Accountable Care Organizations in California: Lessons Learned

by Clive Riddle, November 10, 2010

While attending the recent Accountable Care Congress in Los Angeles, I had the pleasure of hearing Accountable Care Congress give a presentation on the recently released Integrated Healthcare Association white paper on Accountable Care Organizations in California. I highly recommend you check out the document at: http://www.iha.org/pdfs_documents/home/ACO_whitepaper_final.pdf

The 32 page report includes some great data and discussion, and makes the following nine points regarding lessons learned from the California experience to date:

1. A variety of organizational structures are effective at delivering high quality coordinated care; at least as important to success as structure are an organization's capabilities, culture, and infrastructure, as well as the alignment of goals between the organization and its individual physicians.
2. In California, a range of relationships exist between physician organizations and hospitals. Alignment of incentives between physician organizations and hospitals offer important opportunities for performance improvements across the entire continuum of care.
3. As a method of payment, capitation can be effective at encouraging coordinated care, but payment methods should vary across ACOs depending on an organization's ability to assume risk. Fee-for-service payment with shared savings has not proven a successful incentive for the efficient delivery of care.
4. Health plans acting in concert on payment methods and performance measurement helped facilitate the growth of California's provider organizations, and should also play an integral part in fostering ACO development nationally.
5. ACOs are not a panacea for health care spending control. Some large provider organizations have gained bargaining power and raised prices. Capitation payment and consumer cost sharing partially offset tendencies toward raising prices.
6. ACOs must be agnostic to insurance type; most provider organizations in California have focused on commercial, Medicare, and Medicaid HMO plans for their patients, but for ACOs to be viable across the country, mechanisms must be found to encourage PPO and traditional Medicare and Medicaid patients to use their services.
7. Balancing patient choice with the desire to decrease costs and effectively coordinate care is difficult. California's experience underscores the challenge of promoting care coordination in an environment of unrestricted provider choice.
8. Regulation of the financial solvency of provider organizations is important to ensure market stability.
9. Consumer protections from capitated provider organizations need to be balanced, not overburdening.

Prescribing Profits

By Kim Bellard, November 10, 2010

Marcus Welby pushing more expensive drugs on his patients in order to increase his income?  Impossible to imagine!  Of course, Marcus Welby was a family physician not given to costly treatments, and is now almost entirely unknown to anyone under 50, but one has to wonder what’s become of our health system given what some physicians are doing with their prescribing pads. 

The New York Times recently broke a story that Genetech was giving eye doctors “secret rebates” to use the more expensive Lucentis instead of Avastin to treat age-related macular degeneration (AMD).  Ironically, Avastin is also made by Genetech, and has been used for AMD for several years, although it was not designed or approved to treat that condition.  Lucentis can be more than ten times the cost per dose, the bulk of which is usually paid for by Medicare and private insurance.  However, there is yet no data to suggest that Lucentis is more effective than Avastin; even if equally clinically effective, it certainly would be much less cost-effective at its current pricing.  The rebates can reportedly amount to tens of thousands of dollars for a physician practice each quarter.  The Times quoted one retinal specialist as saying “There’s no way to look at that without calling it bribery.” 

Alas, the influence of financial considerations on prescribing costlier care appears not to be an isolated problem.  In 2006 Mirelle Jacobson and colleagues asked the question “Does Reimbursement Influence Chemotherapy treatment for Cancer treatment” in Health Affairs.  The good news is that reimbursement did not appear to impact the initial decision to administer treatment, but the bad news is that physicians who received more generous reimbursement did, in fact, administer more costly drugs. 

Medicare has attempted to address the cancer treatment reimbursement issue – to neither side’s evident satisfaction – and recently United Healthcare has initiated a program of its own.  It announced a pilot program that pays oncologists for the entire treatment program, regardless of the drugs administered.  It deliberately tries to remove – or at least limit the continued growth of – the portion of the physicians’ income based on profits from chemotherapy drugs.  In its coverage of the program, The New York Times quotes an oncologist as saying “A lot of us want to get out of selling drugs.”  Aetna and several other payers are developing their own programs.

Of course, one doesn’t have to work too hard to find studies demonstrating disturbing impacts of other perverse financial incentives within our fee-for-service system.  For example, studies indicate the clear impact of physician ownership of ambulatory surgical centers on number of surgeries performed (see, for example, Hollingsworth or Mitchell.  Similar results exist for imaging.  Then there is the oft-cited New Yorker article by Atul Gawande on the peculiarly high cost of care in McAllen, Texas.  There are both anti-kickback and self-referral (aka Stark) laws to prevent such apparent abuses or conflicts of interests, but one would have to conclude they are not having quite their intended effects. 

So what’s the big deal?  If patients want to buy services from physicians, why should they – or we – care about how much money those physicians might be making on those services?  Isn’t that capitalism?

Yes and no.  I cling to belief in a market-based structure for our health system, with appropriate protections for low-income and other disadvantaged individuals.  I have no problem with people making money in the health care system, and think it is great when individuals and institutions that achieve better results for their patients get more patients and make more money. 

Unfortunately, our system doesn’t make it easy for that to happen the way one might want it to.  The above examples highlight two key missing pieces that are needed for a truly market-based health care system:

• Performance: for the most part, patients don’t have good information on the efficacy or relative performance of the treatments they are “buying” or on the providers from whom they are receiving them.  They certainly can’t be viewed as making informed decisions.  It’s hard to say who to blame more for not caring more about making such information readily available – patients or health care providers – but there can be no real health care reform without that kind of information, comparing treatment options and providers. 
• Other People’s Money: if consumers want to spend their own money on frivolous or overpriced goods, well, that’s their right in a capitalist economy.  Most health care spending, though, is paid for via public or private insurance, which is a little bit of the patient’s own money and a lot of other people’s money.  As a result, they spend it differently, sort of like a college student using his/her parents’ credit card.  We can’t bend the cost curve unless both patients and health care professionals stop thinking of health care spending as other people’s money. 

Let’s get this straight: I think most physicians are good people trying to do a good job for the patient in a hopelessly complex, fragmented, and frustrating health care system.  Nor would I point the finger (at least not singularly) at health insurance companies, pharmaceutical companies, or hospitals, the entities who are most often cited by the public as the culprits.  It is the structure of the system that is failing us, with the various incentives either explicitly or implicitly built into it that don’t reward the best performance. 

Health plans, include Medicare, are working hard on “pay-for-performance” (“P4P”) programs that reward physicians for appropriate performance, particularly in terms of quality and sometimes cost-effectiveness.  Lester and colleagues studied the impact of both addition and subsequent removal of financial incentives on four clinical indicators.  They found that scores did increase with the incentives, but unfortunately fell again once they were removed.  It’s good that physicians improved their performance given targeted financial incentives, but it is troubling that they reduced that clinically appropriate behavior when no longer paid “extra” for it.  Such programs are certainly a start in the right direction, but at this point are still only a small step.

George Bernard Shaw, writing in a different time and about a different health care system, summed the problem very well: “That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity. But that is precisely what we have done. And the more appalling the mutilation, the more the mutilator is paid.” 

It’s a prescription for disaster.

