After reviewing my browser links on articles I referenced frequently from 2010, I have compiled my most memorable reads below. In no particular order, they represent high impact citations on how future health reform may affect physician or hospital measurement, possibly countering trends that could lead to less effective policy, or at minimum, unhelpful judgments.
While not directly clinical, they all associate with the evaluation of our practice patterns and outcomes. For that reason, even if you normally limit yourself to CPC’s, Clinician’s Corner, or Update in Cardiology, they are worth a skim; each theme should be on your radar for the near term. Additionally, do not let the terms “payment,” “spending,””measurement,” or “margins” scare you back to another review on hospital-acquired infections (save it for the SHM annual meeting).
In advance, I avoided some topics due to coverage overload. On that list, I include Accountable Care Organizations (ACO’s), Comparative Effectiveness Research (CER), Patient Centered Medical Homes (PCMH’s) and Electronic Medical Records (EMR). No doubt, articles will emanate on these subjects in the coming months and they will get coverage in the mainstream press. However, ingrained in ACO’s, PCMH’s, and CER are some of what I include, mainly, the underpinnings of what makes these seemingly rock solid entities tick, and how their chaotic interiors may be misunderstood.
Predictably perhaps, I cite the Dartmouth Atlas frequently in the first cluster because of the intense passion it evokes, its wide scope in the literature base, and the role it plays in PPACA.
Finally, I do not critically appraise each citation, but only give a short overview on why they are relevant or interesting.
1. Payment Policy Based on Measurement of Health Care Spending and Outcomes: JAMA
A succinct review on why clinicians should partially yield when considering Dartmouth findings—not that they are incorrect, but data can speak many languages and the approach to analysis is the take home here. The article includes a useful figure as well, and it assists in clarifying how the Dartmouth investigators examine the Medicare cohort.
2. Critics Question Study Cited in Health Debate: NY Times /February 18 NEJM
This article from the NYT lit a firestorm with both the reporters and Dartmouth investigators submitting long letters of defense. All worth a read to get a sense of what this database is all about. Additionally, see the February 18 NEJM for additional point, counterpoint along the same vein.
3. McAllen And El Paso Revisited: Medicare Variations Not Always Reflected In The Under-Sixty-Five Population: Health Affairs
The atlas concerns itself with individuals older than age 65, i.e., folks in Medicare. The matter here is whether the conclusions derived in this population extrapolate to those not participating in the program. This obviously has great relevance on how we analyze practice patterns in the younger, commercial population. This paper reexamines the two cities Atul Gawande wrote about in his seminal 2009 New Yorker article, only now with a “youthful” cohort. The results may surprise you, and leads to greater questions, such as, are differences related to the unique characteristics of each group, or are the providers approaching payers differently.
4. Geographic Correlation Between Large-Firm Commercial Spending and Medicare Spending: AJMC
The above investigators are best in class. Many bemoan market power of late, and the question of whether provider concentration affects prices comes up frequently. Medicare outlays are relatively uniform, but commercial ones are not (we negotiate); what if two related regions with different provider concentrations utilized services similarly but one area grossed more, perhaps a lot more? Have a glance to see why for a potential explanation. Hint: Think Massachusetts.
5. Measuring Regional Variation in Service Use: MedPAC
If you are not familiar with MedPac, click through—they report to Congress on the state of Medicare and publish excellent reports. This citation highlights why regional variation in service use is not equivalent to regional variation in Medicare spending, i.e., one city may spend $8K per beneficiary, while another spends $6K/year. The fact is quantity of services delivered are often similar after adjustments. However, some spending areas demonstrate up to 25% differences between them, and signals that volume and cost require separate consideration. The Dartmouth data undergoes a more refined analysis and offers up interesting findings.
6. Regional Variations in Diagnostic Practices: NEJM
I am disappointed this study did not get more notice, as it calls attention to a fatal flaw in our risk adjustment approach. It is not the docs or coders per say that may introduce error, but likely where you live. Hail from Seattle, and your CMI (case mix index) is “x.” However, move to Miami and “x” increases by 20%. Why? More specialists, more tests, and thus, more “diagnosed” illness and this has an impact on how we characterize our population’s burden of disease. This is hugely important and has implications on how the number crunchers scrutinize regional practice patterns.
7. Variability in the Measurement of Hospital-wide Mortality Rates: NEJM
I am increasingly disturbed that mortality rates have become the proxy metric of choice in judging outcomes quality. This commentary got my attention, but the above paper drove it home. The variability and coarseness of this measurement is inappropriate to assess a service line or hospital, and it is not ready for prime time.
1. Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer: NEJM
This was a highly cited article, and for good reason—the investigators demonstrated that palliative care optioned to patients with metastatic cancer not only improved quality of life, but survival. It adds to the growing body of literature on this subject, and concludes what many of us who do this already suspect. Mainly, the investment in time to provide this service is worthwhile and necessary. If only the vocal opponents to advance care planning took notice. One of the year’s most helpful studies—both in the clinical and policy domain, and I hope more data comes our way using this care approach. SHM needs a position statement on this matter.
2. What Changes In Survival Rates Tell Us About US Health Care: Health Affairs
If you think poor US health outcomes are due to smoking, obesity, traffic fatalities, and homicides, well, not so fast. Our risk profiles are improving relative to other nations and the answer as to why we may underperform, as always, is uniquely American. Read on.
