Archive for Value-based health care
by Vijay Goel
May 1, 2008 at 4:31 am · Filed under Business of Health, Medical Tourism, Value-based health care
Consumer-focused Care spoke with Kenneth Mayes, Marketing Director for Bumrungrad International, a leading player in medical travel/ medical tourism in Southeast Asia, as a world class, JCAHO accredited (the American hospital accrediting organization) facility.
The interview took place at the World Health Care Congress and a podcast and a transcript (available on consumerfocused care) lay out the conversation below.
(Due to Technical difficulties, please access the podcast on medical tourism at Bumrungrad here–WMA format, 4.5MB)
by JMoore
April 23, 2008 at 2:51 pm · Filed under Policy Makers, Consumer Engagement, Health IT, Transparency/Public Disclosure, Value-based health care
WHCC 2008 just wrapped up with a final keynote from Secretary Leavitt. Leavitt’s keynote was a progress report on the four cornerstones that have driven HHS under his leadership.
Cornerstone One: Standard Quality Measures
There has been a lot of quality metrics established, but agreement on the standards by which these will be measured is still a big challenge. Leavitt believes we are moving too slow. Currently, HHS is doing an inventory of the quality measurements they are currently using throughout HHS. They have identified 100 of them and will be going public with these measures this year.
Cornerstone Two: Standards for Cost of Care
Leavitt came down hard on healthcare costs and billing structure stating:
Our billing system in healthcare is insane.
He went on to draw an analogy between a consumer buying a car and a consumer buying knee replacement surgery going on to say we need to challenge the assumption that buying healthcare services is any different from other industries. Leavitt believes that current efforts striving for the perfect solution will never move us forward - he again stated we are moving to slow. We need to strive for good, not perfection. CMS is currently aggregating its cost for common procedures data and will make that publicly available to push the cost transparency issue forward. Getting back to that knee/car analogy, CMS covered the costs for 250.000 knee surgeries in 2007, the costs for those procedures will be made public this year.
Cornerstone Three: Interoperable EMR
Sees HHS steadily marching forward on interoperability. Quite proud of the establishment of CCHIT and the certification process used to insure EMR software is in compliance to interoperability standards. HHS, via it National Health Information Network (NHIN), will test flow of data among several systems by end of this year. Next year, he foresees this moving beyond test data to the flow of real data and scale-up.
While Leavitt recognizes the challenge of a broader NHIN and interoperability with fewer than 10% of small practices having an EMR system, he gave little concrete guidance on how to overcome this issue. They are looking to change the economic equation to promote adoption. What that equation will be remains to be seen, but I’d look to CMS as the prime leverage point.
One of his chief objectives this year is to see further adoption of eRx practices, which he will promote strongly. Currently looking to attach eRx requirements with physician reimbursement payment rule of he CMS bill before Congress.
Cornerstone Four: Incentives to Seek Value
He saved the fuzziest statements for this last cornerstone. Again, Leavitt promoted the need to establish standards for value metrics and incentives. Also emphasized the need for trust among all stakeholders to get this to work. The biggest challenge that HHS has uncovered here is that value and incentives are driven locally. Therefore, HHS’s role will be to establish the standards, and let the local community drive incentives. Chartered Value Exchanges, of which 14 have been awarded/funded to date, will be the mechanism to drive value and incentives at the local level. Goal is to have 50 opertational by 2010.
Leavitt closed his presentation by stating he sees the unbridled rise in healthcare costs as the biggest threat to our nation’s national economic security. Solving the healthcare puzzle is this generation’s challenge.
Analysis:
Yes, movement on Cornerstones One and Two has been glacial. Too many vested interests have very strong financial reasons to stall any progress on cost and quality transparency. While it appears that HHS will look to further leverage the clout of CMS, seems too little too late, unless of course the next administration picks up where Leavitt left off and pushes even harder to make this happen. In full agreement with Leavitt that we should strive for good enough and not perfection. Advocates for perfection are the ones truly stalling the process.
For Cornerstone Three, do believe that for all the complaining I have heard, all-in-all, CCHIT is moving the interoperability ball forward and EMR companies are structuring their solutions to comply. Now we just need to educate the physician. Here, HHS has fallen far short of the mark. For all the talk about wanting to drive adoption among physicians, adoption is still horribly low. Coupled with strong incentives to encourage adoption (CMS payment structure?) HHS could do more in educating physicians on what’s in it for them. The EMR market is still surprisingly fragmented, and even for me, an HIT analyst who covers this market for a living has a difficult time keeping up with all of them. Maybe CCHIT can provide some guidance here as well.
