By Patricia Kime, Staff writer
A veterans advocacy group says a complete overhaul of the Veterans Affairs health system — to include partially privatizing services — is needed to improve care for current veterans and ensure the system’s future viability.
A report issued by a task force formed by Concerned Veterans For America calls for revamping VA medical facilities under a non-profit government organization and proposes changes that would shift more veterans into private health insurance programs.
The recommendations in “Fixing Veterans Health Care” would “advance long-term reforms of the current system, while addressing the immediate needs of veterans,” said the authors, including Tennessee Republican and former Senate Majority Leader Dr. Bill Frist and former Rep. Jim Marshall, a Vietnam veteran and Georgia Democrat.
“If proactive and fundamental reforms are not made soon, demographic realities will force further drastic and reactionary changes,” the authors wrote.
Details of the 100-page report were addressed during a five-hour conference on VA health care hosted by CVA in Washington, D.C., on Thursday.
The recommendations included:
*Splitting the Veterans Health Administration into two entities, a hospital system responsible for medical centers and clinics and a health insurance oversight office.
*Closing underutilized health facilities and streamlining services.
*Providing health care at VA medical facilities for veterans with service-connected medical conditions who want to stay in the system; and offering private health coverage to veterans who can’t get to a VA health facility or want to see a private physician.
Under the plan, veterans who have severe disabilities or fall in higher priority groups would get more money to pay for premium health care coverage; lower priority groups would have access to private care but would be required to pay more in cost-shares.
Although Congress passed the Veterans Access Choice and Accountability Act last year that gave VA $15 billion to hire new physicians and let veterans seek private care, CVA officials say the law doesn’t’ go far enough to fix VA’s chronic problems.
“The veterans’ health system is still broken. The VA Choice program does not allow for true choice because VA still determines who can access the program … and in the future, VA is going to see massive underutilization. We need to solve these problems,” said Daniel Caldwell, CVA’s legislative and political director.
“Veterans can go out and get health care when they want it … that’s what we were trying to do with the Choice card. But VA has erected obstacles which … are clearly in violation with the intent of the law,” Sen. John McCain, R-Ariz., said at the summit.
In some cases, veterans waited months for care and some died while on waiting lists.
The troubles brought about passage of the Veterans Access Choice and Accountability Act, which Frist, Marshall and others called a good “first step” but a “temporary one whose funding is expected to run out in a few years.”
“In the end, VACAA has kept the VA bureaucracy in control, and offers few real choices to veterans. This task force seeks to flip that equation. Our proposal puts veterans in control of their health care,” they wrote.
The report’s release quickly drew comments and criticism from those skeptical of its findings and recommendations.
VA Secretary Bob McDonald said taking care of veterans at VA is a “sacred mission,” and added that while outside care should supplement care provided by VA doctors, it should not replace it.
“Reforming VA health care cannot be achieved by dismantling it and preventing veterans from receiving the specialized care and services that can only be provided by VA,” McDonald said.
Paralyzed Veterans of America said it welcomes discussion on veterans health care reform but cautioned against privatized care because it would remove protections veterans have being treated within the VA system.
“Privatizing health care for veterans will create a cottage industry for ambulance chasers who will be the only available option for veterans with medical malpractices cases,” PVA officials said in a release.
Stewart Hickey, national executive director of AMVETS, addressed the summit, saying “most of what is in the report is good.” But he added that persuading other veterans groups to support the plan would be difficult because they are interested in preserving the status quo.
Lawmakers who spoke at the summit in favor of reform included Reps. Jeff Miller, R-Fla., Jackie Walorski, R-Ind., Tulsi Gabbard, D-Hawaii, andSen. Marco Rubio, R-Fla.
None said they would sponsor a draft version of a bill proposed in the report, the Veterans Independence Act, but agreed that the proposals would start a dialogue about long-term reform of VA health.
Frist and Marshall acknowledged as much in the report. “No plan is perfect. While we believe that our proposal would significantly improve veterans health care, we know the plan would benefit from continued refinement and input from interested parties,” they wrote.
Nearly 9 million veterans are enrolled in VA health care.
According to VA, the department made more than 2 million authorizations for veterans to get care from non-VA providers from May 1, 2014 through Feb. 1, equaling $6.7 billion in care.
The figures represent a 45-percent increase when compared with the same period in previous years.
CVA officials said one of the goals of its recommendations is to steer VA back toward caring primarily for veterans with service-connected conditions.
“Eligibility would be limited to service-connected disabilities and those who are indigent. VA health was never intended to be an entitlement program,” Caldwell said.
Since its creation in 2012, CVA has drawn attention for its outspoken criticism of President Obama and held a summer-long “defend freedom” tour that decried current government policies, with members saying those policies undermine both military and economic security.
In turn, the group has been criticized for receiving most of its financial backing from conservative political groups.
