Fwd: qotd: HMOs score poorly on access

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-------- Original Message --------
Subject: qotd: HMOs score poorly on access
Date: Thu, 28 Mar 2013 12:35:24 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



State of California
Office of the Patient Advocate
HMO Quality Ratings Summary - 2013

"Health Care Quality is getting the right care at the right time."

* poor
** fair
*** good
**** excellent

First rating is for "HMO provides recommended care,"
and the second rating is for "Getting care easily":

*** * Aetna Health of California, Inc.
*** * Anthem Blue Cross - HMO
*** ** Blue Shield of California - HMO
*** * CIGNA HMO
*** * Health Net of California, Inc.
**** ** Kaiser Permanente - Northern California
**** * Kaiser Permanente - Southern California
*** * Sharp Health Plan
*** * UnitedHealthcare of California
*** ** Western Health Advantage

http://reportcard.opa.ca.gov/rc2013/hmorating.aspx


Comment: California's Office of the Patient Advocate defines health
care quality as getting "the right care at the right time." So how well
are the HMOs doing?

To assess whether or not the right care is being provided, the HMOs
report their compliance with standard Health Plan Employer Data and
Information Set (HEDIS) measurements. The HMOs make certain that their
health care professionals are aware of the 37 HEDIS measurements that
will be made, and that they know that it is important to be certain that
compliance is documented.

All ten of the California HMOs were able to document that they were
either "good" or "excellent" at providing the right care for these 37
measured clinical recommendations. No measurement was made of the
hundreds of thousands of other clinical decision processes that take
place. It remains debatable as to whether 37 HEDIS measurements are
adequate to determine if the HMO is always good or excellent at
providing the right care, but there are those of us who have our doubts
(pardon the cautious, restrained language).

So regardless of whether or not it was the right care, was it provided
at the right time? Patients were surveyed about "experiences in getting
appointments with doctors and other providers when needed and getting
tests, treatments and other care without delay." No HMO was rated
excellent; no HMO was rated good. Three were rated fair, and seven were
rated poor. At least from the patients' perspective, care was not being
provided at the right time.

Under a single payer system, patients have free choice of their health
care professionals and institutions. HMOs take away that choice,
subjecting patients to severe financial penalties should they obtain
care outside of the HMO. The results of this survey suggest that, once
HMOs have captive patients, they limit access by limiting system
capacity and by establishing queues that are beyond the tolerance of
their patients.

The delegated model of HMOs has no place in a single payer system since
they function more as intrusive private insurers rather than as truly
integrated health care delivery systems.

HMOs that are fully integrated health care delivery systems, such as
Kaiser Permanente, do have a place in a single payer system. Right now,
Kaiser is heavily dependent on workers enrolling in Kaiser's plans
through their employment, often choosing Kaiser as their least-worst option.

Once we have a single payer system with patients choosing their health
care based on perceived quality, to compete successfully with the rest
of the health care delivery system, Kaiser will have to show that they
can deliver the right care at the right time. After all, that's what
single payer is all about.

Fwd: qotd: A joint-replacement pavilion limited to prima donna doctors and rich patients

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-------- Original Message --------
Subject: qotd: A joint-replacement pavilion limited to prima donna
doctors and rich patients
Date: Tue, 26 Mar 2013 12:16:29 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



MercuryNews.com
March 25, 2013
Fremont's Washington Hospital: Joint replacement patients, doctors
excluded from new facility
By Ashly McGlone

When Robert Cantley needed both knees replaced in August, he was
expecting to recover from the surgery at Washington Hospital's fancy,
new $42.7 million Center for Joint Replacement.

According to hospital marketing brochures, the center offered "A Higher
Level of Care" in a 20,000-square-foot space featuring 25 private
patient rooms, a "breathtaking physical therapy space" and a beautifully
landscaped therapy garden.

Instead, Cantley did his physical therapy sessions in a dimly lit
hallway on the sixth floor of the main hospital in what he described as
"a miserable set of circumstances."