Corenerstone Four is my least favorite and was where Leavitt made the least clear statements. Defining value and structuring incentives around value is an extremely hard thing to do. The Chartered Value Exchange sounds like a re-branding of the failed RHIO concept and I don’t give these new exchanges any more chance of surviving than its predecessor. Secretary Leavitt, with all due respect, throw this one in the can and go with a three legged stool, afterall, a three legged stool is more stable anyway.
CIGNA & WellPoint to Make PHRs Portable in 2008
You heard it here first folks, CIGNA and WellPoint will make member data portable by end of 2008, following the lead of Aetna and UnitedHealth.
Sat in on the session, Critical Health IT, which had representatives of WellPoint and CIGNA talk about their consumer and broader health IT initiatives. During Q&A got a chance to ask both why have they not come forward with a public statement that they support the portability of a member’s PHR. (Note, during their own prepared remarks they gave somewhat dismal views of PHRs stating adoption has been a challenge). Both stated that they have every intent of making a member’s data portable. WellPoint and CIGNA are currently deploying the CCR standard internally to insure that the data will be portable and enable a member to populate a PHR of their choosing outside of their health plan. They also went on to state that this will be completed in 2008.
Towards the end of our exchange on this question, the WellPoint representative went on to state that they still have issues regarding privacy and releasing such data to a non-covered entity. GIGNA nodded in agreement. What a load of bull, particularly after WellPoint has had a few privacy/security breaches of their own.
Hey WellPoint, its my data, let me choose whether or not I wish to take the risk and stop being so damn paternal. Or is it, you just don’t want anyone between you and me? Watch out, you are about to be dis-intermediated.
And finally, thank you to the WHCC 2008 team for inviting me to attend what has been an excellent event. Your ability to bring together many of the leaders in the healthcare industry is to be commended. I have learned much in these two and a half days, so thanks again for the opportunity to participate.
John Moore is Managing Director of Industry Analyst firm, Chilmark Research
by Vijay Goel
April 21, 2008 at 10:48 am · Filed under Consumer Engagement, Pay-for-Performance, Prevention and Health Promotion, Business of Health, Value-based health care, Population health management
George Halverson, Kaiser Permanente’s CEO gave a keynote earlier today at the World Health Care Congress in Washington DC. The statistics he gave were compelling. The opportunities, also, really interesting. From a consumer perspective, the prescription he wrote was not– heavy on centralized best practice reminiscent of the socialistic command & control approach rather than incentives for innovative practice.
The issues today are pretty clear– we are focusing our resources heavily on the sickest individuals.
- 1% of the sickest consume 35% of the health spend
- 10% of the population consumes 80% of the health spend
Even more compelling are the stories of conflicting interests, where an institution such as Virginia Mason is able to significantly reform health costs through better treatment up front (in this case imaging)– only to find a 30% revenue cut putting the institution at a disadvantage in being able to meet payroll and overhead expense.
But these innovations, although they lowered costs and seemingly were good for patients, hurt Virginia Mason’s bottom line. For example, “the big employers saved $100,000 in the first year. But Virginia Mason fell into the red on the average migraine case, instead of breaking even as before.”
The diagnosis was clear– hospitals and hospital systems make such a large sum off of “excess” care, that they can’t afford to get off the gravy train by doing the right thing.
In my mind, this is where the solution laid out was exceedingly non-consumer friendly.
Halverson suggested that universal mandates are required to make health affordable– taking spend for the sickest 1% from $12K/month down to a more manageable $300/month. This makes sense if one looks at the purpose of insurance as a mechanism for wealth redistribution/ wealth transfer. Thus, universal healthcare has an individual mandate– the healthiest are subsidizing the sick at a level that they can’t reasonably expect to recoup.
From the viewpoint of the healthy consumer, spending $300/month for no benefit is a poor economic choice. The business model for insurance in fact rests on a different trade-off, the payment of an underwritten premium that matches actuarial risk against level of insured protection (e.g., amount of potential claim payment one could attain if the risk in fact occurs). The healthy consumer then faces one of two choices– pay premiums to insure against future risk or opt out of insurance altogether. As insurance costs go up, and are focused on highly technical solutions with marginal benefit, we would expect to see the largely healthy opt out, as we are starting to see in the employer health insurance market, via CDHP plans or dropping the benefit completely, as the job. Employers are increasingly showing that they believe health insurance’s cost is not a good value for the job(s) it was hired to perform.
The solution is unlikely to come from the hospital system that is disincented to cut its own throat by reducing the cost/ delivery of high tech care. Instead, how can we create incentives that increase reimbursement/ wealth for those that reduce the shift of the “healthy” 80% into the “sick” 20%? How can we also create better value for those currently seeing minimal value for their contributions, and limit the spigot being poured, without accountability, into the sickest 1%?