Officials noted that the report has bipartisan authorship and support and urged lawmakers to read it and consider its recommendations.
“[Fixing VA] has to be a bipartisan project … similar to when we passed welfare reform. This is an important report that creates a large structural proposal for how you really put veterans first,” former Speaker of the House Newt Gingrich said.
Staff writer Leo Shane III contributed to this report.
N Engl J Med 2015; 372:793-795
“Tonight, I’m launching a new Precision Medicine Initiative to bring us closer to curing diseases like cancer and diabetes — and to give all of us access to the personalized information we need to keep ourselves and our families healthier.”
— President Barack Obama, State of the Union Address, January 20, 2015
President Obama has long expressed a strong conviction that science offers great potential for improving health. Now, the President has announced a research initiative that aims to accelerate progress toward a new era of precision medicine (www.whitehouse.gov/precisionmedicine). We believe that the time is right for this visionary initiative, and the National Institutes of Health (NIH) and other partners will work to achieve this vision.
The concept of precision medicine — prevention and treatment strategies that take individual variability into account — is not new1; blood typing, for instance, has been used to guide blood transfusions for more than a century. But the prospect of applying this concept broadly has been dramatically improved by the recent development of large-scale biologic databases (such as the human genome sequence), powerful methods for characterizing patients (such as proteomics, metabolomics, genomics, diverse cellular assays, and even mobile health technology), and computational tools for analyzing large sets of data. What is needed now is a broad research program to encourage creative approaches to precision medicine, test them rigorously, and ultimately use them to build the evidence base needed to guide clinical practice.
The proposed initiative has two main components: a near-term focus on cancers and a longer-term aim to generate knowledge applicable to the whole range of health and disease. Both components are now within our reach because of advances in basic research, including molecular biology, genomics, and bioinformatics. Furthermore, the initiative taps into converging trends of increased connectivity, through social media and mobile devices, and Americans’ growing desire to be active partners in medical research.
Oncology is the clear choice for enhancing the near-term impact of precision medicine. Cancers are common diseases; in the aggregate, they are among the leading causes of death nationally and worldwide, and their incidence is increasing as the population ages. They are also especially feared, because of their lethality, their symptoms, and the often toxic or disfiguring therapies used to treat them. Research has already revealed many of the molecular lesions that drive cancers, showing that each cancer has its own genomic signature, with some tumor-specific features and some features common to multiple types. Although cancers are largely a consequence of accumulating genomic damage during life, inherited genetic variations contribute to cancer risk, sometimes profoundly. This new understanding of oncogenic mechanisms has begun to influence risk assessment, diagnostic categories, and therapeutic strategies, with increasing use of drugs and antibodies designed to counter the influence of specific molecular drivers. Many targeted therapies have been (and are being) developed, and several have been shown to confer benefits, some of them spectacular.2 In addition, novel immunologic approaches have recently produced some profound responses, with signs that molecular signatures may be strong predictors of benefit.3
These features make efforts to improve the ways we anticipate, prevent, diagnose, and treat cancers both urgent and promising. Realizing that promise, however, will require the many different efforts reflected in the President’s initiative. To achieve a deeper understanding of cancers and discover additional tools for molecular diagnosis, we will need to analyze many more cancer genomes. To hasten the adoption of new therapies, we will need more clinical trials with novel designs4 conducted in adult and pediatric patients and more reliable models for preclinical testing. We will also need to build a “cancer knowledge network” to store the resulting molecular and medical data in digital form and to deliver them, in comprehensible ways, to scientists, health care workers, and patients.
The cancer-focused component of this initiative will be designed to address some of the obstacles that have already been encountered in “precision oncology”: unexplained drug resistance, genomic heterogeneity of tumors, insufficient means for monitoring responses and tumor recurrence, and limited knowledge about the use of drug combinations.
Precision medicine’s more individualized, molecular approach to cancer will enrich and modify, but not replace, the successful staples of oncology — prevention, diagnostics, some screening methods, and effective treatments — while providing a strong framework for accelerating the adoption of precision medicine in other spheres. The most obvious of those spheres are inherited genetic disorders and infectious diseases, but there is promise for many other diseases and environmental responses.
The initiative’s second component entails pursuing research advances that will enable better assessment of disease risk, understanding of disease mechanisms, and prediction of optimal therapy for many more diseases, with the goal of expanding the benefits of precision medicine into myriad aspects of health and health care.
The initiative will encourage and support the next generation of scientists to develop creative new approaches for detecting, measuring, and analyzing a wide range of biomedical information — including molecular, genomic, cellular, clinical, behavioral, physiological, and environmental parameters. Many possibilities for future applications spring to mind: today’s blood counts might be replaced by a census of hundreds of distinct types of immune cells; data from mobile devices might provide real-time monitoring of glucose, blood pressure, and cardiac rhythm; genotyping might reveal particular genetic variants that confer protection against specific diseases; fecal sampling might identify patterns of gut microbes that contribute to obesity; or blood tests might detect circulating tumor cells or tumor DNA that permit early detection of cancer or its recurrence.
