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Monday, October 23, 2017

The unhappy intersection of health care data and clinical quality oversight policy

Kip Sullivan, JD has a doozy of a post up at THCB:
MedPAC Sinks Deeper Into the MACRA Tar Pit

The Medicare Payment Advisory Commission (MedPAC) has done it again. At their October 4, 2017 meeting they agreed to repeal the Merit-based Incentive Payment System (MIPS), an insanely complex and evidence-free pay-for-performance scheme within the larger program known as MACRA. Instead of examining how they made such a serious mistake in the first place (MedPAC has long supported turning fee-for-service Medicare into a giant pay-for-performance scheme), they repeated their original mistake –- they adopted yet another vague, complex, evidence-free proposal to replace MIPS.

MedPAC’s history gives us every reason to believe that when they discuss their “repeal and replace MIPS” proposal at their December 2017 and January 2018 meetings, they will refuse to discuss their “replace” proposal in any detail; they will not ask for evidence indicating their proposal is safe and effective; and in their March 2018 report to Congress they will foist upon CMS the dirty work of figuring out how to make their lead balloon fly. CMS will dutifully write up a gazillion pages of gibberish describing how the new program is supposed to work, it won’t work, MedPAC will return to the scene of the crime years later and, pretending they had no part in creating it, propose yet another evidence-free tweak. And so on.

MedPAC is caught in a trap of their own making. They endorse health policy fads without any evidence and without thinking through the details; then when the fads don’t work, rather than review their defective thought process, they endorse other iterations of the fads, again without evidence and without thinking through the details. The tweaked version of the fad fails, and MedPAC starts the cycle all over again. Two analogies for this trap or vicious cycle occur to me. One is the tar pit where mastodons got stuck and died; struggle only caused the dimwitted creatures to sink faster. The other is the hedge fund that gradually becomes a Ponzi scheme. Investors like Bernie Madoff make bad investments, and when the investments go south, instead of admitting their mistakes, they induce their investors to throw good money after bad…
Read all of it. Link in the title. Docs have been complaining angrily about "quality reporting measures" since I worked in the Meaningful Use program. MACRA is merely the successor to this data burden, with some new twists going to payment reforms. Some of the comments illustrate the problem nicely:
Kip, can we be BFFs? You have a knack for putting into words exactly my feelings about all this mess of buzzword care and puffery language to assuage the politicos to feel that they are getting “Value” for their healthcare dollar. CMS and ONC and MEDPAC and all the others have made such a mess, it truly should be flushed. Attribution, There is no possible way to attribute costs to my part of the care for a fractured hip, when the patient has kidney disease, heart disease, GI problems, diabetes, etc. What part of the readmission within 90 days is “my” fault if I fixed the hip perfectly, but the patient suffered a hypoglycemic episode at 67 days? And how many click boxes, data entry points do I need to do? Do you really think that my reporting of preop antibiotics is anything but 100%? It always is. Yet somehow, MACRA MIPS values this, yet I have to report it ? Stupid. And its self reporting…no chance for inflation of “Value” by admins, right? All this counting of numerators and denominators and attesting has led to what, exactly? Nothing but burned out MDs that are distracted from real care. Worse, it drive MANY away from caring for the more fragile. less healthy, socially isolated, etc as it will make MY NUMBERS look worse if they have complications or higher resource use, like they are admitted to a skilled facility after a total hip, as they have no one to care for them at home, and they are anxious about going home. Is that my fault? Some articles in this blog has shown that public reporting of these “values” “Complications” etc are definitely driving MDs from caring for those that will ruin my numbers, even with 1 or 2 complicated patients. Think bundled care here. Why would I EVER operate on anyone that could kill my bundle and cost me money, punish me, report nasty numbers on me. Its just the nature of the beast. You punish me for caring for complicated patients both health and social, forget getting any kind of care. Thats EXACTLY what ACOs and BUNDLES do. MIPS MACRA are just the main stage of that mess. I found it extremely disheartening that MEDPAC is grasping at ANY buzzword straw to get themselves out of the MIPS MACRA mess and they initial thought was to just PUNISH providers for FFS no matter what, as FFS is obviously the devil to MEDPAC, so they are dying for a new set of abbreviations, mantras that can be the solution to the scourge that is FFS. What a nightmare, and they are in charge. They should be forced to read your blog. I love your work Kip, please keep it coming.
William Palmer, MD
It seems pretty clear that defining and measuring quality in healthcare has long been an enormous challenge and remains one. We also don’t want to create disincentives for doctors to be willing to care for the highest risk, most complex patients. It’s also pretty clear that the fee for service payment model provides incentives to provide too much care and HMO’s provide incentives to provide too little care. We also have too much defensive medicine because our society is inherently more litigious than others.
At the same time, healthcare costs rose from around 5% of GDP in 1960 to between 17% and 18% of GDP today partly because of huge advances in what modern medicine can do for us patients and partly because of high prices, especially for drugs, devices and, to some extent, imaging. Moreover, most patients can’t afford to pay for the expensive procedures without health insurance. Balance billing, if we had it, would be an additional cost burden that wouldn’t count toward insurance deductibles and OOP limits. That would be a big problem for most people as well.

