Entries in Reform & Regulatory (107)

Wednesday
May102017

An Interview With Kaiser’s Robert Pearl, MD on Mistreated Patients and the American Health Care System

By Clive Riddle

By Clive Riddle, May 10, 2017

 

Doctor Robert Pearl, certainly a prominent figure in American healthcare today, agreed to sit down and expand upon his thoughts on the American health care system in 2017 and its impact upon patients. His new book, Mistreated - Why We Think We're Getting Good Health Care and Why We're Usually Wrong has just been released this month by Public Affairs, and we hoped he would elaborate on some of the questions that come to mind from issues raised in Mistreated, and in his public speaking appearances.

 

Robert Pearl, MD, is executive director and CEO of The Permanente Medical Group, responsible for the health care of 3.8 million Kaiser Permanente members, and he is the president and CEO of the Mid-Atlantic Permanente Medical Group. He is on faculty at Stanford and has taught at Duke, UC Berkeley, and Harvard. His column on Forbes.com addresses the business and culture of health care, and he has been featured in national media including Time, ABC News, USA Today, and NPR.

 

So here’s what Doctor Pearl shared with us in response to our half dozen questions:

 

Q. You have been an influential healthcare stakeholder and thought leader for some time. American healthcare has been problematic for even longer. What confluence of events influenced you to write this book at this juncture?

 

Doctor Pearl: The American health care system is walking towards a cliff, and if nothing is done to change course, we will step over the edge and crash to the ground below. We spend almost 50% more than any other country in the world and our outcomes are in the lower half of industrialized nations. Hundreds of thousands of people die each year from failures in prevention and medical error, including my dad. Our system most closely resembles a 19th century cottage industry. It is fragmented, with doctors scattered across the community and hospitals in every town, piece meal, what we call fee-for-service and using information technology from the last century. The cost is rising faster than our ability to pay. The government is spending 40% of tax revenues on health care today, and with 10,000 people becoming eligible for Medicare every day, that will rise rapidly in the future. And businesses are implementing high deductible insurance products, with patients increasingly unable to pay the out of pocket expense. In other words, the "patient" is becoming critical. I wrote Mistreated for two reasons. The first was my career long desire to make American health care better. And the second to prevent other people from losing their parent prematurely. For both reasons, all profits from the book will be given to charity to provide care to patients unable to access it today.

 

Q. You have written about how healthcare organizations should be less, and not more, regulated in some respects - for example reducing regulation in order to facilitate workflows that would allow hospital patients to get more uninterrupted sleep during the night. You also have written that a single payer system is not the answer for American healthcare. What legislative changes do you advocate in your book?

 

Doctor Pearl: I believe that change can best happen through transparent and fair competition. Making it possible for insurance companies, ACOs and large, multi-specialty medical groups to offer products that patients can understand, compare and choose among would be valuable. I have confidence in the wisdom of people and businesses to make the best selection, once they have broad choice and sufficient information.

 

I also believe that the government needs to address the egregious pricing by many drug companies. The patent laws were written for the greater good of all. They were designed to encourage R&D and focus drug companies on solving the most important clinical problems that exist. They never were designed to allow manufacturers to buy the rights to long standing, inexpensive drugs and raise their prices 500% - 5000 %.

 

Q. You cite three technologies as being key to transforming American health care: Video and digital photography; Data analytics; and EHR. These are not exotic items. So what are some primary factors in 2017 that are still holding us back from deploying these three items at optimal levels?

 

Doctor Pearl: There are three reasons I believe these technologies are not more broadly used. The first is that to use them effectively requires an integrated delivery system that is prepaid with effective physician leadership. Without all three pillars, the information in the EHR will be incomplete, the data analytics difficult to apply, and applications like video economically problematic.  The second reason is physician inertia. According to the Rand Corporation, it takes 17 years for a great idea to become common practice. Finally, when it comes to video and digital, the problem with these technologies is that they are inexpensive. As such, there is no manufacturer or device company that wants to invest the dollars needed to encourage and train physicians to embrace these patient conveniences. And without this level of support change is slow to happen.

 

Q. Speaking of exotic technologies, you are not necessarily the biggest fan of focusing on all things new and shiny, and have cited the challenges in overcoming behavioral biases in that direction. What are some significant examples of technologies that have at this point benefited from undeserved demand from consumers or providers?

