healthcarereimagined

Disagreement about the role of markets lies at the root of many of our fiercest health care controversies. One side believes that unleashing market forces will rescue our health care system. From this viewpoint, government involvement is inherently destructive, except in rare circumstances. Many opponents of the Affordable Care Act share this opinion.

The other side believes that health care markets are deeply flawed and that government must play a major role in achieving a higher-performing health system. These people point out that markets make no claim to ensuring equity in the use of health care resources, only improved efficiency. Supporters of the ACA tend to hold this view.

Given this fundamental divide, it’s worth considering the conditions underlying the effective functioning of market economies, whether those conditions currently prevail in health care and, if not, what changes would be required to establish them.

Students learn in Economics 101 that several assumptions must hold for free markets to achieve their potential:

• First, consumers and suppliers of goods and services have perfect — or at least sufficient — information. They know or can find out the price and quality of available products.
• Second, consumers and producers are rational. They make reasoned decisions about what to purchase and supply. These decisions maximize their welfare as consumers and their profits as businesses.
• Third, it is easy for producers to enter markets, thus assuring that monopolies don’t form, and that increased competition occurs where prices are excessive, reducing prices to efficient levels.
• Fourth, in any market, there are large numbers of firms selling a homogeneous product.
• Fifth, individual firms cannot affect market prices.

Practically speaking, these conditions rarely exist in pure form anywhere in our economy. In the case of health care, there are a variety of different types of markets. For example, employers purchase insurance, large hospital systems purchase medical supplies, and individuals purchase insurance plans. These markets may embody these conditions to varying degrees, but the most basic health care markets, in which consumers or patients directly buy health care services, depart from this ideal dramatically, as the following examples illustrate.

To begin with, health care consumers not only lack perfect information, but often any information at all. At present, prices in the U.S. health care market are virtually unknowable. Quality data are scant, imperfect, and often confound even experts. Further, medicine is a complex science-based service: even highly trained health professionals struggle to stay current. As a result of social media and the internet, consumers are better informed than ever before, but most depend on advice from health professionals to make informed health care purchases. This kind of imperfect information may help explain why consumers in high-deductible health plans are equally likely to reduce their use of high-value or low-value health care services. They are just as likely to forgo their blood pressure treatments as unnecessary back surgery.

Health care consumers also face unusual challenges to making rational decisions. In medicine there is a saying that any doctor who treats herself has a fool for a patient. Even the most informed individual can have difficulty acting rationally when confronting the emotional turmoil that accompanies their own illness or that of a loved one. Beyond this, there are clear situations where patients’ cognitive abilities are compromised, for example, in cases of stroke, dementia, intoxication, loss of consciousness, delirium, or mental illness.

Competent patients have the inherent right to make their own medical decisions, and many do so wisely and well. But market advocates also must recognize the special obstacles to rational decision-making that face health care consumers.

Consolidation among insurers and health care organizations has radically reduced the number of providers selling health care and health insurance in many U.S. health care markets. Recent work shows that providers in 90 percent of U.S. markets are highly or “super” concentrated.

This consolidation and resulting lack of competition has enabled individual providers to charge excessive prices in many markets. Similarly, government-granted patents create monopolies that enable drug manufacturers to set astounding prices for new drugs and raise them almost at will.

These and other departures from the conditions necessary for effective market functioning suggest the dangers of uncritical reliance on free markets to improve our health care system. At a minimum, advocates of market solutions would be wise to consider three interventions that could increase the probability that markets will function as desired.

1. Develop better information on prices and quality. Consumers need information to make informed decisions. Publishing raw data on the prices of care — often referred to as price transparency — is insufficient because it rarely reflects the actual cost consumers face during an episode of care. The price of a chest x-ray that diagnoses pneumonia, for instance, is a poor indicator of the costs of a subsequent hospitalization, not to mention the downstream costs for any previously undetected lung disease. To make health care markets work, advocates must develop approaches to price transparency and quality measurement that are meaningful and understandable to consumers.
2. Foster markets for health services that pose the smallest challenges to rational decision-making. Certain health services — often referred to as “shoppable” — involve tests or treatments that are either elective, relatively simple to understand, or nonurgent, which allows patients time to learn and think about them. Examples include screening tests for generally healthy individuals (e.g., colonoscopies, mammograms), elective surgeries (e.g., hip and knee replacement), or necessary but nonemergent care (e.g.,whether to add insulin to a diabetic regimen). Fostering competitive forces in these areas could improve the functioning of the health care market overall. But reformers should be aware that these services are likely to account for a minority of health care activities and, frequently, are not the most expensive ones.
3. Promote competition. Unless government finds ways to restore competition among providers where it no longer exists, markets can’t succeed. This is true both for health care services generally and pharmaceuticals in particular.

