By Renee Y. Hsia and Matthew Niedzwiecki
International Journal for Quality in Health Care, August 31, 2017

Abstract:

Objective
To better characterize and understand the nature of a very conservative definition of ‘avoidable’ emergency department (ED) visits in the United States to provide policymakers insight into what interventions can target non-urgent ED visits.

Design/setting
We performed a retrospective analysis of a very conservative definition of ‘avoidable’ ED visits using data from the National Hospital Ambulatory Medical Care Survey from 2005 to 2011.

Participants
We examined a total of 115,081 records, representing 424 million ED visits made by patients aged 18–64 years who were seen in the ED and discharged home.

Main outcome measures
We defined ‘avoidable’ as ED visits that did not require any diagnostic or screening services, procedures or medications, and were discharged home.

Results
In total, 3.3% of all ED visits were ‘avoidable.’ The top five chief complaints included toothache, back pain, headache, other symptoms/problems related to psychosis and throat soreness. Alcohol abuse, dental disorders and depressive disorders were among the top three ICD-9 discharge diagnoses. Alcohol-related disorders and mood disorders accounted for 6.8% of avoidable visits, and dental disorders accounted for 3.9% of CCS-grouped discharge diagnoses.

Conclusions
A significant number of ‘avoidable’ ED visits were for mental health and dental conditions, which the ED is not fully equipped to treat. Our findings provide a better understanding of what policy initiatives could potentially reduce these ‘avoidable’ ED visits to address the gaps in our healthcare system, such as increased access to mental health and dental care.

From the Discussion
Our findings serve as a start to addressing gaps in the US healthcare system, rather than penalizing patients for lack of access, and may be a better step to decreasing ‘avoidable’ ED visits.

https://academic.oup.com…

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Comment:

By Don McCanne, M.D.

This study is helpful in that the authors deliberately used a very conservative definition for which emergency department visits were avoidable. Under such a definition, 97% of visits were appropriate. The significance of this is that, instead of establishing often punitive policies to keep patients from supposedly abusing the emergency department, we should instead establish policies that would improve access for patients to more appropriate health care services and facilities.

A health care system designed to benefit the medical-industrial complex, including the private insurance industry, is going to use resources and incentives differently than a public system designed to benefit patients. Single payer supporters should have no difficulty in conceiving what those differences might be regarding urgent and emergency care.

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Proposed Iowa Medicaid change would eliminate months of retroactive benefits

By Clark Kauffman
The Des Moines Register, August 30, 2017

Currently, Medicaid has a retroactive-eligibility provision that provides payment for health care services that were delivered in the three months leading up to a person being formally declared eligible for Medicaid.

It’s intended to ensure that health care providers accept patients even when those individuals have yet to apply for Medicaid. It often comes into play when people are hit with an unexpected health crisis and need immediate admission to a care facility. With retroactive payment, the facilities have some assurance that Medicaid will eventually pay for the care that pre-dates the decision on eligibility.

The Iowa Department of Human Services has asked the federal Centers for Medicare and Medicaid Services for permission to eliminate the three-month time-frame and have Medicaid pay only for the care that’s delivered from the first day of the month in which the patient applies for eligibility. The state says the move would save Iowa Medicaid, which serves more than 600,000 people and is funded by both the state and federal government, $36.7 million. The state’s share of the savings would be $9.7 million.

If approved, Iowa would become one of the first states in the nation to deny Medicaid beneficiaries three months of retroactive coverage. With more than 3,300 individuals enrolling in Iowa Medicaid each month, 40,000 Iowans would be affected by the change, which DHS hopes to implement in just four weeks, on Oct. 1.

The proposal is the result of actions taken by the Iowa Legislature during the 2017 session. Lawmakers approved a Human Services appropriations bill that specified several mandated cost-containment measures, one of which directed DHS to eliminate retroactive benefits for all Iowa Medicaid applicants. To do that, Iowa first needs the approval of CMS.

In its formal request to the federal agency, DHS says the change would “encourage individuals to obtain and maintain health insurance coverage, even when healthy.” It also says the change would make Medicaid more “closely aligned with the commercial market,” which doesn’t provide retroactive coverage to its customers.

http://www.desmoinesregister.com…

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Comment:

By Don McCanne, M.D.