 

Doctor Pearl: As you note, as a nation we are attracted to the new and the hyped. A variety of expensive medications fit this description. Often they have minimal improvements over what was previously available, or extend life by a few weeks for most patients.  Another example is Artificial Intelligence. It sounds great, but most of the systems are really just fancy computers with physician developed algorithms, not real self-learning applications. Similarly, expensive fitness trackers are minimally better than the free application on your smart phone. And medical wearable devices can transmit hundreds of heart rhythm tracings, but doctors don't want them cluttering up their EHRs, and rarely do they add value for someone without a known cardiac arrhythmia.

 

Q. You are a strong advocate for clinical integration. What in 2017 are the biggest impediments in urban markets that lack adequate clinical integration? And how do we bring greater clinical integration to rural America?

 

Doctor Pearl: In urban areas, the limitations are the associated changes that need to happen. For integration to add value, you need to create a structure with the right number of physicians from each specialty. Often there are too many or too few in a typical community. For the new structure to add major value, reimbursement needs to change, rewarding prevention and avoidance of medical error as highly as intervention. And altering how doctors are paid is always contentious. The computer systems need to connect, and that is difficult to accomplish today. Finally, physician leadership is essential, and that requires investments in training and a willingness of all to relinquish autonomy.

 

In some ways the rural areas could be easier. In this case I believe the structure can be virtual, with specialists in more urban areas linked to primary care in the rural location. We are already using this type of approach in our on-site clinics located in large businesses. Here specialists whose offices may be in a hospital miles away can consult on a employee needing specialty expertise without having to ask the patient to drive to the physicians' location and miss a day of work. Over half of the time, this solves the patient's problem.

 

Q. In what ways do you hope consumers will change their actions or thought processes as a result of reading your book? And in what ways do you hope other healthcare stakeholders will be influenced?

 

Doctor Pearl: I wrote Mistreated for the patient in all of us. My father was a professional with well trained doctors, and yet, he experienced a medical error from the lack of a comprehensive electronic health record and inability of his doctors to communicate effectively.  The first step to transforming American health care is to help people see what they are missing and why. Having done so, I would hope they would begin to make different choices in the health plan and delivery system they select. Information can be difficult to obtain, but increasingly it is available. Choose a five star program in Medicare or on the health care exchanges. Check to see if there is reported data on outcomes for various procedures like heart surgery, and go to the programs with the best results. Ask physicians before you have a procedure how many of these they did last year, and choose ones with the highest volume. And when you are in a hospital or doctor's office, and anyone fails to wash their hands before examining you, speak up.

 

Specific to the medical profession, my hope is that change will happen soon, rather than waiting for the predictible crisis. The current system isn't working for clinicians any more than patients. The fragmentation that exists today leads to isolation. Fee-for-service makes doctors feel like they are having to run faster and faster, and convince patients they need things done that often add little value. The lack of technology and medical information leads to errors. And the lack of leadership reduces coordination of care and produces growing frustrations in the practice of medicine.  Change always is difficult and scary, but it can happen. And when it does, I believe both patients and physicians will benefit immensely.

 

The current system is broken. I am optimistic that when large numbers of people from diverse backgrounds come together to talk about their experiences and recommendations, that we can improve health care delivery in the future. That is my hope in writing the book. The path I describe is the one I believe best for the nation, but I look forward to learning from others. If Mistreated stimulates discussion, debate and improvement, and as a result tens of thousands of lives are saved each year, then my father's death will have served a purpose.

 
Friday
May052017

Different Approaches in Tackling the Surprise Medical Bill Problem

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By Clive Riddle, May 5, 2017

 

Surprise medical bills – from out of network physicians affiliated with network hospitals, and other similar situations – have been a long standing problem vexing consumers, providers, plans, employers and regulators. This simmering issue began boiling over the past few years as growth in narrow networks and ever increasing retail charges exacerbated the problem.

 

Arizona last week had Senate Bill 1441 signed into law: “The legislation, which takes effect in 2019, will allow a consumer with an out-of-network bill exceeding $1,000 to contact the Arizona Department of Insurance to request the appointment of an arbitrator. The insurer and health-care provider must try to settle the dispute through an informal telephone conference within 30 days of the consumer's arbitration request. The case advances to arbitration if the two sides cannot agree to an amount, with the insurer and health-care provider splitting the cost. Either party would have the right to appeal an arbitrator's decision to the county Superior Court.”

 

Oregon, Texas and Nevada, to name some states, currently have legislative activity of different kinds on this front.

 

Gastroenterology & Endoscopy News ran a nice April 20th 2017 article, Out-of-Network Billing: ‘Surprise Billing’ or ‘Surprise Gaps In Insurance Coverage’? that included a great summary of state level initiatives addressing these surprises.  Included in this discussion was:

·         A number of states are linking reimbursement to rates determined by the independent third-party database.