Such innovations will first need to be tested in pilot studies. We will initially want to take advantage of the rare settings where it is already possible to collect rich information through clinical trials, electronic medical records, and other means.
Ultimately, we will need to evaluate the most promising approaches in much larger numbers of people over longer periods. Toward this end, we envisage assembling over time a longitudinal “cohort” of 1 million or more Americans who have volunteered to participate in research. Participants will be asked to give consent for extensive characterization of biologic specimens (cell populations, proteins, metabolites, RNA, and DNA — including whole-genome sequencing, when costs permit) and behavioral data, all linked to their electronic health records. Qualified researchers from many organizations will, with appropriate protection of patient confidentiality, have access to the cohort’s data, so that the world’s brightest scientific and clinical minds can contribute insights and analysis. These data will also enable observational studies of drugs and devices and potentially prompt more rigorous interventional studies that address specific questions.
Such a varied array of research activities will propel our understanding of diseases — their origins and mechanisms, and opportunities for prevention and treatment — laying a firm, broad foundation for precision medicine. It will also pioneer new models for doing science that emphasize engaged participants and open, responsible data sharing. Moreover, the participants themselves will be able to access their health information and information about research that uses their data.
The research cohort will be assembled in part from some existing cohort studies (many funded by the NIH) that have already collected or are well positioned to collect data from participants willing to be involved in the new initiative. Creating this resource will require extensive planning to achieve the appropriate balance of participants, develop new approaches to participation and consent, and forge strong partnerships among existing cohorts, patient groups, and the private sector. It will also be crucial to carefully examine the successes and shortfalls of other longitudinal cohort studies.
Achieving the goals of precision medicine will also require advancing the nation’s regulatory frameworks. To unleash the power of people to participate in research in innovative ways, the NIH is working with the Department of Health and Human Services to bring the Common Rule, a decades-old rule originally designed to protect research participants,5 more in line with participants’ desire to be active partners in modern science. To help speed the translation of such discoveries, the Food and Drug Administration is working with the scientific community to make sure its oversight of genomic technology supports innovation, while ensuring that the public can be confident that the technology is safe and effective.
Although the precision medicine initiative will probably yield its greatest benefits years down the road, there should be some notable near-term successes. In addition to the results of the cancer studies described above, studies of a large research cohort exposed to many kinds of therapies may provide early insights into pharmacogenomics — enabling the provision of the right drug at the right dose to the right patient. Opportunities to identify persons with rare loss-of-function mutations that protect against common diseases may point to attractive drug targets for broad patient populations. And observations of beneficial use of mobile health technologies may improve strategies for preventing and managing chronic diseases.
Ambitious projects like this one cannot be planned entirely in advance; they should evolve in response to scientific and medical findings. Much of the necessary methodology remains to be invented and will require the creative and energetic involvement of biologists, physicians, technology developers, data scientists, patient groups, and others. The efforts should ideally extend beyond our borders, through collaborations with related projects around the world. Worldwide interest in the initiative’s goals should motivate and attract visionary scientists from many disciplines.
This initiative will also require new resources; these should not compete with support of existing programs, especially in a difficult fiscal climate. With sufficient resources and a strong, sustained commitment of time, energy, and ingenuity from the scientific, medical, and patient communities, the full potential of precision medicine can ultimately be realized to give everyone the best chance at good health.
Article link: http://www.nejm.org/doi/full/10.1056/NEJMp1500523
Interview with Dr. Francis Collins on what to expect from the recently announced Precision Medicine Initiative. (10:07)
By Heather Caspi |
What’s in an EHR? As the Department of Defense prepares to select a new electronic health record system, some are advocating that it go with an open-source solution—not just to benefit of the DOD but to use the $11-billion program to benefit the healthcare industry at large.
Why it matters to the DOD
In a new report released by the Center for New American Security titled “Reforming the Military Health System,” the authors argue that the selection of a closed, proprietary system would trap the DOD into vendor lock, health data isolation and a long-term contract with technology that will age rather than evolve.
Co-author Stephen L. Ondra, a former senior advisor for health information in the White House Office of Science and Technology Policy, tells Healthcare Dive that an open-source solution could more easily adapt to meet future modernization and interoperability needs, and could more creatively be tailored to the DOD’s requirements.
Ondra says most commercial EHR systems are developed around the fee-for-service revenue cycle, a model that is not particularly relevant to the DOD and its healthcare system. He says an EHR for the DOD should be focused on the clinical care management aspect of these programs, which would require lengthy and expensive modification.
