July 6th, 2011 by DavidHarlow in Health Policy
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Massachusetts Attorney General Martha Coakley released her office’s second annual report, An Examination of Health Care Cost Trends and Drivers (PDF; see also press release), which contains a wealth of critical data analysis — and also highlights how little we know about certain things — providing some important context for the discussion of the proposed Part III of Massachusetts health reform, a bill filed by Governor Patrick which would create all-payor ACOs and a system of global payments.
At this late date, few would argue against a move a way from fee-for-service reimbursement for health care, or adding quality metrics to the mix, and tying financial rewards to providers to their performance measured against these metrics. (Consider the Massachusetts Blue Cross Blue Shield ACQ (alternative quality contract) experience.) The AG’s report, however, highlights the wide disparities in payments to providers based on negotiating strength, rather than quality or cost of care (as noted in last year’s AG report; check out the 2009 special commission report, too). Read more »
*This blog post was originally published at HealthBlawg :: David Harlow's Health Care Law Blog*
June 14th, 2011 by DavidHarlow in Health Policy, Opinion
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There has been a significant outcry against the proposed ACO regs: everything’s wrong and nothing’s right about them, or so some would have us believe. (The comment period is still open, and CMS is still soliciting input; much of the outcry is a form of posturing and negotiation … not that there’s anything wrong with that.)
Today’s “nattering nabobs of negativism” focus on: the estimated price tag for complying with the regulatory requirements (IT and other infrastructure incuded), the slim chance of success by ACOs in righting the wrongs of decades of bloat in the health care system, the premature pledging of allegiance to an idea only partly proven through the PGP demo, the likelihood of failure due to the whole endeavor’s being tied to FFS reimbursement, on the one hand, and due to exposure of ACOs to downside risk, on the other, the unreasonable reliance on dozens and dozens of quality measures . . . and the list goes on. For further detail, see, e.g., David Dranove’s recent post decrying unproven theories baked into the ACO program (with a link to info on the PGP demo’s results, and differing interpretations of those results; check out the lively discussion in the comments to Dranove’s post on The Health Care Blog), Jeff Goldsmith’s opposition to ACOs as conceived in the ACA (and alternative proposal discussed in the linked post), and Mark Browne’s search for a few good quality measures. (This has been a recurring theme for me as well; I would love to find six or eight meta-measures that predict all others; Mark links to the AHA’s comments on the ACO rule, which are worth a read). Read more »
*This blog post was originally published at HealthBlawg :: David Harlow's Health Care Law Blog*
April 11th, 2011 by DavidHarlow in Health Policy
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ACO regulations and related federal issuances hit the street last Thursday, after several months of waiting — from CMS, OIG, FTC, DOJ and IRS. They cover the waterfront, ranging from the central regulation defining the structure and workings of the ACO, to limited Stark self-referral ban and anti-kickback statute waivers in the fraud and abuse arena, to new frameworks for antitrust analysis, to rules governing joint ventures involving taxable and tax-exempt organizations.
I had the opportunity to discuss the regs the day after they were issued on a special edition of the Blog Talk Radio show, ACO Watch, hosted by Gregg Masters (@2healthguru). Gregg’s guests included Mark Browne (@consultdoc), Vince Kuraitis (@VinceKuraitis), Jaan Sidorov (@DisMgtCareBlog) and yours truly (@healthblawg). We are geographically diverse, and bring a variety of perspectives to the table. I invite you have a listen — we enjoyed the opportunity to discuss the rules, we all learned from each other, and we hope you enjoy the conversation as well. (It runs about 90 minutes.)
Update 4/5/2011: For a collection of ACO analyses curated by Anita Samarth see: http://bit.ly/ACO-Analyses.
Here are a few points to consider as part of a first look at the ACO rules:
1. The rules were worth the wait. There are a lot of moving parts to coordinate, and the multi-agency effort really came together. The CMS rule also retains a fair amount of flexibility. Some requirements are very specific, but others much less so. (For one example of specific guidelines, take a look at the eight-part definition of patient-centeredness; an organization must satisfy all eight in order to be an ACO. Other requirements have no detail at all, and CMS will look to applicants to explain how they meet the requirements, without giving any hints.)
2. This is the Frankenstein regulation: A Medicare beneficiary must sit on the board of the ACO, CMS must approve all marketing materials before they are used …. These requirements may be traced back to origins in CMS demonstration project and Medicare Advantage policies, respectively, and illustrate the way in which CMS took a short statute and really put some meat on the bones. Some may balk at the weight of the requirements limiting the options of an ACO.
3. CMS has bootstrapped a law aimed at ACOs serving at least 5,000 Medicare beneficiaries each into a system of rules that effectively requires that commercial business be handled in an ACO-like manner. This, among other infrastructure requirements (e.g., 50% of ACO docs must be meaningful users of EHRs), leads to the conclusion that there will be relatively few ACOs, at least initially. CMS estimates 75-150 nationwide. There are, of course, many unanswered questions about what a commercial ACO would look like. One model I am familiar with — here in the People’s Republic of Massachusetts — is the AQC, or Alternative Quality Contract offered by Blue Cross Blue Shield of Massachusetts to providers enrolled in its HMO Blue product. One question is whether a slightly different financial model could apply to the commercial side of the house. One model worth a close look is Jeff Goldsmith’s proposed ACO model, which would treat primary care, emergency and diagnostic care, and episodes of specialty care in three distinct ways.