·         In New York  “Hospitals must disclose which health plans they accept and list standard charges for services. Perhaps most important, they must alert patients that physicians working at an in-network facility may not actually participate in the insurance network and can therefore bill patients directly.”

·         “California recently passed a law that settles out-of-network billing disputes by using one of two benchmarks. Providers will be reimbursed the greater of either 125% of Medicare rates or the insurer’s average contracted rate for the same or similar services in the same geographic region.”…but “not surprisingly, the California law is already being challenged in court.”

·         “Florida’s new law sets reimbursement for out-of-network claims at the lesser of: the provider’s charges; the UCR provider charges for similar services in the community where the services were provided; or the charge mutually agreed to by the insurer and the provider within 60 days of the submittal of the claim. The key in Florida moving forward will be how UCR is defined.”

 

The American Journal of Managed Care  has just issued a release discussing an article in their current issue: Battling the Chargemaster: A Simple Remedy to Balance Billing for Unavoidable Out-of-Network Care, in which “two doctors and two lawyers say they have a solution that doesn’t require legislation: better use of contract law…..Authors Barak D. Richman, JD, PhD; Nick Kitzman, JD; Arnold Milstein, MD, MPH; and Kevin A. Schulman, MD, say the problem starts with the ‘chargemaster,’ a hospital’s master list of prices for billable services. The authors say the defining feature of the chargemaster is that it is ‘devoid of any calculation related to cost,’ and has no relation to local market conditions.”

 

They release continues that “acontract law solution empowers the very parties who currently are being exploited by out-of-network charges,” they write. An emerging consensus, supported by a key court ruling, finds that providers are not entitled to ‘chargemaster’ rates, because neither the patient nor the payer agreed to them. Instead, the authors write, the law “entitles providers to collect no more than the prevailing negotiated market prices” for out-of-network care. In other words, rates already negotiated by hospitals, doctors, and area payers are the norm, not those artificially inflated on the ‘chargemaster.’ This leads to a stark conclusion, the authors find. ‘Providers have no legal authority to collect chargemaster charges that exceed market prices for out-of-network services, nor are payers under any obligation to pay such chargemaster prices.’ The authors make their case in a legal analysis available online.”

 

So while “the authors praise state legislators for trying to end surprise medical bills, they say the courtroom is the proper place for these disputes. Other remedies, like bans on out-of-network bills, don’t encourage cost-saving steps or competition.”

 
Friday
Mar242017

What Hashtag to Use When Firing Off a Post on Healthcare Reform?

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By Clive Riddle, March 24, 2017

 

You want more people to read everything you have to say about whichever side of the wall you’re on in the great repeal and replace debate. Or you just want to know what trendy term to search on so you can read what everyone else is saying on the subject. What hashtag to use…what hashtag to use?

 

We compiled a list of the hashtags surrounding the debate and had them analyzed using keyhole.co, which tracks twitter usage during the past 36 hours or so. As of noon Eastern time today, here’s what we found for twenty one selected hashtags that had surfaced the most during our research, presented in alphabetical order:

 

·         #aca 705 posts | 2,191,075 reach

·         #ahca 405 posts | 18,106,544 reach

·         #BecauseOfMedicaid 500 posts | 302,037 reach

·         #coveragematters 272 posts | 448,981 reach

·         #fullrepeal 50 posts | 1,400,049 reach

·         #healthcarebill 94 posts | 4,154,646 reach

·         #healthcarereform 595 posts | 4,472,503 reach

·         #IfILoseCoverage 391 posts | 1,232,293 reach

·         #killthebill 729 posts | 2,153,734 reach

·         #MakeAmericaSickAgain 703 posts | 935,553 reach

·         #NoRepealWithoutReplace 31 posts | 28,318 reach

·         #obamacare 85 posts | 43,583,728 reach

·         #passthebill 704 posts | 48,210,419 reach

·         #ProtectOurCare 707 posts | 2,217,826

·         #readthebill 589 posts | 1,871,228 reach

·         #RepealAndReplace 706 posts | 44,990,188 reach

·         #ryancare 706 posts | 2,365,314 reach

·         #saveaca 705 posts | 2,234,518 reach

·         #SaveMedicaid 43 posts | 124,503 reach

·         #SaveTheACA 711 posts | 2,061,039 reach

·         #trumpcare 736 posts | 1,741,593 reach

 

The number of posts vs reach reflects the number of tweeters vs the number of tweetees. One tweet from @realDonaldTrump of course goes a long ways in reach.

