Entries in Riddle, Clive (293)

Thursday
Jul162009

Checking out CMS’ Hospital Compare

 By Clive Riddle, July t6, 2009

Last week, CMS issued an announcement touting “important new information was added to the Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare Web site that reports how frequently patients return to a hospital after being discharged, a possible indicator of how well the facility did the first time around” They noted around 20% of hospitalized Medicare beneficiaries experience a readmission within 30 days from discharge.

This prompted me to take the opportunity to check out Hospital Compare again, and see what was going on in that cyber neck of the woods. Here’s a few things I learned:

  • The tool is being used. Hospital Compare has been on-line since 2005. Last year the site 18 million+ page views, and is receiving around 1 million page views monthly during 2009.
  • Here’s how CMS describes the what information Hospital Compare provides: “The Hospital Compare Web site will show a hospital’s mortality or readmissions rate is ‘Better than,’ ‘No different from,’ or ‘Worse than’ the U.S. national rate...Hospital Compare also includes 10 measures that capture patient satisfaction with hospital care, 25 process of care measures, and two children’s asthma care measures. The site also features information about the number of selected elective hospital procedures provided to patients and what Medicare pays for those services.”
  • So what are you supposed to do with this information? CMS states that “Public reporting of these and other measures is intended to empower patients and their families with information they need to engage their local hospitals and physicians in active discussions about quality of care..” Charlene Frizzera, CMS Acting Administrator, tells us "Providing readmission rates by hospital will give consumers even better information with which to compare local providers. Readmission rates will help consumers identify those providers in the community who are furnishing high-value healthcare with the best results. CMS believes that all hospitals, regardless of their readmission and mortality rates, should use the data available in these free, detailed reports to find ways to continually improve the care they deliver.”
  • Of course, has lawyers on staff, and the hospital web site counsels us that we really shouldn’t “view any one process or outcome measure on Hospital Compare as a tool to ‘shop’ for a hospital” and that “consumers should gather information from multiple sources when choosing a hospital.”
  • If you really want to swim around in the hospital compare data, they do provide the option to download the entire database (9MB).
  • How old is the data, and how often is it updated? The collection period for the process of care quality measures is generally 12 months. Currently, the Hospital Compare quality measures are refreshed the third month of each quarter. The collection period for the mortality and readmission measures is 36 months. The risk-adjusted 30-day risk-adjusted mortality and readmission measures for heart attack, heart failure and pneumonia are produced from Medicare claims and enrollment data. The mortality and readmission quality measures will be refreshed once annually.
  • Downloading and then sifting through the actual database, I came across a table summarizing the national averages (as opposed to the hospital and state specific averages typically displayed in the online reports, or national data just for a specific item. Below are tables with the national HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey data and the national mortality readmission data.

 

HCAHPS Measures

HCAHPS Response Categories

Overall Survey %Response Rate

How often were the patients rooms and bathrooms kept clean?

Room was always clean

69%

How often were the patients rooms and bathrooms kept clean?

Room was sometimes or never clean

10%

How often were the patients rooms and bathrooms kept clean?

Room was usually clean

21%

How often did nurses communicate well with patients?

Nurses always communicated well

74%

How often did nurses communicate well with patients?

Nurses sometimes or never communicated well

6%

How often did nurses communicate well with patients?

Nurses usually communicated well

20%

How often did doctors communicate well with patients?

Doctors always communicated well

80%

How often did doctors communicate well with patients?

Doctors sometimes or never communicated well

5%

How often did doctors communicate well with patients?

Doctors usually communicated well

15%

How often did patients receive help quickly from hospital staff?

Patients always received help as soon as they wanted

62%

How often did patients receive help quickly from hospital staff?

Patients sometimes or never received help as soon as they wanted

12%

How often did patients receive help quickly from hospital staff?

Patients usually received help as soon as they wanted

26%

How often was patients pain well controlled?

Pain was always well controlled

68%

How often was patients pain well controlled?

Pain was sometimes or never well controlled

8%

How often was patients pain well controlled?

Pain was usually well controlled

24%

How often did staff explain about medicines before giving them to patients?

Staff always explained

59%

How often did staff explain about medicines before giving them to patients?

Staff sometimes or never explained

23%

How often did staff explain about medicines before giving them to patients?

Staff usually explained

18%

Were patients given information about what to do during their recovery at home?

No, staff did not give patients this information

20%

Were patients given information about what to do during their recovery at home?

Yes, staff did give patients this information

80%

How do patients rate the hospital overall?

Patients who gave a rating of 6 or lower (low)

10%

How do patients rate the hospital overall?

Patients who gave a rating of 7 or 8 (medium)

26%

How do patients rate the hospital overall?