He argues that a proprietary system would be inadequate as it would leave the DOD with a single vendor’s solutions. “You don’t have some of the creativity and innovation that an open source system would have because you’re limited to a single vendor’s view and skills,” Ondra says.
In addition, he notes, proprietary systems have less incentive to provide interoperability solutions because their business model aims to lock people into using that particular system.
“I think the commercial systems are very good at what they do,” Ondra said. However, “they are not ideally designed for efficiency and enhancement of care delivery, and I think the DOD can do better with an open source system both in the near-term, and more importantly in the long-term, because of the type of innovation and creativity that can more quickly come into these systems.”
Why it matters to everyone
Whoever gets that $11-billion award is going to have a lot of money to develop EHR technology—and whether they are serving an open or closed solution will determine whether the innovations remain stovepiped from the rest of the industry, notes report author Peter L. Levin, a former chief technology officer at the Department of Veterans Affairs.
“If the DOD were to choose to go with a closed, proprietary system, it has the potential of stifling innovation in the rest of the industry,” Levin says. “If they go with an openly-architected, standard space and modular system, then really in a very simple way, they are spreading the innovation resources around.”
“Instead of concentrating it all in one place and letting that vendor own all of the innovation, they’ll be able to nourish and support the various components that comprise these complicated enterprise resource platforms in a way that will not only be beneficial to the DOD and the country in the long run, but will tremendously benefit the country and other kinds of innovations now,” Levin said.
Levin adds that the same arguments for the DOD to select an open-source EHR system apply to private healthcare systems as well. He asks consumers to imagine if they could only talk to people with same phone carrier, or only go to gas stations for their particular make of car.
He argues that private hospitals and private payers have been unwittingly supporting the continued isolation and segmentation of the commercial solutions.
“Healthcare suffers tremendously in terms of cost and outcome because of these isolated systems,” he says, “and that’s just as true for the private sector as it is for the public sector.”
Ondra adds that the DOD’s choice will set an example from which both open and closed source providers could learn.
“I think that a major government contract would send the message that the current systems, as good as they are, are not fully meeting the needs of clinical care in a way that is efficient for the provider,” he says.
“Going to an open source for the DOD gives the opportunity to have rapid development of things that are more helpful to care delivery, more efficient for the provider, because the customer then is the deliverer of care, and not the finance department of a care delivery system,” Ondra said.
by Derek A. Haas
, Yudit C. Krosner
, Nirvan Mukerji
, and Robert S. Kaplan
December 26, 2014
“I would have written a shorter letter but did not have the time,” Blaise Pascal, the 17th century French mathematician and philosopher, once apologized. Unfortunately, the same problem often arises when physicians manage the care of patients with chronic conditions such as diabetes, heart failure, and kidney disease. If they had more time (and in some cases, motivational skills), they could better persuade patients to make the sacrifices and hard choices to change their lifestyles and to follow the recommended treatment plan.
Pressuring physicians to maximize the number of patients they see and minimizing the time they spend with each is one of five counterproductive mistakes that health care providers often make in trying to reduce costs — the subject of a recent article in the Harvard Business Review.
Overworked physicians rarely have the time for these difficult conversations, especially when they are restricted to 20- to 30-minute appointments, with much of the front end spent updating a patient’s medical record. When physicians spend an inadequate amount of time with their patients, the patients may not fully understand the importance of complying with all aspects of their recommended treatments, which eventually leads to deteriorating health and higher treatment costs. Approximately 50% of patients with chronic conditions do not take their medications as prescribed.
To illustrate the problem, consider our research on the cost of treating patients when their kidneys begin to lose their ability to filter blood. Should the kidneys of a patient with such a chronic disease completely fail when a transplant is not immediately available, the person needs dialysis several times a week to filter and clean the blood. How the patient starts on dialysis has enormous health and cost implications.
The vast majority of patients should do peritoneal dialysis at home or start with hemodialysis at a dialysis center. Both approaches require a vascular surgeon to create a fistula or a graft to connect an artery and a vein in the forearm. The surgery must be performed well before dialysis starts since a fistula can take about three months and a graft several weeks to “mature,” or be ready to be used for dialysis. (The alternatives are having either a preemptive kidney transplant or a peritoneal dialysis catheter placed, which also require advance planning.) If dialysis is required and a matured graft or fistula is not available, the patient must start with a catheter inserted into a vein in the neck or chest, a process that leads to a much higher risk of infection, blood clotting, and death.
Despite the large health benefits from an optimal dialysis start, more than 50% of patients nationwide begin dialysis via a catheter. Some of these occur because primary care physicians wait too long to refer their patients to nephrologists. Once referred, many patients are in denial that they will need dialysis or that they will need it as soon as actually occurs. Such patients may not adequately prepare for this eventuality despite a timely recommendation by their nephrologist.