The need for retroactive qualification for Medicaid is obvious. Healthy individuals who otherwise would qualify for Medicaid on an income basis frequently do not want to bother signing up when they think they would have little use for the program. But unexpected, serious medical problems do occur, and retroactive qualification would cover care provided before enrollment could be completed.

It is not clear why the Iowa state government would want to deny that coverage when, in fact, it does fulfill the intent of the Medicaid program to cover health care for those individuals who otherwise cannot afford it. It seems to represent just plain meanness on the part of the legislators and state administrators who are pushing for denial of this important coverage. The savings to the Iowa government would be less than $10 million – a pittance relative to the importance of this program.

This perverse behavior on the part of Iowa’s stewards reinforces some important principles:

* Above all, lifelong coverage for everyone should be automatic. Coverage should not be dependent on ever-changing personal circumstances.

* Coverage should not be based on ability to pay, but rather should always be automatic. Each individual’s contribution to the national health program should be based on ability to pay, but that is entirely separate from the principle that each person receives health care based on need for that care, regardless of what has been paid.

* Payment to the providers of health care should not depend on whether or not the patient has the resources or coverage to pay for that care, but rather it should be made automatic through public administration of the funds in a universal risk pool.

* The Iowa state administrators say that slashing retroactive coverage would align the state more closely with the commercial insurance market. Our outrageous costs in an underperforming system are due in a large part to reliance on the commercial market. Using the private insurers as a model is the opposite of what we should be doing.

* Perhaps the most important lesson is that we should reject the calls to turn over the health care financing of federal health programs to the states since too many of them are proving to us that their preferred policies are heartless. The federal government has a duty to ensure that every individual receives the health care that he or she needs. We cannot turn that responsibility over to state bureaucrats who have already proven to us that they do not care about the health and welfare of their people.

We all should care, and an improved Medicare for all would make it automatic so that we do not have to give another thought about administrative excesses designed to interfere with care, like the denial of retroactive authorization – a concept totally foreign to a financing system specifically designed to advance health care justice.

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By Andy Slavitt
JAMA Forum, August 30, 2017

This current debate isn’t over as long as the administration clings to talk of repealing the ACA. Still, the movement toward a single-payer system or another variant is beginning. There will be much written about the ideas that will shape our future. Whatever those ideas are, if we want them to succeed, we must begin now to create the ingredients for successful legislation finally worthy of our country.

https://newsatjama.jama.com…

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Democrats Should Negotiate with the GOP on Health Care

By James C. Capretta
RealClear Health, August 30, 2017

While in office, President Obama often remarked that the ACA relies, at least in theory and to a degree, on the Republican principles of markets and private insurance. He was right, even if he failed to note that the ACA also includes levels of governmental control and federal spending that Republicans were never going to support. If Democrats are willing to abandon dreams of single-payer and stick with a framework that features competition and consumer choice, it should be possible to find common ground with Republicans while moving even closer to the enrollment of all Americans in a health insurance plan.

http://www.realclearhealth.com…

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Comment:

By Don McCanne, M.D.

Andy Slavitt and James Capretta both support moving forward with health care reform, though one might be considered center-left and the other center-right. So where are we headed?

Republicans support less government and more markets and competition. In contrast, there has been a surge of Democrats voicing support for a government single payer program. But what is the actual record of Democrats?

Since the neoliberals assumed control of the Democratic Party, they have supported market solutions – first with the failed Clinton effort, and then with the Affordable Care Act and their marketplace insurance exchanges of private plans. Even well established government programs are shifting to the private sector with an expansion of private Medicare Advantage plans in the Medicare program, a massive transfer of Medicaid to private Medicaid managed care organizations, and even transferring care of VA patients into the private sector through the Veterans Choice Program.

In his full article (link above), Slavitt states, “Our goal should be to develop policies that we have real-world experience with, so we can avoid think-tank fantasies that either overstate the power of free markets or fail to see the unintended consequences of government intervention.” That’s very neoliberal of him.

Capretta states, “If Democrats are willing to abandon dreams of single-payer and stick with a framework that features competition and consumer choice, it should be possible to find common ground with Republicans while moving even closer to the enrollment of all Americans in a health insurance plan.” That’s very conservative of him.

