Reform Rodeo

1. Useful Tools:  The Commonwealth Fund has released a nice tool that provides a timeline of ACA, as well as a means by which to filter the provisions based on a number of criteria.

2. Misinformation: Maggie Mahar describes some of the misinformation that is coming out of the state of Texas regarding health care reform.

3. Exchange Obstacle: Timothy Jost provides a fantastic overview of the obstacles that states and federal governments will face in the process of implementing the exchanges under the ACA.

4. Preventive Care: Somewhat out of character, the Los Angeles Times runs a piece about the irrationality that has surrounded the Preventive Services Task Force and evidence-based medicine in general.

5. Pharma Initiatives: The New England Journal of Medicine provides an overview of the policy initiatives and incentive programs that govern market exclusivity of pharmaceuticals.

Reform Rodeo

1. HRW’s Frank Pasquale’s post on reciprocal transparency — the idea that companies and other entities should be more transparent with respect to their data collection practices as patients become more transparent — is featured on The Health Care Blog.

2. On KevinMD.com, Maggie Mahar discusses what she thinks would happen if health reform is killed.

3. At the New England Journal of Medicine, Timothy Jost discusses recent rules governing the controversial restrictions on medical loss ratios.

4. Kaiser Health News has a short video up of their interview with the AMA’s president, Cecil B. Wilson, where they discuss the AMA’s new strategy regarding the “doc fix” that is set to cut physician reimbursement by up to 30 percent by Dec. 1st.

5. Chris Fleming at the Health Affairs Blog describes a new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation that covers the new process of “grandfathering” insurance plans under the health reform statute.

Accountable Care Organizations: Landmark Report from California

Earlier this week the Integrated Healthcare Association (IHA) released an important whitepaper entitled “Accountable Care Organizations in California — Lessons for the National Debate on Delivery System Reform.” (Click here for a pdf of the whitepaper). The IHA describes itself as: “a statewide multi-stakeholder leadership group that promotes quality improvement, accountability and affordability of health care in California. “

ACOs have been discussed before at HRW in the context of reforming the health care delivery system. Unfortunately, ACOs are relatively new and untested. This is what makes California — a tried-and-true state policy laboratory — a valuable laboratory for health reform, particularly for models like the ACO that the reform law attempts to leverage. The tables provided in the whitepaper make it easy to appreciate California’s experience with ACOs:

The upshot of IHA’s report are the ten lessons that they have distilled from the 285+ physician organizations that together display many of the characteristics of ACOs. These lessons are as follows:

Lesson One: 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.

Lesson Two: 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.

Lesson Three: 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.

Lesson Four: 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.

Lesson Five: ACOs are not a panacea for healthcare spending control.

Lesson Six: 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.

Lesson Seven: 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.

Lesson Eight: Regulation of the financial solvency of provider organizations is important to ensure market stability.

Lesson Nine: Consumer protections from capitated provider organizations need to be balanced, not overburdening.

Lesson Ten: Special attention must be given to establishing ACOs in areas with social and economic challenges.

There is a common thread that runs through many of these lessons: the tension between new organizational models and the payment models that currently exist:

In California, provider organizations have developed hand-in-hand with HMO products, and have been largely unsuccessful in their attempts to diversify into serving PPO patients. This has been driven in part by regulatory restrictions at both the State and  Federal  level  surrounding  providers  accepting capitation  and  FFS  payments. Downward trends in HMO enrollment in California have meant that this failure to diversify has limited the impact of the state’s physician organizations. In order for ACOs to flourish, laws and policies must allow for innovative provider payment arrangements, regardless of insurance type, and internal organizational changes will be needed to adapt to different payment methods.

As the report goes on to describe:

The greatest challenge and greatest opportunity facing ACOs in California and elsewhere is the potential for integrating the coordinated care programs developed originally for HMO and other narrow network insurance products into PPO and other broad network products.

The managed-care backlash of the 1990s is a reminder that past is prologue.  Increased consumer choice through products like PPOs is likely here to stay for quite some time. What remains to be seen is how the future regulations governing ACOs will promote greater collaboration in the delivery of care while embracing the payment models that consumers have come to appreciate and expect.

Reform Rodeo

Medical Loss Ratio: Kaiser Health News reports on tomorrow’s vote by the National Association of Insurance Commissioners on ACA’s contentious rules dictating minimum medical loss ratios.

Cleaning the DSHs: Health Affairs cogently explains the difficulties that the ACA will face when reforming the Disproportionate Share Hospital (DSH) framework that reimburses uncompensated care under Medicaid.