Impact and Implications of Comparative Effectiveness Research

by William DeMarco, November 2, 2010

MCOL asked me to respond to the following questions for their Thought Leaders publication: What will be the impact and implications of Comparative Effectiveness Research on U.S. health care delivery, in the short-term, and in the long-term? How dependent is CER, going forward, on federal policy and funding?

My abbreviated response is included in the current issue of Thought Leaders, but I wanted to provide a more complete response below.

Comparative effectiveness research is somewhat of a newcomer to healthcare.
Borne out of early practice variation studies at Dartmouth and other universities that reported surprising gaps in the delivery of care at the physician level, the CER takes this one step further to explain not just what the variance is but what the norm should be as a best practice.

These evidence based norms and practice guidelines are intended to give us a starting point to what we have been missing and that is ambulatory care comparators and a full disclosure of what are the best practices for a specific diagnosis for a specific population of patients with similar co morbidities and health status.

For decades we have seen hospital data on costs and length of stay being produced as DRGs and admissions data were available and understandable to many of us as a common unit of measurement and cost. Payers saw this as a large bottom line expense not realizing that the reason people were admitted was not because the hospital made that decision rather the doctors made the decision to admit based upon what they thought was a diagnosis that warranted such and action.

As we begin to look for root cause as to why the doctor thought this admission should occur we see again variation in practice style, training and capability come into play. The patient variation suddenly becomes key to understanding the physician logic and we start to see a move towards patient and population management which the CER process is trying to address.

Now we should have the ability with millions of records and billions of dollars invested in CER by HHS to discover just what is an appropriate admission for a specific diagnosis and begin to track this through impatient and outpatient treatment which is an imperative for a better understanding of how best to handle chronically ill populations as well as some of the less critically ill who need to be treated BEFORE they move to stage three or four cancer.

We have always asked about how lower back pain should be treated for the 70 year old versus the 50 year old, we have always wondered whether the mammogram should be done annually at 40 or 50 or is to tied to whether or not the patient has a predisposition and family history.

These are worth studying in terms of screening and are also worth building available database to see what works because much to the surprise of the public not all patients are treated the same because not all doctors are trained the same. Once can see a pattern of care in the medical notes and billing for a patient with hypertension yet 5 other doctors in the same group may treat this hypertension differently. Who is right and what is the best guideline to follow is.

In addition these guidelines change as we move from the discoveries and technologies of health care. CAT scans are useful but are they as useful for some illnesses as a MRI or would a simple x-ray do?

Most patients still ask for antibiotic for a cold yet truthful doctors will say it’s a virus and you have to ride it out... we can see how a national registry would enable our medical training and treatment expectations to come together over time to rid the system of wasteful tests and spending and assure both doctor and patient the results are predictable based upon good scientific population studies.

However we can also see the negative side of the argument.

In England and other countries we have seen the rise of the QUALY measurement that is used to determine wethere4 a patient really is a candidate for a specific procedure.

In several situations the QUALY dictates whether the man or women with stage 4 cancer gets treatment, whether the baby with an incurable disease is treated at all.

QUALY is the measurement of cost versus treatment for many countries and with CER we could see this occur here in the US as Harvard and other universities begin to but a VALUE on a human life.

The QUALY can be used to make some of the treatment decisions and also can place a number on ones forehead for underwriting just like a FICA score does for credit and loans.

Several states have banned using clinical effectiveness and similar means to be used to withhold issuing policies for GROUPS but as we see a move towards more individual policies with newly promised insurance exchanges and the like we see a potential for QUAYS being used to justify higher premiums or cancellation of insurance policies when the score does not justify expenditures of funds for saving or even extending a life represents a potential risk to an insurance and healthcare system that is already under funded.

One can see that in the hands of some insurers this methodology could be brutally unforgiving. In the hands of government one can see they like the idea of numbers and distancing themselves from patients just setting in motion a number and backing into a Medicare or Medicaid budget.

This Kevorkian factor represents all that most of us in health care and the health plan business are against but represents both am moral and ethical battles to fight to police one another and make sure we are not letting statistics dictate the value of a human life.
Rather we would like to see a more fruitful transition of using CER to build upon health and prevention. To determine what in a person’s lifestyle could be changed to avoid diabetes and heart problems, what could be done in an exercise routine to strengthen a back injury without needing formal rehab?

So what can health plans do? As the CER begins collecting data we see the opportunity for health plans to collaborate on a regional basis to also pool de-identified data to determine unique care patterns in their area that can be addressed or diagnosis that can be mentored to determine an outbreak of disease or unseal pattern in treatment protocols during different times of the year.

Lack of Iodine in the water in Detroit affecting thyroids, sinusitis conditions in Seattle affecting respiratory illnesses, allergies in droves in an urban population that uses antibacterial soap extensively could all tie to an unusual outcome unless treated,

Moreover these local models would have a national comparator baseline to look at but also contribute to local CER research that could help streamline care and diagnosis precision but most certainly would, be a way to obtain even further ROI on data collection process at the Health plan, ACO or similar integrated system.

This moves health plans data away from the typical claims warehouse into a life-science role that could also be shared with Pharma for testing and data sharing as well as scientific studies by local and regional medical schools to look at systemic variation in population health.

Health plans are already doing this in some cities such as ICSI in Minnesota and similar efforts are being headed by employers in Las Vegas and St Louis to try and come up with a value comparison of outcomes to be shared with all health plans in developing and monitoring their individual P4P and global payment reforms.

CER offers wonderful tools and more discussion of its application by the scientific community can help us really understand what works and what works best in short term and long term treatment.

If the research should go the other direction of assigning dollar amounts to QUALYS and reduction of services to those who need hope the most we will see a rapid de-funding of the program and a very loud outcry from the scientific and religious communities.

Health reform arguments have already surfaced this debate between the use of CER as a practice guideline builder versus a potential rationale to limit care. Health Plans have it in their power to build local and regional warehouses for clinical and scientific research always sharing such research with a national clearinghouse such as CER.

No to Apple Pie and Free Preventive Care

By Kim Bellard, October 28, 2010

Much has been made about the recently effective provisions of the Patient Protection and Affordable Care Act that require health insurance plans to cover many preventive services without cost-sharing.  Increasing the use of preventive services, and removing financial barriers that might prevent people from using them, are the kinds of things that most people – in both political parties -- seem to automatically approve of.  It’s practically un-American not to favor the idea.

Well, I’m as patriotic as the next person, I love my mom, but I don’t like apple pie and I don’t think free preventive care is necessarily a good idea.

While some studies over the years have found that increased use of certain preventive services is cost-effective, the evidence is neither universal nor entirely clear-cut.   For example, Joshua T. Cohen, PhD. and his colleagues raised this question in an article in The New England Journal of Medicine, and concluded that many preventive measures are not cost-effective.  They urged that care be taken to target cost-effective measures, which the new law purports to do, by focusing on “evidence-based preventive services.”  Still, not everyone is persuaded that even this focus will deliver intended savings; for example, the American Academy of Actuaries raised several good points in their response to the Interim Final Rules promulgated by HHS last summer.  Ambiguity about interpretation, over treatment, and cost-shifting to preventive service coding are cited as examples of potential problems that could have the result of increasing costs.  

I’m not going to try to argue on either side of that particular debate; I’ll leave that for the researchers, actuaries, and other number-crunchers.  My skepticism is whether making access to these services without cost-sharing via health insurance is good public policy. 

