Sunday, April 1, 2012

A Tough Week

Today’s Managing Health Care Costs Indicator is Five

It’s been a tough week for health care wonks of my persuasion.  

The Supremes – or at least the all-important Anthony Kennedy – suggested that the individual mandate could be toast, which would mean that the Affordable Care Act would insure millions fewer Americans.  Scalia et al suggested that if the mandate fell, the Court should invalidate the entire law, which would mean years or decades before we start trying the many good ideas embodied in this bill – including a path to generic biologic drugs, more comparative effectiveness research, and pilots to bundle payment.   The ACA is imperfect – but is chock full of good ideas for how to improve value in health care.  Many of these ideas won’t work as well as we would hope – but if we aren’t experimenting responsibly, our health care cost crisis will just continue to get worse and worse.

We need five justices to uphold the mandate, or at least to fail to declare the entire ACA unconstitutional. 

Two studies that came out this week also heightened my sense of malaise.  

The Premier Medicare Pay for Performance pilot – in which a group of 252 hospitals could earn bonus payments for improving certain quality metrics – showed no effectiveness whatsoever in lowering 30 day mortality.  NOW- this project wasn’t aiming to lower mortality. The bonuses were to encourage higher scores in certain evidence-based quality metrics – such as use of beta blockers and aspirin for heart attacks  and rapid antibiotics for pneumonias.   The reasoning was that this could improve quality and lower costs.
 Click Image to Enlarge. Source 

There are a lot of reasons why the Premier Medicare project might not have worked

·      The quality metrics might not actually be associated with lower mortality (good ideas –but not effective at diminishing death rates)
·      30 day mortality might be a bad metric itself – perhaps the hospital has more control over 15 day mortality, or 45 day mortality
·      The risk adjustment could have been flawed
·      The incentive might not have been large enough. The incentive was distant from the action, and although there was a potential penalty, hospitals could drop out if they faced a penalty.
·      The communication with the thousands of medical staff of these hospitals might have been ineffective

But all of this is whining.  Bottom line – this is  a deeply disappointing study.    Kudos to CMS, Premier, and Jha et al for publishing these negative results.  The only way to move forward effectively is to publish both positive AND negative results.

Ashish Jha had a double header in the NEJM last week – he also had an editorial suggesting that the emphasis on preventing hospital readmissions might be misdirected.  Hospital readmissions are staggering in the US Medicare population (almost one in five in 30 days).  However, readmissions are much lower in those under 65.   Further, Jha points to a literature review from the Canadian Medical Association Journal (The JAMA of the North) that showed that with clinical record review less than 12% of readmissions were judged to be preventable.  Overall only 2.2% of discharges led to a preventable readmission in this literature review.  Jha points out that penalties for high readmission rates could inadvertently penalize hospitals with lower mortality rates (who discharge patients who are by definition sicker).  Emphasizing the “wrong” measure draws our attention from other areas that may lead to better outcomes or more cost savings.

Now that we see coherent arguments against focusing too much attention on the “core measures” in the Premier demonstration and readmission rates, we just have to identify  on which metrics we SHOULD focus our attention.

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