ACO Antitrust: At the Health Care Blog, David Dranove discusses what he believes is a looming antitrust crisis surrounding  accountable care organizations (ACOs)

On QALYs: One of the fathers of the Quality Adjusted Life Year  (QALY) — the metric often used to measure comparative effectiveness — laments its near rejection in the ACA.

Economics: In the first of a series, Maggie Mahar provides a remarkably detailed  analysis of the economic impact of the ACA.

Reform Rodeo

Photo by David Monniaux

1. ACO Yo!: The Healthcare Economist discusses recent research into how the accountable care organization (ACO) model may be leveraged by providers to increase prices. For those looking to learn more about ACOs, the New England Journal of Medicine has recently released a video which can be found here.

2. Playing Politics?: Merril Goozner picks up on questionable appointments to the Patient-Centered Outcome Research Institute — the entity that PPACA tasked with increasing our utilization of comparative effectiveness research.

3. Mandate Mania: Tim Jost provides an update (and overview) of the constitutional mandate case in Michigan.

4. SCOTUS and Vaccine Lawsuits: The Washington Post details the Supreme Court’s effort to determine whether lawsuits by people alleging harmful effects from childhood vaccines should be allowed.

5. Certification: Jon Halamka provides the second part to his clarification of HITECH’s EHR Certification process. The first part can be found here.

6. Fragmentation Symposium: Concurring Opinions held an online book review symposium of Barak Richman, Daniel Grossman, and Frank Sloan’s chapter,  Fragmentation in Mental Health Benefits and Services, in Our Fragmented Health Care System: Causes and Solutions (Einer Elhauge, ed. 2010).

Will Physicians and Hospitals Ever Get Along? Prospects for Defragmentation in a Post Health Care Reform World by Richard Saver

Waldo’s Optimal Fragmentation by Elizabeth Weeks

Why “House” is the True American Health Care Hero, And What To Do About It by Vickie Williams

Getting Mental Health Coverage Wrong by John Jacobi

A Guide to the Patient-Centered Medical Home

White House at Night, Vincent Van Gogh (1853-1890)

As the United States continues on its path towards reforming its health care system, it will be governed primarily by the Patient Protection and Affordable Care Act (PPACA). One of the means by which the legislation attempts to institute reforms is through the use of pilot programs. In a previous post, I examined the pilot program known as the “accountable care organization” (ACO) which effectively formalizes and leverages existing  networks of physicians and providers in an effort to increase cooperation across the continuum of care; the hypothesis being that an organization that is accountable for a broader range of care can more effectively coordinate and efficiently deliver that care.

PPACA does not limit itself to ACOs. Another pilot program contained in the legislation is the medical home, commonly referred to as the “Patient-Centered Medical Home” (PCMH). The PCMH concept is not new. The American Academy of Pediatrics coined the term medical home back in 1967. Through the following decades, the concept of a medical home has, however, been refined. Throughout the 1970’s, the American Academy of Pediatrics continued to discuss the important role of a medical home in pediatric care, releasing a number of reports focusing on the proper role of a medical home for pediatric care.

That medical homes were spawned in the context of pediatrics is not  surprising: children are particularly unable to coordinate their own care, or, in many cases, even effectively communicate the narrative of the care which has transpired.  As such, it becomes the role of  parents, physicians, and others in the health care delivery system to communicate and coordinate the care of  the child. Parents are not always available or able. Logically, there must be some locus of coordination. In some ways, the primary care physician within the Patient- Centered Medical Home stands figuratively, as regards the coordination of medical care, in loco parentis.

Recognizing the importance of the medical home, the AAP created a task force to define the medical home.  In 1996, the influential Institute of Medicine embraced the concept of medical homes. They did not, however, limit their discussion of the medical home to children, but instead stressed the importance of care coordination for many, if not all, patients. (Click here to read IOM’s discussion on the matter). IOM’s belief in the general importance of medical homes has proven prescient in light of the ever-increasing complexity of clinical diagnosis and treatment that operates in an increasingly fragmented health care system. It has become increasingly difficult, even for adult patients, to communicate and coordinate care.

Principles of Patient Centered Medical Homes

In 2007, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association released “Joint Principles of the Patient-Centered Medical Home.” In it they distilled the following seven principles of the medical home. They are, in part:

1.       Personal physician – each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

2.      Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

3.      Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

4.      Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

5.      Quality and safety are hallmarks of the medical home.

6.      Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.

7.      Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home.

