Cost, Quality and Access in Health Care: Are All Three Out of Reach? Really?

Maybe the Disease Management Care Blog has been wrong.  And maybe there are implications for health reform.

The DMCB explains.

When it lectures at population health conferences, it patiently explains that health care data analytics will always involve trade-offs between speed, accuracy and detail.  For example if it wanted insight on the quality of care for a cohort of persons with diabetes, it could want the results tomorrow (speed), that captured 100% of the population (accuracy) and included standard deviations as well as age and sex breakdowns (detail). 

Analytics always must decide to pursue two out of three.  For example, the DMCB might want detail and accuracy, but that will take extra time. 

And so it goes.

An example from a parallel universe is the automobile market.  One Mr. Ford got past selling cars that were any color the customer wanted so long as they were black, Detroit infamously forced consumers to make trade-offs in speed, safety, gas mileage and quality.

2015 may be a watershed year where much of the DMCB's trade-offs are false choices. 

Bob Dylan argues that global consumers can have speed and safety and mileage and quality; he may have a point.

Returning to the health care industry, the DMCB wonders if the electronic record's expanding ability to capture patient detail combined with logarithmic growth in computational processing power will give providers the ability to hit "Ctrl-F1" and get an immediate, detailed and comprehensive on-screen report on the status of all persons with a particular attribute, like the presence of diabetes.

Which brings the DMCB to the infamous health care "iron triangle" of quality, access and cost.  The DMCB believes that the re-emergence of narrow insurance networks is simply a trade-off of access in exchange for quality and cost.  On the other hand, if consumers demand access and quality, they might have to settle for the high out-of-pocket costs of a stinky "bronze plan."

But here's the rub.  If Detroit can move the needle on automobiles and if the electronic record and supporting infrastructure is finally reconciling speed, accuracy and detail, who says the health care industry won't eventually crack the quality, access and cost conundrum?  The DMCB thinks it may take a while (Detroit took decades) but if the current pain over Obamacare eventually results in getting all three, maybe it will have been worth it.  Maybe it is within reach.

Just maybe. We'll see.

Maintenance of Certification (MOC) Update: A Health Reform Lesson

The 1967 Corvair. A non-PHB version

Long ago, when the Population Health Blog was courting the future PHB spouse, our unspoken understanding was that if the PHB liked its unsafe-at-any-speed 1967 Corvair, it could keep its unsafe-at-any-speed Corvair.

The sweet perfume of our relationship more than made up for the odor of car exhaust, unsightly blemishes, noisy rattles and rusted floorboards.

Cracking the windows, touches of spray paint, the AM radio volume knob and care where you placed your feet also helped.

It wasn't until courtship turned to relationship that the spouse's true thinking began to manifest itself.

That's why, years later, the PHB was unsurprised by President Obama's disavowal of his you-can-keep-your-health-plan assurances. Substitute Federal minimal essential benefit requirements, narrow networks and unaffordable premiums for spousal safety demands, mocking eye-rolling and intrusive hints about the merits of a new car, and readers should understand the PHB's acquiescence.

So the PHB shrugged off the notification that its life-long American Board of Internal Medicine (ABIM) specialty credential wasn't really a life-long credential.  

Enter maintenance of certification or "MOC."

More background can be found here, but, briefly, the sweet perfume of accomplishment was overcome by the MOC stink of intrusive, unproven as well as expensive documentation, education and testing renewal requirements.

Thousands of the PHB's physician colleagues were less submissive about the matter in print and on-line. There were also competitive threats, lawsuits, online petitions, and websites. The American Medical Association weighed in. And then state medical societies, which have a vital interest in serving their membership, began to sound the alarm.

And it paid off. 

While the PHB would have predicted that the academics populating the ABIM leadership were about as likely as Mr. Obama or the PHB spouse to change their minds, they've issued a "we got it wrong and sincerely apologize" announcement. 

As a result, many of their documentation requirements are on hold, the test is being revamped, fees are being reduced and the education options are being broadened.

Good for the ABIM and good for the practice of internal medicine.

This kind of mea culpa is a good first step in engaging the opposition and is likely to turn many critics into allies. More importantly, this is a great example of the impact of grass roots activism and the advocacy of organized medicine.

