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Seeing Clinician Slack As A Strategic Investment


August 1st, 2014

Editor’s note: In addition to Roy Rosin, this post is also coauthored by Evan Fieldston and David Asch. 

The French filmmaker Jean Renoir said, “the foundation of all civilization is loitering,” expressing the view that transformative value is created when people have time to step back and imagine a better way. Most businesses today seem to take a contrary position. Organizations in health care and beyond have spent a generation attacking slack, removing inefficiencies within processes and budgets. The narrow operating margins of health systems have led many to turn to companies such as Toyota or General Electric (GE) to learn about lean or Six Sigma techniques.

Subsequently, frontline clinicians are easy targets for attacks on slack. They are among the most expensive personnel within health systems and their productivity drives profitability. Working at the top of one’s license is set as a goal — reflecting the view that anything that can be delegated to a less expensive resource should be, and that everyone should be adding directly measurable peak value at all times.

A problem in translating lessons derived from general management experience is that even when conceptually appealing, they rarely meet medicine’s evidentiary standards defined by randomized trials or carefully controlled observations with homogenous populations, standardized interventions, and explicit outcomes. Instead, management lessons often take the form of stories – and perhaps only those selected to support a particular point.

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IOM Graduate Medical Education Report: Better Aligning GME Funding With Health Workforce Needs


July 31st, 2014

After nearly two years of deliberation, the Institute of Medicine (IOM) Committee on the Governance and Financing of Graduate Medical Education (GME) has issued its report. It presents a strong case for the need for change and a strong case for its recommendations.

The members of the Committee and the IOM are to be commended for their hard work, vision, and a high quality report. The report presents a clear path to a system that would help produce a physician workforce better aligned with the nation’s needs and a framework for a rational and defensible expenditure of nearly 15 billion dollars in public funds each year on GME.

Issues related to GME financing have been contentious for many years. In 1965, Congress included GME financing under Medicare reimbursement in what was intended to be a temporary arrangement. Nearly 50 years later, we are still trying to find a permanent and more rational way to finance and pay for the training of physicians as an alternative to the current complex, arcane formula built on Medicare inpatient days. Despite the well-documented shortcomings of the current system and numerous studies, attempts to find agreement on how to change and improve GME financing have been unsuccessful.

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Revisiting Primary Care Workforce Data: A Future Without Barriers For Nurse Practitioners And Physicians


July 28th, 2014

Editor’s note: Debra Barksdale and Kitty Werner also coauthored this post. 

With the full implementation of the Patient Protection and Affordable Care Act (ACA), there have been major concerns about the looming primary care provider shortage. The National Center for Health Workforce Analysis predicts shortages as high as 20,400 physicians by 2020, and increases in medical school graduates entering primary care residencies have been anemic.

Physician shortages can be addressed by the rapid growth of nurse practitioners (NPs), trained in primary care, along with the redesign of primary care to include teams that can be led by both physicians and NPs. But our nation’s primary care needs can only be met if states allow NPs to practice to the fullest extent of their training without unnecessary requirements for physician supervision.

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Shifting Motivations: Rethinking Primary Care Physician Incentives In Health IT Implementation


July 21st, 2014

Clinician adoption and implementation of health information technology (IT) has increased significantly since the passage of the HITECH Act in 2009. Dedicated efforts and large financial incentives have spurred innovation and motivated progress in many aspects of information technology, including information exchange and community-level health IT implementation. Yet poor usability of systems and overwhelming reporting burden still present barriers to optimal use of health IT.

Health IT capabilities — such as automated performance feedback; shared documentation with patients; population health tools; and clinical decision support, facilitating evidence-based health care — can potentially drastically improve quality of care, particularly in primary care practices. However, the current incentive and payment structures are not aligned with productive use and spread of health IT innovation. When many primary care physicians use electronic health records (EHRs), the problems they are now tasked to solve relate to billing and coding compliance and to achieving “meaningful use” through the Centers for Medicare and Medicaid Services (CMS) EHR Incentive Programs; many clinicians and systems are not encountering or using EHRs as productive clinical tools.

Perhaps the focus of providers and health systems on meeting the technical and administrative requirements of “meaningful use” has obscured the creative opportunity for clinicians to explore how to use EHRs to improve care, and to see their own actions as part of the solution to effective implementation. Strategies that focus on creating space for discovering ways that IT can support effective health care — e.g., more flexible payment models with emphasis on population health outcomes — may be more successful than those that focus on health IT adoption.