In their background on the new preventive care rules, HHS says that Americans only use preventive services at about half the recommended rate, citing a study by McGlynn, et. al.  However, as best I can tell, that study talked about recommended care on a number of fronts, and did not cite financial barriers as the key problem.  The McGlynn study is indeed very troubling, but it left me wondering why physicians were not doing a better job giving their patients recommended care, not why patients were failing to show up for it. 

Preventive care is something that most Americans should be able to afford.  If it is too expensive for at least middle class Americans to pay for directly, then we have an even bigger problem, because paying for it via health insurance is still going to require that middle class to pay for it, along with everything else insurance covers.  I get frustrated when policymakers and pundits seem to think employers and insurance companies pay for health insurance with “their own” money.  These entities aren’t like the federal government, which can print money and/or borrow money from China.  It is a poorly understood truism that insured people pay for insurance; the insurance companies essentially redistribute the money from people who don’t use services to those who do.  Money for employer-based health insurance is coming out of workers’ paychecks; they just don’t always realize it.

That’s the basis of the problem.  We are getting further and further divorced from the cost of health care.  Health care is scary because no one knows if tomorrow they’ll get hit by a bus or feel a cancerous lump, and be faced with bills that are hundreds of thousands or even millions of dollars.  That’s why people have historically bought insurance: to protect against unforeseen and potentially catastrophic expenses.  

Preventive care isn’t like that.  The expenses are not usually huge, nor are they unpredictable.  These should be budgetable expenses, like scheduled maintenance for one’s car.  Yes, there are lower income people for whom even these expenses are unaffordable and who do need financial assistance in paying for them, but removing the apparent financial obligation from everyone as a way to solve that problem is not only overkill but expensive overkill.  Health insurance is not a good vehicle for income redistribution; it is a mechanism to redistribute money to people using services from people not using services.

I also have to wonder: if preventive visits are so important, why aren’t we including dental check-ups or eye exams?  Certainly the same arguments used to justify medical preventive visits should apply here too, especially given the increasingly accepted linkage between oral and overall health.   I say that with a wary eye to the slippery slope we’re already on; whatever preventive services will be covered initially, one has to strongly suspect that it will only be the beginning.  There is not much political will to take away a benefit once given, so services are likely to only be added to the list, not removed if/when new data comes out to challenge the efficacy of the service.  If you don’t agree, just ask Jerry Brown about the wisdom of questioning the efficacy of mammograms…

The oft-used argument is that preventive visits will pay off in the long run, although – as the studies cited above indicate – that is not always the case.  The argument posits that making it “free” now will incent people to obtain the care.  The hidden premise to this argument is that people don’t view preventive care as being of value unless it is free.  I.e., they are not smart enough to take care of themselves and won’t take the right actions for their best long-term health.  Well, in a country with 33% obesity rates and 20% smoking rates, that does appear to be a valid argument – but I’m skeptical that those people are going to be motivated to act in that interest simply by removing cost-sharing for their annual exam either.  

I hate to sound like a Grinch by not supporting “free” preventive visits, but they’re not truly free.  To me, the core issue is how to make people care about taking care of themselves, with part of that including getting appropriate care.  Call me a cynic, call me uninformed, but giving away “free” preventive care seems more like just bread and circuses for the masses compared to the underlying problem of motivating people to be responsible for their health and well-being.

Scary Stuff

by Kim Bellard, October 25, 2010

Two studies were released in the past week that are appropriate harbingers of Halloween.  The Centers for Disease Control announced that one in three adult Americans will have diabetes by 2050.  Earlier in the week, researcher Philip F. Stahel, M.D. and his colleagues published a study in the Annuals of Surgery detailing the disturbing number of wrong site or even wrong patient surgeries.

I’m not sure which study scares me more.

The CDC projections suggest a sharp increase from the current one in ten prevalence of adult diabetes.  An aging population, an increase of minority populations most at risk of developing diabetes, and persons with diabetes living longer are cited as key reasons for the increase.  Diabetes rates have already more than doubled over the last thirty years, and are closely tied to higher health expenditures and adverse health effects on impacted individuals.  Even if actual rates end up only half as bad as the CDC fears, it would still be a train wreck for health care in America.

Dr. Stehel’s study found 27,370 adverse events from January 2002 through June 2008, using a database of 6,000 physicians in Colorado.  These adverse events included 25 wrong patient and 107 wrong site operations, and came despite widely adopted universal protocols developed by the Joint Commission that were intended to avoid such mistakes.  “These happen much more frequent than we think,” Dr. Stehel says. “This is just the tip of the iceberg.” 

Diabetes, of course, can be often controlled through proper diet and exercise.  Its increase has often been tied to the similarly large increases in obesity in America – nearly 34% of adults are now considered obese, double the percentage thirty years ago, while childhood obesity rates have tripled during the same period; 17% of children are now obese.  Increased availability of fast food and lack of adequate exercise are commonly cited as reasons for the increase in obesity.  While many persons with diabetes are often unaware of having it, obesity is harder to not be aware of.  It’s not that people don’t know that they should eat better, get more exercise, and keep control of their weight; it just seems that fewer people are willing to make the necessary efforts to do so. 

Similarly, the universal protocols are supposed to ensure “never events” such as surgery on the wrong patient don’t happen, but “never events” reflect more of a goal than an achieved outcome.  The researchers note that the blame for the mistakes fall across the medical profession.  Dr. Stehel says doctors should take more personal responsibility for their errors.  

For both problems, we don’t need magic bullets; we need the appropriate parties taking responsibility for themselves.  Unfortunately, that is not as easy as it sounds.  No one wants to develop diabetes, and no physician wants to operate in the wrong site/patient.  Yet here we are.

It does seem that somehow personal accountability in health care is getting lost.  Patients too often abdicate their own decision-making for their physician’s judgment and treatment, and physicians often don’t have adequate mechanisms to admit, track and improve on their errors.  Physicians should be able to expect that patients are doing their best to maintain and improve their own health, and patients should be able to expect that physicians are doing the right thing at the right time for the right reasons.  One would have to be something of an optimist to believe that either of those behaviors are always the case. 

Halloween is all about mock scares, with children trick-or-treating in cute costumes (while receiving lots of candy that probably help drive up those childhood obesity rates!).  These studies reveal real boogeymen, things that should frighten us and cause us all to act.  These aren’t the first unsettling revelations about how poorly our health system works at times, despite its high costs.  How many more of these scary stories do we need to see before we get serious about improving it?

Hospital Mortality at Five Star versus One Star Facilities

by Clive Riddle, October 22, 2010

HealthGrades, which touts itself as the “leading independent healthcare ratings organization” has just released a study of patient outcomes at U.S. hospitals, stratified by their ratings, that found “patients at 5-star rated hospitals had a 72% lower risk of dying when compared with patients at 1-star-rated hospitals.”

Other well known ratings and ranking of U.S. hospitals include the U.S. News and World Report rankings of U.S. Best Hospitals, which is based on AHA data in part. Consumer Reports also offers hospital ratings based on results from CMS’ Hospital Consumer Assessment of Healthcare Providers and Systems survey, known as HCAHPS, and CMS directly offers Hospital Compare at Medicare.gov, also providing HCAHPS results.