The Cornerstones of Patient Centered Medical Homes

Diane Rittenhouse and Steven Shortell have distilled four cornerstones for PCMHs from the above principles:

The four cornerstones of PCMHs, as represented in a talk given by Dianne Rittenhouse

Recently, Rittenhouse gave a talk to UCSF where she did an excellent job of explaining the four cornerstones in the context of the U.S. health care system. The link below jumps straight to the discussion of the cornerstones or you can watch the presentation in its entirety below.

A Discussion by Dianne Rittenhouse on the Cornerstones of the PCMH

As is clear from the joint principles and cornerstones, primary care is the distinguishing factor of the PCMH, as opposed to other models such as the ACO. As Rittenhouse and her colleagues have noted: “The PCMH model emphasizes the creation of a strong primary care foundation for the health care system, and the ACO model emphasizes the alignment of incentives and accountability for providers across the continuum of care.”

Patient Centered Medical Homes in Practice

Are PCMHs a pipe dream? Do we have any experience with them? The answer to the second question is yes, a substantial number of PCMH demonstrations are occurring throughout the country. A recent study by Bitton and colleagues at Harvard Medical School looked at 26 currently active PCMH pilots that incorporated 14,494 physicians, 4,707 practices, and served nearly 5 million patients. The researchers found that there were two ways of using PCMHs to transform health care delivery: a “consultive model” and a “chronic care model.” (For more information see Bitton et al., “Patient Centered Medical Home Demonstration Projects,” Journal of General Internal Medicine, available here.)

The chronic care model focuses on using quality improvement coaching to identify characteristics of care systems that must be changed to improve the treatment of chronic diseases.  The consultive model typically features proscriptive change in practice management most often carried out by external facilitators hired to organize assessment and transformation. (See Bitton page 590). As Bitton notes, the majority of pilot programs surveyed used the chronic care model, with those groups focusing specifically on asthma and diabetes. These initiatives were often the product of state activities, including Regional Health Information Organizations (RHIOs), Quality Improvement Organizations, and other state programs.

In order to become a PCMH, most practices have needed to apply to be recognized as such. The application process often requires the use of an assessment tool created by the National Committee for Quality Assurance — a group comprised of the same organizations who released the Joint Statement mentioned earlier. To accomplish this process the NCQA created the Physician Practice Connections - Patient-Centered Medical Home (PPC-PCMH) program to create a framework for medical home recognition. As stated on the NCQA website: “There are nine PPC® standards, including 10 must pass elements, which can result in one of three levels of recognition. Practices seeking PPC®-PCMH^TM complete a Web-based data collection tool and provide documentation that validates responses.” These standards are used to gauge the “medical homeness” of the applicant.

Payment Reform as the Rate-Limiting Step

As noted by Rittenhouse and others, payment reform is one of the cornerstones of the PCMH model. In the demonstrations currently underway, payment reform has been typically realized by a “three part” model adopted by the Patient-Centered Primary Care Collaborative (PCPCC) — a coalition of major employers, consumer groups, patient quality organizations, labor unions, and others, that have come together to facilitate the creation of PCMHs. The payment model is comprised of:

1.      Ongoing fee-for-service payments

2.      A fixed (typically monthly) case management fee; and

3.      Pay for Performance potential bonus payments

As the PCPCC states: “Payment reform should correct existing imbalances and distortions in physician payment and take into account value created by primary care, especially in the areas of cost, quality, care coordination, access, and patient centeredness.” However, the Bitton study had some unfortunate conclusions with respect to payment reform in extant PCMHs. The study found that many of the PCMH demonstrations currently retain the fee-for-service model as the core method of reimbursement and, despite the efforts at creating a common framework, “substantial variability” in the form, payment methods, and means of practice transformation. Such variation does not seem to favor smaller practices.

Though the PCPCC has attracted a broad range of industry groups to sign on to their PCMH model, it is unclear how a model that retains the traditional fee-for-service framework will work. Even if the FFS model could work, Bitton’s study found that only some of the demonstrations included up-front payments that could be put towards the required investments for transformation.  For the ACO model, upfront costs and uncertainties can be more easily absorbed because of the larger organizational structure of the ACO. However, many primary care physicians practice in small groups. The IT investments and other transformations will require time and resources that many primary care physicians may find difficult to swallow. Moreover, as Rittenhouse notes, the PCMH model does not provide incentives to those outside of primary care to work with the primary care physicians collaboratively. This will only compound the difficultly of  implementing PCMHs. Rittenhouse does, however, offer a glimmer of hope: the synergizing role of ACOs. As ACOs will benefit from the primary care focus of PCMHs, Rittenhouse believes that PCMHs can leverage the ACOs delivery system infrastructure to make the implementation of PCMHs more realistic.

