value-based purchasing (VBP) programs & ACA

The quality of healthcare services is so complicated, then how to incorporated the true "quality and value" into the payment system? below is from Jason's <Health Reform's Value-Based Purchasing Provisions>:

The Affordable Care Act of 2010 includes a number of provisions to study and/or implement value-based purchasing (VBP) programs in the United States' health care system.  These provisions target Medicare payment policies in particular.  Today I review a Robert Wood Johnson (RWJ) article which provides an overview of the ACA provisions related to VBP.

There are four Sections of the ACA which I will focus on: Section 3022, 3007, 3013, and 3021.  Let's get to it.

• Section 3022 calls for a Medicare Shared Savings Program, which would provide payments specifically for new accountable care organizations. The legislation specifically requires measurement and assessment of quality as reflected in clinical processes and outcomes, patient and caregiver experience with care, and utilization reflecting efficiency and effectiveness of care, such as hospital admissions for ambulatory care sensitive conditions.

• Section 3007 creates a new "value-based payment modifier," which, starting in 2015, will be used to provide differential payments based on quality and cost of care. Since the payment adjustments are to be budget neutral, some physicians would receive bonuses and others penalties under this provision. Presumably, the IOM's study will be influential in determining how CMS might apply a value-based payment modifier.

Further, the Act continues to advance the notion of bringing value into payments made to physicians, hospitals, and other providers through established payment mechanisms:

• Section 3013 provides for the identification of gaps in quality measures and authorizes (but does not appropriate) funding intended to fill those gaps, relying on collaboration between CMS, the Agency for Healthcare Research and Quality (AHRQ) and the National Quality Forum, which will be primarily responsible for identifying the measure gaps. Priorities are to be given to the following areas: i)  health outcomes; ii)  functional status; iii) coordination of care; iv) meaningful use of health IT; v) safety; vi) patient experience; vii) efficiency; and viii) disparities.

• Section 3021 creates a Center for Medicare and Medicaid Innovation within the Centers for Medicare and Medicaid Services to test payment and service delivery models that reduce costs while preserving or enhancing the quality of care provided under Medicare, Medicaid, and CHIP, and funds it at $10 billion every 10 years. The legislation specifically suggests pursuing models that transition providers away from fee-for-service and toward comprehensive pay

Source:

• Berenson RA "Moving Payment from Volume to Value: What Role for Performance Measurement?", Quick Strike Series, Urban Institute, Robert Wood Johnson Foundation, Dec 14, 2010.

什么是ACO？

ACOs are sometimes said to be the brain child of Elliott Fisher, who heads the Dartmouth Atlas Project. But as Uwe Reinhardt pointed out the other day, the idea is actually an old idea. It's called Kaiser Permanente.

ACOs have been called "HMOs on steroids." They will have capitated payments and, like the traditional HMO, the ACO will get to keep any money it doesn't spend. But the organization will also incorporate all the latest fads in health policy: electronic medical records (EMRs), pay-for-performance (P4P) incentives, quality report cards, etc.

The results from the few demonstration projects with ACOs are lackluster and mixed. But that doesn't seem to matter to the Obama administration. Medicare will start contracting with ACOs beginning next year.

If that doesn't strike you as strange, you need to know that "evidence-based medicine" is one of the buzz words among policy wonks these days and is supposed to be the foundation for ACO management. But if that's a good idea for doctors, isn't it equally good for policymakers? If we abided by evidence-based policy, would we put all of our marbles in the ACO basket? Basically no.

The latest comprehensive review of all the studies of report cards and other quality-measuring-and-reporting techniques finds they don't work and may do more harm than good. Just as teachers will "teach to the test" if test results are how they are graded and rewarded, doctors will tend to "practice medicine to the test" if that is how they are paid. If you're the patient, that may not be good for you. The latest comprehensive review of all the studies of electronic medical records finds they do not live up to their promises. And the most recent study of pay-for-performance from Britain finds that it doesn't work either.

What about Kaiser? Its integrated medical records system is impressive and Kaiser is also promoting e-mail and telephone consultations. On the other hand, Harvard Business School professor Regina Herzlinger has taken the organization to task for letting people die.