At the end of the day, what I want as a patient is good care, from both primary care doctors and specialists at a cost that won’t bankrupt me or the country. What those of us who invest in healthcare and health insurance companies want is for them to be sufficiently profitable to produce an adequate risk-adjusted return on our capital relative to other investment alternatives, again without bankrupting the country.

So what’s the answer to the cost conundrum? My own preferences include price transparency to allow both patients and referring doctors to identify the most cost-effective, good quality providers in real time, comprehensive tort reform to reduce defensive medicine, more use of data analytics to go after fraud, especially in the Medicare and Medicaid programs, and a lot less futile care and the end of life much of which patients don’t even want.

While doctors claim that they only account for 10% of healthcare costs after deducting practice expenses, their decisions to order tests, prescribe drugs, admit patients to the hospital, consult with patients and perform procedures themselves drive virtually all healthcare spending.

The docs are in a position to have the best ideas to bring healthcare costs under control relative to GDP but their preference is to be left alone to take care of patients. As Steve2 noted in a recent blog post, nobody cared about healthcare costs when they were 5% of GDP. At 18%, we have to care. Where’s the physician leadership on this issue?
Recommend you peruse all of the comments below the post as well.

One of my long-time wisecracks:
Just as no amount of calling point-to-point interfaced data exchange "interoperability" will make it so, neither will calling Process Indicators "CQMs" (Clinical Quality Measures) make them so.
Process indicators are, in the aggregate, very loosely-coupled proxies for "quality of care." Whether they are uniformly efficacious, or a precious-time-wasting check-box click burden continues to be a matter of heated dispute.

Kip Sullivan concludes:
...In my next comment I will explore the history of this habitual failure. I will focus on the commission’s endorsement of pay-for-performance in 2003 and how that endorsement led the commission into the MACRA tar pit.
I look forward to reading it.

Other THCB posts tagged "Kip Sullivan."


Speaking of "science" and "wellness" quackery. Timothy Caulfield:

Wellness Brands Like Gwyneth Paltrow's GOOP Wage War on Science
Despite the best efforts of journalists and doctors, debunkers are not winning the wellness war.

Gwyneth Paltrow's wellness obsession has become one of the more reliable punchlines in Hollywood, but she may very well have the last laugh. The actress-turned-wellness-guru is now known as much for her acting as for her scientifically dubious lifestyle brand, Goop. In 2016, the company raised tens of millions of dollars in venture capital, all despite unrelenting mockery in the press. The marketing for some products is so ridiculous I sometimes wonder if Goop is really just a form of clever satire aimed at the dangers of pseudoscience. (If this is true, mission accomplished.)

But assuming this isn’t performance art, the increasing popularity of companies like Goop is a cause for legitimate concern. Despite the best efforts of journalists and doctors, the debunkers are not winning the wellness war. Indeed, there is evidence that the trust people place in traditional sources of science is eroding.

And it’s not just science — global trust in institutions everywhere is plummeting. While these are socially complex phenomena, I believe there are several powerful — and, ultimately, tremendously harmful — rhetorical devices deployed by the multibillion-dollar wellness industrial complex that have facilitated its cultural ascendency. By examining these devices, perhaps we can make people think twice before they try being voluntarily stung by bees as a cure for inflammation…
Another good read. I was struck by how little has changed on this front across the 19 years since my elder daughter died. I wrote on my 1998 essay:
Is science the enemy? To the extremist "alternative healing" advocate, the answer is a resounding 'yes'! A disturbing refrain common to much of the radical "alternative" camp is that medical science is "just another belief system," one beholden to the economic and political powers of establishment institutions that dole out the research grants and control careers, one that actively suppresses simpler healing truths in the pursuit of profit, one committed to the belittlement and ostracism of any discerning practitioner willing to venture "outside the box" of orthodox medical and scientific paradigms...
Different day, same bullshit.

Recall also my prior post "I am not a scientist?"

More to come...

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