Note: this post is cross-posted on Consumer focused care
by Fred Fortin
March 5, 2008 at 10:46 pm · Filed under Insurance, Public Purchasers, Health Plan/Payer CEOs, Policy Makers, Regulators, Universal Coverage, Business of Health, Value-based health care, Ethics
I’m attending the AHIP health policy conference in Washington, DC this week and getting an earful about the elections and healthcare reform. Some impressions:
First up on the podium was Chris Matthews, TV commentator of Hardball fame. Matthews is a good speaker and captures the audience right away. He believes anyone of the three presidential candidates could take the election. Yes, there is still a path for Hillary to get the nomination but a lot depends on what happens today at the polls in Texas, Ohio, Rhode Island and Vermont.
To Matthews, America is in a “rut”. The people want change, they want deliverance. And doing nothing is definitely “out”. Obama is different, not your typical politician and he believes that this election is really going to be “transformative”, the likes of which we have not seen for quite a while. While he did not address health care reform in a specific way, Matthews argues that real political change only comes from brilliant, dramatic, unpredictable and grand moves. So I don’t think health care incrementalism is in Matthews’ play book.
Donna Brazile, TV political commentator and Chair of the Democratic National Committee’s Voting Rights Institute, and super-delegate, also believes that voters are in a foul mood. There “will be blood in this election”, she says. The next president will inherit a divided country and healthcare will be right in the middle of it. In addition, the deterioration of the economy will make health care reform doubly difficult. Even so, Democrats will want to get something in healthcare reform on the table quickly after the election.
Michael Murphy, Republican Political Consultant, and TV Commentator, on this point, says a McCain presidency may, contrary to popular thinking, do more for healthcare reform since if it is proposed by Democrats, the Republicans will block it. Like Nixon going to China, you need a conservative to front this kind of liberal change.
Dan Crippen, former Director of the Congressional Budget Office, observes that many people think rising health care premiums are capricious acts; they go up by themselves and are unrelated to cost structure. He asks “How do we change the 30 year old question in healthcare from ‘who should pay’ to ‘what are we buying’.”
Ezekiel Emanuel, Chair of the Department of Clinical Bioethics, Warren G. Magnuson Clinical Center, National Institutes of Health, asks the question of how do we make sure that the process of healthcare reform is legitimate if we need to make sacrifices? What voices need to be heard? He also agrees with many of the other speakers that we need to better assess what we’re spending our money on in healthcare. We need a better strategy. In responding to those who say that cost should not be a consideration in delivering healthcare, he advocates, that cost is an essential ethical consideration in healthcare because cost has an impact on our ability to pay for other critical services and needs. And that fact alone makes it an ethical dimension worth weighing.
In a similar vein, Paul B. Ginsburg, President, Center for Studying Health System Change, provokes the audience on questions about the importance of equity in healthcare, and the public tolerance for administrative control of the distribution of health care services. Containing health care costs will be painful, he reminds us. There is no painless solution. Ginsburg warns that health care financing systems can fail, but that they fail slowly. This health care crisis has been with us for over a decade. However, the affordability problem is now invading the middle class, crowding out other important needs.
The final speaker of the day one was the notable Theodore R. Marmor, Professor Emeritus of Public Policy and Management, and Political Science, School of Management, Yale University. Marmor observes that the lack of consensus should not be surprising since with healthcare we have five Americas: The British model embodied in the Veterans Administration system; the German social insurance program model in Medicare; the 19th century poor laws model in Medicaid; the private health insurance system; and pure charity medicine.
His own criteria for judging health reform proposals are fairly simple: Does is include everyone as payers and recipients for care? Does it cover what ordinary people think is medical care? Does it contain fiscal restraints to prevent the raiding of either the public or personal funds? It is accountable for results? And is the protection portable?
Marmor would like to see a real national conversation about healthcare since right now he feels what Washington is saying up to this point is pure gibberish. How, he asks, can we avoid another mistake like that which was made by the Clintons without a real national dialogue and consensus? We cannot wait another decade for an answer.
US Senator Ron Wyden took the stage first thing the morning of day two of the conference. He’s a frequent speaker at this conference usually focusing on his ‘Healthy Americans Act’ as a step towards real healthcare reform. He says the first 100 days for the new president will be critical for healthcare. Democrats — if they win — will need to put something on the table quickly. Congress is getting ready to act and Wyden does not want a repeat of the now infamous Clinton failure of 1994. This time there is an opportunity to do healthcare reform right. He wants a system where everyone has a basic private portable health insurance plan.
Recent history shows states cannot fix healthcare by themselves because the big drivers are federal, such as Medicaid and Medicare. And if we don’t fix the private market, the country will go single payer. Wyden wants a new private health insurance market that breaks the dependence on employer-sponsored coverage. His plan would still offer a choice of an employer plan. But his ‘Healthy Americans Act’ now before Congress would provide for an alternative to both single payer, and an over-dependence on employer-sponsored healthcare.