But let's give Kaiser the benefit of the doubt for the moment. The real question is not: how well does Kaiser perform? There are lots of centers of excellence around the country: Cleveland Clinic, Mayo Clinic, Intermountain Healthcare. The real question is: can the performance be replicated?

There is no law against ACOs (other than Stark restrictions that limit flexibility). So if ACOs can reduce costs and raise quality, why don't we see them everywhere?

As it turns out, when Kaiser tried to replicate in Dallas what it does in Palo Alto, it failed. This isn't surprising. If high-quality, low-cost medicine were easy to replicate we wouldn't be having all the problems we are having.

When health policy experts associated with the Brookings Institution studied the "best" hospital regions around the country, they found few objective (replicable) characteristics. Some had doctors on staff. Some paid fee-for-service. Some had electronic medical records. Some did not. A separate study of high-performing doctor groups found much the same thing.

Evidence-based policy would admit ignorance about what works and why, and would let a thousand flowers bloom. It would pay more for low-cost, high-quality care, regardless of how it is achieved. We have previously suggested ways of doing that.

By contrast, the non-evidence based approach of the Obama administration will force everybody into the same model. As Scott Gottlieb has pointed out, this approach not only will stifle innovation and entrepreneurship, it is already causing venture capital to leave the health care market completely.

So how do we explain the administration's commitment to ACOs? Whether they raise or lower costs, whether they raise or lower quality, there is one thing that ACOs will indisputably accomplish. They will drive doctors into organizations where their behavior can be controlled. For the first time in our history, both the practice of medicine and the way money is spent on medical care will fall under federal control.

ACOs are the portal through which we will all march toward a truly nationalized health care system.

source：http://healthblog.ncpa.org/the-hmo-in-your-future/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+TheJohnGoodmanHealthBlog+%28John+Goodman%27s+Health+Policy+Blog%29

职工医疗保险阻碍“企业家精神”

Is employer-based health insurance a barrier to entrepreneurship?

Robert W. Fairliea, Kanika Kapurb,
Abstract
The focus on employer-provided health insurance in the United States may restrict business creation. We address the limited research on the topic of "entrepreneurship lock" by using recent panel data from matched Current Population Surveys. We use difference-in-difference models to estimate the interaction between having a spouse with employer-based health insurance and potential demand for health care. We find evidence of a larger negative effect of health insurance demand on business creation for those without spousal coverage than for those with spousal coverage. We also take a new approach in the literature to examine the question of whether employer-based health insurance discourages business creation by exploiting the discontinuity created at age 65 through the qualification for Medicare. Using a novel procedure of identifying age in months from matched monthly CPS data, we compare the probability of business ownership among male workers in the months just before turning age 65 and in the months just after turning age 65. We find that business ownership rates increase from just under age 65 to just over age 65, whereas we find no change in business ownership rates from just before to just after for other ages 55–75. We also do not find evidence from the previous literature and additional estimates that other confounding factors such as retirement, partial retirement, social security and pension eligibility are responsible for the increase in business ownership in the month individuals turn 65. Our estimates provide some evidence that "entrepreneurship lock" exists, which raises concerns that the bundling of health insurance and employment may create an inefficient level of business creation.

source：doi:10.1016/j.jhealeco.2010.09.003

法律眼中的住院医师

潇湘渌水 @ 2011-02-24 22:48

在NEJM这篇“Residents: Workers or Students in the Eyes of the Law?”中讨论了不同机构的眼中对住院医师定位的看法，住院医师到底是工作者还是学生？那么很重要的是--在法律眼中呢？同时本文也围绕2011年1月11日美最高法院的一项裁决进行了阐述，其中：

On January 11, 2011, the Supreme Court ruled in an 8-to-0 decision (Justice Elena Kagan was recused) that the Treasury regulation making residents categorically ineligible for the student exemption was a “perfectly sensible” way of distinguishing education from service for the purposes of the tax code. Chief Justice John Roberts wrote that residents could reasonably be construed as “the kind of workers that Congress intended to both contribute to and benefit from the Social Security system.”