The Thirteenth Annual HealthGrades Hospital Quality calculated that if all hospitals performed at the level of their 5-star rated hospitals, 232,442 Medicare lives could potentially have been saved from 2007-2009 (the study period.) The study analyzed mortality and complication rates using 40 million hospitalization records obtained from CMS.

The study found overall hospital mortality rates declined by 7.98% from 2007 to 2009. Of the 17 mortality-based diagnoses and procedures analyzed, two experienced increased mortality rates – gastrointestinal surgeries (+8.76%) and coronary intervention procedures (+9.26%). HealthGrades rated individual hospitals with a 1-star (below average), 3-star (average) or 5-star (outperformed national average) rating in each of 26 procedures and diagnoses, from bypass surgery to total knee replacements.

Other findings released from the study included:

• The highest unadjusted mortality rates are among sepsis, respiratory failure, and gastrointestinal surgeries and procedures (20.59%, 19.45%, 10.29%, respectively).
• The most improvement in unadjusted mortality was seen in chronic obstructive pulmonary disease (18.73%), bowel obstruction (14.72%), heart attack (13.68%), and stroke (13.50%).
• Approximately 55.91% (129,949) of the potentially preventable deaths were associated with just four diagnoses: sepsis (48,809); pneumonia (29,017); respiratory failure (26,361); and heart failure (25,762).
• On average, one in nine patients developed a hospital-acquired condition, across the nine procedures evaluated for inhospital complications, from 2007 to 2009.

On average, a typical patient would have a 80.40% lower risk of developing one or more inhospital complications by going to a 5-star rated hospital compared to a 1-star and a 63.64% lower risk of developing one or more inhospital complications by going to a 5-star compared to the U.S. hospital average.

The State of Health Care Quality 2010

By Clive Riddle, October 15, 2010

NCQA has released their annual quality report:  The State of Health Care Quality 2010: Reform, The Quality Agenda and Resource Use.  The 162 page report provides their annual analysis of quality measures and data from over 1,000 health plans that represent 118 million U.S. members.

This year’s report addresses the concept of Relative Resource Use (RRU): which “indicates how intensively health plans use health care resources (such as physician visits and hospital stays), compared with other plans in the same region, serving similar members. When used alongside quality measures, RRU makes it possible to talk about quality and cost simultaneously. Given the definition of value as the intersection of health plans’ spending (resource use) and their results, RRU reveals the value that plans offer.” NCQA analysis found that “many plans that deliver below-average quality use above-average levels of resources. More care is not always linked to better results.”

Another significant issue raised in the report was that commercial plan 2009 childhood vaccination rates dropped almost four percentage points. NCQA speculates that “a possible cause of this drop is commercial plan parents may refuse vaccines for their children based on the unproven, but increasingly popular, notion that vaccines cause autism. Celebrity activists are outspoken advocates of this view. Interestingly, we see vaccination rates in Medicaid – the program serving the poor – continuing to steadily improve. “  NCQA President Margaret O’Kane tells us “The drop in childhood vaccinations is disturbing because parents are rejecting valuable treatment based on misinformation. All of us in health care need to work together to get better information to the public.”

The report also measures the state of the states, indicating the top ten and bottom ten states for quality, based on four measures for ranking

1. Comprehensive Diabetes Care (ten indicators)
2. Controlling High Blood Pressure (one indicator)
3. Persistence of Beta Blockers After a Heart Attack
4. Cholesterol Management for Patients with Cardiovascular Conditions (two indicators)

States included in the Top Ten, based on mean of rates: CA, IA, MA, MN, ND, NH, OR, SD, VT, WU

States included in the Bottom Ten, based on mean of rates: AK, AL, AR, DE, LA, MS, NC, OK, SC, TN

NCQA/Consumer Reports 2010 HMO Rankings

By Clive Riddle, October 7, 2010

NCQA has released its rankings of HMO and Point of Service plans around the nation for 2010, via Consumer Reports.

According to NCQA, themeasures and methodology used to rank plans did not change from 2009. Details on the methodology and guidelines are listed at http://www.ncqa.org/rankings .

Below are the top ten ranked private plans (excluding Medicaid and Medicare plans). You will note that regional and non-profit plans (vs. national for-profit) and integrated plans are well-represented.

NCQA 2010 National Ranking of HMOs: Top Ten Private Plans

1. Harvard Pilgrim Health Care (MA, ME)
2. Tufts Associated Health Maintenance Organization (MA, RI)
3. Harvard Pilgrim Health Care of New England (NH)
4. Capital Health Plan (FL)
5. Geisinger Health Plan (PA)
6. Grand Valley Health Plan (MI)
7. Group Health Cooperative of South Central Wisconsin (WI)
8. Fallon Community Health Plan (MA)
9. Kaiser Foundation Health Plan of Colorado (CO)
10. Health New England (MA)

Source: Consumer Reports: The 2010 rankings of HMOs from the National Committee on Quality Assurance

Source URL: http://www.consumerreports.org/health/insurance/best-health-insurance-privateRatings-1.htm

Notes: Private plans exclude Medicaid and Medicare.  This year, the NCQA ranked 227 HMOs and point-of-service plans with a total enrollment of about 42 million. Not all HMOs are on the list; some do not submit data to the NCQA, or submit insufficient data, and others decline to make it public.

Kaiser Permanente Goes “Open Source” With Their Internal Medical Terminology

by Clive Riddle, October 1, 2010

In Meaningful Use news, Kaiser Permanente has announced that they are donating their “Convergent Medical Terminology (CMT) to the International Healthcare Terminology Standards Development Organisation (IHTSDO©) for U.S. distribution through the U.S. Department of Health and Human Services (HHS) so that all health care providers—large and small—can benefit from the translation-enabling technology.”

The stated objective is to make KP’s experience and formerly proprietary system available to help U.S. health professionals and hospitals achieve key meaningful use standards set forth by the Office of the National Coordinator of Health IT and the Center for Medicare and Medicaid Services.

HHS Secretary Kathleen Sebelius has commented that “one of the key challenges to achieving a coherent health record for every U.S. consumer is the need for consistent data across all systems and institutions. This donation of the Convergent Medical Terminology from Kaiser Permanente addresses that critical need by making it easier for health professionals and patients to create standardized data in electronic health records."

Jack Cochran, MD, Executive Director of The Permanente Federation added that “utilizing a common terminology that translates complex medical concepts into language that is both clinician- and patient-friendly has helped us coordinate teams, improve the quality of care for our patients and enhance efficiency in our organization. We would like to share the tool we developed with the country."

Kaiser’s system involves “the production of structured health data by creating and linking clinician- and patient-friendly terminology to the health data standards now required for U.S.-wide use. The Convergent Medical Terminology[CMT] has been developed by clinicians and technologists over many years. It is in active use to document thousands of patient encounters every day.”