But how will health insurers respond to these proposed new changes? Cajoling his audience of health plan representatives, he argues that his approach would be one way to stop playing the healthcare blame game, replete with its usual designated healthcare villain of the day being held responsible for all that is wrong in healthcare. Health plans have all too often shared this distinction.
Andy Stern, President of Service Employees International Union, started his talk with an all-too-familiar tragic story of a healthcare disaster that end bankrupting an American family. He then switched gears to share the changes his own union has had to undergo to confront the new global economy. Healthcare, he believes, has also not reacted well to this new global economy. What we have now is a healthcare sector; what we need to build is a healthcare system. “Change is inevitable but progress is optional,” he lamented.
If there is one truth about healthcare reform, Stern believes, it is that the longer you wait, the worse it gets. And the US employer-based healthcare system is not sustainable for the economy of the future. It is dead and it’s time for hard choices. We need to move on to a more competitive approach. But he doesn’t think the country is ready, willing or able to go for a single payer system. We have to build a broader coalition on healthcare and negotiate a new blend in order to move on.
Stern warned that there is a big target painted on health insurers and the bullets are getting closer. Health insurers will have to walk in a new direction. People are ready for change. But where is the solution? “Be the agents of change”, he charged, “not the assassins of change”.
Gail Wilensky, Senior Fellow, Project Hope and a former Medicare chief, observed that even when we have expanded access to healthcare — such as the recent addition of drug benefits to Medicare, we still have problems with cost and quality. Medicare’s cost is unsustainable and its population is becoming more politically forceful. The program’s provider financial incentives are perverse and its spending constraints are ineffective when it comes to value and quality. It will be an immense challenge to moderate the Medicare’s cost growth.
Bruce Vladeck, Senior Health Policy Advisor, Ernst & Young, and also a former Medicare chief noted that the healthcare reform proposals put forth by the presidential candidates rarely mention Medicare or Medicaid. Problems with Medicare are the problems with the healthcare system generally speaking. He argues that Medicare costs — even with new efficiencies — cannot be sustained without new money. Politicians need to be more open and explicit about this hard fact. And he adds, that we must stop confounding the problems having to do with improving the quality of healthcare, with the problems of moderating the cost of care. It is a fantasy, he says, that improved quality will save serious money in healthcare.
by Scott MacStravic
February 3, 2008 at 10:44 pm · Filed under Insurance, Employer CEOs, Disease Management, Value-based health care, Health Management
Though most of Walter McClure’s early discussions about buying right, as well as most discussions of value-based purchasing (VBP) in general, are devoted to sickness care, it seems to me that its greatest application may end up being to health care, in its real meaning. While consumers are bound to be confounded by emotion and pressed for time when making most sickness care decisions, they can afford to both take the time and be more “rational” about choices regarding where they will look for long-range health management services.
Of course, in most cases, at present, at least, their choices are limited or dictated by employer or insurance plan sponsors of health and disease management (HDM) services, since these sponsors pay the costs thereof. Sponsors have the same challenges as do consumers when it comes to identifying the best choices for HDM services – there is very little information available, and none that I know of from any objective comparison source, on which services and providers are best.
Moreover, the “prices” that HDM providers charge vary widely, not merely in amount, but by the type of service provided, the size of the population served, and the basis used for pricing. Most HDM suppliers charge on either a per population basis, or per participant in particular HDM interventions. Such prices cannot be compared at all, unless predictions are made of the numbers of the people in a given population who will participate. Moreover, a few HDM suppliers offer guarantees or risk/reward contracts that override the per population or per participant fees they charge, where the only way the final costs and results can be determined is after results happen and are evaluated.
For consumers who buy their own HDM services, prices tend to vary widely, and again based on different foundations entirely. Many simple, Internet-based interventions are free, or cost no more than $5 per month or so, though some cost as much as $20 per month. Others are part of pre-priced packages, which may run hundreds, even thousands of dollars depending on their length, their intensity, and which health professionals offer them. Still others include HDM services as a major element of their annual retainer for “concierge/boutique” medicine, which may range from a few hundred dollars a year, through a few thousand, and up to as much as $100,000 for the very wealthy.
But there is one great advantage to HDM providers – they are already measuring and publishing their results, not merely their qualifications and care processes, which often comprise the main “quality” information offered by sickness care providers. These results are heavily canted toward payers’ interests in saving money, which may not be material to consumers, at all, but they at least address payers’ main concerns. This often includes quality measures such as participant satisfaction and perceived benefits, including self-rated confidence in their ability to manage their health status, risks, or diseases.