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The Alternative Payment Methodology In Oregon Community Health Centers: Empowering New Ways Of Providing Care


July 21st, 2014

Editor’s note: This post is part of a periodic Health Affairs Blog series, which will run over the next year, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation. The authors of this post are part of the team evaluating the Oregon model.

The Alternative Payment Methodology (APM) demonstration project enables participating Oregon community health centers to receive a monthly payment based on the size and composition of their patient population. This payment replaces the model of earning revenue based on the number of individual patients seen, shifting the paradigm from the number of doctor visits to the provision of high-quality, team-based, patient-centered care.

So what are the real changes physicians are seeing on the ground in clinics where APM is being implemented?

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Positive Results For 2012 Physician Quality Reporting System And eRx Program


July 17th, 2014

In April, the Centers for Medicare & Medicaid Services (CMS) released the 2012 Physician Quality Reporting System and Electronic Prescribing (eRx) Experience Report, showing a significant increase in participation in two programs that allow eligible professionals to earn incentive payments through voluntary participation.

Record Participation in 2012

With over 430,000 professionals participating in the Physician Quality Reporting System (PQRS) and more than 340,000 e-prescribing, the 2012 report marks encouraging progress in efforts to improve quality measurement and reporting through the PQRS and eRx programs. Thanks to increased participation, more clinicians are actively measuring and reporting on quality and focusing on improvement.

CMS is beginning to add this information to Physician Compare, a website that can be viewed by patients. Measuring, transparently sharing, and improving quality performance provide the keys to a better health system.

At CMS, we are pleased by the success of these programs and other CMS quality measurement programs. We are also encouraged by the potential of these initiatives to empower patients and providers with information that can support care coordination and improved delivery of care.

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Asking The Wrong Question About Health Professionals


July 15th, 2014

I spent a significant part of my professional career pursuing “rational” policies to guide the numbers of health workers needed. I now understand that most of these moves on the policy side were fool’s errands, when measured against the powerful corrective forces of the labor and education markets.

In fact, the elasticity of these markets has been generally unanticipated by most of the workforce models. For instance, few recognized the shrinkage of incoming nursing classes in the waning years of the twentieth century. It was only in 2001, when the number of nurses passing the licensing exam fell to 28 percent, less than it had been just six years before, that alarm bells went off. New policies spurred the creation of schools, existing programs were expanded, and a raft of workplace changes were put in place to make nursing more attractive and sustainable. By 2005, more candidates passed the exam than in 1995, the previous high water mark. By 2009, the number had increased by 38 percent.

Similar unexpected market responses have been reflected in such trends as the growth of osteopathic medical colleges, expansion of proprietary allied health education, delayed retirement by many professionals, and a host of second-career entries into health professional work.

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ACAView: New Findings On The Effect Of Coverage Expansion Since January 2014


July 9th, 2014

Editor’s note: In addition to Josh Gray, Iyue Sung also coauthored this post. 

Together, athenahealth and the Robert Wood Johnson Foundation (RWJF) have undertaken a new joint venture called ACAView, as part of the foundation’s Reform by the Numbers project, a source for timely and unique data on the impact of health reform.

The goal of ACAView is to provide current, non-partisan measurement and analysis on how coverage expansion under the Affordable Care Act (ACA) is affecting the day-to-day practice of medicine. athenahealth provides a single-instance, cloud-based software platform to a national provider base.

Any information that our clients enter using our software is immediately aggregated into centrally hosted databases, providing us with timely visibility into patient characteristics, clinical activities, and practice economics at medical groups around the country.

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Do Insurance Marketplace Consumers Need More Doctor Choices In-Network, Or Just Better Information?


June 26th, 2014

Media outlets have focused extensively on consumer complaints about “limited networks” and not being able to find a doctor under qualified health plans (QHPs) offered through the Health Insurance Marketplaces (HIMs). In response, the Obama administration released new standards which will require all QHPs to contract with a larger proportion of essential community providers within its service area. This means that health plans will be forced to accept more health care providers within their network, which may potentially increase costs for consumers.

At the heart of the recent changes lies a fundamental question worth exploring: Is consumer satisfaction with, and perceptions of health plan “network adequacy” grounded in the number of choices for doctors within network, or is it something different?

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Correcting The Blind Spot In Accountability: The Role Of Pharmacy Care


June 25th, 2014

Editor’s note: In addition to William Shrank, this post is also coauthored by Andrew Sussman, Patrick Gilligan, and Troyen Brennan.

The Centers for Medicare and Medicaid Services (CMS) recently issued a Request for Information (RFI) to solicit suggestions about how to improve the Accountable Care Organization (ACO) programs. CMS stated that they seek recommendations about how the ACO program might evolve to “encourage greater care integration and financial accountability.”

