Julie Ferguson’s Workers’ Comp Insider hosts a Health Wonk Review edition that examines the key health policy issues for the upcoming year.
You are currently browsing the monthly archive for January 2012.
Tags: HWR
For many years, fee for service payment was the status quo. FFS model encourages hospitals to adopt the following strategies to maximize market share and profits:
- Centered on short-term acute care
- Focused on specialist alignment
- Driven by a volume-based service-line strategy
- Using expensive medical equipment purchases to encourage physician referrals
- Attracting patients with new construction in support of market share growth
- Short-term acute hospitals focus on profitable service lines such as oncology, cardiology, neurology, and orthopedics.
Specific examples of this growth are abundant. In Indianapolis, all four of their hospital systems built coronary surgery centers at a combined cost of $210 million. A community hospital 15 miles north of the city opened a smaller, open-heart surgery program. In Cincinnati, nine hospitals performed open heart surgery. Eight Boston Hospitals Have da Vinci System, which may indicate that robotic surgery may be used for marketing purposes.
However, health reform has started to change these trends. Medicare is instituting more bundled payment (e.g., dialysis payments) rather than pure fee-for-service. Further, Medicare’s Shared Savings Program (MSSP) aims to use Accountable Care Organizations (ACOs) to coordinate patient care improve quality and reduce the rate of growth in health care spending.
How will hospitals respond to the changing market landscape? One way hospitals can improve their margins is to only treat healthier patients to improve their performance in the case where risk adjustment methods are imprecise. Also, provider mergers may be a trend. Access larger populations will lessen risk providers must bear under new payment models. Larger size also means that hospitals can negotiate better rates with suppliers. Hospitals will likely sell redundant or non-core assets.
Hospitals will also adopt new technology to better manage care. For instance, Henry Ford Health System in Detroit uses an embedded specialized software called RadPort in its electronic physician order entry system that prompts physicians to enter specific information when ordering radiology tests. The pilot, funded with a CMS grant, will see whether these prompts will reduce utilization levels.
- Source: Avalere Health Webinar, “Increasing Capital Productivity in a Value-Based World“, October 26, 2011.
Tags: Bundled Payment, Hospitals, Productivity, Value-Based Purchasing
The answer is probably not. The NCQA defines 149 factors which would make a practice a successful medical home. These include physician access during and after office hours, electronic access to patients information, availability of clinical data and use of that data for population management, identification of high risk patients, ability to refer patients to available community resources, care coordinate, and quality measure tracking.
As recent Health Economics articles finds that almost half of physician practices fail to meet the NCQA’s medical home standards. Specifically,
“Forty-six percent…of all practices lack sufficient medical home infrastructure. While 72.3 percent…of multi-specialty groups would achieve recognition, only 49.8 percent…of solo/partnership practices meet NCQA standards. Although better prepared than specialists, 40 percent of primary care practices would not qualify as a medical home under present criteria.”
Tags: Medical Home, NCQA, Patient-centered, Quality
In 2015, Medicare will begin implementing a value-based purchasing (VPB) program for physicians. Initially the program will target only certain physicians and groups of physicians, but by 2017 all physicians is participate in this program.
The VBP program will evaluate physicians along two broad dimensions: quality and cost. In the final rule:
Section 1848(p) of the Act requires the Secretary to ‘‘establish a payment modifier that provides for differential payment to a physician or a group of physicians’’ under the physician fee schedule ‘‘based upon the quality of care furnished compared to cost *** during a performance period.’’ The provision requires that ‘‘such payment modifier be separate from the geographic adjustment factors’’ established for the physician fee schedule. In addition, section 1848(p)(4)(C) of the Act requires that the value modifier be implemented in a budget-neutral manner.
Quality
The current quality measures to be used include:
- The measures in the core set of the Physician Quality Reporting System (PQRS);
- All measures in the Group Practice Reporting Option (GPRO) of the Physician Quality Reporting System; and
- the core measures, alternate core, and 38 additional measures in the Electronic Health Records (EHR) Incentive Program measures.
Cost
The current measures of cost CMS is using are total per capita cost measures and per capita cost measures for beneficiaries with four chronic conditions (COPD; heart failure; coronary artery disease; and diabetes).
By January 2012, however, CMS will choose an episode grouper which can evaluate physicians based on episodes of care. Specifically:
Section 1848(n)(9)(A) of the Act requires us to develop by January 1, 2012, an episode grouper that combines separate, but clinically related items and services into an episode of care for an
individual, as appropriate.
Other Issues
One of the main problems of the physician VBP is attribution of patients to doctors. In managed care organizations, patients are assigned a primary care doctor or gatekeeper who are responsible for the patient’s overall care. In Medicare, the patient can see any willing provider; because the primary care doctor cannot restrict the patient’s choice of care, it is more difficult to hold them responsible for the care. Specifically, Medicare beneficiaries never have to choose a primary care doctor, so identifying the doctor to be ultimately responsible for each patient’s overall care is difficult.
Physicians require additional information to understand why the received the VBP scores they did. For this purpose, CMS will create Physician Feedback Reports, confidential reports providing more detailed information of the underlying factors which produce these scores.
For the VBP modifier in 2015, CMS will use 2013 as the initial performance period 2013. This means that payment adjustments in 2015 will be on care provided 2 years ago. Although evaluating physician performance, allowing for appeals and adjusting payments takes time; two years is a long lead time.
