Wednesday, February 10, 2016

Performance [Measure] Anxiety

Just as the U.S. healthcare system is about to make performance measurement a central feature of…well, just about everything doctors do…some prominent and highly influential physicians are asking for a pause and reassessment.  

Writing for the New York Times, Dr. Bob Wachter argues that “Two of our most vital industries, health care and education, have become increasingly subjected to metrics and measurements. Of course, we need to hold professionals accountable. But the focus on numbers has gone too far. We’re hitting the targets, but missing the point ...“

The drive to performance measurement, he says, started “innocently enough” as "evidence mounted that both fields were producing mediocre outcomes at unsustainable costs.” Now, though “the measurement fad has spun out of control.  There are so many different hospital ratings that more than 1,600 medical centers can now lay claim to being included on a ‘top 100, ‘honor roll,’ grade ‘A’ or ‘best’  hospitals list. Burnout rates for doctors top 50 percent, far higher than other professions. A 2013 study found that the electronic health record was a dominant culprit. Another 2013 study found that emergency room doctors clicked a mouse 4,000 times during a 10-hour shift. The computer systems have become the dark force behind quality measures.  Education is experiencing its own version of measurement fatigue. Educators complain that the focus on student test performance comes at the expense of learning. Art, music and physical education have withered, because, really, why bother if they’re not on the test?”

He’s not the only Dr. Bob who is anxious about performance measures.  Dr. Bob Berenson, who has for years played a key role in influencing Medicare payment policies as a former Vice Chair of the Medicare Payment Advisory Commission and, in the 1990s, as acting administrator of CMS, takes on the “myth” that W. Edwards Deming, the famed quality improvement guru, said that “if something cannot be measured, it cannot be improved”—the justification offered by many for the proliferation of performance measures.   According to Dr. Berneson, Deming actually wrote the opposite, “It is wrong to suppose that if you can’t measure it, you can’t manage it—a costly myth.”  Dr. Berenson continues  “The requirement for measurement as essential to management and improvement is a fallacy, not a self-evident truth and not supported by Deming, other management experts, or common sense. There are many routes to improvement, such as doing things better based on experience, example, as well as evidence from research studies.”

He argues that the Medicare Access and CHIP Reauthorization Act (MACRA), which will steadily increase the amount of Medicare payments to physicians that are based on measures of value, will likely turn out to be “a doomed attempt to measure value.”   “Practical challenges aside, pay for performance for health professionals may simply be a bad idea. Behavioral economists find that tangible rewards can undermine motivation for tasks that are intrinsically interesting or rewarding. Furthermore, such rewards have their strongest negative impact when they are perceived as being large, controlling, contingent on very specific task performance, or associated with surveillance, deadlines, or threats..."

And then there is Dr. Bob Centor, chair Emeriti of the ACP Board of Regents, who is a long-time critic of performance measures.  Writing in his DB’s Medical Rants blog, Dr. Centor notes “I first wrote about my concerns [about performance measures] over 10 years ago.  In those early days of the blogosphere, few experts paid attention to our ranting.  .  .We can only hope that these commentaries will stimulate greater attention on the problems of performance measurement.  Read these [Dr. Wachter’s and Dr. Berenson’s] commentaries and understand the bloggers made these points 10 years ago.  We understood what could go wrong and predicted the current problems.  Of course we were labeled kooks back then.”

As a Bob myself (albeit not a doctor!), I think we all need to consider the advice of these three very thoughtful and respected Dr. Bob’s about the hazards of performance measures.   The potential for unintended consequences is real, including contributing to physician burn-out by adding more unnecessary administrative burdens to an already burdensome system, undermining professionalism, exacerbating health care disparities (because physicians who serve underserved populations may not score as well on some of the measures), and creating the medical equivalent of teaching to the test, as physicians divert their attention to the aspects of care being measured at the expense of those not being measured.