Reform Rodeo

Photo by David Monniaux

1. The American Medical Association: In the face of new health reform requirements that are now in effect, many of the top insurers have dropped child-only health plans.

2. Kaiser Health News Daily Report: Health Care reform’s elimination of discrimination based on pre-existing conditions has not fully materialized; In a sign of what could be a backlash against health care reform, the 3M corporation announced that it will stop offering its health insurance plan to retirees. Click here for the Daily Report.

3. In a sea of pessimism, the New England Journal of Medicine explores the lessons of a health care success story: Grand Junction, Colorado — one of the cities that Atul Gawande detailed in his celebrated article in the New Yorker.

4. At the Health Care Blog, Michael Lake explores recent trends in HIT, while providing many helpful links.

5. Webcast 1: On Tuesday, October 5th: Maggie Mahar and others will be participating in a webcast where they will discuss health care reform. Click here for Mahar’s overview on her Health Beat blog, including a link to the freely-accessible live stream.

An Evening with New Jersey’s Top Cop

On September 23rd, 2010, Paul J. Fishman, United States Attorney for the District of New Jersey, provided insight into his state’s approach to prosecuting health care fraud. He spoke here at Seton Hall Law School, presented by our Center for Health & Pharmaceutical Law & Policy.

First, some background on the U.S. Attorney. Mr. Fishman graduated magna cum laude in 1978 from Princeton University and cum laude in 1982 from Harvard Law, where he served as the Managing Editor of the Harvard Law Review. After a clerkship with the Hon. Edward R. Becker of the U.S. Court of Appeals for the Third Circuit, he became an Assistant U.S. Attorney for the District of New Jersey, where he served as Deputy Chief of the Criminal Division, Chief of Narcotics, Chief of the Criminal  Division, and First U.S. Attorney. From 1994 to 1997, Mr. Fishman served as a senior advisor to the Attorney General and Deputy Attorney General of the United States on a variety of law enforcement, policy, legislative, national security, and international matters, as well as on specific investigations and prosecutions.

Mr. Fishman’s talk, entitled “Why Prosecuting Health Care Fraud is a Top Priority in New Jersey,” drew a diverse crowd comprised of professors and law students from Seton Hall, as well as many in the health care industry and government who were presumably keen to divine the U.S. Attorney’s future prosecutorial plans.  The talk opened with an acknowledgment that the Department of Justice  (DOJ) and the Department of Health & Human Services are working more closely than ever in terms of combating health care fraud. Mr. Fishman noted the importance of this relationship given the myriad opportunities for health care fraud that present themselves throughout the sector’s vast supply chain.

At the outset, Mr. Fishman underscored his desire to leverage emerging technology to better distill trends in the flow of health care dollars in New Jersey. Such analytical technology — already being employed in New Jersey — can help detect anomalous spending patterns that may signal potential fraudulent activity.

Mr. Fishman stated that over the next few years, the number of cases being prosecuted will go up, including both criminal and civil fraud prosecutions. Recognizing the budget shortfall facing New Jersey, Mr. Fishman was quick to note that DOJ is in fact cash flow positive, citing research finding that the DOJ collects $4 for every 1$ spent on investigations.

The U.S. Attorney discussed New Jersey’s unique demographics. With over 100 hospitals,  360-plus nursing homes, 200 private pay home care agencies, and scores of pharmaceutical companies, the New Jersey  health care industry is robust — making it a sizable target for health care fraud.

But as Mr. Fishman notes, it is not just the medical-industrial complex that distinguishes the Garden State’s health care landscape: 38 percent of NJ’s population is overweight, the state ranks ninth in the U.S. in terms of the percentage of elderly residents, and it spends 20 percent more on health care spending on the elderly than the national average. These statistics, according to Mr. Fishman, make the New Jersey health care system an even larger opportunity for fraud.

Mr. Fishman noted a number of specific areas of criminal activity that his office will be focusing on, including:

1. Cases in which people are providing services in a way that is “inconsistent with their stature in the health care industry.” This category would include, for example, individuals pretending to be licensed physicians.
2. Prosecuting fraudulent prescriptions that are written for unneeded services. Mr. Fishman mentioned fraudulent activity in the durable medical equipment field as an example.
3. Staged accidents that seek to defraud the reimbursement system.
4. Traditional Stark and Anti-kickback issues.