Given our desperate need for health care reform, the appeal of market solutions is understandable. But it is naïve to assume that they will work in health care just like they do in other sectors. It is time for a frank, open, and nonideological discussion of the problems markets can address in health care and how we can create conditions that will enable markets to function as intended.

Article link: https://www.commonwealthfund.org/blog/2018/creating-effective-health-care-markets

(Reuters Health) – Health data breaches are on the rise, a new study shows.

While the largest number of data breaches occurred at health care providers’ sites – such as hospitals and physicians’ offices – it’s health care plans that account for the greatest number of patient records stolen over the past seven years, according to the study published in JAMA.

“The climb in the total number of records breached is primarily attributable to very large breaches of electronic systems,” said study leader Dr. Thomas McCoy, an assistant professor of psychiatry and medicine at Harvard University and director of research for the Center for Quantitative Health at Massachusetts General Hospital in Boston.

And while large centralized databases offer health researchers a goldmine of records that can be used to improve healthcare, you have “to balance the risks (of being hacked) against the benefits to research,” McCoy said.

McCoy and his coauthor analyzed all data breaches that were reported to the Office of Civil Rights at the U.S. Department of Health and Human Services from January 2010 through December 2017. The researchers looked at trends in the numbers and types of breaches reported in three categories: those taking place at health care providers, at health plans and at businesses associated with healthcare.

The analysis turned up 2,149 breaches involving a total of 176.4 million patient records, with individual breaches ranging from 500 to nearly 79 million patient records. During the seven-year period, the total number of breaches increased every year except for 2015, starting at 199 in 2010 and rising to 344 in 2017.

While 70 percent of all breaches involved data stored by health care providers, the breaches involving data kept by health plans accounted for 63 percent of all stolen records.

The researchers found that 510 breaches involved paper and film records, which impacted about 3.4 million patients, as compared to 410 breaches of network servers that impacted nearly 140 million records. The three largest breaches together accounted for more than half of the stolen records.

Why would thieves want your health data?

“There’s financial data embedded in health data – your name, your address, your social security number,” said Chris Carmody, senior vice president of infrastructure and services and president of ClinicalConnect Health Information Exchange at the University of Pittsburgh Medical Center in Pennsylvania. “With that information someone could go out and get a credit card account. Or a criminal could go out and sell it on the dark web, the shady part of the internet where identities are sold and traded.”

Healthcare-related organizations have become a more interesting target as they have increasingly adopted digital records, said Carmody, who is not affiliated with the new research. “They’re going after the easiest target and unfortunately healthcare has that stigma,” he said. “The benefit of this research paper is that it highlights cyber security threats. It will probably happen to most organizations at one point or another and maybe even multiple times.”

While the risk of theft is real, Carmody doesn’t suggest doing away with electronic records. “They empower patients,” he explained. “So the message shouldn’t be to ask your doctors to stop using electronic records, but rather to ask what they are doing to protect your data.”

Theoretically, it’s also possible that thieves could try to sell health data to employers wanting yet another source of information on prospective hires, said Michael Pencina, vice dean for Data Science and Information Technology at the Duke University School of Medicine in Durham, North Carolina.

Still, the risks are small compared to the benefits that are already accruing from big health data, said Pencina, who is not affiliated with the new research. With a huge source of information on various diseases, researchers can devise new treatments and tests, he added.

Access to a large number of scans, for example, can help scientists “teach” computers to spot diseases “with accuracy that matches or exceeds what a human can achieve,” Pencina said.

With this kind of data, “the potential is huge,” Pencina said.

SOURCE: bit.ly/2EM1XZO Journal of the American Medical Association, online September 25, 2018.

Article link: https://mobile.reuters.com/article/amp/idUSKCN1M524J

Donald Rebhun September 25, 2018

But it would take a change of culture and investment to make that happen

The ongoing conversation around health care in the United States presents a daunting question: How is it that this country—with all its wealth, education and innovation—has among the highest health care costs of any industrialized nation, yet its clinical outcomes still lag behind?

Illustrating the point, according to a Kaiser Family Foundation analysis, disease burden in the U.S. is greater than in other similar countries, with poorer management of preventable diseases resulting in increased use of emergency rooms, increased hospital admissions, worse outcomes, higher costs, and higher mortality rates.

