December 2010

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Medicare Hospital Value-Based Purchasing

December 7, 2010 in Hospitals, P4P, Quality | 4 comments

The Health Reform (ACA) legislation mandated Medicare establish a hospital value-based purchasing (VBP) program by 2012.  In fact, the Deficit Reduction Act of 2005 already authorized Medicare to develop a plan to implement VBP for 2009.   How will they do this?  A CMS report from 2007 sheds some light on the topic.

Since 2005, Medicare began the Reporting Hospital Quality Data for Annual Payment Update (with the incredibly unintelligible acronym of RHQDAPU).  RHQDAPU at first just required hospitals to report quality measures.  The Health Reform VBP initiatives, however, will begin to pay hospitals based on their performance on these metrics.  The 2007 CMS report claims that any VBP plan should contain the following 7 components.

  1. A Performance Assessment Model that is used to score a hospital’s performance on a specified set of measures, generating a Total Performance Score for each hospital.
  2. Translation of the VBP Total Performance Score into an incentive payment.
  3. A measure development process, including selection criteria for choosing performance measures for the financial incentive, and candidate measures for VBP Program start.
  4. A phased approach to transition from RHQDAPU to VBP.
  5. Redesigned data submission and validation infrastructure to support the VBP Program requirements.
  6. Enhancements to the Hospital Compare website to support expanded public reporting of performance results.
  7. An approach to monitoring VBP impacts, including potential impacts on health disparities.

Below I discuss aspects of hospital VBP in more detail.

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The Benefits Package is Here

December 6, 2010 in Carnivals | No comments

The first ever Employee Benefits Blog Carnival has been posted at the See First blog.

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How prevalent are errors in medical research?

December 6, 2010 in Pharmaceuticals, Reviews | 2 comments

The latest issue of The Atlantic has profiles brave thinkers. One of these brave thinkers is Dr. John Ioannidis, who is profiled in “Lies, Damned Lies, and Medical Science.” Dr. Ioannidis challenges much of the medical establishment by charging that most medical studies are biased, misleading, or flat out incorrect. In the article, author David H. Freedman writes that “He [Dr. Ioannidis] charges that as much as 90 percent of teh published medical information that doctors rely on is flawed.”

Today, I review some excerpts from this very interesting article.

Bias in Physician Treatment

One study showed that “…the appendices removed from patients with Albanian names in Greek hospitals were more than three times as likely to be perfectly healthy as those removed from patients with Greek names.”

Bias in Research studies

In a discussion with colleagues, Ioannidis suggested that it could be possible “drug companies were carefully selecting the topics of their studies–for example, comparing their new drugs against those already known to be inferior to others on the market–so that they were ahead of the game even before the data juggling began?” In addition, “drug studies have the added corruptive force of financial conflict of interest.”

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End of weekend links

December 5, 2010 in Current Events | No comments

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Keep Your Identity Small

December 3, 2010 in Miscellaneous | 2 comments

I came across this essay from Paul Graham and it truly an excellent piece of insight about how one’s identity informs your opinions.  Are you Jewish?  You’re more likely to support Israel in any debate.  Are you a Moslem?  Then you are more likely to side with Palestinians. This is true almost regardless of the specific topic being discussed or the merits of either side.  Mr. Graham’s essay below elaborates on this idea.  I have reprinted it in its entirety.

“I finally realized today why politics and religion yield such uniquely useless discussions.


As a rule, any mention of religion on an online forum degenerates into a religious argument. Why? Why does this happen with religion and not with Javascript or baking or other topics people talk about on forums?

What’s different about religion is that people don’t feel they need to have any particular expertise to have opinions about it. All they need is strongly held beliefs, and anyone can have those. No thread about Javascript will grow as fast as one about religion, because people feel they have to be over some threshold of expertise to post comments about that. But on religion everyone’s an expert.

Then it struck me: this is the problem with politics too. Politics, like religion, is a topic where there’s no threshold of expertise for expressing an opinion. All you need is strong convictions.

Do religion and politics have something in common that explains this similarity? One possible explanation is that they deal with questions that have no definite answers, so there’s no back pressure on people’s opinions. Since no one can be proven wrong, every opinion is equally valid, and sensing this, everyone lets fly with theirs.

But this isn’t true. There are certainly some political questions that have definite answers, like how much a new government policy will cost. But the more precise political questions suffer the same fate as the vaguer ones.

I think what religion and politics have in common is that they become part of people’s identity, and people can never have a fruitful argument about something that’s part of their identity. By definition they’re partisan.

Which topics engage people’s identity depends on the people, not the topic. For example, a discussion about a battle that included citizens of one or more of the countries involved would probably degenerate into a political argument. But a discussion today about a battle that took place in the Bronze Age probably wouldn’t. No one would know what side to be on. So it’s not politics that’s the source of the trouble, but identity. When people say a discussion has degenerated into a religious war, what they really mean is that it has started to be driven mostly by people’s identities.


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Does the Frequency of P4P Evaluations affect Performance?

December 2, 2010 in P4P, Quality | 1 comment

“Reinforcement theory from psychology literature suggests that changing behavior by incentives is easiest when the linkage between behavior and incentive (or positive reinforcer) is clearest, and the reinforcers are placed in routine. “  Does that mean that more frequent P4P evaluations and payments are optimal?  More frequent physician performance payments increase administrative cost, but may be worthwhile if this quality measure system improves performance.

A paper by Chung et al. (2010) aims to verify if physicians respond better to more frequent incentives.  The authors randomized assign physicians at the Palo Alto Medical Clinic (PAMC) of the Palo Alto Medical Foundation (PAMF) to two groups.  The first group received quarterly P4P bonuses and the second group received annual P4P bonuses.  Both groups, however, received reports evaluating their performance on a quarterly basis.

The authors found no difference between the quarterly and annual payments.  One could explain these findings a number of ways.  First, it could be the case the the frequency of payment does not matter.  On the other hand, it could be that the frequency of payment matters, but the change in physician performance over time was so small that the payments themselves had little effect.  For instance, if factors such as patient adherence matter more than physician actions, then the frequency of P4P payments will matter little.  It could also be the case that it is not the frequency of payment that matters, but the frequency of reporting.  Finally, the reporting could be too high level.  If physicians receive insufficient detail of how they performed at a patient level, it will be difficult for them to understand why they received the score they did.  Thus, although this study finds that payment frequency does not affect performance, I remain unconvinced that payment and/or reporting frequency does not affect physician responses to quality evaluations.

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World AIDS Day + CoR

December 1, 2010 in Carnivals, Current Events | No comments

Today is World’s AIDS Day.  Typically this is a day for bad news, but there are some positive trends in the AIDS epidemic.  Time notes that “The number of new infections is falling, as are AIDS-related deaths. Overall, 33 countries have seen their infection rate drop by more than 25% between 2001 and 2009, thanks, in part, to HIV prevention efforts. ”  In addition, condom usage is gaining ground even around conservative cultural circles.  This year, the Pope stated that there are some cases where condoms are acceptable.  Nevertheless, over 33 million people are still living with HIV or AIDS, including 2.6 million people who were newly infected in 2009.

In other reading, the Huffington Post has gathered a list of the seven best books about HIV/AIDS.

On a lighter note, for those of you wanting to engage in risky behavior…head over to Insurance Coverage Law in Massachusetts blog for the latest edition of the Cavalcade of Risk.

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Success Defined

December 1, 2010 in Miscellaneous | No comments

“It’s quite simple, really. Double your rate of failure. You’re thinking of failure as the enemy of success. But it isn’t at all.”

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