Cantley's physician, Dr. John Jaureguito, who has been on the medical
staff at Washington for 18 years, said the arrangement means his
patients get "second-class" treatment. "Therapy is literally in the
hallway," he said. "I've never come across anything like this before."

What Cantley and many other patients at the public hospital didn't know
was that access to the new center, the only facility of its kind in the
Bay Area, is restricted to just two orthopedic surgeons at the hospital
-- the only ones on the Washington staff who met 24 criteria set by the
hospital.

Those two doctors -- long the hospital's primary joint replacement
specialists -- played a critical role in the creation of the lucrative
new center, and one of them acknowledges he helped create the criteria
that have excluded many of his fellow surgeons. Some of those surgeons
and their patients are crying foul, saying the result is a "two-tier"
system of care that favors wealthier patients and chosen doctors.

"It is a community hospital, serving the public," Cantley, 78, told the
publicly elected Washington Township Health Care District board at a
meeting last month. "The public in no way, shape or form should be
excluded from the new wing."

The only two surgeons who qualified, Dr. John Dearborn and Dr. Alexander
Sah, received a five-year contract from the hospital to staff the center
through May 2017 while maintaining their status as independent
contractors, not employees, according to the contract.

The average single joint-replacement surgery performed at Washington
Hospital in 2011 cost nearly $160,000, more than twice the California
average, state data show.

According to one of Dearborn's secretaries, neither he nor Sah accepts
Medi-Cal or Alameda Alliance, which serve low-income residents, but
typically carry lower reimbursement rates for doctors and hospitals than
does Medicare.

http://www.mercurynews.com/bay-area-news/ci_22853885/fremonts-washington-hospital-patients-doctors-excluded-from-new


Comment: There are ten orthopedists on the staff of Washington Hospital
in Fremont, California who perform joint-replacement surgery, but only
two are allowed to use the hospital's state-of-the-art Center for Joint
Replacement. The Center charges more than twice the average for
California, while the two approved surgeons apparently have a policy of
discouraging low-income residents, including Medi-Cal patients.

Perhaps the most appalling consequence is that the patients of the other
eight orthopedists receive their post-op physical therapy in the hallway
of the main hospital rather than in the new "breathtaking physical
therapy space."

As a community hospital, serving the public, and with pressure from the
state Department of Public Health and the Washington Township Health
Care District, it is likely that this arrangement will be modified.

So what does this have to do with health care reform? We can ask
ourselves if a single payer system that separately budgets capital
improvements would have ever allocated funds for a state-of-the-art
center serving only two prima donna surgeons and their affluent patients
exclusively. Of course not. Attention surely would have been directed to
a decision on whether or not it was even appropriate to establish a
separate joint replacement pavilion. Likely the funds would have been
better spent on improving or replacing existing surgical and physical
therapy facilities.

Achieving the goal of health care justice for all will be made that much
more difficult if our health care professionals and administrators fall
below the ethical plane that we envision for the healing arts.

Fwd: qotd: Can we recover waste by identifying geographic variations in health care?

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-------- Original Message --------
Subject: qotd: Can we recover waste by identifying geographic
variations in health care?
Date: Mon, 25 Mar 2013 12:10:23 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



The National Academies
Institute of Medicine
Interim Report of the Committee on Geographic Variation in Health Care
Spending and Promotion of High-Value Health Care: Preliminary Committee
Observations (2013)

A geographic value index would adjust payment to all providers within a
defined area based on aggregate measures of spending and quality. The
committee sought to determine empirically whether providers within a
defined area behave similarly (e.g., exhibit similar patterns of service
use across sub-regions, clinical conditions and quality measures).
Consistent with a body of literature, analyses commissioned by the
committee observed variation in health care spending at every geographic
level (Hospital Referral Regions, Hospital Service Areas, Metropolitan
Statistical Areas) studied, and additional research found variation
among hospitals within Hospital Referral Regions, among physicians in
the same group practice, and even within individual providers when
treating different conditions. Further, Hospital Referral Regions do not
consistently rank high or low across quality measures, nor is there a
consistent relationship between utilization and various quality
measures. These preliminary observations suggest that a geographic value
index would reward low-value providers in high-value regions and punish
high-value providers in low-value regions.