If this can happen in this corner health care, perhaps there are other areas of health reform where a well placed apology might be a good first step.

The magnanimous PHB is also happy to admit that, in retrospect, the spouse was right about the Corvair. At one point, highway snow was blowing up into the passenger compartment.  At 60 miles an hour.  Seriously.

Since then, it has gotten to like and keep lots of other stuff.  It makes having to pay so much for its own heath insurance a little more tolerable.

Image from Wikipedia

A Health Policy Test

The Disease Management Care Blog remembers those frustrating medical school exams that asked for the best combination of answers from two columns. Unfortunately, the DMCB never quite mastered the professors' trickery.

In response, the DMCB has fashioned it's own test. The good news is that for this quiz, there is no right answer!

Match the numbered statements to the best lettered conclusion below:

1) Asking the White House to fix healthcare.gov's "back-end" enrollment problems will be like.....

2)  Labor leaders are discovering that the Washington DC's commitment to AMA-style special carve-outs is like....

3) The White House's surprise that health insurers act like, well... health insurers when it comes to reconciling price, quality and network access is like......

4) Having the "non-partisan" Kaiser Health News saying "it will be challenging for the Affordable Care Act to fully live up to it's name" is like....

5) Assuming market-dominant hospitals will do the "right thing" for the Affordable Care Act is like.....

+++++

A) ..... trying to sell Putin bobble-head dolls at a LGBT Pride parade

B) .... hiring the mayor of Atlanta as the tour guide on a trip to the Peoples' Republic of Northeast Vortexistan

C) .... giving Justin Bieber a dozen eggs and a bottle of Xanax.

D) .... the NFL kicking off a "we're knocking concussions out of the game" ad campaign.

E) .... being surprised that a smart former chief federal law enforcement officer in New Jersey has no evidence of personal involvement in a revengeful plot to close some bridge lanes

CMS and Health Reform: More of the Same

Unmentioned.....

Whoa, with breathless media coverage like this (dramatically change! ambitious!) you'd think that the Feds had just announced something important about health reform. 

After reading the CMS press release, a CMS blog post and this article in the New England Journal, the Population Health Blog has concluded that it's more of the same. 

As the PHB understands it, Medicare's January 26 announcement is that it will build on three ongoing reforms:

1. Financial incentives to expand "alternative payment" methodologies to 30% of all reimbursement by 2016 and to 50% by 2018.  These include accountable care organization arrangements, monthly fees to Patient Centered Medical Homes and use of bundled payments.  In addition, 85% of fee-for-service payments that are still in place will be linked to quality by 2015, with an increase to 90% by 2018.

2. Promoting "provider integration." That apparently means a new forum called the Transforming Clinical Practice Initiative, with a first yet-to-be-planned meeting in March of 2015.  In addition, CMS will continue to rely on its Partnership for Patients and the Patient Centered Outcomes Research Institute.

3. Information technology (IT) including more promotion of electronic records, meaningful use, interoperability and universal information technology standards.

[Yawn]

The cynical PHB is not impressed. The Obama Administration was using, is using and will continue to use faux announcements to advance its reforms.  What's more, when it reads the CMS pabulum, it's riddled with the same top-down mainframe rhetoric on realigning care, moving from volume to value, accountability, alternative payment models, serving populations, building a better system, increasing coordination, convening meetings, promoting information technology etc. There are no new details here.

The PHB will share three insights, however:

1. CMS, Ms. Burwell and their White House handlers lost an opportunity to reach out to the Republicans about the sustainable growth rate and leveraging that to build on multiple areas of agreement to jumpstart bipartisan reform.  Doing so could have accelerated the forward momentum of value-quality-cost-based reforms beyond the 2016 elections.

2. That being said, health care providers need to increase their familiarity with the opportunities as well as perils of payment reform as well as the very real barriers to fixed payment schemes.

3. The announcements are a reminder how CMS is still fixated on the EHR, while the real innovation is occurring in handhelds and their associated applications.  The PHB figures that its not about the providers and their desktop electronic records, but about patients and their smart phones. As these devices continue to grow in speed, power and sophistication, providers who figure out how to use the iPlatform to leverage self-care, communication and decision support will thrive.....

With or without Medicare's incentives, promotion or IT policies.

Image from Wikipedia