There is also the built-in advantage for consumers that they can take all the time they need to make choices about participating in HDM initiatives, in most cases, since there is rarely an urgent or emergent need involved. If people are screened at an employer health fair and learns that they have an emergent level of blood pressure, for example, which may happen, the usual response is to refer them immediately to their personal physician, or to a physician who can see them right away, rather than wait for an HDM program to begin.
Moreover, insurers and employees often offer useful information on the HDM providers they contract with, together with not merely free participation, but often incentives to enroll, as well. The main limitation in applying VBP to consumer decisions lies in the absence of any national body that makes comparisons across different options. We know that Medicare has found many, indeed most of the disease management efforts by specialized suppliers wanting, but these efforts apply to the narrow domain of chronic diseases, rather than the broad domain of health.
Moreover, they do not include what may be the most important outcomes criteria for employers and the health plans that serve them – the total economic impact of managing disease. Medicare deals solely with the costs of healthcare as its measure of economic impact, while employers and their health plans are looking at workers compensation and disability costs as well. And more important, they are looking at absenteeism, presenteeism, and overall productivity as well as performance impacts of HDM. These are often two to five times greater than healthcare costs, alone, and therefore much more likely to be appreciated and continually sponsored by their sponsors.
If employers and commercial insurers clamor loudly enough for, and especially if they offer to financially sponsor a national body to conduct the same kinds of systematic analysis of HDM programs and providers as has been called for with sickness care, the current lack of comparative data may be overcome, gradually at least. Already, Regence Blue Shield in the Pacific Northwest is collecting and publishing information on clinics and large medical groups in terms of their ability to manage the diseases of their patients, which covers at least chronic condition management performance.
If employers and payers expand or coordinate their efforts, measures of success and prices on HDM services may actually become a reality before similar information on sickness care. Physicians and hospitals have shown great reluctance to contribute to or accept comparative ratings by any third party, disagreeing on complex and confounding quality criteria. The criteria for HDM interventions are generally already agreed upon, by both providers and their customers, so agreeing on a set of measures should not take nearly as long.
Moreover, if payers demand comparative information from all HDM providers, in some standard format and understandable mode of reporting, providers will have little choice but to deliver it. No provider will want to be shut out of consideration for having failed to provide the information called for by their prospects and current clients. And as long as this information includes measures of results for consumers who participate in HDM programs, which it will have to in order to achieve competitive levels of participation among populations at risk, consumers will be well informed as well.
We are not even at the beginning with respect to comparison websites or “report cards” in HDM as is true with sickness care. But once we get started, we are likely to find that it take far less time and effort to create the comparative databases and mechanisms needed for VBP, to the benefit of payers, consumers, and all good performers of HDM services.
by Scott MacStravic
February 3, 2008 at 10:43 pm · Filed under Insurance, Employer CEOs, Value-based health care
When Walter McClure, PhD began promoting his “Buy Right” idea in the 1970s, he may have had no idea that the idea would be resurrected in the 2000s as “Value-Based Purchasing”. The two labels apply to basically the same ideas: 1) that a market-based solution was the best way to improve the healthcare system: and 2) that if consumers, employers, insurance plans, and governments had the right mix of incentives and information to do so, they would purchase the best kinds and providers of healthcare, rather than the not so good.
Dr. McClure and I had some arguments over the potential for an unregulated free market to ensure major reforms in health care, though the idea was a good one even in the 1970s, when I lived, worked, and studied in Minneapolis, where he was working with Dr. Paul Elwood at the Interstudy “think tank”. He persuaded many people that the idea was sound, though its reformulation and re-labeling as “value-based purchasing” might have surprised him. The challenges in implementing the idea have always been to ensure that all parties in the healthcare system have aligned incentives based on buying and providing “right”.
The information elements of buying right have long been missing, or only partly developed over the past thirty and more years. But at least there have been major strides made in that direction. Only recently, however, have there been widespread efforts to ensure the consumer incentives/motivation element, as well. Only if consumers have the information, motivation and time needed to systematically seek out the best treatments and providers will value-based purchasing (VBP) by them be possible. And the same applies to all purchasers of health care; employers, commercial and government insurers.
The time element has always been a complication when the VBP idea is intended to apply to sickness care purchasing decisions. In the past, few patients or family members had a long time to do the information searching, comparisons, and careful, rational decision making envisioned for VBP, though payers normally did. Unless patients, themselves, half of the “rewards” for the best treatments and providers may get lost, i.e. the shift of consumer choices toward the best vs. the merely good, and away from the poorest options.
McClure saw this reward mechanism as the most appropriate and available one. He argued that “The only way to reward a provider or plan for efficiency and quality us with more patients.” [J. Iglehart Competition and the Pursuit of Quality” Health Affairs 39:2 Spring 1988 79-90] This was certainly true in the ‘80s, though since then pay-for-performance (P4P) schemes involving both commercial and government insurers, as well as employers and coalitions, have emerged to supplement this pure market mechanism.
