The Disease Management Care Blog (DMCB) welcomes readers to this edition of the Health Wonk Review. The DMCB is a physician-writer with knowledge and experience in primary care, health insurance, population health and health information technology. That's why it's delighted to host this compendium of recent writings from the best health policy bloggers offering insights you won't find anywhere else. Read this and the DMCB assures your Huff Po addled colleagues will admire you and your USA Today reading opponents will envy you.
For example, this HWR has a conservative who actually likes health insurance exchanges and a progressive who is disappointed with a key aspect of the Affordable Care Act. There's also a unique description of an important collaboration among competing commercial health insurers and a thoughtful discussion of the downsides of preventing HIV infection. You'll also find a detailed report on how the evening news blew the coverage of an important cancer screening guideline update.
And don't be put off by the wide ranging number of posts. Read what captures your interest, follow the links and come back as often as you like. The DMCB will leave the light on for ya.
Most readers of this Health Wonk Review are undoubtedly sophisticated and dispassionate experts on hospital quality, consumerism, patient satisfaction and outcomes. Well, Neil Versel of the Meaningful Health IT News blog shows us how that learning contrasts with watching a terminally ill loved one with Multiple System Atrophy struggle with distant physicians, medication errors, incomplete care planning, lack of basic health services, ignored advance directives and occasional Keystone Kops style encounters with health workers who should know better. And we wonder why Americans are so fed up with the U.S. health care (non) system? Egads, says the DMCB.
A Medicare Hospital Measure Called "MSPB"
Speaking of hospitals and quality, CMS has started to publicly report peri-hospitalization health care costs using a metric called the Medicare Spending Per Beneficiary (MSPB). According to Jason Shafrin of the Healthcare Economist Blog in this post titled "Measuring Hospital Efficiency," Medicare is now reporting a roll-up of all payments made to docs and the facility three days prior, during and 30 days after a hospital stay. Non-surprisingly, some areas of the country have much higher MSPBs than others. Yet, despite its merits, Jason reports that the measure is not without controversy because we don't know enough about the link between the MSPB and outcomes (does more spending result in high quality?) or if reported higher costs were the the result of waste (for example, unnecessary or redundant testing) versus additional necessary care (perhaps extra days in a rehab facility after discharge were worth it). The one thing the DMCB does know is how necessary it will be to use the acronym "MSPB" the next time it steps up to a microphone at a health policy confab. It can't wait.
When is an admission to the hospital not an admission? That's the conundrum tackled by Dr. Brad Flansbaum of The Hospitalist Leader blog, who helps the reader understand how hospitals use their inpatient facilities to treat outpatients. The key distinguishing factor is a limited 24-48 hour course of care that is aimed at returning the patient home. Unfortunately, outpatient care is covered with an outpatient insurance benefit that can include significant out-of-pocket expenses. Medicare has policies that require providers to inform beneficiaries of the financial impact of being in "observation status" but as the line that separates inpatient and outpatient care continues to be blurred, it's likely we'll have to wait for global payments or shared risk arrangements to reconcile patient coverage expectations and billing systems. Until that happens, Brad has quotes a Medicare official who assures us that CMS is "considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system." Right.
Accountable Care Organizations
While the mainstream focuses on Medicare's ACOs (for example), Blue Shield of California, CalPERS, Hill Physicians Medical Group and Dignity Health quietly partnered back in 2007 on a shared savings program that apparently resulted in a noisy $20 million in savings. Glenn Melnick and Lois Gree over that the Health Affairs Blog have authored an interesting interview-narrative about this initiative that is full of interesting lessons. These lessons include the importance of physician buy-in and participation, a system-wide working familiarity with old-fashioned capitation, a supportive pre-existing provider culture, an emphasis on reducing readmissions, using wellness to reduce use of pricey bariatric surgery services, data liquidity, increasing use of evidence-based guidelines at the point of care, patient "repatriation" from non-participating care settings, data dashboards and empowering non-physicians to engage patients in self-care. The California HealthCare Foundation has committed to completing a full evaluation of the outcomes next year. The DMCB commits to using some new health policy jargon it discovered in reading this post: "actualize" and "head in a bed."
Roy Poses of Health Care Renewal continues to expose the folly running rampant in the U.S. health care system, this time by looking at the "CEO as False Messiah." Dr. Poses cautions readers to pause any time they run into local or national leaders who are uncritically hailed as "visionary." It's far more likely that their fawning admirers have been seduced by a toxic level of charisma that often leads to catastrophe. Get real, advises Roy, and admire such folks for being smart while keeping a skeptical eye on their ability to produce results.
The Doctor-Patient Relationship
David Williams of the Health Business Blog uses a Health Affairs article on "shared decision making" to reflect on the upsides of being labelled a "difficult patient." Researchers found that an important barrier to forming a doctor-patient relationship is the fear among health care consumers that expressing a preference will annoy their doctor. David argues that's not such a bad thing, especially since modern consumers now have the option of seeking a second opinion, getting another doctor and ultimately refusing a questionable treatment. The DMCB really agrees with David's perspective because it wants to be liked by him.