Yet I disagree with Dr. Berenson that MACRA was a “bad idea” and “likely doomed attempt to measure value.”  Not only was MACRA the means for getting the universally loathed Medicare SGR formula repealed (without it, we’d still likely be facing double-digit SGR cuts in payment to physicians), MACRA is really about making fundamental, and, I would argue, needed reforms to how physicians are paid and care is delivered—moving payments away from rewarding volume, engaging patients in their own care and in shared decision-making with their physicians, and moving care delivery away from silos of care into integrated, team-based, and patient-centered models like Patient-Centered Medical Homes.   Keep in mind that paying physicians based on volume—that is, fee-for-service—itself has many documented adverse consequences on patient care, including higher costs, over-testing, and the over-valuation of procedures at the expense of primary care and cognitive care.  Under FFS, physicians who see the most patients and spend the least time with them, and who order or perform the most procedures, are rewarded; physicians who see fewer patients yet spend more time with them, and who do not order or perform procedures, are penalized.  MACRA is an effort to change all of this by putting the emphasis on value rather than volume, moving physicians and Medicare payment policies away from fee-for-service.

Yes, performance measurement is an important part of MACRA, but the goal really isn’t for Medicare to impose ever more measures on physicians just because it can.  Rather, it is to use Medicare payment policies to encourage innovation in how care is delivered, and then carefully apply measures to assess how well those innovations are contributing to the Triple Aim of better individual health, better population health, and lower per capita costs—all things that, it seems to me, can be measured, especially the latter two, even if the most commonly used measures today don’t yet fit the bill.  Further, MACRA itself calls for harmonization of measures across the current Medicare reporting programs, creates a process for the medical profession and others to propose new and better measures, and other needed improvements.

The three Dr. Bobs are right, in that we shouldn’t design payments and delivery systems around performance measures. We shouldn’t think that care will be better if we dangle a few dollars out to physicians for meeting this measure or that.  Instead, we should figure out what works to help physicians achieve the Triple Aim, including better ways to organize and deliver care, and then judiciously apply a core, harmonized, and improved set of measures to track progress, while always being on the look-out for unintended adverse consequences.  MACRA may very well turn out to be an imperfect framework to achieve this, but it is a good start and should be given a chance to work.

Today’s question: Do you agree or disagree with what the three Dr. Bobs have to say about performance measures?

Thursday, January 14, 2016

The State of Obamacare

The Affordable Care Act, aka “Obamacare” was only briefly mentioned by President Obama in is his final State of the Union Address last night.  Rather than offering a chapter-and-verse defense of what he believes that the ACA has accomplished, he discussed it in the broader context of making “basic mobile as everything else is today” for people “short of retirement":

“...That’s what the Affordable Care Act is all about. It’s about filling the gaps in employer-based care so that when we lose a job, or go back to school, or start that new business, we’ll still have coverage. Nearly eighteen million have gained coverage so far. Health care inflation has slowed. And our businesses have created jobs every single month since it became law.”

The Republican counter to the President’s address, offered by South Carolina Governor Nikki Haley,  gave short shrift to Obamacare, briefly mentioning it (although  not by name) as one of the changes that would come if  Republicans held the White House:

“We would end a disastrous health care program, and replace it with reforms that lowered costs and actually let you keep your doctor.”

I know that most people have made up their minds about Obamacare and aren’t likely to be persuaded by data and evidence offered by one side or the other.  Yet Obamacare is going to be one of the top issues in the 2016 election, despite the little attention given to it last night.  It’s present and future shouldn’t be based on partisan talking points, but on a factual, evidence-based assessment of what we now know about its impact.  Otherwise, how will we know what is working, what isn’t and what should be changed?

Fortunately, there is a growing body of solid evidence available on its impact on jobs, access, costs, and quality.  Most of it does not support the “Obamacare is disastrous” meme offered by its critics; rather, recent studies suggest that the law has helped improve access to care for millions.  Yet the trend to high deductible plans is worrisome. This is what we know:

1. Has Obamacare resulted in job losses, forced people into part-time jobs, and discouraged people from working?

The evidence so far suggests that none of these predicted adverse impacts has occurred.

