“[T]he model for the ACO program … has been tested in the PGP demonstration project that began in 2005. In the demonstration, 10 group practices … were permitted to receive bonus payments if they passed quality-of-care thresholds and achieved savings…. [T[he year 2 evaluation report documented that the essential reason for the overall savings across the 10 sites of about 1% … was from diagnosis coding changes the PGP sites initiated….” Robert A. Berenson, “Shared savings program for Accountable Care organizations: A bridge to nowhere?” American Journal of Managed Care, 2010; 16:721-726., 723.
Prevention PreventionDisease management“Coordination” (gate-keeping, utilization review)Report cards and P4PElectronic medical records If ACO proponents have other mechanisms in mind, what are they?
“Although some preventive services do save money, the vast majority reviewed in the health economics literature do not.” “Although some preventive services do save money, the vast majority reviewed in the health economics literature do not.” Joshua T. Cohen et al., “Does preventive care save money? Health economics and the presidential candidates,” New England Journal of Medicine 2008;358:661-663.“It’s a nice thing to think, and it seems like it should be true, but I don’t know of any evidence that preventive care actually saves money.” Jonathan Gruber, economist at the Massachusetts Institute of Technology, quoted in David Leonhardt, “Free lunch on health? Think again,” New York Times, August 8, 2007, C 2.
“The cost of caring for CVD, diabetes, and CHD over the coming 30 years will be on the order of $9.5 trillion. If all the recommended prevention activities were applied with 100% success, … total medical costs [would rise] by $7.6 trillion (162%).” “The cost of caring for CVD, diabetes, and CHD over the coming 30 years will be on the order of $9.5 trillion. If all the recommended prevention activities were applied with 100% success, … total medical costs [would rise] by $7.6 trillion (162%).” Richard Kahn et al., “The impact of prevention on reducing the burden of cardiovascular disease,” Circulation 2008;118:576-585, 580.
“Even for the most optimistic picture – a 30-year horizon and assuming no turnover [patients stay with the same plan for 30 years] – the net effect on diabetes-related costs would be an increase of about 25%.” [P 261] “The [disease management] program used in [this] study may be too expensive for health plans or a national program to implement.” [P 251] “Even for the most optimistic picture – a 30-year horizon and assuming no turnover [patients stay with the same plan for 30 years] – the net effect on diabetes-related costs would be an increase of about 25%.” [P 261] “The [disease management] program used in [this] study may be too expensive for health plans or a national program to implement.” [P 251] David M. Eddy et al., “Clinical outcomes and cost-effectiveness of strategies for managing people at high risk for diabetes,” Annals of Internal Medicine 2005;143:2512-64.
“On the basis of its examination of peer-reviewed studies of disease management programs…, CBO finds that to date there is insufficient evidence to conclude that disease management programs can generally reduce the overall cost of health care services.” “On the basis of its examination of peer-reviewed studies of disease management programs…, CBO finds that to date there is insufficient evidence to conclude that disease management programs can generally reduce the overall cost of health care services.” Congressional Budget Office, An Analysis of the Literature on Disease Management Programs, October 13, 2004, http://www.cbo.gov/showdoc.cfm?index=5909&sequence=0, accessed September 25, 2005.
“[T]he results of our review suggest that, to date, support for population-based disease management is more an article of faith than a reasoned conclusion grounded on well-researched facts. ... Most of the evidence on disease management programs to date is derived from small high-intensity programs focusing on high-risk patients that are typically run as part of a demonstration project by the providers at a single site. This evidence suggests that those programs typically lead to better processes of care, but the evidence for improved long-term health outcomes and cost savings is inconclusive. ... [T]he vendor-run assessments typically do not meet the requirements of peer-reviewed research ....” “[T]he results of our review suggest that, to date, support for population-based disease management is more an article of faith than a reasoned conclusion grounded on well-researched facts. ... Most of the evidence on disease management programs to date is derived from small high-intensity programs focusing on high-risk patients that are typically run as part of a demonstration project by the providers at a single site. This evidence suggests that those programs typically lead to better processes of care, but the evidence for improved long-term health outcomes and cost savings is inconclusive. ... [T]he vendor-run assessments typically do not meet the requirements of peer-reviewed research ....” Soeren Mattke et al., "Evidence for the effect of disease management: Is $1 billion a year a good investment?" American Journal of Managed Care 2007;13:670-676.