To understand these issues better, we formed a project team to study patients that started on dialysis in 2011 and 2012. It analyzed historical data of 167 patients insured by Kaiser Permanente in the Georgia Region, and used time-driven activity-based costing to assess the costs of care received one year prior to the start of dialysis and also the charges incurred for one year after starting dialysis. We learned that health complications in the year following a sub-optimal start of dialysis led to nearly $20,000 in extra treatment costs per patient.
Interestingly, the patients in our study who started on dialysis with a fistula or graft largely had the same breadth of nephrology care — number of nurse visits, nephrologist phone calls, care manager coordination, classes, and initial consults — during the one year prior to the commencement of dialysis as those who started sub-optimally with a catheter. Even including the extra cost of the vascular surgery, the costs of treating the two sets of patients before dialysis began were about the same.
A few differences did exist between the two sets of patients, likely reflecting the better compliance of patients that started dialysis optimally. Patients with an optimal start received, on average, one more follow-up visit (5 vs. 4) with the nephrologist. Patients who started optimally were also somewhat more likely to have attended a class to learn about the options for starting on dialysis and were more likely to have attended the class farther ahead of the start of dialysis.
Dr. Nirvan Mukerji, a nephrologist and a coauthor of this article, believes that he could significantly increase the percentage starting optimally if he could spend an additional 30 minutes with each patient, counseling them on how to best prepare for dialysis as their kidney disease progresses. While his full schedule had previously prevented him from spending that additional time, he is now testing the use of extended office visits for patients with advanced chronic kidney disease as well as alternative options, such as having patients already on dialysis make presentations with him at the education class. We estimated that the incremental cost for the extended meeting or the educational class presentation would be under $200, a small price to pay to avoid the health risks and $20,000 in higher treatment costs that typically occur in the first year after a patient starts dialysis sub-optimally.
There are many other examples of how primary care doctors treating chronic diseases, such as diabetes and congestive heart failure, could offer better advice and achieve better treatment compliance if they had more time to spend with their patients. The costs of such extra time would be repaid many times over, often by orders of magnitude, through fewer future complications. Attempting to improve a physician’s productivity by placing arbitrary limits on length of appointments or setting high targets for the numbers of patients that he or she should see each day lowers costs at the front end of a care cycle. But they incur much higher costs later in the cycle when preventable complications are treated in emergency rooms and intensive care units.
Derek A. Haas is a project director and fellow at HBS and a founder of Avant-garde Health.
Yudit C. Krosner is director of specialty-care strategy and practice management at the Southeast Permanente Medical Group in metropolitan Atlanta.
Nirvan Mukerji, MD, is a practicing nephrologist and the chief of nephrology in the Southeast Permanente Medical Group in metropolitan Atlanta.
Doctors and patients in the United States must work together to minimize waste in health care. The millions of health care decisions made each day — to see a provider, complete a medical test, fill a prescription, or undergo a procedure — come with benefits, risks, and costs. Many of the choices are well informed by clinical evidence and expertise. But all too often they are driven by habit, hunches, or misaligned economic incentives, leading to substantial overuse of unnecessary, even harmful, services. The Institute of Medicine estimates that unnecessary services represent about 10% of all U.S. health care spending — nearly $300 billion a year.
In 2012, the American Board of Internal Medicine Foundation launched the Choosing Wisely campaign to encourage doctors and patients to discuss the issue of unnecessary tests and treatments, also known as “overuse.” Building on initial efforts by primary care organizations, more than 60 medical specialty societies have identified more than 300 recommendations that should be addressed. The Choosing Wisely campaign focuses almost exclusively on professional education (through participating medical societies) and on public education in the form of videos and brochures for patients produced by Consumer Reports. As more and more health care organizations, medical groups, and individual doctors implement its recommendations, Choosing Wisely is helping to transform the culture of health care. That cultural shift helps to ensure that new approaches to quality management, price transparency, and economic incentives for providers ultimately bear fruit in reducing overuse.
Choosing Wisely has renewed the focus on overuse, but the campaign had its precursors. In the 1980s, researchers at RAND developed an approach for classifying health care into four categories of appropriateness, ranging from necessary services, whose benefits clearly outweigh the risks (not performing these services constitutes underuse), to inappropriate services, whose risks for harm exceed the potential benefits (performing these services constitutes overuse). Subsequent studies have documented substantial overuse of common procedures such as hysterectomy, common medications such as antibiotics, and even chemotherapy. Overuse of surgery or chemotherapy clearly has potential harms.
Other examples of overuse, however, are subtler. For example, an estimated 25% of Medicare beneficiaries undergo an imaging test for uncomplicated low-back pain. That may seem harmless on its face, but almost all patients with this symptom recover without an invasive procedure — and, in response to the imaging results, some patients undergo additional procedures they don’t actually need. Similarly, more than half of antibiotics prescribed for common colds and coughs may be unnecessary.