Tags: CMS, doctor, Medicare, physician, Reimbursement, Value-based modifier, Value-Based Purchasing, VBP
- Final thoughts from a dying cancer researcher.
- Are economists in awe of CEOs?
- My Life as an Undocumented Immigrant.
- National Health Insurance decreases mortality.
- Length of stay in public vs. private providers.
Tags: Links
Although Health Reform has passed, many of its mandates–such as Health Insurance Exchanges–have not yet been implemented. As the cost of health care has been growing over time, the number of uninsured has also been growing.
The California Health Care Foundation examines the uninsured in California in more detail. Although Texas has the highest share of individuals uninsured (27.3%), California has the largest number of uninsured individuals in the country (6.9 million) and one of the largest share of (21%). One of the reasons for this decline is a decrease in the share of firms offering insurance. The share of non-elderly Californians who obtain their insurance through their job has declined from 65% in 1987 to 53% in 2010. Part of this decrease has been offset by a rise in the share of Californians covered by Medicaid.
Some other highlights from the CHCF report include:
- Employees in businesses of all sizes are more likely to be uninsured in California than in the United States.
- Nearly one-third of the uninsured in California and the nation have family incomes of $50,000 or more.
- Fifty-three percent of California’s uninsured children are in families where the head of household worked full-time during calendar year 2010, down from 61% in 2008.
- About 60% of the uninsured population are Latino.
Below are two charts displaying the insurance source for Californians in 2010 and 2000.
For more facts and figures, see the CHCF Snapshot, California’s Uninsured, Dec 2011.
Tags: California, Uninsured
This question may not be as far fetched as it seems. According to a California Maternal Quality Care Collaborative (CMQCC) White Paper:
“Cesarean delivery rates in both California and the United States as a whole rose by 50 percent between 1998 and 2008, climbing from 22 percent to 33 percent of all births in just a decade. This upward trend, which is seen for every type of woman regardless of race/ethnicity, age, weight, or the gestational age of the pregnancy, shows no signs of reversing. The increasing rates are largely the result of two factors: a significant rise in first-birth cesareans done in labor, and a marked decline in vaginal births after a prior cesarean (VBAC).”
As any good economist would say, there are two factors affecting the change in Caesarean rates: demand and supply. On the demand side, women are more comfortable having a Caesarean than ever before. When a woman is pregnant, more of their peers will have had a Caesarean and the are thus their fear of this major surgery may decrease. Further and with the tremendous amount of faith most women place in modern medicine and their physicians specifically, Caesareans may seem like a more ‘advanced’ way to give birth.
On the supply side, there is a simple reason why Caesareans have risen: money. Physicians get paid more when they do Caesareans. Further, a vaginal birth takes a long time and involves a lot of watchful waiting and monitoring. The Caesarean procedure–although much more intensive and generally worse for the women–is much faster. According to the CMQCC report, “Many nurses talked about the timing of cesareans done during labor, citing the competing demands on physicians for clinic appointments and their desire for balance between work and the rest of life”Kaiser Permanente, where physicians are paid a salary and beneficiaries receive all services from KP docs, generally have among the lowest Ceasarean rates in the state of California.
Doctors do not find it profitable to supervise vaginal birth. And to be honest, I don’t blame them. A typical vaginal birth without complications may not require much direct supervision of a physician. Substituting more labor (i.e., time spent with the patient) by using a midwife in place of more capital (i.e., human capital that the physician accumulated) is more likely to produce better birth outcomes for the average women. Physicians could be brought in only for complicated cases which require additional expertise and surgical skills.
Source:
- Main EK, Morton CH, Hopkins D, Giuliani G, Melsop K, Gould JB. Cesarean Deliveries, Outcomes, and Opportunities for Change in California: Toward a Public Agenda for Maternity Care Safety and Quality. CMQCC White Paper 2011
Currently, physicians are the dominant force in determining how health care is provided in the United States today. Nurses, however, also play a vital role in the provision of health care services. Although there are about 660,000 physicians in the U.S., there are 2.6 million registered nurses and another 750,000 LPNs.
Leveraging the skills of these nurses the utmost capacity is vital to maximizing the efficiency of the health care system. In a recent report from the Institute of Medicine (IOM), the policy recommendations focused on four main issues:
- Nurses should practice to the full extent of their education and training.
- Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
- Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States.
- Effective workforce planning and policy-making require better data collection and information infrastructure.
In general, although the recommendations are sensible, physicians may fear that nurses will begin taking some of their market share. A more detailed explanation of my views of these recommendations is listed below.
Read the rest of this entry »
Tags: Nurses, Nursing, Shortage, Workforce Planning
I am currently attending the American Economic Association (AEA) Annual Meeting in Chicago. The Presidential Address was given by Bengt Holmstrom (Massachusetts Institute of Technology) on “The Nature of Liquidity Provision: When Ignorance is Bliss.”
Although there are numerous presentations on health care, such as the Health Insurance and Health Care Practice seminar lead by Amy Finkelstein. Other sessions of note include:
- The 2006 Massachusetts Health Care Reform
- Children’s Health and Education in China
- Selection and Moral Hazard in Health Insurance
- Behavioral Economics and Health
- The Dynamics of Health and Wealth among the Elderly
- Medicare and Prescription Drugs
- What Determines the Performance of US and International Healthcare?
The full schedule is available here.
Tags: AEA
Recent comments