3. Primary Care: A Critical Review Of The Evidence On Quality And Costs Of Health Care: Health Affairs
The health reform mantra continues to reverberate, and the message is clear: we need more primary care providers. This outstanding review looks at the evidence, and the findings are unexpected. It is not how you train, but the organizational system you reside in, and how you practice.
4. Private-Payer Profits Can Induce Negative Medicare Margins: Health Affairs
A stand out, and don’t let the title divert you, this paper turns a common refrain heard by all of us in the hospital on its head: Medicare underpays and to compensate, commercial payers must make up the shortfall. Actually, it is the commercial plans that may overspend as hospitals engage in the medical arms race and in the process, max out surplus cash.
5. President Obama’s Coronary Calcium Scan: Archives of IM
Okay, a bit of fluff, but the subtext is serious. Have a dose of do as I say, but not as I do from the editor of Archives. Read it.
Physicians Take Heed:
1. The Effect of Different Attribution Rules on Individual Physician Cost Profiles: Annals of IM
Given all the inputs and complexities that go into tabulating an episode of care, how do folks who make physician attribution sound so simple react when they see a conclusion such as this: “Depending on the alternate rule used, between 17% and 61% of physicians would be assigned to a different cost category than that assigned by using the default rule.” This is not encouraging.
2. How Medicare’s Payment Cuts For Cancer Chemotherapy Drugs Changed Patterns Of Treatment: Health Affairs
Think doctors do not respond to financial signals? We are self-interested professionals (like anyone else), and this is one of many recent papers demonstrating behavior change resulting from alteration in fees. Physicians switched from dispensing the drugs that experienced the largest cuts in profitability, to other high-margin drugs in order to compensate for lost income.
3. Could Medicare Readmission Policy Exacerbate Health Care System Inequity?: Annals of IM
A must read for any hospital-based doc or administrator concerned with CMS readmission policy. Articulate commentary on the flaws of evaluating why folks reenter the hospital and the shortcomings of our current system. Serious stuff, and while we know we must scrutinize care patterns to minimize unnecessary presentations, I am afraid the cart gets placed before the horse again.
4. Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program: Annals of IM
Medical malpractice is a frontline issue in doctor circles, and various pilots and proposals are progressing to assist in resolving this dilemma. The approach of the Michigan investigators encompasse error disclosure in real time, and the results are impressive. While not exportable to every practice locale, it is thought provoking and a good first step.
5. Physicians’ Opinions About Reforming Reimbursement: Archives of IM
Disheartening, and if primary care physicians are considering cross subsidies from subspecialists to compensate for insufficient income, think again. Perhaps the teachers union will assist.
On ACO’s: The medical community’s enthusiasm is a harbinger of good things to come. Everyone is a winner. Increased quality, lower costs, and better performers receive improved compensation. What is not to like.
A Woody Allen quotation describes care integration best –“Right now it’s only a notion, but I think I can get the money to make it into a concept, and later turn it into an idea.” Get ready, because when it gets to the idea stage, and parties realize they might suffer losses, hold on to your hats. ACO’s will not be the emperor’s new clothes thereafter. Substitute PCMH for ACO and you can write the same bullet.
Hot topics: Vitamin D, Radiation and CT overuse, PPI-Clopidogrel Interactions, LABA’s and anticholinergic MDI’s associated with increased mortality.
This Year’s Mammogram-USPTF Kafuffle: Lung Cancer Screening, Sodium/Sugar intake = obesity vs. personal responsibility, Avastin and Provenge foreshadowing CER battles, tempering of personalized medicine (not ready for prime time), FDA missteps, P4P/EMR is fallible and needs work.
Sharpest Columnist on health care issues: David Leonhardt of the NYT, and you just might think he is a physician based on his astute and usually spot on observations. If you do not read him, start, every Wednesday in the business section.
Best Health care Blog: The Incidental Economist. My interest span for new blogs is about a month. Perhaps there a half dozen must-reads in my feeder that keep my attention, and I would categorize TIE as the finest. The title is deceptive (this is not a site about the mortgage meltdown and TARP), and is brainy, sharp, and an evidence-based exploration of serious economic, policy, law, and population health issues. The readers and comments are earnest and so is the blogging team. If you want to learn something, go there. Trust me.
Best Health Series: WSJ, NYT, ProPublica (click on links for Medicare fraud, oversight of radiology, and dialysis debacles respectively). This is why we need good journalism.
Biggest health care Issue for next year: The Budget. You read correct. That is the 800-pound gorilla…and not the latest cardiac toy. The health care sector will not suffer huge damage this year, but 2011 will give us the first glimpse of what is in store. I do not say this jokingly. The house of medicine has no idea how painful the future will be for the next decade.
Finally, anyone who follows the news is aware of the constitutional battle involving the individual mandate, i.e., can the government require you to purchase health insurance? If there was any news story that was worthy of the typical American reaction to why equating buying health insurance when you need it is equivalent to buying home insurance when your house is burning down, well, it is this story of a house burning down. So instructive. Watch the video to learn what happens when rugged individualism starts getting real.
Anyway, enjoy and see you in 2012!
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.
Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.
Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.
He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.