The RFI explicitly stated that they seek information about how to better integrate Part D expenditures into ACO cost calculations to make pharmaceuticals part of the approach to care delivery and health care transformation.

The deadline for comments about encouraging Part D integration in ACOs has now passed. But the issue extends beyond ACOs. In addition, bundled payments and patient-centered medical home programs target hospitals and primary care providers to promote higher quality and lower cost care. All these programs have largely excluded prescription drug costs in their calculus, and offer no direct incentives for Part D plans to participate in and improve care.

Nonetheless, retail pharmacies and Part D plans have developed a number of strategies to participate. As CMS and policymakers reconsider ACO regulations to stimulate greater integration of prescription drug use in delivery system reform, we thought it important to offer a description of the marketplace response to payment reform activities at large.

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Behind The Numbers: Slight Rise In Health Care Spending Growth Projected


June 24th, 2014

PwC’s Health Research Institute (HRI) released its ninth annual Medical Cost Trend: Behind the Numbers report today. This forward-looking report is based on interviews with industry executives, health policy experts, and health plan actuaries whose companies cover a combined 93 million members. Findings from PwC’s Health and Well-being Touchstone Survey of 1,200 employers from 35 industries are also included.

HRI projects that after a five-year contraction in spending growth in the employer-sponsored market, the growth rate will rise to 6.8 percent in 2015, up from the 6.5 percent projected last year.

What are the biggest drivers of the growth in health care costs? We identify four cost inflators in this report, and I would like to highlight two. First, the economy. More than five years after the end of the Great Recession, the improved economy is finally translating into greater medical spending. Consumers are now addressing health issues they ignored or postponed previously.

Secondly, the high cost of specialty drugs. While only four percent of patients use specialty drugs, those medications account for 25 percent of total U.S. drug spending. And estimates are that U.S. specialty drug spending will quadruple by 2020

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The Role Of Sales Representatives In Driving Physicians’ Off-Label Prescription Habits


June 19th, 2014

Off-label prescribing is widespread in Canada and the United States (U.S.). One in nine prescriptions for Canadian adults are for off-label uses with the highest percentages coming from anticonvulsants (66.6 percent), antipsychotics (43.8 percent), and antidepressants (33.4 percent). Overall, 79 percent of the off-label prescriptions lacked strong scientific evidence for their use.

For 160 drugs commonly prescribed to U.S. adults and children, 21 percent were for off-label indications totaling 150 million prescriptions. In this case, 73 percent had little to no scientific backing and once again psychoactive drugs such as gabapentin had the highest level of off-label use.

Moreover, doctors do not seem to know what are and are not approved FDA use for many of the drugs that they prescribe. Now an article published in the June issue of Health Affairs by Ian Larkin and colleagues points to active promotion by sales representatives as one reason for the widespread off-label use of antipsychotics and antidepressants in children.

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This Is Not Your Mother’s Payment Model: Reflections On The APM Pilot


June 18th, 2014

Editor’s note: This post is part of a periodic Health Affairs Blog series, which will run over the next year, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation.

In early 1994, as I went about finding a practice to join after residency, every physician with whom I spoke discussed managed care at length. As a young family physician dedicated to prevention and early intervention, I was convinced that managed care answered many of the historical challenges faced by primary care physicians. At last we’d be able to pay for the social workers who could facilitate important mental health care and human services for our patients and for the group nutrition classes we wanted to run in our practices.

Yet just four years later, as I left private practice to return to academic medicine, managed care was virtually dead. All its promise had been undermined by a range of structural and environmental challenges.

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Thoughts On The VA Scandal And The Future


June 13th, 2014

For eight years, until May 2013, I directed the Department of Veterans Affairs (VA) medical research program from its Central Office and became familiar with the operations of the Veterans Health Administration (VHA). It was my only VA job and I felt honored to be part of the VA’s vital mission, as did most VA employees I met. Based on this experience, I have some ground level observations on the state of the VA and its future planning in light of the present scandal.

VA’s Scope and Assets

VA has three components: a large health system (VHA), a benefit center (Veterans Benefits Administration, or VBA), and the highly regarded National Cemetery Administration. All report to the VA Secretary but have different missions, issues, and management requisites. For example VHA was a pioneer in the Electronic Health Record (EHR), while VBA has had a more recent painful conversion to information technology (IT). VHA is run by the Undersecretary for Health, on whom VA Secretaries almost totally rely given their general lack of experience in health care.