There are numerous opinions coming from inside and outside of the medical community on how best to improve treatment quality and outcomes, boost patient experience and reduce the cost of care. We believe that medical organizations that embrace integrated coordinated care are uniquely positioned to help drive the changes needed.  There are groups throughout the country that have decades of experience practicing coordinated care and many more that are embracing this care delivery model each year. It is worth taking a closer look at how these groups are financially structured and the foundations of their clinical cultures.

The vast majority of American health care providers are still operating in a model that the industry refers to as “fee-for-service,” in which the provider is paid based on the services and treatment rendered, not on the patient’s health outcome (quantity rather than quality).  However, very different types of health care finance models have existed for decades. Most accept a variety of payments including shared savings, bundled payments, being part of an accountable care organization (ACO), shared risk and full risk.

In the full risk model, a provider organization is paid a flat per-patient, per-month rate. The group thus accepts the clinical and financial accountability of a defined population. In order for organizations to be successful under this and other risk-based contracting models, they must have: an engaged and committed clinical and business leadership; invested in building a unique infrastructure with focus on prevention and early detection; and an advanced care management department working closely with numerous healthcare professionals, applying innovative resources and programs and using data/analytics to improve the quality of care delivery. This model places financial incentives for providers to keep the patient in the best possible health in order to reduce downstream health problems and complications with their associated costs.

In the short term, a fee-for service financial model may offer steady, predictable income; however, it is not a sustainable strategy for the long term. Making the shift from a volume-based fee-for-service model to a value-based risk-bearing care model can prove to be beneficial for patients and the medical organizations themselves. But how and what changes are needed by organizations, most of which recognize that these and other changes are inevitable?

While many medical groups claim that they are “patient centered,” the key is implementing day-to-day action that proves it. For example, HealthCare Partners, a DaVita Medical Group, has spent the last three decades caring for hundreds of thousands of patients in Southern California. Over that time, we built an intentional culture where patients are at the center of the clinical model. In this model, coordinated teams align with physicians who have the independence to develop a care plan in collaboration with their patients. This basic but fundamentally unique approach laid a cultural foundation for all of our clinical programs and naturally fostered an environment where a full-risk model has been highly successful.

Our group and other medical groups that prioritize value-based care use key performance indicators to determine how successful this approach has been, such as monitoring how often patients are going to the emergency room for non-emergent care and how often they are being admitted to the hospital. Typically, a group’s assumed financial risk, coupled with a patient-centered culture, heightens the organization’s focus on, and investment in, helping to safely promote avoidable hospital stays and deliver the right care, in the right place, at the right time.

As Health Care Costs Remain on Top of Voters’ Minds, Americans Cite Unexpected Medical Bills as Their Top Problem, Ahead of Premiums, Deductibles and Drugs

Public Not Confident in President Trump’s Calls on Drug Companies to Lower Prices

As a federal court considers a challenge to the Affordable Care Act’s constitutionality, the public, including most Republicans, wants protections for people with pre-existing conditions preserved, the latest Kaiser Family Foundation tracking poll finds.
Large majorities of Americans say it is “very important” to retain the ACA provisions that prevent insurance companies from denying coverage based on a person’s medical history (75%) and from charging sick people more (72%). This includes majorities of Democrats, independents and Republicans, as well as majorities of those with and without people with pre-existing conditions in their households.

The ACA’s pre-existing condition protections have emerged as a hot topic in some key Congressional races in part because of a pending legal challenge filed by 20 state attorneys general. The Trump Administration has opted not to defend the law’s pre-existing condition protections in the case, and a federal district court in Fort Worth, Texas is scheduled to hear arguments on the challenge today. Republican Senators also introduced a bill to address the issue if the ACA were overturned, though some analysts say its protections fall short.
Four in 10 Americans (41%) say they are “very worried” that they or a family member will lose coverage if the Supreme Court overturns the ACA’s pre-existing condition protections. In addition, half (52%) are “very worried” they or a family member will have to pay more for coverage.
Americans Cite Unexpected Medical Bills as Their Top Health Cost Concern
The public overall also sees health costs as a major problem – with six in 10 (58%) saying they are “very concerned” about increases in what people pay for health care.
When given a list of possible worries, unexpected medical bills tops the list that includes other health care costs such as premiums, deductibles and even drug costs. Two-thirds (67%) say they are at least “somewhat” worried about affording an unexpected medical bill – more than say the same about their deductibles (53%), drug costs (44%) or premiums (42%).
Unexpected medical bills also ranked higher than other pocketbook concerns such as gasoline or transportation costs (46%), monthly utility bills (43%) and rent or mortgage (41%).
Overall, 39 percent of insured adults ages 18-64 say that in the past year they have received an unexpected medical bill – either from a doctor, hospital, or lab that they thought was covered and their health plan either didn’t cover the bill at all or covered less than they expected. For 10 percent of insured adults ages 18-64, the surprise bill was related to care received from an out-of-network provider.