Kaiser Permanente's CMT donation incorporates the following:

• terminology content KP has already developed
• a set of tools to help create and manage terminology,
• processes to control the quality of terminology that is developed.
• mappings to classifications and standard vocabularies, such as the Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT©) already accepted by U.S. and international health policy makers

Kaiser provided the following additional information about their CMT system:

• CMT is used in the underlying architecture of Kaiser Permanente's HIT systems to support data flow between health care providers. It provides mapping to standardize the use of terminology and ensure systems, some already in use in most U.S. medical offices, can talk to each other effectively. The utilization of CMT will support a common set of medical concept descriptions so that one doctor's diagnosis can be reconciled with another's. CMT includes the key taxonomies required for stage one of the Meaningful Use program such as problem list sets in SNOMED CT. Thus, it can help clinicians map to the standards set forth by the Office of the National Coordinator of Health IT and the Center for Medicare and Medicaid Services.

• CMT is a core component of Kaiser Permanente's comprehensive electronic health record, KP HealthConnect®, helping physicians communicate with their patients more clearly. KP HealthConnect is the world's largest private electronic health record, connecting more than 8.6 million people to their physicians, nurses, and pharmacists, personal information, and the latest medical knowledge.

• CMT is also utilized by Kaiser Permanente's personal health record, My Health Manager, on kp.org so that patients can get a better understanding of their medical care. My Health Manager provides patients with secure, timely access to their lab test results, medication information and refill capabilities, summaries of their health conditions, and other important health information at just the click of a mouse. The technology empowers patients to manage their health by allowing them to access health information and tools and securely e-mail their doctor.

World Alzheimer's Day- September 21st

by Clive Riddle, September 21, 2010

In observance of World Alzheimer's Day, Alzheimer’s Disease International has issued the World Alzheimer Report 2010. Here’s ten quick facts we gathered from the report:

1. There are 35.6 million people living with dementia worldwide in 2010
2. The total estimated worldwide costs of dementia are US$604 billion in 2010
3. Total dementia costs account for around 1% of the world’s gross domestic product
4. The total estimated worldwide costs of dementia are US$604 billion in 2010
5. Direct medical costs account for 16% of total dementia costs
6. Direct social care costs account for 42% of total dementia costs
7. Costs of informal care (unpaid care by families, etc.) account for 42% of total dementia costs
8. About 70% of worldwide dementia costs occur in Western Europe and North America
9. If dementia care were a country, it would be the world’s 18th largest economy, ranking between Turkey and Indonesia
10. If dementia were a company, it would be the world’s largest by annual revenue, exceeding Wal-Mart (US$414 billion) and Exxon Mobil (US$311 billion).

Dr Daisy Acosta, Chairman of Alzheimer’s Disease International tell us,. "this is a wake-up call that Alzheimer’s disease and other dementias are the single most significant health and social crisis of the 21st century. World governments are woefully unprepared for the social and economic disruptions this disease will cause."

Here, verbatim, is what the report recommends at this point in time:

• Governments worldwide should act urgently to make Alzheimer’s disease a top priority and develop national plans to deal with the social and health consequences of dementia. Several countries have moved forward to develop national plans, including France, Australia and England. It is critical for other governments to follow suit.
• Governments and other major research funders must increase research funding to a level more proportionate to the economic burden of the condition. Recently published data from the UK suggests that a 15-fold increase is required to reach parity with research into heart disease, and a 30-fold increase to achieve parity with cancer research.
• Governments worldwide must develop policies and plans for long-term care that anticipate and address social and demographic trends and have an explicit focus on supporting family caregivers and ensuring social protection of vulnerable people with Alzheimer’s disease and other dementias.
• The scale of what is facing us elevates this to a global challenge, which must be addressed as a top WHO priority and on the G-20/G-8 agenda.

Analytics in the People's Republic of China

By Clive Riddle, September 17, 2010

 This week, the National Predictive Modeling Summit was held in the Washington DC area. During the Thursday afternoon workshop on International Analytics issues, Rong Yi, PhD, Senior Consultant at Milliman, Inc. gave a presentation on Predictive Analytics and the People's Republic of China.

Here’s some of what Rong had to share on health care and analytics in the People's Republic:

• 22% world’s population, 2% world’s health care resources.
• China’s health care spending is 4.7% of GDP.
• 2/3 of the population are in the rural area, supported by only 20% of health care resources.
• Chronic conditions account for 80% of deaths in China
• Hypertension: 18.1% of population (160 mil), increased by 33% in 10 years.
• Diabetes: 9.7% (92 mil) adult diabetes, 15.5% (148 mil) prediabetes.
• Overweight and Obesity: 8.1% children age 7-17, 22.4% adults
• 14 different ministries and commissions are involved in China’s public health and healthcare policymaking
• Rural Coverage: the New Cooperative Medical System started in 2003,  with 100% reach at village level as of 2010
• Urban Coverage: Workers medical insurance started in 1998; Residents medical insurance started in 2007
• Private insurance: Chinese insurers dominant, foreign insurers 5% in market share; Starting in 2011 foreign insurers are allowed to enter the China market for individual and group health insurance
• Reform includes an investment of 2,000 new hospitals in 2009-2012; 3,700 new community health services centers, and 11,000 new community health services stations
• State of Predictive Analytics:  (1) No claim-based predictive modeling at the present time; (2) commercial use of scoring methods and HRA tools include-  HRA research committee under China’s CDC, Proprietary HRA tools developed on China’s data, and specific scoring tools, e.g., ICU scoring systems, disease-specific scoring; (3) Disease risk prediction models based on health screening data on large population in which long term risks are modified using long-term factors such as lifestyle and behavioral factors (smoking, exercise)

Workers Comp: Medical Benefits Slice of the Pie is now the biggest

by Clive Riddle, September 10, 2010

The National Academy of Social Insurance (NASI) has just released a 112 page report: Workers Compensation Benefits, Coverage and Costs 2008 which provides  comprehensive data on workers' compensation cash and medical payments for the nation and for each state, the District of Columbia, and federal programs.

This year, for this first time ever, the report finds that medical benefit claims exceed cash compensation payouts. Here is a summary data table provided by the NASI:

Figure 1: Workers' Compensation Spending, 2008
Type of Spending	Billions of Dollars	Percent  Change
Total benefits paid	$57.6	4.4
Medical payments	29.1	8.8
Cash benefits	28.6	0.3
Employer costs	78.9	-6.7
Amount per $100 of Covered Wages	Per $100 of Payroll	Dollar Change
Benefits paid	$0.97	$0.03
Medical payments	0.50	0.03
Cash payments to workers	0.48	-0.01
Employer costs	1.33	-0.11
Source: National Academy of Social Insurance, 2010.

Continual health care inflation, utilization and other medical cost escalators are blamed. John F. Burton, Jr., chair of the report panel tells us: The growth in medical spending may reflect both higher prices for medical care and greater use of services. The increase is the continuation of a long-term trend since 1980, but this is the first year that payments for medical care were more than half of all workers' compensation benefits."

However, one additional factor is probably in play. Given 2008 data would be the first year to reflect the great recession, intuitively one might assume the cash compensation slice of the pie was diminished by a shrunken work force.  So while health care costs are an easy target and typically a deserved scapegoat, the economy would seem an equal explanation for why the pie is being sliced up differently.

Have you taken a prescription drug during the past month?

by Clive Riddle, September 3, 2010

CDC’s National Center for Health Statistics has just released a Data Brief: Prescription Drug Use Continues to Increase: U.S. Prescription Drug Data for 2007-2008  [Gu Q, Dillon CF, Burt VL. Prescription drug use continues to increase: U.S. prescription drug data for 2007-2008. NCHS data brief, no 42. Hyattsville, MD: National Center for Health Statistics. 2010.]