Sponsored by MedtronicA collaboration of the editors of Harvard Business Review and the New England Journal of Medicine, exploring best practices for improving patient outcomes while reducing costs.
During the past 15 years, our health care system has made substantial strides in reducing underuse of high-value services. However, progress on overuse of low-value services (to which one quarter of Medicare beneficiaries may be exposed) has lagged, especially in regions that have higher levels of spending and that have more specialists relative to primary care physicians.
Overuse in health care has been tough to address for several reasons:
- Americans are prone to think that more health care is better, so they often bristle at recommendations that seem to limit choice or advise waiting to see whether a symptom improves. The prospect of not ordering a test or a treatment, even when that approach constitutes better quality, stokes fears about “rationing.”
- Some erroneous beliefs, such as the benefit of treating a cold with antibiotics, are so ingrained that public education campaigns can take years to have an impact.
- Doctors often overvalue their own services, despite evidence to the contrary. For example, in 2013, more than a year after the U.S. Preventive Services Task Force concluded that routine prostate cancer screening with PSA testing has more potential harms than benefits, a urologist advised viewers of NBC’s Today Show, “There are no complications to screening. What we want people to know is, get your PSA baseline at the age of 40.”
- Economic incentives can be perverse, as when fee-for-service payments encourage potentially unnecessary services or when patients don’t know the cost of a service they are receiving.
Choosing Wisely and other ongoing reforms in health care aim to address each of those impediments to progress, as we discuss below.
As early as 1986, RAND researchers wrote, “Physicians today face mounting pressures to use procedures only when clinically valid criteria indicate that they are appropriate.” Nearly 30 years later, those pressures persist. The Choosing Wisely campaign and the broader medical community are beginning to make a dent in overuse by focusing on these dimensions:
Putting quantity in the context of quality. Choosing Wisely helps patients and doctors see that more care is not always better care. Doctors have long known about some of the opportunities for reducing the quantity of care without compromising quality, such as not getting an imaging test for uncomplicated low back pain or not ordering an annual cardiac stress test in patients without symptoms. In these instances, Choosing Wisely can help educate patients about why an unnecessary test could wind up being bad for them so that doctors and patients can have more constructive conversations about the tests. For other, newer recommendations, Choosing Wisely may need to gain traction with doctors first. For example, the American Geriatrics Society advises limiting aggressive treatment of older patients with diabetes to prevent harmful episodes of low blood sugar — this recommendation has the potential to change the way many doctors practice.
Changing how quality is managed. We need to move from a quality assessment system that merely tracks use of services to a quality management system that helps providers and patients make better decisions about when care is necessary or inappropriate. That means using personalized assessments of potential benefits and harms, as well as taking into account the preferences of patients who are well informed about their options. For example, new guidelines for preventing heart disease use a personalized assessment that helps doctors identify an individual patient’s risk for a heart attack — and whether that patient should take a cholesterol-lowering statin drug and at what dose. Although Choosing Wisely does not specifically develop such tools, they are consistent with the culture of more-efficient, patient-centered quality management that the campaign promotes.
Helping doctors reconceive the value of their services. Most physicians are enthusiastic about limiting access to expensive tests that have little or no benefit as a way to curb excessive health care costs. Nevertheless, nearly three-quarters of doctors believe that the average physician orders unnecessary tests at least once per week, most often stemming from fear of lawsuits and general clinical uncertainty. In its campaign to educate doctors through their professional societies and the public through Consumer Reports, Choosing Wisely is promoting the view that not ordering unnecessary services can have as much value for patients as ordering appropriate tests and treatments.
Re-envisioning payments and pricing. With reforms in how insurers pay for medical services, doctors will need to think more carefully about which services they provide and for whom. For example, a “bundled payment” for an episode of care, such as all services related to knee-replacement surgery, could result in fewer unnecessary services within that episode (though some episodes of care may be unnecessary to begin with). Global capitation — a fixed, per-person, per-month fee regardless of the services provided — may encourage doctors to focus on limiting overuse and less on reducing underuse. Greater transparency of health care prices may also prompt patients and doctors to discuss when medical services are unnecessary. Choosing Wisely does not directly address such cost-related initiatives, but its focus on limiting overuse (in the interest of optimal care for patients) complements those aims.
All of these reforms will require careful consideration of unintended consequences, so that our efforts to limit overuse do not foster underuse of high-value services. We must continue to test approaches to limit overuse while ensuring that necessary services are provided. The principles of the Choosing Wisely campaign are consistent with this type of judicious approach. In a 2014 survey, 21% of doctors indicated that they were aware of the Choosing Wisely campaign, and 62% of that subgroup reported taking steps to reduce unnecessary services (compared with 45% of doctors who were not aware of Choosing Wisely). Clearly, many doctors have taken note of the campaign in its first two years, but many others remain to be engaged, and we will need new data to determine whether overuse of health care is actually declining.