source：http://healthpolicyandreform.nejm.org/?p=13586&query=TOC

公私部门的角色PPP

又一篇PPP-公私部门 潇湘渌水 @ 2011-02-23 11:40 又是一篇PP(Public and Private)的文章，看完后我不禁莞尔。 谁说私人营利医疗效果不好，事实上，它不仅可以效果好，又可以成本低，作者甚至还建议（出人意料地）：要求私人医疗服务那些保险不足的人群是有效果的。paper的发现是虽然私人医疗会挑选相对低风险的患者，但是在“慈善要求法案（Hill Burton Act）”的约束下，私人医疗会多快好省的对待病人，减少侵入性治疗（也就等于低成本了），一旦符合法案要求了，又会马上转到公立医院去。这时候就可能出现两种情况了：一种是效果不行，public要继续提供服务，二种是不必要。paper的发现是后者，public的后续服务对患者健康产出没有边际效用了。Great -- private，赞一个。 Back to writing of this paper，我真想说gorgeous，以前我有个“我是粉丝”的收藏夹，赫然Prof Almonda就是其中一员，哈哈 偶像那，致敬！ Public vs. private provision of charity care? Evidence from the expiration of Hill–Burton requirements in Florida Douglas Almonda, b, Janet Curriea, b, This paper explores the consequences of the expiration of charity care requirements imposed on private hospitals by the Hill–Burton Act. We examine delivery care and the health of newborns using the universe of Florida births from 1989 to 2003 combined with hospital data from the American Hospital Association. We find that charity care requirements were binding on hospitals, but that private hospitals under obligation “cream skimmed” the least risky maternity patients. Conditional on patient characteristics, they provided less intensive maternity services but without compromising patient health. When obligations expired, private hospitals quickly reduced their charity caseloads, shifting maternity patients to public hospitals. The results in this paper suggest, perhaps surprisingly, that requiring private providers to serve the underinsured can be effective. Keywords: Infant health; Charity care; Cesarean section; Prematurity; Hill–Burton JEL classification codes: I12; I18 source: doi:10.1016/j.jhealeco.2010.11.004 阅读全文() / 评论 / 给潇湘渌水留言 / 扔小纸条 收藏: QQ书签 del.icio.us

药物创新过程中-公私部门的角色 潇湘渌水 @ 2011-02-17 22:51 我因为一直对公私部门感兴趣，自然不会放过这篇文章：讲的是公私部门在药物创新中的各自地位，作者研究的数据是88-05年的通过的药物信息，他们发现政府直接资助发展的药物在优先审查“priority-review”药物名单（相当于与最具创新的新药）中更重要，相比较与那些标准审查的药物，由此作者认为这可以提供一条线索来思考是否存在药物利润向公部门输送。我觉得这篇文章很有利于我思考以前我对比的另一个问题--即公私部门的HRH--很有借鉴参考意义。 What Are The Respective Roles Of The Public And Private Sectors In Pharmaceutical Innovation?  Bhaven N. Sampat1, Frank R. Lichtenberg Abstract What are the respective roles of the public and private sectors in drug development? This question is at the heart of some policy proposals, such as those that would give the government a share of profits from drugs at least partly developed with federal research dollars. This paper provides empirical data on these issues, using information included in the patents on drugs approved between 1988 and 2005. Overall, we find that direct government funding is more important in the development of “priority-review” drugs—sometimes described as the most innovative new drugs—than it is for “standard-review” drugs. Government funding has played an indirect role—for example, by funding basic underlying research that is built on in the drug discovery process—in almost half of the drugs approved and in almost two-thirds of priority-review drugs. Our analyses should help inform thinking about the returns on public research funding—a topic of long-standing interest to economists, policy makers, and health advocates. source: http://content.healthaffairs.org/content/30/2/332.full 在药物研发中公共和私人部门究竟分别处于什么样的角色呢？这个问题是某些政策提案的核心内容，比如某些提案认为至少部分由联邦研究经费发展出来的药物应该给政府一部分利润。本文使用了1988-2005年的通过的药物及包括专利的信息为这些议题提供经验证据。总之我们发现政府直接资助在“优先审查”药物名单（有时被认为是最具创新的新药）中比那些“标准审查”的药物更重要。政府资助已经在大部分通过审查的药物以及三分之二的优先审查药物中扮演了应该间接的角色--比如通过资助药物发现过程中的基础研究。我们的分析应该可以帮助引发关于公共研发资助回报的思考--这是一个经济学家、政策制定者和健康倡导者长期的兴趣话题。