The pro-market, pro-corporate views of the neoliberals place them in the same camp as the conservatives in regard to financing health care. Many Democratic politicians have given token tribute to single payer, even to the extent of signing on as co-sponsors of Conyers’ single payer bill – HR 676. But several of them qualify their support by describing single payer as being merely an “aspiration” but not a practical consideration at this time when we need to be supportive of the Affordable Care Act. More private Medicaid managed care. More private Medicare Advantage plans. More private VA care. More private plans in the ACA marketplaces. Introducing a public option that is public in name only since it would be designed along the model of private plans while being prohibited from competing “unfairly” and would be financed without government funds – crapola insurance.

There is a night and day difference between financing health care in the marketplace through private insurance and financing it through a government national health program. One is framed around businesses and the other is framed around patients. Today the conservatives and neoliberals are offering us only the business approach supervised by the medical-industrial complex.

Harold Pollack is a highly respected health policy expert from the University of Chicago who sometimes drives us at PNHP a little bit crazy with the legitimate concerns he expresses about the politics and logistics of single payer, even if none of it is insurmountable. But he said something interesting the other day: “Republicans’ failed repeal-and-replace effort has solidified the consensus around universal coverage and provided an exemplar process for radical policy change. A lot of Democrats are saying: ‘If they can try doing this with something so unpopular that would hurt tens of millions of people, why can’t we do something on that order that would be popular and help tens of millions of people?’”

Yes, why can’t we? Not just the Democrats, but all of us. Like maybe single payer.

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Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January – March 2017

By Robin A. Cohen, Ph.D., Michael E. Martinez, M.P.H., M.H.S.A., and Emily P. Zammitti, M.P.H.
National Center for Health Statistics, August 2017

This report provides health insurance estimates from the first quarter of the 2017 National Health Interview Survey.

In the first 3 months of 2017, 28.1 million (8.8%) persons of all ages were uninsured at the time of interview — 0.5 million fewer persons than in 2016 (a nonsignificant difference) and 20.5 million fewer persons than in 2010.

In the first 3 months of 2017, among adults aged 18–64, 12.1% were uninsured at the time of interview, 18.9% had public coverage, and 70.5% had private health insurance coverage.

Among adults aged 18-64, 70.5% (138.8 million) were covered by private health insurance plans at the time of interview in the first 3 months of 2017. This includes 4.8% (9.4 million) covered by private health insurance plans obtained through the Health Insurance Marketplace or state-based exchanges.

The percentage of adults who were uninsured for at least part of the past year decreased, from 26.7% (51.0 million) in 2010 to 16.7% (33.0 million) in the first 3 months of 2017. There were no significant changes from 2016 through the first 3 months of 2017.

In the first 3 months of 2017, 42.3% of persons under age 65 with private health insurance were enrolled in an HDHP, including 16.9% who were enrolled in a CDHP (an HDHP with a health savings account [HSA]) and 25.3% who were enrolled in an HDHP without an HSA. The percentage of persons enrolled in an HDHP increased 17 percentage points, from 25.3% in 2010 to 42.3% in the first 3 months of 2017. More recently, the percentage of those enrolled in an HDHP increased, from 39.4% in 2016 to 42.3% in the first 3 months of 2017.

https://www.cdc.gov…

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Comment:

By Don McCanne, M.D.

There are some important observations here on where we stand with insurance coverage in the United States.

* Coverage has stabilized with about 28 million people (8.8%) remaining uninsured. Under our current system of financing health care, those remaining uninsured will be very difficult to cover, even with tweaks to the Affordable Care Act.

* Among adults aged 18–64, 12.1% remain uninsured. That is a particularly difficult population to insure under our current system.

* There has been no significant further improvement in the numbers of individuals who remain uninsured for part of the year – 33 million (16.7%). Intermittent coverage is hazardous to both health and personal finances.

* The percent of individuals under 65 enrolled in a high deductible health plan (HDHP) continues to increase – now at 42.3%, an additional 2.9% increase in the last year alone, and 60% of individuals with an HDHP did not have a health savings account to back them up. This trend has continued to increase exposure to medical debt, already a major problem in the United States.