Patients who gave a rating of 9 or 10 (high)

64%

How often was the area around patients rooms kept quiet at night?

Always quiet at night

56%

How often was the area around patients rooms kept quiet at night?

Sometimes or never quiet at night

13%

How often was the area around patients rooms kept quiet at night?

Usually quiet at night

31%

Would patients recommend the hospital to friends and family?

NO, patients would not recommend the hospital (they probably would not or definitely would not recommend it)

6%

Would patients recommend the hospital to friends and family?

YES, patients would definitely recommend the hospital

68%

Would patients recommend the hospital to friends and family?

YES, patients would probably recommend the hospital

26%

 

 

Condition

Measure Name

National Mortality_Readm Rate

Heart Attack

Hospital 30-Day Death (Mortality) Rates for Heart Attack

16.6

Heart Attack

Hospital 30-Day Readmission Rates for Heart Attack

19.9

Heart Failure

Hospital 30-Day Death (Mortality) Rates for Heart Failure

11.1

Heart Failure

Hospital 30-Day Readmission Rates for Heart Failure

24.5

Pneumonia

Hospital 30-Day Death (Mortality) Rates for Pneumonia

11.5

Pneumonia

Hospital 30-Day Readmission Rates for Pneumonia

18.2

 

Wednesday
Jul082009

Medicare Drug Coverage and the Impact on Overall Health Care Spending

By Clive Riddle, July 8, 2009

An important paper reporting on results of an NIH funded study : “The Effect of Medicare Part D on Drug and Medical Spending”was posted online last week with the New England Journal of Medicine: [Volume 361:52-61 July 2, 2009 Number 1] and authored by Yuting Zhang, Ph.D., Julie M. Donohue, Ph.D., Judith R. Lave, Ph.D., Gerald O'Donnell, M.S., and Joseph P. Newhouse, Ph.D..

The pharma industry for decades has been a proponent that appropriate prescription coverage can have a positive impact on overall health care costs. Certainly Medicare policy advocates argued the point in the debate leading up to establishment of Medicare Part D prescription coverage earlier this decade. Now that time has passed, the opportunity has arisen to examine the actual data to address this issue.

The study examined over 35,000 Medicare members from Pennsylvania’s Highmark Blue Cross Blue Shield from 2004 through 2007. The study included a control group with employer based retiree drug coverage that did not change after Part D took effect, and had $10 to $20 copayments with no spending limits or coverage gaps. Three groups were also examined that had no or limited drug coverage before Part D, and then enrolled as in Part D plan as of January 2006. One group had no previous drug coverage, and the other two had previous drug benefits with quarterly spending limit caps.

The study found that the cost of introduction of Part D benefits for those with no or very limited prior coverage was approximately offset by savings in overall health care costs, but overall health care spending did increase for those with more generous prior coverage.

In comparison to the control group, after introduction of Part D, the average total monthly drug spending was $41 higher (74% increase) for enrollees with no previous drug coverage, $27 (27% increase) higher among those with a previous $150 quarterly cap, and $13 higher among those with a previous $350 quarterly cap (11% increase.) Furthermore, overall monthly medical expenditures (excluding drugs) were $33 lower in the group with no previous coverage, $46 lower in the group with a previous $150 quarterly cap, but $30 higher in the group with a previous $350 quarterly cap.

The study concluded that “The offsetting reduction in medical spending in the two groups with the most limited previous benefits was probably due to improved medication adherence among enrollees with chronic conditions.” The study also addressed the overall health care cost increase for the group with more generous prior coverage: “Why did medical spending rise in the group with a previous $350 quarterly cap (the most generous previous coverage among the three intervention groups), as compared with the no-cap group? The additional use of prescription drugs in all three groups probably included both overuse of some drugs and underuse of others, but the proportion of the increase that was overuse may have been highest in the group with the most generous previous coverage. Our finding that the use of oral antidiabetic drugs did not change significantly in this group is consistent with this hypothesis.”

The References section at the end of the report is well worth browsing, as links to various prior studies are provided. Beyond the References provided in the report, I found two other studies that proved to be of particular interest while researching this topic:

The AARP Public Policy Institute published “How Prescription Drug Use Affects Health Care Utilization and Spending by Older Americans: A Review of the Literature” by Cindy Parks Thomas, Ph.D., Brandeis University, Schneider Institute for Health Policy, in April 2008. Key conclusions from this 57 page report include: (1) “Prescription drug coverage can produce cost offsets from reductions in non-drug services, such as hospitalizations and emergency visits.”; (2) “Studies that incorporate increased longevity into spending projections suggest that cost offsets may diminish over time.”; and (3) “Strict benefit limits of all kinds decrease prescription drug use and increase use of other medical services, including acute and long-term care services.”