Here’s a laundry list of what you can glean from the eight page report on U.S. prescription drug use:

• 48% had taken a prescription drug(s) during the past month, up from 44% ten years prior
• 31% had taken two or more prescriptions during the past month, compared to 25% ten years prior
• 11% had taken three or more prescriptions during the past month, compared to 6% ten years prior.
• 52.8% of those with health insurance had taken a prescription drug during the past month, compared to 28.5% without health insurance
• Among children (under age 12), less than 10% used two or more prescription drugs in the past month and only 1% used five or more.
• Among older Americans (aged 60 and over), more than 76% used two or more prescription drugs and 37% used five or more.
• The prescription drugs used most of for children aged 0-1 were Bronchodilators for Asthma (5.7% used)
• The prescription drugs used most of for adolescents aged 12-19 were CNS stimulants for ADD (6.1% used)
• The prescription drugs used most of for adults aged 20-59 were Antidepressants (10.8% used)
• The prescription drugs used most of for adults aged 60+were Cholesterol lowering drugs (44.9% used)
• Total U.S. spending for prescription drugs was $234.1 billion in 2008, more than double what was spent in 1999

The report is based on the National Health and Nutrition Examination Survey (NHANES) which examines a range of other aspects of national health and nutrition components as well, designed to monitor the health and nutritional status of the civilian noninstitutionalized U.S. population using a nationally representative survey population.

COBRA Costs: The Good News, Bad News and Good News

by Clive Riddle, August 27, 2010

The good news: earlier this summer, PricewaterhouseCoopers, in their Behind the Numbers Medical Cost Trends for 2011 report, had this to say about COBRA costs:  “COBRA costs are expected to return to more normal levels in 2011. COBRA subsidies passed by Congress in 2009 created a 1% upswing in the medical trend. Laid-off workers who continued their healthcare coverage typically incurred medical costs of two to four times higher than those of other workers. In 2010, the combination of higher unemployment and new government subsidies to pay for COBRA coverage led to a significant increase in COBRA coverage. A combination of declining unemployment and expiration of the COBRA subsidies is expected to lead to reduced enrollment in COBRA in 2011.”

The bad news: Aon Consulting has just released results from their 2010 Benefits Survey, which found average monthly COBRA premium costs increases from 2009 for the cheaper HMO policies took an extra annual $360 for single coverage and $960 for family coverage from the unemployed and others who opted for COBRA coverage. Here’s a table we compiled from the Aon survey results:

COBRA Monthly Premiums	2010	2009	% Increase	Total Increase
HMO
Employee Only	$429	$399	7.5%	$30
Employee +1	$879	$783	12.3%	$96
Employee + Children	$872	$844	3.3%	$28
Employee + Family	$1,251	$1,171	6.8%	$80
PPO
Employee Only	$449	$439	2.3%	$10
Employee +1	$925	$903	2.4%	$22
Employee + Children	$875	$909	-3.7%	-$34
Employee + Family	$1,310	$1,275	2.7%	$35

"The increased frequency and duration of COBRA use is creating a significant strain on the program, leading to higher costs. Those who are unemployed, and facing uncertainty about employment prospects and future COBRA availability, are utilizing the program more than we've traditionally seen to treat a variety of conditions prior to potentially losing coverage. This coupled with the high unemployment rate, is placing the COBRA program in a unique and unprecedented position."" John Zern, Aon Consulting’s executive vice president and Health & Benefits Practice director tells us.

The good news: the COBRA premium increased from 2009 to 2010 on a percentage basis were in line with non-COBRA premium increases, even though the population would be considered to be much higher risk.

The Difference a Year Makes: H1N1 Adieu

By Clive Riddle, August 13, 2010 

The CDC Situation from their H1N1 Swine Flu web site: “The U.S. Public Health Emergency for 2009 H1N1 Influenza expired on June 23, 2010. On August 10, 2010, the World Health Organization (WHO) International Health Regulations (IHR) Emergency Committee declared an end to the 2009 H1N1 pandemic globally…..Internationally, 2009 H1N1 viruses and seasonal influenza viruses are co-circulating in many parts of the world.  It is likely that the 2009 H1N1 virus will continue to spread for years to come, like a regular seasonal influenza virus.”

WHO reported this week that “in the majority of countries, out-of-season 2009 H1N1 outbreaks are no longer being observed, and the intensity of 2009 H1N1 influenza virus transmission is lower than that reported during 2009 and early 2010.

CDC reports that as in years past, beginning in October, 2010, they will provide weekly reports of influenza surveillance information throughout the season with the publication of FluView available at www.cdc.gov/flu/weekly

So how should we behave in a post pandemic world? WHO recommends that surveillance and vaccination during the post-pandemic period include:

• monitoring for unusual events, such as clusters of severe respiratory illness or death;
• investigating severe or unusual cases, clusters or outbreaks to facilitate rapid identification of important changes in the epidemiology or severity of influenza;
• maintaining routine surveillance, including for influenza-like illness and cases of severe acute respiratory infections;
• continuing to use routine channels of data transmission, such as FluID, FluNet, and EUROFlu, to transmit data from the routine surveillance of respiratory disease;
• monitoring the H1N1 2009 virus for important genetic, antigenic or functional changes, such as antiviral drug sensitivity;
• WHO strongly recommends vaccination of high-risk individuals in countries where influenza vaccines are available.

What Do We and EBRI Really Know About Consumer-Driven Health Plans?

by Clive Riddle, August 6, 2010

EBRI (Employee Benefit Research Institute) has just published a 28 page issue brief by Paul Fronstin, Director of EBRI’s Health Research and Education Program:  What Do We Really Know About Consumer-Driven Health Plans? A decade since their introduction in various forms that evolved over time, numerous studies consumer driven plans have since left a data trail that EBRI has followed and attempted to map.

The report concludes that: “the percentage of employers offering an HRA- or HSA-eligible plan increased from below 5 percent in 2005 to between 12−15 percent by 2009…. However, recently, the percentage of small firms that offered a CDHP declined while larger firms continued to add a CDHP as an option. Overall, 19.1 million, or 11 percent of people with either employment-based coverage or individually purchased insurance, were enrolled in a CDHP in 2009….Generally, premiums for CDHPs were lower than premiums for non-CDHPs….However, CDHP premiums may be lower than non-CDHP premium simply because the CDHP population is healthier, and there is some

evidence of this.…The studies agree that use of preventive services did not change (upward or downward) as a result of the CDHP…. Concerning how CDHPs affect prescription drug use, studies found that overall use of brand-name prescription drugs fell… CDHP enrollees increased their use of the mail-order pharmacy option.”

Perhaps the most meaningful analysis of other studies is saved for last: “While HRAs and HSA-eligible plans look a lot alike, the differences are significant enough to warrant separate analyses of the impact of the plans. Also, most of the research to date has focused on plan design and has ignored the impact of the consumer-driven account on use of health care services and overall spending. Individual contributions to HSAs and employer contributions to both HSAs and HRAs may affect the use of health care services. Furthermore, account balances may have an effect as well: Individuals may use health care services differently, depending on how much money is being contributed to the account, especially relative to the deductible; amounts rolled over; and portability of the account. Despite the growing body of evidence on the effect of CDHPs on cost and quality, there are many unanswered questions.”