There will be those celebrating the success that these numbers represent when compared to 2010, but there should be no celebration when tens of millions remain exposed to physical suffering and personal debt – problems that could be ameliorated by simply enacting and implementing a single payer national health program.

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Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO

By John Hsu, Mary Price, Christine Vogeli, Richard Brand, Michael E. Chernew, Sreekanth K. Chaguturu, Eric Weil and Timothy G. Ferris
Health Affairs, May 2017

We examined the impact of patient participation in a Pioneer ACO and its care management program on rates of emergency department (ED) visits and hospitalizations and on Medicare spending.

From the Study Results

Overall participation in the ACO was associated with a reduction in Medicare spending of $14 per participant per month, a decline of 2 percent. This association was not significantly different from no change, but the magnitude of the decline was comparable to estimates in previous studies.

From the Limitations

The analyses also focused on Medicare spending but did not assess total spending, including program costs. To our knowledge, no other study of ACOs has included program costs in its analysis.

From the Discussion

There were modest overall ACO spending reductions, with magnitudes comparable to those of all ACOs as described in other published reports and generally consistent with the assessment of the Partners ACO by CMS.

http://content.healthaffairs.org…

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On the Ethics of Accountable Care Research

By Kip Sullivan, J.D.
The Health Care Blog, August 25, 2017

The paper I am examining is the third that Hsu et al. have published in Health Affairs about Partners’ Pioneer ACO, the second largest of the 32 ACOs that entered Medicare’s Pioneer ACO program in 2012.

They found that Partners’ ACO cut Medicare’s costs by a statistically insignificant 2 percent. This outcome is consistent with CMS’s data on the performance of Medicare ACOs, as well as the extremely rare studies of total spending by private-sector ACOs. The only papers seeming to contradict this bad news are two “studies” of simulated ACOs . We may infer from the literature that if ACO start-up and operating costs, including the costs of disease management programs, are taken into account, ACOs are raising total health spending.

However, in this third paper, Hsu et al. did not convey to their readers the impression I have just conveyed: Despite their insignificant results, they claimed Partners’ ACO is cutting costs. “Our major overall finding is that participating in an ACO and a care management program lowered utilization and spending,” they concluded.

Hsu et al. employed two tactics that lulled readers into thinking their data supported their claim that Partners’ ACO “lowered spending.” The first was to treat the statistically insignificant reduction in Medicare spending as if it were statistically significant. The second was to ignore the overhead costs incurred by CMS and Partners’ ACO, a problem that occurs so frequently I have proposed giving it a name – the “free-lunch syndrome.”

Hsu et al. reported that Partners’ ACO cut Medicare spending on beneficiaries attributed to the ACO by CMS during 2012 and 2013 by a statistically insignificant 2 percent. As the authors put it, “this association was not significantly different from no change” (p. 880). Yet the authors treated this 2 percent difference as if it were significant. Throughout the paper they claimed Partners’ ACO had lowered “Medicare spending.” They did so in the title (“Bending the spending curve….”), the abstract (“ACO participation had a modest effect on spending”), and in the text (see the quote above, as well as, “There were modest overall ACO spending reductions….” and, “This study provides some evidence of how one large … ACO appears to have achieved its stated savings….”).

Even if the 2-percent savings had been statistically significant, the authors should have subtracted from the claimed savings the cost of the interventions that led to the savings. These costs fall into two categories: Those CMS incurred to run the Pioneer program and those Partners’ ACO incurred attempting to achieve savings. Not reporting these offsetting costs made it easier for Hsu et al. to mislead readers into accepting their statement that Partners’ ACO “bent the cost curve.”

Hsu and his co-authors in fact warned readers that they intended to ignore all “program costs” incurred by the ACO, CMS or any other entity, that is, all costs that didn’t require reimbursement by Medicare under Parts A, B or D. They didn’t say why. The only explanation they offered was, “To our knowledge, no other study of ACOs has included program costs in its analysis.” This is true. The vast majority of American health policy researchers think it’s totally appropriate to ignore program costs when analyzing the impact of ACOs. Moreover, they think that if their limited analysis shows the ACO cut Medicare’s gross spending it’s ok to state repeatedly the ACO “bent the cost curve” or “lowered spending.”