Half (50%) of those who had an unexpected medical bill say the amount they were expected to pay was less than $500 overall. Smaller shares say the amount was between $500 and $999 (16%), between $1,000 and $1,999 (12%); or $2,000 or more (13%).

Partisans Split on Effectiveness of Trump Administration’s Efforts to Lower Drug Prices

President Trump recently has publicly criticized several drug companies and called on them to lower the cost of their prescription drugs. A majority (55%) of the public say that this strategy of publicly calling on drug companies to lower their costs will not be too effective or at all effective. Fewer (42%) say it will be very or somewhat effective.

There are large partisan differences. Three-fourths of Democrats (74%) say this strategy will not be effective, while two-thirds of Republicans (67%) say it will be effective. More independents say it will not be effective than will be effective (57% v. 41%).

In addition, 38 percent of Americans say they are either “very” or “somewhat” confident that President Trump and his administration will be able to deliver on his promise that Americans will pay less for prescription drugs than they pay now. This number remains virtually unchanged since March 2018, before the administration released its “American Patients First” plan aimed at lowering drug prices.

The public debate over drug prices appears to having an impact on the public’s views of drug companies. When asked about the reasons behind rising health care costs, an increasing share of the public blames prescription drug companies. Eight in ten (78%) say drug companies making too much money is a “major reason” why people’s health care costs have been rising, up from 62 percent in 2014.

Other top causes in the public’s mind include fraud and waste in the health care system (71%), hospitals charging too much (71%), and insurance companies making too much money (70%). About six in 10 (62%) say a major reason for rising costs is due to the expense of new drugs, treatments, and medical technologies.

Fewer, but still about half, say doctors charging too much (49%), an aging population (47%), and medical malpractice lawsuits (45%) are “major reasons” for rising costs. Less than half blame people getting more services than they really need (41%), the Affordable Care Act (39%), the Trump administration’s recent actions on health care (38%), or people not shopping for lower-priced services (28%).

Across Parties, Costs Top Voters’ Health Care Concerns Heading into the Midterm Elections

The poll finds corruption in Washington, health care and the economy and jobs are what voters want to hear candidates discuss on the campaign trail ahead of November’s midterm election. Fielded after of the indictment of Michael Cohen and initial trial of Paul Manafort, this is the first time the KFF poll included corruption in Washington, D.C. in the list of possible campaign topics, and the issue jumped to the top of the list.

Three in 10 of voters (30%) say Washington corruption is the “most important” topic for candidates to discuss, with health care (27%) and the economy and jobs (25%) close by. In June, when Washington corruption wasn’t offered as an option, health care and the economy topped the list of topics voters want to hear candidates discuss.

Battleground voters – those living in states and districts that the Cook Political Report rates as having the most competitive House, Senate and gubernatorial races – rank campaign topics similarly, with corruption (32%), the economy and jobs (27%) and health care (26%) topping their list of “most important” topics.

When voters are asked what health care issue they most want to hear the candidates discuss, a quarter (27%) mention health care costs – three times the share that mention any other health care issue, such as increasing access (9%), universal coverage (8%), Medicare or senior concerns (7%), or prescription drug costs (7%). Health care costs are the top health care issue mentioned by Democratic voters (29%), independent voters (29%), and Republican voters (25%).

Half of Public Views the ACA Favorably This Month

This month marks the 90^th time that KFF has asked about the public’s perception of the Affordable Care Act on a poll since April 2010. This month, half (50%) of the public holds a favorable view of the law, while 40 percent hold an unfavorable view. Similar shares of Republicans hold unfavorable views (78%) as Democrats hold favorable views (77%). Half (50%) of independents holds favorable views toward the ACA, while 39 percent hold unfavorable views.

Methodology

Designed and analyzed by public opinion researchers at the Kaiser Family Foundation, the poll was conducted from August 23-28, 2018 among a nationally representative random digit dial telephone sample of 1,201 adults. Interviews were conducted in English and Spanish by landline (301) and cell phone (900). The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on subgroups, the margin of sampling error may be higher.

Article link: https://www.kff.org/health-reform/press-release/poll-acas-pre-existing-condition-protections-remain-popular-with-public/

Sep 14, 2018