The Washington Post reports that “During the debate over President Obama's signature health-care law, opponents warned that the law would discourage large numbers of Americans from working, force millions into part-time jobs and make it more difficult to find work. Three new studies released this week suggest that, so far, it hasn't happened.”  One of the studies, the Post observes, looked at “whether employees have chosen to work less in order to qualify for Medicaid, which became available to a larger group of people under health reform. The new research on the effects of the Medicaid expansion does not suggest that people are looking to limit their earnings. On the contrary, some might even be looking to work more.”

Bloomberg New’s Editor-in-Chief Matthew Winkler reports that the ACA has had a “benign” impact on the economy:

“The [U.S. economy’s] investment boom continues unabated after an estimated 17.6 million Americans gained some form of health-insurance coverage following enactment of the Affordable Care Act in March 2010. Instead of being the economic catastrophe predicted by congressional Republicans, all of whom voted against it, Obamacare proved benign for U.S. business and healthcare companies delivered the best total return (income and appreciation) of any industry since October 2013, when the law took effect for most people, according to Bloomberg data.” 

2. Has Obamacare reduced the number of uninsured and increased access to care?

It is now an indisputable fact that the ACA has reduced the numbers of uninsured person.  The U.S. Census Bureau found, “In 2014, the percentage of people without health insurance coverage for the entire calendar year was 10.4 percent, or 33.0 million, lower than the rate and number of uninsured in 2013 (13.3 percent or 41.8 million). Between 2008 and 2013, the uninsured rate was relatively stable. In 2014, the uninsured rate sharply decreased, which was the largest change in the uninsured rate throughout this period.”  The Commonwealth Fund reports that the uninsured rate dropped in every U.S. state and the District of Columbia—with the biggest gains in coverage coming from states that expanded Medicaid.

Yet some ACA critics, while conceding there are fewer uninsured, argue that access has not necessarily improved because the coverage they get is inadequate, especially for those enrolled in Medicaid.  But we now have a growing body of evidence that as people have gained coverage, including for those enrolled in Medicaid, barriers to access are falling as a result:

The LA Time’s Noam Levy reports that “states' Medicaid expansions through the Affordable Care Act are helping low-income patients access medical care and improving hospitals' bottom lines, according to two new studies that add to growing evidence about the benefits of the health law. Fewer low-income residents of Kentucky and Arkansas, two poor states that expanded Medicaid in 2014, reported problems paying medical bills after the coverage expansions, especially compared with residents of Texas, which has rejected the health law. And hospitals in Medicaid expansion states saw a marked decline in the share of patients without insurance compared with hospitals in states that have not broadened access to Medicaid, a second study found.”

And the same Commonwealth Fund study discussed earlier found that the ACA has reduced cost barriers to patients obtaining needed care.  “Many people with no or inadequate insurance coverage skip needed care or struggle to pay medical bills. One of the central aims of the ACA is to improve access to care by removing financial barriers. From 2013 to 2014, the share of adults (age 18 and older) who said they went without care because of costs declined by at least two percentage points in 21 states. This is likely a result of expanded insurance coverage as well as improvements in the economy.”

3. Is Obamacare driving up premiums?

The evidence suggests that on average, employer-based premium increases have been very modest since Obamacare became law, especially compared to the norm 10 years ago.  A survey of 2000 large and small employers conducted by the Kaiser Family finds that premiums for employer-based family coverage in 2015 increased by an average of 4 percent.  The survey, which is conducted annually, also provides historical context for the current premium increase.  From 1999 to 2005, the average annual premium  for family coverage increased by 11% per year,  slowed to 5% in 2005 to 2010, and has remained at 5% from 2010 (the year Obamacare became law) through 2015.