VHA is divided into 21 networks and has 8.9 million enrollees (out of the 22 million U.S. veterans). It cares for 6.4 million veterans annually at over 1,700 sites of care, including 152 hospitals, about 820 clinics, 130 long-term care facilities, 300 Vet Centers for readjustment problems, and a suicide hotline, as well as homelessness and other programs. It has partly trained two-thirds of U.S physicians and made groundbreaking medical research contributions. These assets create strong constituencies for VA both within and outside the veterans’ community.

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Changing Provider Networks In Marketplace Health Plans: Balancing Affordability And Access To Quality Care


June 11th, 2014

Editor’s note: In addition to Sabrina Corlette, JoAnn Volk, Robert Berenson, and Judy Feder coauthored this post. 

Twelve percent of the complaints to California’s Department of Managed Health Care this year relate to access to care problems. In New Hampshire, consumers were upset to learn that their local hospital had been excluded from the network of the sole insurance company participating on the state’s health insurance marketplace. In reaction to concerns about narrowing networks, legislators in Mississippi and North Dakota considered “any willing provider” legislation this year.

But at the same time, the Congressional Budget Office expects narrow networks to help reduce marketplace costs by billions of dollars. Network configurations clearly offer consumers a cost-access trade-off. Narrowing networks is by no means a new trend – using network design to constrain providers’ price demands has long predated the Affordable Care Act (ACA). In the new marketplaces, insurers are using narrow networks to help keep premiums low for price-sensitive purchasers. But if a plan’s low premium reflects limited network access, its policyholders might not only face compromised quality care but unanticipated and potentially crippling financial liabilities.

Regulators are recognizing this trade-off and reconsidering network standards at the state and federal level. But regulators face a challenge: If they overly constrain insurers’ ability to negotiate with providers, consumers could face significant premium increases. On the other hand, if they ignore provider participation issues, consumers will lack confidence that there is a sufficient network to deliver the benefits promised without posing financial or quality risks.

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The Latest Health Wonk Review


June 10th, 2014

Joe Paduda offers the latest edition of the Health Wonk Review at Managed Care Matters. Joe is “not taking any time off” and covers the latest in health policy blogging, including a trio of Health Affairs Blog posts.

Joe features HA Blog posts by Bob Berenson and Stu Guterman on provider consolidation and market power in health care; these posts were written in response to a Health Affairs Web First package on the same topic. Joe also includes Amy Berman’s post on being diagnosed with terminal cancer and choosing palliative care, written in response to the May Narrative Matters essay by Diane Meier.

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Making Markets Work In Health Care: What Does That Mean?


June 3rd, 2014

Editor’s note: See Robert Berenson’s post on consolidation and market power in health care, also published today, and watch for more on these subjects in Health Affairs Blog.

Health Affairs last week posted a set of papers that represent several perspectives on Provider Consolidation in Health Care: Challenges and Solutions. To provide a context for these papers and for the broader discussion of how to make markets work in health care, I suggest a couple of thoughts.

There are two types of markets in health care: the market for health services and the market for health coverage—these markets are interrelated, and both of them are broken.

The historical correlation between provider concentration and both higher prices and lower quality is well-documented. With the increased focus under health reform on collaboration across providers and settings, and the increase in physician and hospital consolidation and the purchase of physician practices by hospitals, the concern is that this trend may lead to adverse consequences for the health system.

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Acknowledging The Elephant: Moving Market Power And Prices To The Center Of Health Policy


June 3rd, 2014

Editor’s note: See Stuart Guterman’s post on consolidation and market power in health care, also published today, and watch for more on these subjects in Health Affairs Blog.

Health Affairs recently published a set of papers addressing the problem of provider consolidation and consequent increased prices. Perhaps even more striking than the specific arguments made in these papers is the very fact that smart and busy people other than antitrust economists and lawyers now are actually spending a great deal of their professional time thinking about this problem. High prices and the distortions in markets resulting from differential pricing power have been the unacknowledged elephant in the policy room for decades, even as the policy community and policy makers have wrung their hands over what to do about rising health care costs. More than 40 years ago, President Nixon declared that health care spending increases were “unsustainable.” And here we still are grappling with health care spending.

Over the decades I have been told by smart health economists that the main culprit behind increasing health spending is technology, although the definition of technology turns out to be pretty flexible — new ways of providing care are considered new technology, not just machines and drugs. And nominees for the reason our baseline spending exceeds other countries’ by so much have included administrative complexity in our multi-payer, crazy quilt organization of health care; defensive medicine caused by malpractice concerns; and fraud and abuse. Jack Wennberg and colleagues at Dartmouth have argued that variations in service use that do not increase quality explain spending variations, at least in Medicare where payment (price) variations are not permitted other than to reflect differences in input costs.