The conclusion might de-emphasize the increase in employer popularity with the plans over time, although certainly greater with larger vs. smaller employers as the report notes. The KFF HRET annual survey cited found offer rates with large employers (1,000+) increasing from 10% to 29% from 2005 to 2009, and the Mercer annual survey cited found large employee offer rates ranging from 4% (1,000 – 4,999 employees) to 22% (20,000+)  in 2005, increasing to a range of 24%  (1,000 – 4,999 employees) to 47% (20,000+)  in 2010.

The report conclusions emphasize that offer rates may have stalled with smaller employers, evident in the KFF HRET study, but not evident in the Mercer study. The report detail does provide some meaningful disclosure regarding the oft quoted KFF HRET CDHP data: “Unlike other studies, the survey did not find growth in enrollment between 2008 and 2009. The KFF/HRET survey does not include nonworking adults or children in its estimates. It also does not include federal employees or workers in firms with fewer than three employees. The lack of growth may be due to large margins of error for data related to CDHPs in this survey. The lack of growth may also be due to the fact that, while the survey shows growth in offer rates in large firms, it shows a decline in offer rates among small firms (contrary to the Mercer findings). Because there are many more small firms than large firms, the overall offer rate declined slightly as well.”

Tracking consumer driven enrollment data can be maddening. The report cites six major sources the publish enrollment data, with somewhat materially different results. Variances are due to many factors, from differences in study methodologies as discussed above, to fundamental differences in what is defined as a consumer driven health plan. Should the numbers include all qualified high deductible health plans (HDHPs) even if they have no account based plan attached? Should they include FSAs? Should they include enrollment in other consumerism-labeled products?

Many assume numbers and studies quoted examine just HSA and HRA account based plans. This is not always the case. The EBRI report makes a great attempt as sifting through the data to examine the true HSA and HRA findings. But still, after a decade, as the report concludes, “there are many unanswered questions.”

The Truth Is Out There –Are You?

by Laurie Gelb, July 28, 2010

Health care surveys still ask “analog questions” in a digital world, limiting the impact of disease management, marketing initiatives and even transactional communiqués like EOBs. Besides evoking “socially acceptable” responses (who wouldn’t want to be healthily skeptical and savvy, unless you wanted to be stubborn and oppositional?), surveys in 2010 often still rest on “service as product” and “product = attribute bundle” paradigms, which apply poorly to medicine.

As interventions move into the social and mobile media, the risk of pouring more money and brand equity into misguided action increases. In fact, adding to “stimulus overload” can hasten patient and caregiver denial, apathy, fatalism, overkill – and it’s ever-easier to tell everyone in their social networks how and why they got to that point.

Health care realities that are often overlooked by forced choice (e.g. A vs. B scenarios, point allocations, rankings) and attribute-based questions include:

• N=1. No two patients have exactly the same personal/family histories and environments. Yet we ask everyone the same questions. Why? We have computers now so we can personalize questionnaires in real time, the same way we say we want to personalize interventions.

• Heuristics – shortcuts – are more necessary to making health choices than any other kind. You may be able to consider all the possible routes to work in the morning, but you can’t consider – ever—all the supplements you could be taking.

• Opportunities to re-evaluate choices like daily dosing, glucose monitoring, diet, exercise are infinite– unlike  the dishwasher that you’re basically stuck with for a few years

• Instability/unpredictability of product “attributes” – we don’t all define “effectiveness” the same way, yet we all know what “four bedrooms” means, and the drug you took with no issues yesterday can land you in ER today.

• Inability to create what everyone knows would be the ideal product (want a vitamin water that melts solid tumors?), unlike, say, the cereal industry (Apple Jacks with 12g sugar/serving)

• No single “health personality.” For me, popping a naproxen is nothing; for my son, it’s agonizing. Yet he’s blasé enough to have visited a chiro, whereas I never will. So if you ask the two of us the same questions about beliefs and recent care, you’ll miss why our choices differ.

• In for a penny, in for a pound. A plumber can unclog the kitchen sink with no effect on the bathroom, whereas treatment focused on one system often adversely affects another. And when weighing the zero-sum game of deductibles, co-pays and OOP limits, it’s easy to feel that there are no good choices.

By replacing traditional questionnaires with decision-centered designs in which no two respondents may see exactly the same questions, we can understand and track what our audiences believe they know and the extent to which these beliefs are associated with their choices. With dynamic surveys, domains, measures and thresholds are not pre-established but are provided to us by respondents (with whom we are conversing, not forcing them to abstract something that is very real). This on-the-ground data enables us to better address knowledge gaps, evolving expectations, epidemiology/behavior, barriers to action and more – often with interactive tools. Moreover, patient, clinician and payor thresholds often differ significantly, creating misaligned incentives. When we understand how these differ, we can realign programs for “win/win/win” scenarios that optimize health outcomes.

Change in VBAC Guidelines

by Clive Riddle, July 22, 2010

The American College of Obstetricians and Gynecologists have just issued new guidelines for a vaginal birth after cesarean (VBAC).  Doctor Richard Waldman, president of The College tells us, "the current cesarean rate is undeniably high and absolutely concerns us as ob-gyns. These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate."

Doctor Waldman adds, “Given the onerous medical liability climate for ob-gyns, interpretation of The College's earlier guidelines led many hospitals to refuse allowing VBACs altogether. Our primary goal is to promote the safest environment for labor and delivery, not to restrict women's access to VBAC." The VBAC rate has dropped dramatically during the past 15 years, due to “restrictions that some hospitals and insurers placed on trial of labor after cesarean (TOLAC) as well as decisions by patients when presented with the risks and benefits.”

What has changed? The College guidelines now state women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a trial of labor after cesarean (TOLAC).Proactive counseling is being emphasized, whereby “physicians and patients should consider a woman's chance of a successful VBAC as well as the risk of complications from a trial of labor, all viewed in the context of her future reproductive plans.” They state that women and their physicians may still make a plan for a TOLAC in situations where there may not be "immediately available" staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient's desire to undergo VBAC, it is appropriate to refer her to another physician or center. The new guidelines, Practice Bulletin #115, "Vaginal Birth after Previous Cesarean Delivery," is available in the August 2010 issue of Obstetrics & Gynecology.

Here’s three statistical items supplied by the College:

• U.S. Cesarean delivery rate: 5% in 1970; 31% in 2007.
• U.S. VBAC rate:  5% in 1985; 28% in 1996, 8.5% in  2006
• Risk of uterine rupture during a TOLAC: —between 0.5% and 0.9%

Much Ado about Peer Review

By Clive Riddle, July 14, 2010

JAMA’s current issue features the article: Physicians' Perceptions, Preparedness for reporting, and Experiences Related to Impaired and Incompetent Colleagues, by Catherine M. DesRoches, DrPH et.al. [JAMA. 2010;304(2):187-193. doi:10.1001/jama.2010.921]. The article presents survey results regarding physician peer monitoring and reporting, which nationally polled “2938 eligible physicians practicing in the United States in 2009 in anesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics, and psychiatry. Overall, 1891 physicians (64.4%) responded.”

