Sunday, April 23, 2017

Courant Op-Ed: Plan to ‘Fix’ State Medicaid Program Flawed

From Saturday’s Hartford Courant, “These are lean times and we need our government to be smart about where it puts its resources. We don't need our limited taxpayer dollars spent "fixing" things in our Medicaid program that aren't broken.” The article points out the state’s backward plan, PCMH +, to apply a risky experiment, meant to slow health care growth, to the only part of Connecticut’s health system that doesn’t need it, our Medicaid program. Just because they can.

Thursday, April 20, 2017

FDA committee tackles how to assess drugs that target serious infections but affect small populations

Last week’s meeting of the FDA’s Antimicrobial Drugs Advisory Committee was unusual. We didn’t address the merits of a single new drug the FDA is considering for approval but how to fairly assess drugs that target a single bacterial species causing very serious and deadly infections but that affect small populations. Getting sufficient numbers of appropriate patients for drug trials is challenging in many ways. Often there isn’t time to assess which species of bacteria is the problem, and not treating people as quickly as possible is not an option. As usual, there are no easy answers but the committee provided feedback on the options from diverse perspectives. Many members also thanked the FDA for being proactive in identifying a problem early, and working with companies to help them design meaningful but feasible studies of effectiveness and safety. More regulatory agencies, both federal and state, should take this constructive approach.

Monday, April 17, 2017

CTNJ: CT health policy has trust issues

An OP-ED today in CT News Junkie describes the sorry level of mistrust in CT health policymaking. “Mistrust is pervasive in Connecticut policymaking and it’s blocking progress.” Luckily we know how to fix it – if only we have the sense. Read the piece

Monday, April 10, 2017

Study raises concerns about ACO “savings” and gaming the system

A new study published in Health Affairs raises doubts about the effectiveness of Accountable Care Organizations (ACOs) to both improve the quality of American health care while controlling costs. The study found very high physician turnover rates at a large Medicare ACO and that high cost patients were concentrated among a small minority of physicians. As patients are included in the ACO, and therefore the savings calculation, based on which physician they see – there is great potential for gaming the system. The study found that high cost patients were even more likely to stick with their physician leaving the ACO than healthier patients. If physicians with less lucrative patients leave the ACO, their patients leave with them, and the ACO can increase their “savings” calculation artificially by segmenting the patient population without either improving quality or controlling costs. As the authors conclude, “ACOs’ ability to deliberately select participating physicians year to year, however, creates a relatively simple mechanism to ‘game’ the risk pool . . . . The presence of this mechanism and the ease of its use, especially compared to the more difficult task of redesigning care, could result in an undesirable but powerful temptation for ACOs, particularly those facing financial constraints or pressing financial motivations.”

ACOs are networks of health care providers that, generally, bear some or all financial risk for the care of their attributed members. The latest trendy payment reform models rely on ACOs to control health care costs by sharing both savings and losses with the payer. ACOs are very new and experimental. Results to date have been underwhelming, both in improving the quality of care as well as controlling costs. The new study offers an explanation for that failure.

Recently, Connecticut Medicaid has moved 137,000 members into ACOs as of January 1st and intends to move another 200,000 in next January 1 without a meaningful evaluation of the experiment. The ACO gaming of shared savings payments detected in the study was anticipated by advocates in development of the model, but proposed protections were rejected.

Friday, April 7, 2017

Mistrust in Connecticut health policymaking - Thoughtleaders, public weigh in on the problem and propose solutions

Connecticut health policymaking has trust issues. This year Connecticut health thoughtleaders rated trust among stakeholders at only 26 out of 100 possible points, with zero to ten being the most common response. Low trust scores were found in every stakeholder group. Research confirms that trust is an essential foundation to governing and reform; without it no progress is possible. But in good news, Thoughtleaders and the public have submitted 173 ideas to build trust and move forward. They fall into some themes -- process/respect, more voices engaged, transparency and accountability, keeping promises, using data and best practices, avoiding political agendas/conflicted interests/ethics, better communications, and a large number of very specific ideas for health system improvement. Click here to read thebrief, here for the specific proposals, and here for more ideas. We all need to really listen to all voices, look beyond self-interest, and change how we operate. Are we up to that?

Wednesday, April 5, 2017

April CT Health Reform Dashboard – temporary relief at federal level but troubling payment model returns (again and again and again)

CT’s April Health Reform Dashboard is somewhat more settled than last month – but that’s not a good thing. Efforts to repeal and replace the Affordable Care Act, plus cap Medicaid spending, were temporarily suspended, but are moving again at the federal level in the House. Despite the repeated lessons of history in CT, proponents of financial risk as the single solution to all that ails our health system are at it again. SIM is pushing a primary care capitated model for the entire state, despite extensive evidence that it doesn’t work, and that the primary care system is the worst position to accept financial risk. Thankfully the state recognizes that the model won’t work for Medicaid – but that hasn’t stopped SIM proponents from pushing ahead anyhow. Unfortunately problems persist in PCMH+, Medicaid’s current risky experiment with payment reform – ineffective consumer notices, political and conflicted interests driving policy, no evidence of a system to even detect underservice, and, probably worse, a plan to move ahead pushing another 200,000 people into the experiment before there is any meaningful information (much less a proper evaluation) of what happened to the first 137,000 people. No one is listening to cooler heads urging a moderate, prudent course of making sure people aren’t being harmed and taxpayers aren’t paying more before any expansion -- and maybe fixing the problems – since when did anything this risky work perfectly the first time. Mistrust remains at the core of our problems.

Tuesday, April 4, 2017

Doctor compensation continues to grow, Northeastern physicians about in the middle, Canadians higher

US physicians average $294 thousand in compensation this year, up from $206K in 2011 according to Medscape’s 2017 Physician Compensation Report. Mirroring the US average, physician payment in the Northeast averaged $296K. Canadian physicians are the only nationality paid more than Americans, on average. Specialists make 46% more than primary care physicians, and their compensation is growing faster as well. Among specialties, orthopedists make the most, while pediatricians the least. Three quarters of physicians receive employer-subsidized health benefits and 61% receive dental insurance benefits. While still only a third of US physicians (36%) participate in Accountable Care Organizations, that number is up from 3% five years ago. About half (52%) of primary care physicians have experienced an influx of new patients since implementation of the Affordable Care Act, only 38% of specialists have experienced that trend. Thankfully, 69% of physicians expect to continue to take new and current Medicare and Medicaid patients; 6% won’t take new patients and 2% won’t see their current patients. Three quarters discuss the costs of treatment with patients, either regularly or occasionally. More than half spend over 10 hours/week on administration and paperwork; that number is rising. In very good news, the vast majority in all specialties would choose medicine again as a career.