All of these explanations have merit, but for non-government payers, prices have actually been the main source of high spending and variations in spending, at least in the recent past and probably for much longer. Prices for commercial and self-funded insurance products result from market negotiations between insurers and providers; the balance of power in these negotiations has sometimes shifted, most recently toward many providers, but certainly not all of them — the relatively few remaining independent hospitals and the solo and small physician practices have become “price takers,” even as other providers are able to negotiate payment rates far higher than Medicare benchmarks.

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Chinese Doctors In Crisis: Discontented And In Danger


May 27th, 2014

Chinese doctors are unhappy about their pay and work conditions.  Moreover, they are in danger of physical attack by angry patients and families.  The Ministry of Health estimated that in 2010, 17,243 attack and agitation incidents occurred in Chinese hospitals, an increase of almost 7,000 over five years. Patients, bereaved families of patients who have died in hospitals, and sometimes paid protestors called yinao or “medical troublemakers,” invade hospitals, berate or attack staff, create loud disruptions, and stage mock funerals.

About 30 percent of the attacks were carried out by patients, 60 percent by family members, and the remainder by others, including yinao. About 75 percent of attacks were aimed at doctors.  According to a 2012 survey of nearly 6,000 Chinese physicians in 3,300 hospitals, 59 percent of doctors had been verbally assaulted and 6 percent had been physically assaulted. News accounts for 2002-2011 yielded 124 incidents of “serious violence” against hospitals, including 29 murders and 52 serious injuries. Often violence accompanies demands for cash compensation for harm to patients, including patient deaths in hospitals.

In response, the Chinese Ministry of Public Security has recently announced a new set of security measures for hospitals. Approximately one thousand top-tier hospitals will now have a police presence in addition to their own security guards; alarm systems linked with local law enforcement; enhanced audio-visual surveillance systems; and security posts at entrances similar to those at airports.

The wave of violent attacks on doctors and other medical workers constitutes a significant problem in its own right.  But it is also a reflection of a broader set of problems faced by today’s generation of Chinese doctors.  They are badly paid, both in relation to doctors in other countries, and in relation to other Chinese professionals. As a result, doctors often supplement their low salaries in ways that strengthen the popular impression that they are corrupt, fostering still greater distrust and anger among their patients and patients’ families. A recent survey showed that 67 percent of the Chinese public does not trust doctors’ professional diagnoses and treatment.

The doctors themselves are also dissatisfied with the current state of affairs. A 2011 Chinese Medical Association survey of its members showed fewer than 20 percent of responding doctors to be satisfied with their medical practice environments, while 48 percent rated them “poor” or “very poor”. Doctors were particularly dissatisfied with their pay. They were also concerned about their work conditions.

When respondents were asked to identify sources of work pressure, the most frequent response, at 77 percent, was “high patient expectations.”  Only 21 percent wanted their own children to become doctors. Interestingly, this survey showed that fewer than 10 percent of respondents blamed patients, doctors, or hospitals for their problems; the majority (83 percent) blamed “the system” for the tension between doctors and patients.

In this post, we review that system and highlight sources of doctors’ discontent and the distrust between doctors and patients.

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Health Affairs Web Firsts: Provider Consolidation In Health Care


May 19th, 2014

The clinical and economic virtues of provider consolidation have long been recognized by policy experts, but in recent years, research has shown that large provider organizations may use market power to obtain relatively high prices from payers without necessarily delivering superior quality. Four articles, being released as Web Firsts by Health Affairs, examine the issue from diverse perspectives.

A study from Paul Ginsburg and Gregory Pawlson serves as an issue overview. With continued consolidation likely, the article examines strategies that purchasers and payers can pursue to combat the rising prices that may result from growing provider leverage.

Ginsburg is the Norman Topping/National Medical Enterprises Chair in Medicine and Public Policy at the Sol Price School of Public Policy and the Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California in Los Angeles; Pawlson is a senior medical consultant at the law firm Stevens and Lee in Lancaster, Pennsylvania.

“The success of the private- and public-sector initiatives,” they conclude, “will determine whether governments shift from supporting competition to directly regulating payment rates.”

Looking broadly at the drivers of competitive outcomes, a study from William Sage, the James R. Dougherty Chair for Faculty Excellence, School of Law at the University of Texas at Austin suggests that the health care system’s long history of regulation and subsidy has not only distorted prices but has also altered the nature of the products that the system buys and sells.

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