In brief, Goldsmith recommends risk-adjusted capitation payments for primary care, fee-for-service payments for emergency care and diagnostic physician visits, and bundled severity-adjusted payments for episodes of specialty care. Primary care would be provided through a patient-centered medical home model, which would likely have a collateral effect of reducing the total volume of emergency care and diagnostic physician visits. Specialty care would be provided through “specialty care marts,” ideally more than one per specialty per market to maintain a little healthy competition.
A quick explanation of this approach to an intensivist over the weekend elicited a favorable response.
4. Also in the bootstrapping department, CMS has shifted the ACO from a “shared savings” approach to having ACOs share risk as well as the upside. Of course, this makes a lot of sense; a number of commentators, including the HealthBlawger, had lamented the fact that risk sharing was left out of the statute. CMS has used its general waiver and demo authority under the ACA to move the ACO into risk sharing. The ACO may choose: share risk from day one, and enjoy a potentially higher percentage of the upside, or defer the risk sharing to year three.
5. The retrospective nature of patient attribution and savings calculations mean that each ACO must treat every Medicare fee-for-service patient as if he or she is “theirs.” Patients have the right to decide whether they want their data shared with an ACO; if enough patients are spooked by health care data privacy and security issues, fewer and fewer will authorize the sharing from CMS to the ACO, and the ACO will have to drive by feel — or base its management of Medicare beneficiaries on its management of its general patient population.
6. Organizations that dominate their local markets may be the most successful as ACOs, but they may face the most involved antitrust review at the hands of the FTC/DOJ.
7. Scoring on 65 quality metrics in 5 domains will help determine the amount of any shared savings to be paid to an ACO. One domain, patient experience of care, links up nicely with the patient-centeredness threshhold requirement noted above. (For private sector attention to patient experience, see what the Leapfrog Group is doing in this domain, using some of the same measures.) While some may bristle at the number of metrics, it is worth noting that these metrics are all drawn from existing sets of measures.
8. All in all, the regulations represent the first stage of realizing the ACO vision expressed by Don Berwick last fall: there is a field open to experimentation (albeit a field likely limited to large networks of significant means that can underwrite the up-front infrastructure costs), and the ACO rules sketched out in the statute and further delineated in the regulations will enable CMS to incentivize the provider community to help achieve the triple aim of better care for individuals, better health for populations and reduced per-capita costs.
David Harlow
The Harlow Group LLC
Health Care Law and Consulting
*This blog post was originally published at HealthBlawg :: David Harlow's Health Care Law Blog*
October 27th, 2010 by KevinMD in Better Health Network, Health Policy, News, Opinion, Research
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Authors of a recent study from the Archives of Internal Medicine are unlikely to endear themselves to specialists. As reported by Reuters, and provocatively titled, Do specialist doctors make too much money?, the study gives a per-hour breakdown of how much doctors make.
I think this is a good approach, since annual salary figures do not account for the number of hours doctors work — and in the case of primary care doctors, this includes uncompensated time doing paperwork and other bureaucratic chores.
Here’s what they found:
… the lowest wages — amounting to $60.48 an hour — [were] paid to primary care physicians.
In other broad categories of practice, surgeons took home the highest average hourly wage of $92. Internal medicine and pediatric docs earned about $85 an hour, the researchers report in the Archives of Internal Medicine.
Looking at salaries among 41 specific subspecialties, however, they found neurologic surgery and radiation oncology to be the most lucrative at $132 and $126 per hour, respectively. These were followed by medical oncologists and plastic surgeons, both making around $114 per hour; immunologists, orthopedic surgeons and dermatologists also took in more than $100 an hour. At the low end of specialist pay, child psychiatrists and infectious disease specialists made around $67 an hour.
Of course, regular readers of [this] blog know that healthcare reform will do little to decrease the disparity. The pay raises that will be coming to primary care will be far too little to change the perception that, in the United States, specialists are more valued by far. Read more »
*This blog post was originally published at KevinMD.com*
June 30th, 2010 by KevinMD in Better Health Network, Health Policy, News, Opinion, Research
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Medical schools are traditionally ranked on criteria like research funding and technological innovation. These rankings are highly significant. A place on the U.S. News‘ annual “Best Medical School” list is a coveted spot indeed.
So that’s why there was some media attention paid to a recent study from the Annals of Internal Medicine, which ranked medical schools according to their “social mission” — a phrase that defines a school’s commitment to primary care, underserved populations and workforce diversity. Using this new criterion, some of the traditionally high ranking schools fell significantly. Read more »
*This blog post was originally published at KevinMD.com*