But when people are significantly sick — at urgent or emergent levels, in their own view, at least – they often lack the time needed to study options carefully and completely before deciding where to seek help. And there are undoubtedly still many patients or family members who rely on physician or peer advice and recommendations, which may not relate to objectively measured quality, or knowledge of prices. The price element has long been absent from both the motivation and information dimensions.
But with an increased shifting by employers of the financial consequences of sickness care choices to consumers — via higher deductibles, co-pays, and co-insurance in particular – there is increasing motivation for consumers to become more prudent and informed purchasers. Though only five million or so are currently enrolled in Health Spending Account plans, the number is growing, and if 10-20% of the costs of treatment become their responsibility through co-insurance, or they recognize the impact of their choices on their premium levels and potential to gain or retain individual insurance, they may well make more prudent purchase decisions.
It is perhaps no coincidence that the mechanism that may make the VBP idea operational as far as the information element is concerned has also arisen in Minneapolis – in the form of the website www.carol.com. This site is just getting started, but it contains the information part of the VBP requirement. And because it offers quality and price information in a format that makes comparisons among alternative providers, at least, convenient and fast, it may reduce the time problem to a significant degree.
The site contains information only on Minneapolis-area providers, and only thirty of those, at present, though the number is growing. It offers only quality information supplied by the providers listed, plus patient ratings where any have been supplied by patients, rather than objective ratings comparisons, and only prices for the “packages” or individual services that providers supply. But it is certainly a beginning.
At least one author believes this kind of website may prompt a major change in the way the medical care market works. For example, if a provider visits the site to review its own postings, and checks out its competitors at the same time, it may notice a large discrepancy between the prices if charges vs. a rival. An example was offered of a large local physician clinic that had posted its price for treating a sinus infection as $231. A visit to rival MinuteClinic’s posting revealed that its charge for the same treatment was only $49. This prompted the clinic to at least look for a way it could afford to price competitively, perhaps by relying on a nurse, rather than a physician, to deliver the treatment. [CM Yee “Website May Spark Change in Medical Economics” Minneapolis-St. Paul Star Tribune Jan 27, 2008]
After all, insurance plans, not merely consumers, can visit the site. It is supported by the “tenants” who pay “rent” plus a small fee for each “transaction” recorded for its listing, but is open to all visitors. While insurers negotiate fees with providers, save for governments that can dictate what they will pay, the fact that anyone at all can learn the prices charged by listed providers may bring about the kinds of rewards for low prices, at least, that McClure envisioned, through both consumer and payer choices.
Minnesota Blue Cross/Blue Shield also offers a patient-ratings website to the public for both learning how providers are rated, and adding their own ratings. And the Medica health plans offer www.mainstreetmedica.com as a site for price comparisons of specific procedures across local hospitals and ambulatory care providers, though prices are described in blocks based on ranges of prices in low, medium or high categories. Minnesota is aided by a state law that requires insurers and hospitals to give at least estimates of prices when asked, though this usually takes a day or longer to get for a particular patients’ anticipated care needs.
The idea is that consumers can not only choose the best combination of quality and price, given the limits of information posted on such sites, but actually negotiate prices, or “shop” for as many or which kinds of services individual patients or families decide they can afford. In effect, it puts sickness care providers in much the same category as restaurants, where diners choose from a menu how much and which items to order.
There have been a number of calls for a national body that would conduct objective scientific comparisons of particular medial treatments on their cost-effectiveness. This is only one narrow dimension of quality, of course, reflecting how much it costs to achieve a given result, rather than the overall value of typical results as judged by patients. But by combining such information with other dimensions of quality and particularly with price information, this may enable consumers and payers alike to dramatically improve their ability to make rational and informed VBP decisions.
This is clearly only the beginning of the translation of VBP into practice mechanisms that consumers can actually use, but it may prove to have some significant impact oh providers sensitivity to their own prices and quality, in addition to consumers’ adoption of buying-right behaviors.
by Scott MacStravic
December 12, 2007 at 4:41 pm · Filed under Pharma, Value-based health care, Research
Scientific research into alternative treatments and new drugs are commonly “doubled up” by the combination of looking at two alternatives simultaneously, and by “blinding” both patients and providers as to which patients are getting which of the alternatives.
This serves to minimize bias due to the “placebo effect”. If patients and providers knew which patients were getting the real drug, both might be moved to perceive effects that are not there, or that are due to the “mind-body connection”, rather than the effects of the drug, per se. With “controls” getting placebos, the effect of “pure belief” in the efficacy of the drug would be uniform for all cases, and can be subtracted from the total effect of treatment to calculate the impact of the drug alone.