 

The top ten hashtags in order of posts during this period were: #trumpcare, #killthebill, #savetheaca, #protectourcare, #repealandreplace, #ryancare, #aca, #saveaca, #passthebill, #makeamericasickagain. These were the only hashtags with 700+ posts, with a range of 703-736, so all are being used with similar frequency, and usage of other  hashtags in this genre really drop off after these top ten.

 

With regard to reach, #passthebill, #repealandreplace, and #obamacare were the top three, each exceeding 40 million. #ahca was fourth with 18+ million. #Healthcarereform and #healthcarebill were next, each with 4+ million and it drops off from there.

 

A number of the hashtags (#killthebill, #passthebill) will fall out of use once the #ahca legislative debate is over, while other monikers will likely have legs for some time to come.

 

So pick your hashtag and start posting or browsing.

 
Friday
Mar102017

Your Seven Step Homework Guide for Studying the American Health Care Act

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 By Clive Riddle, March 10, 2017

 

1.       Don’t sweat all the granular details yet. Who knows for certain where the political process will take this proposed Act from here?
 

2.       Watch for the CBO “score” on the Act, which will soon peg estimated cost and volume numbers to what’s being proposed. The CBO score will likely shape discussions from that point forward. The portal for CBO healthcare analysis is www.cbo.gov/topics/health-care.  Here’s two articles about the upcoming CBO score:  Obamacare replacement is hard to score, budget experts say (Washington Examiner) and Nonpartisan Scorekeeper in Hot Seat for GOP’s Obamacare Repeal (Bloomberg).
 

3.       Keep some original sources handy – including a summary from the House’s Energy and Commerce Committee and the s Ways and Means Committee. Also, here’s Paul Ryan’s press release announcing the Act. 
 

4.       Looking for a nice, quick summary of key provisions of the Act? Check out the Association of Health Care Journalists article by Unpacking some key provisions of GOP’s health care bill by Joanne Kenan. Kaiser Health News also has a succinct listing of five key points in comparison to the ACA - Five Ways the GOP Health Bill Would Reverse Course From the ACA by Julie Rovner.
 

5.       Looking for thoughtful analysis of the Act? Check out the Timothy Jost – the oft quoted in national press expert on such matters – in his Health Affairs Blog: Examining The House Republican ACA Repeal And Replace Legislation.
 

6.        Understand some key opposition points from public interest groups: AARP isn’t happy about the increased premium load older individuals would bear in the market, or about Medicare changes. The AMA and AHA don’t like the ultimate reductions in Medicaid and other coverages. Families USA says the only the Healthy and Wealthy will benefit from the bill and also take major issue with the per-capita caps in Medicaid.
 

7.       Getting too tired to read any further? Here’s six selected videos from major organizations discussing the Act.

Friday
Jan202017

2017 MSSP ACOs By The Numbers

by Clive Riddle

 

CMS has announced their 2017 new and renewing ACOs, so we took a somewhat deeper dive into what comprises this year’s MSSP ACO roster, along with who dropped out. For starters, though, here’s the 2017 totals including the other active ACO types (there are also 9 remaining ACOs in the non-active Pioneer model):

  •          MSSP - 480
  •          Next generation - 45
  •          Comprehensive ESRD (CEC) – 47
  •          Total: 572

 

52 MSSP ACOs participating in 2016 dropped out of the program for 2017. 8 of these started in 2012, 11 in 2013, 22 in 2014, 8 in 2015, 3 in 2016.

 

For the 480 MSSP ACOs participating in 2017, with respect their track:

  •          Track 1 – 438
  •          Track 2 – 6
  •          Track 3 – 36

 

17 of these ACOs remain in the non-active Advance Payment program. 45 of these ACOs are the AIM program, and 25 are in the SNF 3 day waiver program.

 

With respect to geography, when classifying the MSSP ACOs by the primary state they serve (many ACOs serve markets in more than one state), 16 states comprise over two-thirds (68%) of the total:

  •          FL 44 ACOs
  •          TX 44 ACOs
  •          NY 34 ACOs
  •          CA 25 ACOs
  •          MI 20 ACOs
  •          NJ 19 ACOs
  •          NC 18 ACOs
  •          IL 17 ACOs
  •          GA 15 ACOs
  •          IN 15 ACOs
  •          MD 14 ACOs
  •          OH 14 ACOs
  •          KY 13 ACOs
  •          VA 13 ACOs
  •          PA 12 ACOs
  •          MA 11 ACOs

 

With respect to their initial year joining the program, MSSPs break down as follows:

  •          2012: 49 ACOs (14%)
  •          2013: 63 ACOs (13%)
  •          2014: 79 ACOs (16%)
  •          2015: 77 ACOs (16%)
  •          2016: 97 ACOs (20%)
  •          2017: 99 ACOs (21%)