The data in Hsu et al.’ paper is useful even if it is incomplete. It contributes to a growing body of evidence indicating that ACOs cannot cut total spending, in part because ACOs cannot focus. They are measured on their ability to cut the cost of an entire population by unspecified means rather than on their ability to cut the cost of a clearly defined slice of their sickest “attributees” by clearly defined methods.

My criticism of Hsu et al. is their misuse of their data. They implied statistically insignificant results were significant, and by stating over and over that Partners’ ACO cut “spending” they misled readers into thinking they had measured total costs when they hadn’t.

Footnote 8:

I encourage readers to peruse RTI’s evaluation of the CMP (care management program) to get a clearer view of the complexity and expense of Partners’ CMP program. To give you just a taste of the resources Partners is investing now for the 4,000 CMP enrollees examined by Hsu et al., consider these excerpts from RTI’s report describing elements of the program for the 2,000 CMP enrollees during 2006-2009:

*  “Eleven nurse case managers [each of whom worked with about 200 patients] who received guidance from the program leadership and support from the project manager, an administrative assistant, and a community resources specialist” (p. 7);

*  “a social worker to assess the mental health needs of CMP participants” (p. 6);

*  “a mental health team director, clinical social worker, two psychiatric social workers, and a forensic clinical specialist (M.D./J.D.), who follows highly complex patients with issues such as legal issues, guardianship and substance abuse” (p. 10);

*  “a pharmacist to review the appropriateness of medication regimens” (p. 6);

*  “home delivery of medications five days per week” (p. 7);

*  “a nurse who specialized in end-of-life-care issues” (p. 7);

*  “a patient financial counselor who provided support for all insurance related issues” (p. 7);

*  “The clinical team leader provided oversight and supervision of case managers” (p. 8);

*  “The medical director provided oversight and day to day management of MGH’s CMP….” (p. 8);

*  “MGH developed a series of clinical dashboards using data from the MGH electronic medical record …, claims data, and its enrollment tracking database” (p. 8);

*  “MGH provided [200] physicians with a $150 financial incentive per patient per year to help cover the cost of physician time for [CMP-related] activities” (p. 8);

*  “a designated case manager position to work specifically on post discharge assessments to enhance transitional care monitoring” (p. 9);“ and

*  “a data analytics team to develop and strengthen program’s reporting capabilities” (p. 10).

http://thehealthcareblog.com…

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Comment:

By Don McCanne, M.D.

Everywhere you turn these days you see articles stating that we need to shift from paying for volume of health care and pay for value instead. They contend that new payment models, such as accountable care organizations, are doing precisely that. Yet evidence for increased value – lower costs and higher quality – is lacking.

The Hsu et al. article from Health Affairs (above) has been cited extensively for demonstrating that this approach is resulting in savings. Yet in the article the authors state, regarding the reduction in Medicare spending, “This association was not significantly different from no change.” Kip Sullivan’s critique details the problems with the conclusions and is well worth reading if you want to better understand health policy chicanery, or at least unrealized health policy wishes camouflaged as health policy science.

This is more than an annoyance. In the past month a multitude of articles have called for rejecting the lure of single payer and instead moving ahead with improving the Affordable Care Act. Many of these articles contend that new payment models are bringing us the cost efficiencies that we need, and so we do not need to resort to the disruptive changes of transitioning to single payer. “There are many ways we can get to a universal system,” they keep telling us.

If you read the health policy literature extensively and carefully you will find that many noted policy experts who have been working on these financing concepts from the beginning have been disappointed with the results. The models are not reducing costs significantly and the improvements in quality are negligible. Nevertheless, the attitude amongst them seems to be that we should continue with these studies, perhaps trying various modifications of the models to see if maybe something will eventually come of it.

But the lay media have not picked up on this. The reporting fad of the day is that we can get to a universal system that is affordable without having to resort to Medicare for all.

From the experience of other nations we already know that single payer would save us hundreds of billions of dollars by reducing administrative waste while using other single payer tools to achieve greater value and equity in our health care system.

In his full article, available at the link above, Kip Sullivan asks a series of questions regarding the ethics of this particular health policy assessment. When the policy community, supported by the lay press, advocates for health care reform that has not held up to scrutiny while rejecting a proven model that does work – single payer – they are indeed compromising ethics, even if some don’t quite understand that.

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