Baoping Shang, and Dana P. Goldman of the RAND Corporation; National Bureau of Economic Research (NBER) published results in 2007 from their study “Prescription Drug Coverage and Elderly Medicare Spending” (with preliminary results published in 2005) that examined Medicare Supplement (Medigap) enrollees with and without prescription coverage. They found that “Medigap prescription drug coverage increases drug spending by $170 or 22%, and reduces Medicare Part A spending by $350 or 13% (in 2000 dollars). Medigap prescription drug coverage reduces Medicare Part B spending, but the estimates are not statistically significant. Overall, a $1 increase in prescription drug spending is associated with a $2.06 reduction in Medicare spending.”

Friday
Jun122009

The Genormous Generic Market

By Clive Riddle, June 11, 2009

 

“Ginormous” is out. “Genormous” is in, at least if Pfizer is editing the Unabridged Dictionary of Pop Buzz Words, as they continue to go on record that they are pursuing generic growth. This week the Associated Press reported that Pfizer “expects to expand its offerings for generic pharmaceuticals by adding products to the business quoting Dave Simmons, Pfizer President of Established Products. A couple of weeks ago Pfizer licensing agreements with two Indian based companies was reported as a major signal of their strategy to seek growth through generics and emerging markets.

 

Continued growth in generics would seem a smart recession and health reform based strategy. But generic growth has been sustained through this and the prior decade through good times as well. Let’s have a look at a few of the factors driving these Genormous numbers: 

  • The Average price of generic vs. brand prescriptions: Brand: $119.51 ; Generic: $34.34 [Prescription Drug Trends, September 2008, Kaiser Family Foundation] 
  • Average Rx Copay by Tier: Generic Tier $10; Preferred Tier: $26; Non Preferred Tier: $46; Fourth Tier: $75 [Kaiser Family Foundation Employer Health Benefits 2008 Annual Survey] 
  • Generic Fill Rates: 65% of all prescriptions and 21% of drug sales [Prescription Drug Trends, September 2008, Kaiser Family Foundation] 
  • Generic Fill Rate by $ Differential between Generic/ Preferred Brand Copay: $ 0- 5: 47.6%; $ 6-10: 49.2%; $11-15: 51.6%; $16-20: 52.6%; $21+ : 55.0% [The American Journal of Managed Care, June 2007, “Copayment Differentials and Generic Utilization” ] 
  • Employer Strategies to Reduce Pharmacy Costs: #1 Mentioned response (75%) was "Promote greater use of generic drugs" (2nd highest response - 48%- was "Improve management of specialty drugs" [Mercer Survey] 
  • The 2009 Survey of Health Care Consumers found that 3 in 10 consumers switched medications in the past year, with 38% of them switching to save money [Deloitte Center for Health Solutions] 
  • IMS Health reports that "annual U.S. prescription sales growth of 1.3 percent in 2008, to $291 billion. Dispensed prescription volume in the U.S. grew at a 0.9 percent pace. Factors influencing the market’s slower growth in 2008 included higher demand for less-expensive generic drugs, lower new product sales, and reduced consumer demand due to the economic turndown." [IMS Annual U.S. Pharmaceutical Sales Report] 
Friday
Jun052009

Wasted Away in Medical Bankruptcyville: Jimmy Buffet meets Warren Buffet

by Clive Riddle, June 5, 2009

Just published this issue in the American Journal of Medicine, by David U. Himmelstein, MD et al, is: Medical Bankruptcy in the United States, 2007: Results of a National Study. Here’s what Harvard’s Doctor Himmelstein has to say about what this study means to you: “unless you're Warren Buffett, your family is just one serious illness away from bankruptcy.”

Now before you go file a legal change of name to Warren Buffet, you should know the paper’s authors are strong advocates of a particular position: a single payer health plan, and their conclusion is that health insurance in its present form will not protect you from medical bankruptcy, only Warren Buffet or a single payer plan will.

The headlines from the press releases regarding the study indicate medical bills cause 62.1% of all bankruptcies. That claim might be open to some interpretation, given 29% of debtors attributed medical bills as the reason for their bankruptcy. Here’s the table from the study that arrives at that figure:

  • 29%: Debtor said medical bills were reason for bankruptcy: 29%
  • Medical bills >$5000 or >10% of annual family income: 34.7%
  • Mortgaged home to pay medical bills 5.7%
  • Medical bill problems (any of above 3) 57.1%
  • Debtor or spouse lost >2 weeks of income due to illness or became completely disabled 38.2%
  • Debtor or spouse lost >2 weeks of income to care for ill family member: 6.8%
  •  Income loss due to illness (either of above 2): 40.3%
  • Debtor said medical problem of self or spouse was reason for bankruptcy: 32.1%
  • Debtor said medical problem of other family member was reason for bankruptcy: 10.8%
  • Respondents listing any of above 62.1%

But quibbling over the above that is not to take away from the seriousness of the findings they present, only to provide some disclosure to those unaware. So without digressing into an argument for or against a single payer health plan, certainly it hard to argue that various health insurance policies exist in the marketplace which leave patients seriously underinsured, and a number of these underinsured patients, in addition to the uninsured, found themselves in bankruptcy.