The survey asked "In the last three years, have you had direct, personal knowledge of a physician who was impaired or incompetent to practice medicine in your hospital, group, or practice?" The study found that:

• 64% agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice.
• 69% said they were prepared to effectively deal with and report impaired colleagues in their medical practice
• 36% do not feel obligated by professional commitment to report such physicians
• 17% had direct personal knowledge of a physician colleague who was incompetent to practice medicine in their hospital, group, or practice.
• Of the 17% with this knowledge, 67% reported this colleague to the relevant authority.
• Physicians working in hospitals or medical schools; and physicians with l0 years or fewer experience, were most likely to report impaired or incompetent colleagues.
• Pediatricians and family practice physicians were the least likely to say they felt prepared to deal such colleagues; anesthesiologist and psychologists apparently felt most prepared
• Most cited reasons for taking no action was (1) belief that someone else was taking care of the problem (19%) belief that nothing would happen as a result of the report (15%) and fear of retribution (12%)

The study concluded that “physicians support the professional commitment to report all instances of impaired or incompetent colleagues in their medical practice to a relevant authority; however, when faced with these situations, many do not report” " Matthew Wynia, director of the AMA Institute for Ethics, comments that “I don't think there's any excuse for less than 100 percent of physicians holding true to these ideals." A free JAMA podcast by JAMA’s editor in chief discussing the survey as part of commentary on the current issue is available for download.

Headlines regarding the article accentuate the minority percentage of physicians who do not report:

Los Angeles Times:  Study shows doctors often eschew watchdog role

CBS News:  Many Docs Don't Blow Whistle On Colleagues

The Washington Post:  Do doctors rat on each other?

This is certainly not the first study to address the issue of physician peer review. Some recent examples include California’s legislatively mandated study, which was released by sub-contractor Lumetra as the Comprehensive Study of Peer Review in California: Final Report, July 31, 2008 which found it was “apparent is that the present peer review system is broken for various reasons and is in need of a major fix”; from Public Citizen-  Hospitals Drop the Ball on Physician Oversight , released May 27, 2009 which concluded a “lack of detection and widespread under-reporting to the National Practitioner Data Bank raise serious questions about hospital peer review.” Modern Physician magazine, in their June 8, 2009 issue ran a lengthy article discussing the debate about the Public Citizen report .

Here’s a few observations for consideration on this issue:

• Regulated peer review focuses on the hospital setting, and is built on a 20^th century model in which a greater degree of care was delivered in a hospital setting. Physician behavior and actions outside the hospital setting are typically under-addressed by state or federal regulations
• Physicians, excel as they do as a profession, are still human, and subject to similar mindsets, pressures and workplace issues as other professions. Who really thinks any other profession subject to peer review would have better reporting outcomes?
• Accountability for professional competence in any profession is much stronger when there is an organization structure that the professional is employed by, or financially belongs to. Organization accountability can be an even stronger continuous force for some than regulatory or even ethical accountability.  Thus large medical groups, medical schools, VA, group health plans and other such entities tend to have less of a problem in this area than open medical staffs. Note the survey findings that “physicians working in hospitals or medical schools; and physicians with l0 years or fewer experience, were most likely to report impaired or incompetent colleagues.” As younger physicians have a greater tendency to practice in larger medical groups and organizations, this issue should experience improvement over time.

Primary Care Access During this Decade

by William J. DeMarco MA CMC, President, Pendelum Health Corporation, July 1, 2010

In the current issue of MCOL’s Thought Leaders newsletter, I was asked: How big of an issue will primary care access become during this decade- what are its implications- and what initiatives (such as medical homes, retail clinics, employer on site clinics, etc) if any, do you think will bring about improvement?" Here is what I replied:

What we continue to learn is that primary care doctors graduate with hopes of becoming the family practice doctor in a smaller town, something we desperately need, but the economics do not permit this new MD to move forward with their career. Because of the large loans and debts of medical school and subhuman conditions of an internship doctors really start out very poor and in debt. The actual earning of a salary does not occur for several years and the salaries for primary care are not rising as fast as specialist salaries. So many are forced to decide to sub-specialize in a more lucrative area where they can make the dollars they want as surgeons of super specialists and join a private practice as a respected member of the medical group.

This drives demand for primary care but until the salary cap blows off or the economics of medical school costs are altered we see the logical overpopulation of specialty practitioners while PCPs are treated as an aside by both hospital’s and physicians. When one calculates the revenue from referrals to specialist and hospitals that a single PCP makes the numbers can be astounding. True the specialists has a higher revenue per patient but the volume of PCP referrals to specialists and hospitals are far greater yet hospitals have been able to keep PCP compensation low and , in some markets, threaten PCPs that they must join the ranks of employed physician or be replaced.

In this vacuum we are seeing innovation. First by remaking primary care as a retail almost impulse buy the for the consumer retailers like Walgreen’s, Target, CVS Wal-Mart and K Mart and even some grocery store chains have brought Primary care to the patient. This is packaged as a Nurse practitioners and offered for common un-complicated illnesses which , for some, is less expensive and less intrusive than the Emergency room and certainly easier than waiting for 4 to 6 weeks for a PCP visit . While this transition occurred Nurse Practitioners and Physicians Assistant salaries shot up some 27% over their colleagues who were still stuck in public health or working as a medical assistant in a practice where physicians did not make full use of their talents.

As Dr Don Berwick ,Nominated CMS chief, has said the best way to manage costs in the delivery of care is to have the most efficient person downstream from the doctors do the work. So you have NPs PAs and RNs doing more of what they are trained to do thereby making the PCP more productive at less cost. In this regard the Employer owned medical practice is gathering steam as more and more employers see the value of designing benefits around the use of early detection and health promotion and less use of unnecessary specialty care unless the PCP has approved it as necessary. A well equipped PCP group practice with NPs and PAs seeing the right patients at the right level of service can be very successful in attracting volume because of its convenience and flexibility for follow-up.

The cost of such a medical group owned by an employer can quickly be paid back in terms of savings to emergency rooms, early detection of serious disease and better coordination of admissions and discharges to avoid readmissions and reduce length of stay for illness or injury. This kind of commitment by management also can create a positive attitude in the employees who feel their employer is not only offering them a way to pay for care through an indemnity insurance plan but also guaranteeing them a place to get it in the workplace. This guarantee is becoming more and more important as less primary care are available and few insurance companies will pay for ER rooms to replace PCP visits.

These various roles of Primary care emphasize team work and coordination of care. Some of the retail clinics are picking up on this as are the hospitals who once feared these competitors have encourage discussion and referrals to assure continuity and communication between patient and practitioners as well as practitioners to practitioners dialogue. Turning this delivery system on its head by having Primary care driven medicine is slowly at work at the federal level with ACOs and MA plans requiring PCP advocates be assigned or selected by each patient. This constant pressure of demand for PCP will, we believe, force hospitals and clinics to rethink their compensation strategies but also put the pressure back on policymakers to revisit funding for primary care spots in rural and urban settings by subsidizing broadly the medical school experience.  By encouraging more newly graduating Physicians, Physicians Assistants and Nurse Practitioners to advance their education with a promise of being that family practice doctor we all want and need