Another report from the Kaiser Family Foundation reports that there is considerable volatility in the premiums charged for health plans offered through the ACA’s  health insurance marketplaces, with  “the percent change from last year in the benchmark [silver plan] premium ranges from -10.6% in Seattle, Washington to 38.4% in Nashville, TN. The simple average of these rate changes is 10.1% before accounting for the premium tax credit.”  After the tax credits subsidy is included, though, a typical 40-year old non-smoker making $30,000 a year would be able to find a marketplace plan in 2016 that costs him slightly less out-of-pocket than in 2015, with a weighted average reduction of 0.7%.

4. Is healthcare becoming unaffordable because of high deductible plans?

Deductibles, co-payments, and co-insurance for health plans offered by employers have been going up for a long time now, well before Obamacare became law.  But deductibles are continuing to increase even with the ACA capping total out-of-pocket expenses. The ACA limits the maximum amount that people have to pay out-of-pocket, yet even with the limits, high cost-sharing plans may still result in expenses that make healthcare unaffordable for many.  In 2016, total out-of-pocket costs (deductibles for qualified health plans, whether offered by employers or through the law’s health insurance marketplaces, are capped at $6,850 for individuals and $13,700 for families.  The law also requires qualified health plans to offer coverage for preventive services that receive an A or B rating from the U.S. Preventive Services Task Force at no out-of-pocket cost to the insured.  The Kaiser Family Foundation’s employer survey reports that since 2010, “deductibles for all workers have risen almost three times as fast as premiums and about seven times as fast as wages and inflation.”

My take on all of this is that Affordable Care Act has done a lot of good for a lot of people, and the “Obamacare is disastrous” meme just isn’t supported by the facts and evidence.

Obamacare hasn’t wrecked the economy, caused job losses, or forced people into part-time work.  The ACA has provided coverage to more than 10 million people who otherwise would have gone without it, driving down the uninsured rate to unprecedented lows.  Those who have gotten coverage have better access to health care as a result of it, including the millions who became eligible for Medicaid.  Premiums in plans offered by employers aren’t skyrocketing, and in fact, have increased modestly and by considerably less than the annual double-digit increases seen 10 years ago.  Premiums in the ACA’s marketplace plans have been more volatile and variable, yet most people can still find a plan with an affordable premium once tax credit subsidies are taken into account.

I realize that the data I cited above doesn’t describe everyone’s experience with the ACA.  For sure, there are some employers who raised their premiums by much more than the average of 4% in 2016.  Yes, there are some employers who may have cut back the hours of their employees.  Studies can only inform us about what the average, or typical experience, has been.  Much of the opposition to the ACA, I think, comes from people whose experiences aren’t the typical ones, who saw their hours cut, or their premiums go up, or heard about people that had such experiences, and they conclude from this, not unreasonably, that this is the case for everyone else.  Such stories provide a powerful narrative to politicians who oppose the ACA.  Yet there is another powerful narrative, the stories of millions of Americans who, because of the ACA, have access to affordable healthcare.

My biggest worry is that the continued growth of high deductible plans will make health care unaffordable for too many, even with the ACA’s limits on total out-of-pocket costs and coverage of preventive services.  Obamacare didn’t create the high deductible problem, but it didn’t solve it either.

In an ideal world, I would love to see candidates and political parties, Republican and Democrat, agree to keep the many things about Obamacare that are working, while making improvements to address the problems created by high deductible plans, narrow networks, and other shortcomings that the law didn’t address or make better.  Not that I expect that to happen anytime soon, of course.

Today’s question: What is your reaction to the evidence on Obamacare’s impact?

Wednesday, January 6, 2016

Will 2016 be a “Happy New Year” for Legislative Advocacy?

For physicians and their professional associations, 2016 will be unlike any other congressional advocacy year in recent memory.  Why?  Because when Congress last April repealed the Medicare SGR formula, it cleared the deck of the one issue that had bedeviled physicians and members of Congress for 14 years, allowing us to finally move on to other issues.

