The Italics and Dot-Dot-Dot Edition of the Cavalcade of Risk

Welcome to your latest edition of the Cavalcade of Risk.  The Population Health Blog is pleased to offer this linked summary of some of the best and latest bloggery dealing with economic risk.

Knowing how busy readers are, this particular edition wanted to focus on the "bottom line" of each entry. The most important insight is at the end of each paragraph.....

Enjoy!

Auto

Wondering if that non-performing capital assessment called a "parked car" can be addressed by "peer-to-peer car sharing?'  Well, if you think you can grab a portion of Hertz's market share by renting that car, you may want to pause and think about what your automobile insurance has to say about it.  Hank Stern over at the Insure Blog points out that a wreck may not be covered leaving you personally responsible for another party's injuries....

Workers Comp

Did you know that employers can be arbitrary, hostile and vindictive?  That employees can be sullen, suspicious and uncooperative?  Toss in a significant  job injury, and you've got is what AMAXX Blog writer Michael Stack describes as an unwritten part of a workers compensation adjuster's job description: being a peacemaker. Employees ultimately do better if they get to work sooner rather than later, and bosses do better they step back and let the workers comp adjuster deal with any possibility of malingering....

Data Privacy

After Target and eBay, your company's (or, come to think about it, government's) databases may not only be next, that possibility is greater than you realize.  RJ Weiss at the Weiss Insurance Agencies does readers a service by summarizing some of the numbers around the risk of data breaches, including a cost of $195 to $246 per record, an average loss of 2.8% of customers and that having strong preventive measures in place can reduce your cost by $8.98 per record.  Important sources of break-ins include those portable devices and sloppy third parties....

Health Insurance

We'd all like to think that hospitals are working hard to reduce costs and increase quality thanks to the government's value-based purchasing initiative.  Jason Shafrin of the Healthcare Economist summarizes a recent peer-reviewed publication on the topic and the bottom line answer is "not exactly." While results may be more a function of the baseline that was used, there was no discernible impact on clinical process or patient experience performance for Medicare beneficiaries....

Speaking of payment initiatives, your host's Population Health Blog (PHB) takes a look at another recent scientific publication that examines how a statewide bundled payment program stumbled.  The process was stymied by the usual payer-provider tensions, inadequate information technology, regulatory concerns and difficulties on defining just what makes up an "episode of care." It turns out that getting bundled payment off the ground is far harder than it looks.... 

Getting health insurance between jobs should be easy, but it's not. Louise over the Colorado Health Insurance Insider cuts through the noise of Obamacare and the individual market by offering up some useful insights, including the definition of a "qualifying event," the 60-day rule and the option of using Medicaid to trigger a qualifying event to navigate the 60-day rule....

The next host of the Cavalcade of Risk is Paul Dzielinski.  The PHB is looking forward to his hosting debut!

Medicare Pay for Performance for Hospitals May Be Flawed

The Disease Management Care Blog is still waiting to be listed in the CMS' "clear accurate information is essential in times like these" Op-Eds & Blogs web page.  Will the CMS mandarins find favor with this particular DMCB post and include it with the other insightful masterpieces they've linked, like "Health Reform Helps Many" and "Public Service Recognition Week?"

Probably not, says the DMCB.  It's not because the DMCB is again linking this report showing how CMS seems to be incapable of delivering disease management services to its fee-for-service enrollees.  It's not because of this report revealing how Medicare's Hospital Compare isn't having much of an impact on outcomes.

It's because the DMCB is bringing up the inconvenient truth of this independent evaluation of Medicare's Premier Hospital Quality Incentive Demonstration. This demo tested whether pay for performance can increase the quality of care for acute heart attack, chronic heart failure, pneumonia, heart bypass surgery and total knee as well as hip replacements.  33 measures for these conditions were collected from 252 participating hospitals. The hospitals that scored in the top measurement deciles received bonus payments, while those that were underperforming were hit with a payment penalty.

Think of it as "pay-for-performance" for hospitals.

After excluding hip and knee surgery (where mortality rates are very low), the researchers were interested in measuring whether the Premier Incentive Demo was associated with one of the most important outcomes of all: lower death rates. Based on 6 million patients' worth of data from 2002 through 2009, the researchers found that there was no difference in overall 30-day mortality rates for all of the four conditions compared to non-demo hospitals (11.8% vs. 11.7%). In addition, mortality rates for the individual conditions of heart attack, heart failure and pneumonia were no different either. For heart surgery, there was a slight excess of deaths in the Premier group (4.1% vs. 3.3%).

These results are quite a contrast from this Premier press release that estimates that the Demo "saved an estimated 6500 heart attack patients." The DMCB suspects that that particular number was derived and extrapolated from prior studies linking less tobacco cessation or greater aspirin use to improved death rates.