On the civil side Mr. Fishman mentioned a desire to reach out to those representing qui tam relators, presumably in an effort to increase the number of qui tam cases brought to his New Jersey office. Mr. Fishman’s qui tam discussion was followed by his general goal of broadening outreach efforts so as to take advantage of the possible early detection of fraud by individuals who may spot a fraudulent activity before such activity is formally recognized. Accompanying  greater outreach efforts will be a tighter integration between the criminal and civil investigatory arms.

Mr. Fishman rounded up his talk with a discussion of deferred prosecution agreements — noting that  while the DOJ often places a huge premium on resolving suits they have not historically focused enough on individual culpability. Accordingly, Mr. Fishman expressed a willingness to go after individuals, and not just corporations, for their actions — predicting an increase in individual prosecutions but maintaining that rates of corporate prosecutions will hold steady.

On the topic of the monitorships that take place in response to non-prosecution and deferred prosecution agreements, Mr. Fishman posited that the monitors should be located in or near the city in which the health care entity is headquartered. Thus, the New Jersey office will be encouraging those in non-prosecution and deferred prosecution to look for monitors in their area. Furthermore, monitors should not have clients with interests that are adverse to the DOJ office, and remained skeptical of the propriety of having white collar defense lawyers acting as the monitors of first resort, notwithstanding their skills. Rather, it is thought that health care entities should look outside the criminal defense bar for monitors, while ensuring that the entity has the requisite integrity and experience to tackle highly complex health care law issues.

In conclusion, Mr. Fishman underscored that deterrence was his guiding principle, with the ultimate goal being the wholesale prevention of health care fraud. Mr. Fishman focused on institutional shortcomings — particularly the lack of a robust relationship between his Office and the health care industry — as a reason his office has failed to sufficiently prevent health care fraud.  However deficient DOJ’s approach to health care fraud has been, the zealousness and creativity of the newly-appointed Mr. Fishman should make even the most seasoned New Jersey health care fraudster nervous.

Reform Rodeo: PPACA Provisions Go Live; Victor Fuchs; Physicals; Google Health

Photo by David Monniaux

1. PPACA News: Kaiser Health News reports on the health care overhaul changes that are occurring this week, including eliminating copays for preventive services and allowing children to stay on their parents’ health plans until 26 years of age.

2. Quality not Quantity: Famed health care economist Victor Fuchs discusses the importance that health care must place on increasing the quality of life as opposed to increasing longevity.

2b. On the Health Care Blog, Matthew Holt interviews Fuchs. Maggie Mahar provides extended commentary.

3. Examining the Exam: NPR has a piece on technology’s role in the fading art of the physical examination.

4. Google Health’s Health: On the Health Care Blog, John Moore of Chilimark Research discusses a recent meeting he had with Google about the future of their once promising but recently stagnant cloud-based EHR system.

5. Mark Your Calendars: Health Affairs announces an October 5th event they will be hosting in Washington D.C. which look at comparative effectiveness research.

Reform Rodeo

Photo by David Monniaux

1. Stem Cell News: A ban imposed by a federal district court on the use of federal funding for embryonic stem cells has been stayed by a court of appeals judge.

2. Important PPACA Case: Kaiser Health News notes that a closely followed hearing is scheduled in Florida for a case filed by 20 state attorneys general that challenges PPACA’s individual mandate.

3. Primary Care no Panacea: Maggie Mahar discusses new research which finds that a greater population of primary care physicians is not a sufficient condition to improving the quality of care.

4. Bending the Cost Curve: The New York Times discusses a new study by The Center for Medicare and Medicaid Services that outlines the future costs of health care under PPACA. The study itself can be found here.

5. On Defensive Medicine: Joe Paduda describes recent research that reveals only a minimal cost for defensive medicine.

Reform Rodeo

Photo by David Monniaux

[Ed. Note: HRW welcomes back Jordan Cohen from his work in Washington at HHS this summer-- the place just wasn't the same without him]

Waste: The New York Times provides an overview of a new study detailing health care wastefulness — which the Times reports as being the first study to quantify the problem.

Berwick’s Pilots: Newly appointed Medicare director Donald Berwick is pushing for hundreds of new pilot programs that would seek to innovate the delivery of health care.

Prognostication: The Health Care Blog’s David Kibbe and Brian Klepper look beyond meaningful use and distill five future trends of patient health data and clinical health information technology.

Meaningful Use FAQs: For those with questions on meaningful use, John Halamka has created FAQs.

PPACA and Employees: Researchers at RAND have published a study predicting PPACA’s effect on workers’ health insurance coverage.

Medicaid Outside the Box: Health Affairs’ Michael O’Grady and Jennifer Baxendell Young have published a post that discusses new ideas for Medicaid financing.

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