What other issues?  As I see it right now, ACP’s advocacy with Congress will now center on making improvements in healthcare policy, for the benefit of physicians and patients, in the following areas:

1. Incentives for chronic care management: starting from the recommendations we made in a letter we sent to the Senate Finance Committee to inform their newly-released Bipartisan Chronic Care Working Group options paper, we hope to see bipartisan legislation introduced and acted upon in both the Senate and House of Representatives to reduce barriers to chronic care management, including waiving cost-sharing requirements for Medicare's chronic care management codes, providing additional and dedicated payments to support the ability of physicians to manage patients with multiple chronic diseases, and reducing regulatory and administrative barriers to provision of chronic care management services.

2. Reform of meaningful use regulations: while we will continue to work with ONC and HHS to improve the meaningful use regulations, we believe that Congress has a role, both in providing oversight and enacting legislation as needed to simplify and improve the current program, especially as it transitions to the new Medicare Incentive Payment System (MIPS) created by MACRA. Congress took an important step in this direction when it passed legislation at the end of last year to allow for a blanket exemption from MU 2 for physicians who were unable to meet the 90-day reporting period requirements because CMS was so late in issuing the final MU 2 rule. We have urged both the administration and Congress to pause any plans to implement Meaningful Use Stage 3.

3. Sustainable Graduate Medical Education funding: ACP will soon be releasing joint recommendations with other internal medicine groups for reforming Medicare GME payments to support an adequate and well-trained physician workforce, particularly in internal medicine and other primary care specialties facing shortages. The paper will offer our alternatives to some of the ideas that the Institute of Medicine put forward that we found problematic. While Congress may not be inclined to enact big GME reforms this year, we believe that our recommendations could inform the discussion going forward, including bipartisan actions that might be taken in 2017 with a new administration and Congress.

4. Increased funding of key health programs: while it was very good news indeed that Congress was able last year to reach agreement on a two year deal to raise the sequestration budget caps, and that Congress also passed an omnibus appropriations bill to fund the federal government through September 30, 2016 that mostly preserved and in some cases increased funding for key health agencies, ACP will be gearing up again to lobby for continued and adequate funding for the fiscal year starting on October 1—including the Agency for Healthcare Research and Quality, National Health Service Corps, and the Title VII Primary Care Training programs.

5. Expanding use of telemedicine: we will be seeking opportunities for legislation to eliminate barriers to effective use of telemedicine, including a recommendation from our new policy paper, which calls on Medicare to lift geographic site restrictions that limit reimbursement of telemedicine and telehealth services by Medicare to those that originate outside of metropolitan statistical areas or for patients who live in or receive service in health professional shortage areas.

6. Integrating mental and behavioral health into primary care: we will be working with both the House and Senate to advance bipartisan legislation to improve access to mental and behavioral health, with a particular emphasis on integrating behavioral health into the primary care setting, as presented in our position paper published last year.

7. Restraining unjustified increases in prescription drug pricing: we will continue to advocate for legislation to restrain the unsustainable growth in prescription drug prices. To this end, ACP will be releasing a new position paper early in 2016 with our recommendations on restraining excessive price increases and increasing transparency while continuing to support innovation.

We will also continue to oppose efforts by Congress to defund or repeal the Affordable Care Act (the latest being a measure, passed by both the House and Senate through a simple majority vote using budget reconciliation, that would gut much of the law). Such efforts have virtually no chance of enactment, though, because President Obama will veto them.

All of which gets me back to the SGR, and why its repeal was such a big victory for organized medicine.  Not only did SGR eliminate the recurring threat of across-the-board payment cuts, it created the space we needed to advocate on a wider range of policies to improve access and quality, including the issues referenced above, most of which we believe can and should enjoy bipartisan support. In previous years, by having to devote most of our attention to the SGR, there was little room to pursue other issues. In that sense, 2016 really is a brand new—and potentially happy—year for physician advocacy with Congress.