“To study whether care coordination improves the quality of care and reduces Medicare expenditures, the Balanced Budget Act of 1997 mandated that the Secretary of Health and Human Services conduct and evaluate care coordination programs…. [p. 604] None of the [15] programs reduced regular Medicare expenditures, even without the fees paid to the care coordination programs. Only two programs had a significant difference in expenditures and, in both of these programs, the treatment group [that is, the group getting ‘coordinated care’] had higher expenditures. “(p. 611) “To study whether care coordination improves the quality of care and reduces Medicare expenditures, the Balanced Budget Act of 1997 mandated that the Secretary of Health and Human Services conduct and evaluate care coordination programs…. [p. 604] None of the [15] programs reduced regular Medicare expenditures, even without the fees paid to the care coordination programs. Only two programs had a significant difference in expenditures and, in both of these programs, the treatment group [that is, the group getting ‘coordinated care’] had higher expenditures. “(p. 611) Deborah Peikes et al., “Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials,” Journal of the American Medical Association 2009;201:603-618.
“Although utilization review is widely used to control health care costs, its effect on patterns of health care is uncertain….We compared the health services provided to 3702 enrollees whose requests were subjected to utilization review (the review group) with the services provided to 3743 enrollees whose requests received sham review and were automatically approved for insurance coverage (the non-review group)…. During the study period, the mean age-adjusted insurance payments per person were $7,355 in the review group and $6,858 in the non-review group (P = 0.06).” “Although utilization review is widely used to control health care costs, its effect on patterns of health care is uncertain….We compared the health services provided to 3702 enrollees whose requests were subjected to utilization review (the review group) with the services provided to 3743 enrollees whose requests received sham review and were automatically approved for insurance coverage (the non-review group)…. During the study period, the mean age-adjusted insurance payments per person were $7,355 in the review group and $6,858 in the non-review group (P = 0.06).” Stephen N. Rosenberg et al., “Effect of utilization review in a fee-for-service health insurance plan,” New England Journal of Medicine 1995;333:1326-1330, 1326.
“[O]ur results show that report cards [on heart surgeons] led to increased expenditures for both healthy and sick patients, marginal health benefits for healthy patients, and major adverse health consequences for sicker patients. Thus, we conclude that report cards reduced our measure of welfare over the time period of our study” (P 577). “[M]andatory reporting mechanisms inevitably give providers the incentive to decline to treat more difficult and complicated patients” (P 581). “[M]ore severely ill … patients experienced dramatically worsened health outcomes.” (p. 583) “Report cards led to a decline in the illness severity of patients receiving CABG [coronary artery bypass grafts] in New York … relative to patients in states without report cards.” (P 583) “[O]ur results show that report cards [on heart surgeons] led to increased expenditures for both healthy and sick patients, marginal health benefits for healthy patients, and major adverse health consequences for sicker patients. Thus, we conclude that report cards reduced our measure of welfare over the time period of our study” (P 577). “[M]andatory reporting mechanisms inevitably give providers the incentive to decline to treat more difficult and complicated patients” (P 581). “[M]ore severely ill … patients experienced dramatically worsened health outcomes.” (p. 583) “Report cards led to a decline in the illness severity of patients receiving CABG [coronary artery bypass grafts] in New York … relative to patients in states without report cards.” (P 583) David Dranove et al., “Is more information better? The effects of ‘report cards’ on health care providers,” Journal of Political Economy 2003;111:555-588.
“Rachel M. Werner and David A. Asch (2005) “Rachel M. Werner and David A. Asch (2005) find that the incidence of cardiac surgery for minority patients relative to white patients declined in New York subsequent to the introduction of report cards.” David Dranove and Ginger Zhe Jin “Quality disclosure and certification: Theory and practice,” Journal of Economic Literature 2010;48:935-963, 955.