Thus the threat of medical bankruptcy does indeed loom over more than the uninsured population. In this recession and season of health reform, it is a very key issue. So here’s some of the other highlights from the study conducted by Doctor Himmelstein and friends from Harvard Medical School, Harvard Law School, and Ohio University and funded by the Robert Wood Johnson Foundation:

  •  Demographically: 60.3% of medical bankruptcies had attended college, 66.4% had owned a home and 20% included a military veteran or active duty soldier.
  • While many of the demographics are very similar, there are a few notable differences in the demographics of those experiencing medical bankruptcies vs. non-medical bankruptcies: Employment (75.5% medical vs. 85.0% non medical); market value of home ($141k vs. $159k); and a lpase in health coverage occuring sometime in the two years before bankruptcy (40% medical vs. 34% non medical)
  • Primary causes of medical bankruptcies: Hospital bills 48%; drug costs (19%); doctors' bills (15%) and insurance premiums (4%). Also, for 38% of cases, lost income due to illness was a factor.
  •  Out-of-pocket medical costs for the bankrupting illness averaged $17,943.
  • In 1981, using the same methodologies, medically-caused bankruptcies were 8% of total bankruptcies. In 2001, the figure was 46.2%
  • 92% of these medical debtors had medical debts over $5,000 or 10% of pretax family income
  • More than 75% of bankrupt families had some form of health insurance
Wednesday
May202009

The Fast and The Furious: Health Care Reform Headlines

By Clive Riddle, May 20, 2009
 
While it remains to be seen if actual health care reform prodded by the Obama Administration and Congress should be described as a fast moving car, or as “The Slow and The Serene,” but at least the rate of headlines spewing out on health reform can be considered, as in the movie title, “The Fast and The Furious.”
 
Just during this week, we’ve been bombarded with developments. Here’s a sampling of what’s come out, under the category of “Who’s going to pay for this mess?”
 
Sodas a Tempting Tax Target
New York Times, May 20, 2009
 
Healthcare Overhaul Could Add Financial Burdens To State
Boston Globe, May 19, 2009
 
New Taxes Loom to Pay for Health-Care Overhaul
Wall Street Journal, May 19, 2009
 
Congress has little appetite for health care taxes
Associated Press/Google, May 18, 2009
 
Senate proposes alcohol, soda tax to fund health care plan
Politico.com May 18, 2009
 
Turning to the policy front here’s a sampling of headlines under the category of standing on soapboxes:
 
Baucus Message to Industry Lobbyists: 'Let the Process Work'
The Washington Post, May 20, 2009
 
The GOP's Health-Care Alternative
Wall Street Journal, May 20, 2009
 
Republicans To Introduce Health Reform Plan That Would Establish State Health Insurance Exchanges, Provide Tax Credits
Kaiser Daily Health Policy Report, May 20, 2009
 
Senators Push for Delay of Public Health-Care Option
Bloomberg, May 19, 2009
 
Senate Finance Committee Releases Policy Paper Describing Options To Pay for Health Overhaul
Kaiser Daily Health Policy Report, May 19, 2009
 
Dems Unclear Where Baucus Will Side on Health Care Reform
Politico.com May 18, 2009
 
Finally, here’s a few entries under that category of Newton’s Third Law That Every Action has an Equal and Opposite Reaction:
 
Physician Practice Interactions with Health Plans Cost $31 Billion A Year, Equaling 6.9 Percent of All Spending For Physician And Clinical Services, New Study Finds
Robert Wood Johnson Foundation Press Release, May 20, 2009
 
Health Insurers Promise ‘Meat’ to $2 Trillion Savings
[Bloomberg reports that health insurers will propose simpler billing for doctors and rewarding better-performing physicians as part of the industry’s White House pledge last week to help shave $2 trillion from U.S. medical bills over the next decade.]
Bloomberg, May 18, 2009
 
DOJ Insurers Probe Sought By Health Care Reform Advocates
The Huffington Post, May 20, 2009
 
Health Plans Support Competition to Benefit Consumers
AHIP Press Release, May 20, 2009

http://www.ahip.org/content/pressrelease.aspx?docid=27096