Thirty years after the concepts of health care appropriateness were first developed, professionalism, payment policies, and science are aligning to create incentives and tools to help limit overuse. Together doctors and patients can choose a less wasteful approach as they aim to improve both the quality and efficiency of health care.
January 26, 2015DOI: 10.1056/NEJMp1500445
Now that the Affordable Care Act (ACA) has expanded health care coverage and made it affordable to many more Americans, we have the opportunity to shape the way care is delivered and improve the quality of care systemwide, while helping to reduce the growth of health care costs. Many efforts have already been initiated on these fronts, leveraging the ACA’s new tools. The Department of Health and Human Services (HHS) now intends to focus its energies on augmenting reform in three important and interdependent ways: using incentives to motivate higher-value care, by increasingly tying payment to value through alternative payment models; changing the way care is delivered through greater teamwork and integration, more effective coordination of providers across settings, and greater attention by providers to population health; and harnessing the power of information to improve care for patients.
As we work to build a health care system that delivers better care, that is smarter about how dollars are spent, and that makes people healthier, we are identifying metrics for managing and tracking our progress. A majority of Medicare fee-for-service payments already have a link to quality or value. Our goal is to have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018. Perhaps even more important, our target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% of payments by the end of 2018. Alternative payment models include accountable care organizations (ACOs) and bundled-payment arrangements under which health care providers are accountable for the quality and cost of the care they deliver to patients. This is the first time in the history of the program that explicit goals for alternative payment models and value-based payments have been set for Medicare. Changes assessed by these metrics will mark our progress in the near term, and we are engaging state Medicaid programs and private payers in efforts to make further progress toward value-based payment throughout the health care system. Through Healthy People 2020 and other initiatives, we will also track outcome measures that reflect changes in Americans’ health and health care.
To drive progress, we are focusing on three strategies. The first is incentives: a major thrust of our efforts is to create an environment in which hospitals, physicians, and other providers are rewarded for delivering high-quality health care and have the resources and flexibility they need to do so. The ACA creates a number of new institutions and payment arrangements intended to drive the health care system in this direction. These include alternative payment models such as ACOs, advanced primary care medical-home models, new models of bundling payments for episodes of care, and demonstration projects in integrated care for beneficiaries dually eligible for Medicare and Medicaid.
Looking ahead, we plan to develop and test new payment models for specialty care, starting with oncology care, and institute payments to providers for care coordination for patients with chronic conditions. Three years ago, Medicare made almost no payments through these alternative payment models,1 but today such payments represent approximately 20% of Medicare payments to providers, and as noted above, we aim to increase this percentage. As part of this work, we also recognize the need to continue to reach consensus on the quality measures used and address issues related to risk adjustment in these new models.
Second, improving the way care is delivered is central to our reform efforts. We have put in place policies to encourage greater integration within practice sites, greater coordination among providers, and greater attention to population health. Through the Partnership for Patients, we have engaged U.S. hospitals in learning networks to focus on high-priority risks to patient safety and have already seen significant improvement. There is now a national program to reduce hospital readmissions within 30 days after discharge, which encourages hospitals to improve transitional care and coordinate more effectively with ambulatory care providers. Readmission rates are decreasing nationwide.2 Through the Transforming Clinical Practice Initiative, we will invest up to $800 million in providing hands-on support to 150,000 physicians and other clinicians for developing the skills and tools needed to improve care delivery and transition to alternative payment models. New Medicaid health homes, patient-centered medical homes, and efforts to reorganize care for people eligible for both Medicare and Medicaid are all designed to foster greater integration and coordination.
Third, we aim to accelerate the availability of information to guide decision making. The Obama administration has led a major initiative in health information technology (IT), focusing on the adoption of electronic health records (EHRs) and their meaningful use as a central avenue for transforming care. The proportion of U.S. physicians using EHRs increased from 18% to 78% between 2001 and 2013, and 94% of hospitals now report use of certified EHRs.3 Ongoing efforts will advance interoperability through the alignment of health IT standards and practices with payment policy so that patients’ records are available when needed at the point of care to permit informed clinical decisions to be made in a timely fashion.
HHS has made a commitment to enhancing transparency in the health care market. For example, the Medicare website enables consumers to compare data on the costs and charges for hundreds of inpatient, outpatient, and physician services. Information is available on the quality of hospitals, physicians, nursing homes, and other providers, enabling consumers to make better-informed choices when selecting providers and health plans.
The ACA established the Patient-Centered Outcomes Research Institute (PCORI), dedicated to generating information that can guide doctors, other caregivers, and patients as they address important clinical decisions; PCORI is working with the Agency for Healthcare Research and Quality to disseminate this information. In the years ahead, the research findings from PCORI, disseminated in part through EHRs, can bring critical clinical information to providers and patients when they need it most, at the point of care.