“There has been enough experience to date with pay for performance and transparency to argue convincingly that neither of these additional mechanisms for compensating physicians will achieve the goal of most patients to receive high-quality, humane, and affordable care…. [citations omitted]. These mechanisms are not silver bullets; they can enhance performance only modestly…. In addition, these mechanisms may have unintended consequences. …. If only a few measures are used in pay-for performance arrangements, clinicians will design particular aspects of their practice to ensure those measures are achieved, even if it means reducing quality of care in other practice areas.” “There has been enough experience to date with pay for performance and transparency to argue convincingly that neither of these additional mechanisms for compensating physicians will achieve the goal of most patients to receive high-quality, humane, and affordable care…. [citations omitted]. These mechanisms are not silver bullets; they can enhance performance only modestly…. In addition, these mechanisms may have unintended consequences. …. If only a few measures are used in pay-for performance arrangements, clinicians will design particular aspects of their practice to ensure those measures are achieved, even if it means reducing quality of care in other practice areas.” Robert Brook, “Physician compensation, cost, and quality,” Journal of the American Medical Association 2010, 304;795-796
“Explicit financial incentives in the pay-for-performance initiative introduced in the United Kingdom in 2004 did not improve the quality of care and clinical outcomes for patients with hypertension in primary care.” “Explicit financial incentives in the pay-for-performance initiative introduced in the United Kingdom in 2004 did not improve the quality of care and clinical outcomes for patients with hypertension in primary care.” Brian Serumaga et al., “Effect of pay-for-performance on the management and outcomes of hypertension in the United Kingdom: Interrupted time series study,” British Medical Journal 2011;342:d108.
“We analyzed physician survey data on 255,402 ambulatory patient visits…. [P E1] …. [N]either EHRs [electronic health records] nor CDS [clinical decision support] was associated with ambulatory care quality, which was suboptimal for many indicators. We noted no association between EHR use and care quality for 19 indicators and a positive relationship for only one indicator. We also found CDS use associated with better quality for only one of 20 quality indicators, refuting our hypothesis that CDS would be associated with improved care quality.” [P E4] “We analyzed physician survey data on 255,402 ambulatory patient visits…. [P E1] …. [N]either EHRs [electronic health records] nor CDS [clinical decision support] was associated with ambulatory care quality, which was suboptimal for many indicators. We noted no association between EHR use and care quality for 19 indicators and a positive relationship for only one indicator. We also found CDS use associated with better quality for only one of 20 quality indicators, refuting our hypothesis that CDS would be associated with improved care quality.” [P E4] Max J. Romano and Randall S. Stafford, “Electronic health records and clinical decision support systems: Impact on national ambulatory care quality,” Archives of Internal Medicine, published online January 24, 2011, doi:10.1001/archinternmed.2010.527.
“We linked data from an annual survey of computerization at approximately 4000 hospitals for the period from 2003 to 2007 with administrative cost data from Medicare Cost Reports and cost and quality data from the 2008 Dartmouth Health Atlas. We calculated an overall computerization score and three subscores based on 24 individual computer applications…. We analyzed whether more computerized hospitals had lower costs of care or administration, or better quality…. As currently implemented, hospital computing might modestly improve process measures of quality but does not reduce administrative or overall costs.” “We linked data from an annual survey of computerization at approximately 4000 hospitals for the period from 2003 to 2007 with administrative cost data from Medicare Cost Reports and cost and quality data from the 2008 Dartmouth Health Atlas. We calculated an overall computerization score and three subscores based on 24 individual computer applications…. We analyzed whether more computerized hospitals had lower costs of care or administration, or better quality…. As currently implemented, hospital computing might modestly improve process measures of quality but does not reduce administrative or overall costs.” David U. Himmelstein et al., “Hospital computing and the costs and quality of care: A national study,” American Journal of Medicine 2010;123:40-46, 40.
HMOs didn’t work because administrative costs offset reduced medical costs, and for reasons set forth below. HMOs didn’t work because administrative costs offset reduced medical costs, and for reasons set forth below.Report cards and P4P don’t work because quality can’t be measured accurately, and Skinnerian tactics work only with simple tasks.Cost of prevention, DM and EMRs outweighs foregone medical expenditures due to better health.