Comparisons of specific therapies that do not involve drugs are normally between the “usual treatment” and the specific therapy under study. These are more difficult to “double blind”, since the provider of the treatment will certainly know whether the patient is getting the usual treatment or the studied alternative. The patient may not know what the usual treatment is, of course, so that “placebo bias” may not be present, or a “sham” version of the therapy may be used as an actual placebo. It is often difficult to “fool” the patient, however, unless the “sham treatment” is perceived as the real thing.
But there are new reasons for adding a third option – “no treatment” to the usual vs. new therapy alternatives or drugs are being studied. For one thing, only the addition of “no treatment” will enable what is the equivalent of a placebo to treatment trials, since usual treatment involves a treatment rather than a placebo. And when comparing drugs, only the no-drug option will be totally devoid of the placebo effect, and provide the basis for learning whether either treatment is as cost-effective as “watchful waiting” for example. This should only be done when ethically acceptable, of course, and when patients are informed.
Moreover, since treatments often have negative side effects, only the no treatment option should be devoid of these, and permit a full and balanced comparison of the logical options. While placebo drugs should have no side effects, usual care may have some, and the net positive vs. negative effects of treatments should be compared to no treatment, where feasible and acceptable, to enable greater learning about what is the best option.
When no treatment is used, there should be no placebo effect for patients who get none. However, the total effects of both real and sham treatment should be included for comparison with no treatment, since the placebo effect is a real benefit to the patient, even if not due to a particular treatment, but to the patients’ belief in its efficacy. Subtracting the placebo effect would eliminate what may be a major portion of the actual benefits patients gain from being treated compared to not.
As we enter the era of “value-based medicine”, and “value-based” purchasing and payment thereof, it makes sense to look at the no treatment option in most cases where it is ethically permissible. Certainly consumers should know how proposed treatments differ in outcomes, including side effects, from both usual care and any new alternative, and so should providers. It is already far too common for providers to use or refer patients to the alternatives with which they are most familiar and comfortable, and perhaps the ones that generate volume and revenue for their practices, as well.
By including a third option of no treatment, and perhaps comparisons to complementary and alternative medicine (CAM) options as well, both consumers and providers, and hopefully payers as well, will have a more complete picture of the full range of options available. Since there are often multiple CAM alternatives as well as multiple options in traditional medicine, all options will probably not be included in any given trial, but multiple trials can cover all reasonable options, while comparing all to each other and the no treatment alternative to all.
For similar reasons, “triple blinding” such studies also makes sense. There has been too much evidence already that the sponsorship of a given study tends to bias the results reported by those who analyze the data. Only if those who perform the analysis are blind as to both which patients got the no treatment option, the usual care, or the alternative being studied, whether a drug or a particular therapy is involved, — and ideally as to who is sponsoring the study — will such bias likely be eliminated.
Bias may be as likely to arise from unconscious optimism or leanings on the part of analysts as from a deliberate attempt to “fudge the data”, but whether conscious or not, analyst bias should be eliminated as well as patient or provider bias. By combining triple options with triple blinding, though this may require higher expenditures for the studies affected, the reliability and validity of results would at least be improved or protected, and we would learn that much more from each study reported.
This might also promote far greater reporting of results that do not promote the interests of the study sponsors. If those who perform the study are separated from sponsors entirely, not only will bias potential be reduced, but we will all gain from the reporting of far more study results than seems to be the case today under current clinical trial methods, where sponsors control which and whether results are reported.
There is a fourth approach that would also add greatly to the public good in regard to clinical trials, of course. That would be the willingness of the media to avoid writing and publishing sensationalist and premature stories about the latest “wonder drug” or treatment. As was pointed out in two books, the first for medicine [SK Sarnoff Sanctified Snake Oil: The Effects of Junk Science on Public Policy Praeger 2001] and the second for CAM [RB Bausell Snake Oil Science: The Truth About Complementary and Alternative Medicine Oxford 2007], the “science” on drugs and treatments is often anything but.
The media tend to publish whatever medical care reports will interest the public, while either not understanding or not caring enough about the validity and reliability of the science behind it. But at least one journalist has recently taken a vow to report anything that is not based on: “… large, randomized, placebo-controlled, and double-blind clinical trials published in high-quality, peer-reviewed medical journals.” [J. Adler “A Big Dose of Skepticism” Newsweek Dec 1, 2007]
He reported being “shamed into” such a vow by reading the Bausell book that described the kind of statistical analysis that journalists should demand to see before writing their reports of findings. When compared to placebos, far too many treatments fail to offer any added benefit, and publishing stories about them, while promoting placebo effects, enables too many people to either make or pay money for useless treatments and nostrums. While this could go too far if popular media only published studies that meet scientific standards and journalists understand the science behind them, given the average statistical acumen of journalists, it could prevent a lot of “snake oil” from doing harm to and wasting money of consumers.