HIV Prevention Is Good News, Right?
Nate Ogden of the InsureBlog walks readers through a fascinating exercise on the costs and ethics surrounding the FDA's approval of HIV-prevention drug called "Travuda." While readers may initially want to hail this medical breakthrough, Nate suggests it's not so simple: 1) the retail cost of the drug is $11,000 a year, which a) contrasts with the $30 a month cost of equally effective condoms and b) would be enough to treat 20 HIV positive patients, 2) persons taking the drug may misuse their new found protection and paradoxically engage in increased risk-taking sexual behaviors and 3) coverage may be mandated as an insurance benefit, which means there'll be one more driver of health care costs for all of us. Another silk purse turned into a sow's ear, says the DMCB.
Would You Like Some Drug Monitoring Along With That Refill?
Never at a loss for words, Joe Paduda of Managed Care Matters takes umbrage with Missouri State Senator Robert Schaaf's opposition to the state's "Prescription Drug Monitoring Program Act." Joe argues that the act would reduce the incidence of drug-drug interactions and lessen prescription drug abuse through doctor shopping. Without passage of the bill, says Joe, kids will lose their moms, Scout troops will have to meet without their den mothers and schools will have teacherless classrooms.Dr. Schaff, who by the way is a family physician and leads a prominent physician liability insurance carrier, has a different perspective. The DMCB predicts the Senator will not find Joe's disapproval very compelling.
HEALTH INFORMATION ANALYTICS
Health Insurer Data Mining
If it's one thing that Medicare has done better than the commercial insurers, it's making its claims data available to health services researchers. The DMCB suspects that the commercial insurers have been reluctant to do so because of the considerable effort involved, concerns about inadvertently running afoul of HIPAA's unwieldy confidentiality provisions, giving their competition otherwise confidential information about payment rates and the lack any relevant value propositions. According to Martin Gaynor at the curiously named Wing of Zock Blog, those barriers have finally been overcome. Aetna, Human, Kaiser and United have all agreed to ship billions of lines of claims data to the not-for-profit Health Care Cost Institute which will make the deidentified data available to researchers. The DMCB agrees that this is a significant development that will allow researchers to mine insights that, thanks to relatively low numbers of patients, non-generalizable health care settings and limited imagination, have been out of reach. The DMCB hopes the data will be made democratically available on as close to an "open source" basis as possible.
Group and Individual Insurance Markets
Need a quick lesson on the fundamental differences between group and individual health insurance policies? Louise over at Colorado Health Insider has a terrific "101" on health insurance guaranteed issue, mandates, underwriting, the role of high risk pools and the impact of Affordable Care Act. The DMCB recommends that everyone - except the White House - bookmark this page just in case we're forced by the Supreme Court into a health insurance reform do-over. The White House is being given a pass by the DMCB because if that happens, no one will really care what they think.
Speaking of the Individual Market....
In case you think all progressives uncritically support the Affordable Care Act, Maggie Mahar at the healthinsurance blog inconveniently points out that a big part of the individual health insurance market will remain broken come 2015. Maggie's post offers up some compelling statistics that demonstrate that many middle aged boomers (yikes, including the DMCB) who are between ages 50 and 64 years won't meet income thresholds for subsidies. As a result, they're looking at the prospect that health insurance premiums could reach an unaffordable average of $7500 a year. Combine that with a lackluster job market, declining incomes and substantial out-of-pocket costs and it is clear that health reform will remain a contentious, time-consuming and difficult work in progress for years to come. In the meantime, the DMCB will wonder about the affordability of essential benefits, the merits of value-based insurance designs, how population health-based care management can help blunt the impact of chronic illness and the wisdom of using limits on age rating to shift costs to the DMCB spawn.
One State's Perspective on Federal Health Reform
While California's budget slides into the sea thanks to an unending budgetary earthquake, every dollar counts. That's why Anthony Wright of the Health Access Blog points out that in addition to the patently obvious merits of assuring access, lowering costs and protecting consumers, the Affordable Care Act is also a windfall for the Golden State. He quotes and links a California-based Bay Area Council Economic Institute report that calculates that the ACA will add close to a 100,000 new California-based jobs and $4.4 billion in additional state output. Alas, says the DMCB, between the U.S. Supreme Court and less-than-expected taxable income from the disappointing Facebook IPO, it looks like fixing Sacramento''s budget woes may need a Plan C.
How Should States Respond to Health Insurance Exchanges?
Conservatives hate those ACA-mandate insurance exchanges, while progressives love them, right? And any Republican Governor that sets up an exchange under the terms of the ACA is a hypocritical closet-supporter of Obamacare? Is that so? John Goodman's Health Policy Blog point-counterpoint posting teaches us that it's not so simple. It turns out that states 1) may fare better with or without the ACA if they maintain control over exchanges, 2) could use the flexibility that comes with control to make insurance exchanges more effective and fair, and 3) with that control will also have a say over the commercial insurance subsidies that will add up to gazillions of dollars. Just in case you think John's post is just a lot of hot air, check out this telling Pennsylvania-based Op-Ed.