Health policy leaders suggest that, to improve value, payment reforms
need to create incentives to encourage behavioral change in the locus of
care (provider and patient), and thus payment should target
decision-making units, whether they be at the level of the individual
providers, hospitals, health care systems, or stakeholder
collaboratives. Payment reforms contained in the ACA (e.g., value-based
purchasing, accountable care organizations, bundled payments) and being
tested in the commercial market and Medicaid, do target decision makers
rather than geographic areas. Because these reforms are relatively new,
there is little evidence to date about their effects on the value of
care. Nevertheless, the results of the subcontractors' work for this
study suggest that tying a decision-making unit's payment to its
actions, as these reforms do, is preferable to induce desired changes in
care. Further, because post-acute care, particularly home health and
skilled nursing, is a major source of unexplained variation in Medicare
spending, reforms that address incentives to overuse post-acute care,
including fraud in that use, could have a large impact on health care
efficiency.

http://www.iom.edu/Reports/2013/Geographic-Variation-in-Health-Care-Spending-and-Promotion-of-High-Care-Value-Interim-Report.aspx


Comment: Health care spending tends to fall under a Bell curve. Most of
it falls in the middle, but some falls under the low end (low-cost) and
some falls under the high end (high-cost). The Dartmouth studies have
confirmed the geographical nature of this distribution. Thus much
attention has been directed to devising methods of recovering the
allegedly excessive spending in the high-cost regions. This report casts
doubt that such an effort would be productive.

To begin with, the Bell curve or Gaussian distribution (normal
distribution) is to be expected even when resources are being used
properly. Further, this variation is found not only between geographic
regions, but also between hospitals within the same regions, between
physicians within the same group practices, and even by the same
physicians managing different conditions. Thus measures designed to
reduce spending only in geographical regions at the high end will be too
blunt because they would reduce not only high-cost care of lower value,
but they also would reduce legitimately high-cost care that is providing
full value.

The authors of this Institute of Medicine report suggest that payment
reforms instead should target decision makers rather than geographical
areas. The decision makers include individual providers, hospitals,
health care systems, and stakeholder collaboratives. Health payment
reforms of the Affordable Care Act are designed to do just that. These
include measures such as accountable care organizations, value-based
purchasing, and bundled payments. Of course, adjusting payments based on
these and similar reforms are much more complex administratively than
merely adjusting payments based on regional spending levels.

It is questionable as to whether or not such payment systems could ever
be effective in significantly improving value in the entire health care
system since most impacts of the payment models are effective only at
the margin, if even there. Further, Gaussian distributions would apply
to these new models as well, making it likely that payment adjustments
would be inappropriate for some, even if appropriate for others.

Think of the Bell curve again, but for decision makers rather than
geographical regions. Many have suggested that 30 percent of health care
represents wasteful spending. What if you lop off the upper 30 percent
of care under the Bell curve? First you have to believe that you can
identify low-value care in advance - a highly unlikely scenario. Then
you have to assume that all care in the lower 70 percent provides value
whereas that in the upper 30 percent does not - a preposterous assumption.

What about the lower 30 percent of the curve. Does it really represent
high-value, low-cost care? Or does it represent care that is not being
delivered (and therefore not measured), even if it should be. Shouldn't
we be directing more efforts to be sure that we are meeting patient
needs, even if it could increase health care spending?

We are looking for ways to slow down the outrageous increases in
spending for what is often mediocre care. These feeble measures that are
designed to tweak decision makers are complex and likely will cost as
much to administer as any meager savings that they could realize. Some
of the ideas may be worth pursuing, such as value-based purchasing, but
we should not deceive ourselves that these are the grand solutions for
our excessive spending.

All other wealthy nations provide care for everyone at much lower costs,
and they have done it without playing these pseudo-wonk policy games. We
can't rely on silly, little tweaks. We need fundamental reform of our
health care financing system. We need a single payer national health
program.