Medicare Is Faulted on Shift to Electronic Records.” The story describes an Office of Inspector General (OIG) report, released November 29, 2012, that faults the Centers for Medicare and Medicaid Services (CMS) for not providing adequate oversight of the Meaningful Use incentive program. Going after “waste, fraud, and abuse” always makes good headlines, but in this case, the story is not so simple.

For those not intimately familiar with the CMS policy, in 2009, Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act. The program, administered through CMS and state Medicaid programs, created financial incentives for doctors (and other eligible professionals) and hospitals to adopt and “meaningfully use” a certified electronic health record (EHR). To receive financial incentives, which began to be paid in May 2011, doctors and hospitals “attest” that they have met the meaningful use requirements, providing an affirmation for which they are held legally accountable.

The process works as follows: health care providers visit a CMS website, register, and enter data demonstrating that their EHRs are “certified” and that they met each of the individual requirements for meaningful use. Then they attest that that all the data they entered is true. For example, a physician might have to report, to meet just one of the 20 meaningful use measures, how many prescriptions she wrote over the past 90 days, and how many she wrote electronically. My conversations with colleagues suggest that it can take a lot of time for providers to gather all the data they need to “attest” to meeting Meaningful Use. Then, CMS runs logic checks to ensure that the numbers entered make sense and, if there are no errors, they cut the provider a check. Through September, 2012, CMS paid out about $4 billion in incentives to 82,000 professionals and more than 1,400 hospitals.

This year marks the fiftieth anniversary of Watson and Crick (and Wilkins) being named Nobel Prize recipients for discovering DNA, the genetic code. In the half century since, there has been an exponential growth of knowledge and accomplishment based on their findings. More recently, a confluence of scientific and technical advances have made possible vast progress in our understanding of human disease, its diagnosis, and the most effective treatment(s). Among these advances are genetic testing, high performance computing platforms, and the electronic health record (EHR), which together offer the possibility of clinically rich databases that link genetic information to treatment outcomes.

These and other advances have made it clear that the genetic predispositions to adult diseases are in many cases extremely complex. In its early phases, human genetics focused on single genes for single diseases that generally occurred in childhood; e.g., Tay-Sachs disease. The genomics of adult diseases—such as coronary heart disease—are associated with complexity resulting from multigene interactions and strong environmental influences (e.g., lifestyle and exposures), that may in some cases result in organ-specific “epigenetic” changes that modify DNA.

A prominent example of how these various factors come together can be seen by looking at diabetes. Having a gene associated with diabetes may modestly increase one’s chances of developing this condition from—let us say—6 to 12 percent. But whether diabetes actually results is influenced by additional factors, such as the sequences of other genes, environmental influences (such as diet and exercise), and age.

Redesigning primary care is an integral part of health reforms in the United States and elsewhere. A new study, released today as a Web First by Health Affairs, reports the results of a survey of primary care doctors in the United States and nine other countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Switzerland, and the United Kingdom.

The survey, conducted between March and July 2012, found US and German physicians the most negative about their health care systems: only 15 percent of US and 22 percent of German practitioners thought their systems worked well. On the brighter side, the survey found that 69 percent of US doctors report the use of electronic health records, bringing use in the United States closer to the Netherlands, New Zealand, the United Kingdom, and Norway, all with near-universal capacity.

Editor’s note: In addition to Stephen Shortell (photo and linked bio above), this post is coauthored by Sarah Weinberger, a graduate student at UC Berkeley; Matt Chayt, an associate at Nossaman LLP; and Ann Marie Marciarille, a visiting assistant professor at the University of California Hastings School of Law.

As defined by the Affordable Care Act and subsequent rulemaking, Accountable Care Organizations (ACOs) are accountable for the cost and quality of care for a defined group of patients. In return, ACOs are able to share in savings that may result from providing cost-effective care, and they sometimes bear risk for excessive spending as well. While originally intended for Medicare beneficiaries, public-sector ACOs have drawn considerable attention from many states as a vehicle for potentially providing more accountable, cost-effective care, to Medicaid and uninsured populations. At least ten states have already launched or are scheduled to launch Medicaid ACO initiatives.

The final ACO rules published by the Centers for Medicare and Medicaid Services specify that federally qualified health centers (FQHCs) and rural health centers are eligible for participation. This change in the original rules and regulations makes it potentially easier for these safety net providers to combine Medicaid and Medicare accountable care initiatives targeted to the dually eligible population in addition to serving the uninsured and Medicaid populations.

But in addition to these opportunities, safety net providers also face particular challenges in providing accountable care. With the aid of a survey administered to safety net providers in two California counties, this post examines those challenges and offers some policy responses.

Note: This blog summarizes key findings from a report by the National Academy of Social Insurance (NASI) Study Panel on Health Insurance Exchanges and the Center for Health Policy and Research at the University of Massachusetts Medical School. The report draws some key lessons from the experiences of the states most advanced in their implementation... Read the rest of this entry »