Links Between Worker's Comp and Health Promotion
Many health care providers regard "worker's comp" as something as a policy sideshow, but Worker's Comp Insider Jon Coppelman shows us that this multi-billion dollar industry is not only a big deal but also not immune to the growing costs of our sedentary lifestyle. When a 50 year old fat ambulance worker's stroke was blamed on a lower extremity paradoxical embolism resulting from hours of sitting, the lifelong care costs were ruled "compensible." Next stops are the diabetes-causing donuts on our way to work and the hypertension from those generously salted fries in the company cafeteria. Mr. Coppleman recommends early adjuster involvement in the claims adjudication. The DMCB wonders if the Workers Comp insurance industry should think about being more proactive, including using risk stratification and advocating for common sense health promotion.
WELNESS AND HEALTH PROMOTION
Wellness! Gotta Have It!
No Health Wonk Review would be complete without one enthusiastic endorsement of all things wellness. Kat Haselkorn of Corporate Wellness Insights steps into that role with copious praise of all the benefits of health promotion, including positive culture change, huge returns on investment, enriched social networks and accelerating employee productivity. Kat suggests that if just one person buys into wellness, the effect can ripple through the company faster than spandex-clad yuppies swarming at an after-work Zumba class.
Wellness! Gotta Keep Funding It!
New blogger Tracey Moorhead of the Care Continuum Alliance writes in the Voice On Population Health Blog about the ill-advised willingness of the U.S. House to steal from the ACA's Prevention and Public Health Fund to extend coverage of student load interest subsidies. Tracey passionately argues the fund has already led to important behavioral health screenings, data infrastructure development and expansion of wellness services in multiple states. Whoa, says the DMCB, which isn't surprised at the Care Continuum Alliance's advocacy on behalf of prevention and population health. Good for them.
And Here's An Added Benefit of Being Fit?
Michael Gavin of the Evidence-Based blog notes that a recently published article in the medical journal Pain shows that athletes have a higher pain threshold. From his point of view, this is why exercise should not only be promoted as an alternative to using dangerous drugs to control pain but as an added overall benefit from achieving maximum fitness. The contrarian DMCB took a look at the abstract and wonders if persons who are naturally blessed with higher pain thresholds are attracted to exercise (or at the very least, find it less unpleasant). While readers are figuring out which is cause and which is effect, they can also show their health knowledge chops by not only referring to exercise related "endorpins" but "endocannabinoids" as the basis for the runner's "high."
Talk about a disenfranchised population. Suffering with highly prevalent rates of Hepatitis C, HIV and mental illness, huge numbers of released prisoners were being left to fend on their own. Harold Pollack, also of the healthinsurance blog describes how thanks to recently passed federal legislation, hundreds of thousands of these individuals will be able to qualify for Medicaid, obtain tax credits that can defray the cost of private insurance and access basic community-based health care services. While health reform is all about the single mom waitress with two kids, the middle America steel worker and the kid with end stage cancer, Dr. Pollack says we all benefit when ex-prisoners are also staying away from crowded emergency rooms, avoiding unnecessary hospitalizations and not burdening over-stretched safety net programs.
IF you believe geriatric care is important, THEN you should read this post BECAUSE you'll get to learn about the "ACOVE" framework. That's the message the DMCB got after reading Chris Langston's post on the Quality of Geriatric Care over at the John A Hartford Foundation. It turns out that the Assessing Care of Vulnerable Elders is a handy IF-THEN-BECAUSE tool that identifies the specific health issues afflicting the elderly and targets geriatriccare planning. Chris argues wider use of ACOVE would increase quality of care in geriatrics and clarify the important differences between general medical versus geriatric conditions.
Here's another anti-ICD-10 rant, courtesy of a post by TBD Consulting's Jonena Relth at the Healthcare Talent Transformation Blog. She argues that veteran front-line health care workers are deeply skeptical about the ultimate value of the insurance billing system's astonishingly complicated specificity and detail. Jonena is concerned that the new coding will paradoxically lead to billing errors and enable greater health insurer mischief. Too bad there wasn't any credit given to the AMA for CMS' decision to delay implementation of ICD-10 as well as the organization's continuing advocacy on the issue. As for the health insurers, the DMCB thinks that given the circumstances of a very hostile Administration and the luster of an ACA-driven enrollment windfall, they quietly came as close as they could to expressing concerns over the wisdom of ICD-10.
and last but not least.....THE NEWS DISAPPOINTS...AGAIN
Prostate Cancer Screening and the News Media
As risks, benefits and alternatives to cancer screening move into the public square, Gary Schwitzer's HealthNewsReview blog offers up this balanced scientific review on the merits of prostate cancer screening by Richard Hoffman and this insightful description on how the mainstream news media made a mess of things. It turns out that the U.S. Preventive Task Force's recommendations weren't really all that new, that a substantial number of physicians have been PSA skeptics for years and that early detection of prostate cancer - whatever its merits - is hugely remunerative to providers. As testimony to the news elites' selective inattention, ask yourself if you should thank Diane Sawyer et al for avoiding this new wrinkle on the topic of lung cancer screening.
Image from Wikipedia