Although we have much to celebrate regarding increased access and quality and reduced cost growth, much of the hard work of improving our health care system lies ahead of us. Care delivered in hospitals was much safer in 2013 than it was in 2010: there were 1.3 million fewer adverse events between 2011 and 2013 than there would have been if the rate of such events had remained unchanged, and an estimated 50,000 deaths were averted. Still, far too many hospitalized patients — nearly 1 in 10 — have adverse events while hospitalized, and many people do not receive care that they should receive, while others receive care that does not benefit them. Growth of health care spending is at historic lows: Medicare spending per beneficiary increased by approximately 2% per year from 2010 to 2014 — a rate far below both historical averages and the growth rate of the gross domestic product.4 Survey data show that more than 7 in 10 people who signed up for insurance in the new health insurance marketplace last year say the quality of their coverage is excellent or good.5 However, it will take additional effort to sustain and augment the positive changes we have seen so far.
We are dedicated to using incentives for higher-value care, fostering greater integration and coordination of care and attention to population health, and providing access to information that can enable clinicians and patients to make better-informed choices. We believe that, by working in partnership across the public and private sectors, we can accelerate these improvements and integrate them into the fabric of the U.S. health system.
Article link: http://www.nejm.org/doi/full/10.1056/NEJMp1500445
JAN. 30, 2015
A secretive group met behind closed doors in New York this week. What they decided may lead to higher drug prices for you and hundreds of millions around the world.
Representatives from the United States and 11 other Pacific Rim countries convened to decide the future of their trade relations in the so-called Trans-Pacific Partnership (T.P.P.). Powerful companies appear to have been given influence over the proceedings, even as full access is withheld from many government officials from the partnership countries.
Among the topics negotiators have considered are some of the most contentious T.P.P. provisions — those relating to intellectual property rights. And we’re not talking just about music downloads and pirated DVDs. These rules could help big pharmaceutical companies maintain or increase their monopoly profits on brand-name drugs.
The secrecy of the T.P.P. negotiations makes them maddeningly opaque and hard to discuss. But we can get a pretty good idea of what’s happening, based on documents obtained by WikiLeaks from past meetings (they began in 2010), what we know of American influence in other trade agreements, and what others and myself have gleaned from talking to negotiators.
Trade agreements are negotiated by the office of the United States Trade Representative, supposedly on behalf of the American people. Historically, though, the trade representative’s office has aligned itself with corporate interests. If big pharmaceutical companies hold sway — as the leaked documents indicate they do — the T.P.P. could block cheaper generic drugs from the market. Big Pharma’s profits would rise, at the expense of the health of patients and the budgets of consumers and governments.
There are two ways the office of the trade representative can use the T.P.P. to maintain or raise drug prices and profits.
The first is to restrict competition from generics. It’s axiomatic that more competition means lower prices. When companies have to fight for customers, they end up cutting their prices. When a patent expires, any company can enter the market with a generic version of a drug. The differences in prices between brand-name and generic drugs are mind- and budget-blowing. Just the availability of generics drives prices down: In generics-friendly India, for example, Gilead Sciences, which makes an effective hepatitis-C drug, recently announced that it would sell the drug for a little more than 1 percent of the $84,000 it charges here.
That’s why, since the United States opened up its domestic market to generics in 1984, they have grown from 19 percent of prescriptions to 86 percent, by some accounts saving the United States government, consumers and employers more than $100 billion a year. Drug companies stand to gain handsomely if the T.P.P. limits the sale of generics.
The second strategy is to undermine government regulation of drug prices. More competition is not the only way to keep down the prices of essential goods and services. Governments can also directly restrain prices through law, or effectively restrain them by denying reimbursement to patients for “overpriced” drugs — thus encouraging companies to bring down their prices to approved levels. These regulatory approaches are especially important in markets where competition is limited, as it is in the drug market. If the United States Trade Representative gets its way, the T.P.P. will limit the ability of partner countries to restrict prices. And the pharmaceutical companies surely hope the “standard” they help set in this agreement will become global — for example, by becoming the starting point for United States negotiations with the European Union over the same issues.
Of course, pharmaceutical companies claim they need to charge high prices to fund their research and development. This just isn’t so. For one thing, drug companies spend more on marketing and advertising than on new ideas. Overly restrictive intellectual property rights actually slow new discoveries, by making it more difficult for scientists to build on the research of others and by choking off the exchange of ideas that is critical to innovation. As it is, most of the important innovations come out of our universities and research centers, like the National Institutes of Health, funded by government and foundations.
The efforts to raise drug prices in the T.P.P. take us in the wrong direction. The whole world may come to pay a price in the form of worse health and unnecessary deaths.
Joseph E. Stiglitz, a Nobel laureate in economics, a professor at Columbia and a former chairman of the Council of Economic Advisers, is the author of “The Price of Inequality.”