“On the basis of recommendations from national clinical care guidelines for preventive services and chronic disease management, and including the time needed for acute concerns, sufficiently addressing the needs of a standard patient panel of 2,500 would require 21.7 hours per day.” “On the basis of recommendations from national clinical care guidelines for preventive services and chronic disease management, and including the time needed for acute concerns, sufficiently addressing the needs of a standard patient panel of 2,500 would require 21.7 hours per day.” Kimberly S Yarnall et al., “Family physicians as team leaders: ‘time’ to share the care,” Preventing Chronic Disease 2009 6(2), http://www.cdc.gov/pcd/issues/2009/apr/08_0023.htm, accessed June 1, 2010.
“Are you feeling down? Have you recently traveled to another country? Do you have more than one sexual partner? Does your child live in or regularly visit a house built before 1950? How do you deal with anger? Any trouble sleeping? Do you wear a seat belt? Do you drink alcohol? Does your vision make it difficult for you to recognize your pills or read medication labels? Do you have a gun at home?” “Are you feeling down? Have you recently traveled to another country? Do you have more than one sexual partner? Does your child live in or regularly visit a house built before 1950? How do you deal with anger? Any trouble sleeping? Do you wear a seat belt? Do you drink alcohol? Does your vision make it difficult for you to recognize your pills or read medication labels? Do you have a gun at home?” Kathleen P Tomaselli, “One more thing,” American Medical News, January 23, 2006, 19.
prevention, prevention,disease management,coordination,report cards and pay-for-performance, andElectronic medical records… what mechanism do ACO proponents think ACOs will use?
Not clear why. Some claim “homes” will be building blocks for ACOs. Others imply “homes” have already shown an ability to do that which HMOs and managed care could not, namely, lower costs by improving care. Not clear why. Some claim “homes” will be building blocks for ACOs. Others imply “homes” have already shown an ability to do that which HMOs and managed care could not, namely, lower costs by improving care.But “medical homes” are almost as vaguely defined as ACOs, and have roughly the same track record, namely, none at all.
“Reforms that support primary care can leverage accountable care, and vice versa. For example, medical homes typically involve additional payments to primary care physicians each month in exchange for physicians’ leading prevention, disease management, and care coordination activities…. Implementing a medical home and accountable care organization at the same time could address budgetary concerns while also providing more incentives for overall care coordination.” “Reforms that support primary care can leverage accountable care, and vice versa. For example, medical homes typically involve additional payments to primary care physicians each month in exchange for physicians’ leading prevention, disease management, and care coordination activities…. Implementing a medical home and accountable care organization at the same time could address budgetary concerns while also providing more incentives for overall care coordination.” Mark McClellan et al., “A national strategy to put accountable care into practice,” Health Affairs 2010;29:982-990, 985
Research on “home”-like entities suggests that integrating more nurses and social workers into primary care clinics improves health, possibly enough to offset the cost of the additional staff. Research on “home”-like entities suggests that integrating more nurses and social workers into primary care clinics improves health, possibly enough to offset the cost of the additional staff.But this simple intervention does not require recycling the HMO experiment.
“[W]e found greater problems with underuse (46.3 percent of participants did not receive recommended care …) than with overuse (11.3 percent of participants received care that was not recommended and was potentially harmful…).” “[W]e found greater problems with underuse (46.3 percent of participants did not receive recommended care …) than with overuse (11.3 percent of participants received care that was not recommended and was potentially harmful…).” Elizabeth A. McGlynn et al., “The quality of health care delivered to adults in the United States,” New England Journal of Medicine 2003;348:2635-2645, 2641.
Wrong diagnosis (FFS); Wrong diagnosis (FFS);Faith-based solutions that raise costs as much as or more than they lower costs:- capitation, which in turn requires
- consolidation
- report cards and
- limited choice (or “invisible enrollment”)
If insurance companies agree to shift risk to clinics and hospitals, who needs insurance companies? If insurance companies agree to shift risk to clinics and hospitals, who needs insurance companies?
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