by Fred Fortin
December 10, 2007 at 5:43 pm · Filed under Uncategorized, Insurance, Health Plan/Payer CEOs, Policy Makers, Consumer Engagement, Business of Health, Value-based health care, Electronic Medical Records
The WHIT 3.0 conference in Washington, D.C. continues to steam along with some great presentations. I particularly liked David Lansky (Senior Director Health Program, Markle Foundation) and his work on the public interest when it comes personal health records (PHR). His thinking involves the creation of a “ecosystem” which is sympathetic to PHRs. Soon, he argues, we will have an ecosystem which sees three main actors: the 21st century consumer, global internet companies, such as Google and Microsoft, and traditional health care institutions. Three separate and clashing cultures now define these actors. You can envision the aggressive consumer, who wants fully what health 2.0 has to offer, tangling with global entities, unregulated and operating on a huge scale, and both of these confronting conservative, slow and paternalistic, traditional health care institutions. He offers some strategies that involve cooperation on data liquidity, building a national privacy and security framework, and evolving a PHR business model that makes PHRs available to all.
But the presentation that I’ve been trying to get my head around was trotted out by Roy Schoenberg (Chief Executive Officer, American Well Systems) and what they are doing in his shop. Roy boasts, — and I tend to think he’s really on to something — that he is developing the “killer app” in health care. His plan is to offer to consumers online access to health care — not just information — 24 hour, 7 days a week, 365 days a year. This ‘access on demand’ to doctors and specialist integrates a host of complex technologies, and unique relationships with health plans and providers to offer real time health care. It brings these services online to a convenient place (the home) where consumers can be comfortable and for less cost.
This is the very definition of a disruptive innovation.
by Fred Fortin
December 9, 2007 at 10:17 pm · Filed under Uncategorized, Health Plan/Payer CEOs, Policy Makers, Health IT, Business of Health, Value-based health care, Electronic Medical Records
Day one of the WHIT 3.0 conference started with a hot and hip review of the first 5,000 days of the internet by Kevin Kelly (Co-founder & Senior Maverick, Wired Magazine) followed by a series of impressive speakers who kept the temperature high until the reception finally cooled us down later that evening. Kelly expounded on the sheer magnitude of the web and his description of the web, which I’ve seen him present before, being just a series of screens to one, huge global machine that is online all the time. He worked the theme that if it’s not on the web or readable by it, it doesn’t exist. That innovation becomes more powerful when you add community and how products are now being transformed, through the web, into services - Kindle is not a digital reading device, but a reading service. For health care, this means taking the electronic medical record and seeing it not as a stagnant file, but a vital component of the medical conversation between doctor and patient, for example.
John E. Abele (Founder and Chairman, Boston Scientific Corporation) in a discussion with Kevin Kelly, made a few points worth noting. With regard to the federal HIPAA law which governs the privacy of medical information for health care organizations in the U.S., John observed that while addressing an important concern, HIPAA has set us back. He asks, “Has it provided more protection for the privacy of our health care information?” Maybe for a small number, but, he says, “we’ve thrown the baby out with the bath water” when it comes to health IT innovation. The law prevents, presumably, more robust sharing of medical information that can lead to better outcomes and more effective health care. On another front, in response to a question about what China has to teach us in health care, John opined that the Chinese Ministry of Health believes that they have a blank slate when it comes to health care reform, and that they have a mission to create a practical health care system. This is something, he says that we in the U.S. may want to watch carefully and learn from their efforts.
David J. Brailer (Former and First National Coordinator for Health Information Technology, and Founder, Health Evolution Partners) polled the audience about where they thought their health data would reside in the future. With health plans? Government? Providers? Information technology companies? The results were typical he says, about even numbers across all four responses making our ability to work through this issue all the more difficult.
Jeffrey Gruen (Chief Medical Officer, Revolution Health) took us through his “Revolutionary Health Care Manifesto” that promised to democratize access to medical information and empower consumers. He realizes that the world is indeed getting flatter — health care included - but, more important, it is spinning faster. He acknowledges that health care folks are over whelmed by the rapidity of change. But we are not the only ones suffering from future shock, so are entire institutions, as they try to understand where it’s all going, and where they stand in it. Health 2.0 to Gruen is all about the bringing together of content, context and community: valuable health information, with “what’s it mean to me” and the ditching of the lecture for a conversation with others.
One other hot spot for the day was the energizing presentation given by Vijay Govindarajan (Professor of International Business’ Tuck School of Business) and author of the book 10 Rules for Strategic Innovators. His provocative comments on goal setting for the true strategic futurist — “set unrealistic goals!” — along with his exhortations for bottom-up thinking, looking beyond the present challenges to what health care could be, and getting on with it — a call for action — couldn’t have been better timed.
More tomorrow.
Next entries »