It seems the math may have been wrong. And it was that same math that led the architects of the Affordable Care Act to establish the Medicare Hospital Value-based Purchasing Program ("Hospital VBP"). As the DMCB understands it, it's just now getting underway.

Egads.

Go to this particular HHS web page and you'll find that the Department....

"...monitors and evaluates programs to assess efficiency and responsiveness and to ensure the effective use of information in strategic planning, program or policy decision making, and program improvement."

Hopefully, the leaders at HHS will be doing precisely that by reexamining its assumptions and it's ability to achieve real value with the Hospital VBP.

Insights on Health Reform, Courtesy of Medical Home News

Getting more brainy

To the chagrin of the DMCB spouse, the Disease Management Care Blog serves for free on several editorial boards. In its estimation, it's well worth the time.  It's closer to breaking news, has met interesting colleagues, gets to read interesting manuscripts and has one more excuse to take a pass on sharing in the intensely engaging drama of Downton Abbey.

One such publication is Medical Home News, and the latest edition, thanks to a back-page "Catching Up With...." interview with former Deloitte executive Paul Keckley, did not disappoint. The DMCB has seen Dr. Keckley's smarts in person in several venues and the MHN piece did not disappoint. When he opines, the DMCB thinks.

Among his brainy insights....

The struggle to prove that the medical home saves money continues not only because there are many models serving many populations with many metrics.  In addition, "each prominent medical home promotes its model as uniquely effective."  The DMCB saw how pride of ownership and proprietary business models balkanized the early disease management industry.  PCMH advocates, you've been warned.

In "some form" ACOs will survive.  The road from where-we-are to where-we-need-to-be will need to include skills in managing populations on a "risk basis." If that's true, the DMCB provocatively wonders if that means that that ACO "form" will be some sort of HMO, which was very good at manging populations on a risk basis.  Time will tell.

The three things getting in the way of "value-based" care are 1) operational and infrastructure costs, 2) payer-provider agreement on how savings will be shared and 3) "the regulatory framework in the ACA and future laws that will define fair play in value-based purchasing."  At first glance, thinks the DMCB, makes sense until it ponders the irony of that 3rd one.

"Tranparency about prices means little."  It's all about networks, reference pricing and leveraging them to extract value.  The DMCB cannot disagree and is reminded that's how health care markets really work.

The biggest disappointment in health reform is how disconnected the consumer remains, while the biggest plus has been the advent of data-driven health care.  The DMCB wonders if the biggest disappointment has been the battering of the "big government" brand, while another plus has been the growth of the DMCB readership.  Time, naturally, will tell.

Image from Wikipedia

Medicare's Expenses Increased by 0.4%? Really? And It's All Because of the Affordable Care Act?

If you're the head of Google and you want to teach about the internet, North Korea is a swell place to visit.  If your goal is air travel safety, the 787 Dreamliner is the plane for you.  If you would like to get the puck from an opposing professional hockey player, saying "please" helps.  And if Medicare costs dip, the Affordable Care Act (ACA) obviously deserves the credit.

Writing on an HHS website, Richard Kronick and Rosa Po announce that 2015 Medicare expenditures per beneficiary grew only by 0.4% over the 2011 baseline.  They credit the ACA's value-based payment (VBP) system, attacks on fraud and abuse, reduced payments to Medicare Advantage plans, cutting hospitals payments and "innovation."

The Disease Management Care Blog isn't too sure about that.

1. This Kaiser Health News article notes the VPB program withholds 1% of hospital payments and uses that fund to award bonuses in what is really a zero sum game.  And this Health Affairs article suggests the overall financial impact of VPB on hospitals is quite minimal anyway. 

2. While there have certainly been some big fraud and abuse busts, there's plenty of reason to still be skeptical about the ability of Medicare's ossified bureaucracy to catch up with the sophisticated criminal enterprises that are routinely fleecing billions from the U.S. taxpayer.

3. As for the one-time payment cuts to providers and insurers, the DMCB is confident that they'll figure out ways to get their money back.  They always do.

4. The innovations are in demonstration phase.  It's too early to tell.

In addition, the DMCB is surprised that Medicare's 2015 insurance claims were ready to be rolled up and quantitated in early 2015. Check out this telling quote from the website:

"2010 and 2011 statistics are calculated on a calendar year incurred-basis. 2015 statistics are calculated on a fiscal year cash-basis, because calendar year incurred-basis data are not yet available." (bolding from the DMCB).

Last but not least, the DMCB believes the lackluster economy has probably had the biggest impact on consumers' willingness to use their Medicare benefit.  While Kronick and Ro state" Medigap" insurance benefits have protected the beneficiaries from the financial pain of Medicare's out-of-pocket expenses, the expense of using a hospital or seeing a doctor is more than the sum of all those medical bills.

Is the DMCB being too skeptical?  Perhaps, but this particular HHS spin is built on assumptions that are backed by associations that are biased by partisan loyalty.  Taxpayers deserve better.

Image from Wikipedia