The Problem With 'Pay for Performance' in Medicine
“Pay for performance” is one of those slogans that seem to upset no one. To most people it’s a no-brainer that we should pay for quality and not quantity. We all know that paying doctors based on the amount of care they provide, as we do with a traditional fee-for-service setup, creates incentives for them to give more care. It leads to increased health care spending. Changing the payment structure to pay them for achieving goals instead should reduce wasteful spending.
So it’s no surprise that pay for performance has been an important part of recent reform efforts. But in reality we’re seeing disappointingly mixed results. Sometimes it’s because providers don’t change the way they practice medicine; sometimes it’s because even when they do, outcomes don’t really improve.
The idea behind pay for performance is simple. We will give providers more money for achieving a goal. The goal can be defined in various ways, but at its heart, we want to see the system hit some target. This could be a certain number of patients receiving preventive care, a certain percentage of people whose chronic disease is being properly managed or even a certain number of people avoiding a bad outcome. Providers who reach these targets earn more money.
The problem, one I’ve noted before, is that changing physician behavior is hard. Sure, it’s possible to find a study in the medical literature that shows that pay for performance worked in some small way here or there. For instance, a study published last fall found that paying doctors $200 more per patient for hitting certain performance criteria resulted in improvements in care. It found that the rate of recommendations for aspirin or for prescriptions for medications to prevent clotting for people who needed it increased 6 percent in clinics without pay for performance but 12 percent in clinics with it.
Good blood pressure control increased 4.3 percent in clinics without pay for performance but 9.7 percent in clinics with it. But even in the pay-for-performance clinics, 35 percent of patients still didn’t have the appropriate anti-clotting advice or prescriptions, and 38 percent of patients didn’t have proper hypertensive care. And that’s success!
It’s also worth noting that the study was only for one year, and many improvements in actual outcomes would need to be sustained for much longer to matter. It’s not clear whether that will happen. A study published in Health Affairs examined the effects of a government partnership with Premier Inc., a national hospital system, and found that while the improvements seen in 260 hospitals in a pay-for-performance project outpaced those of 780 not in the project, five years later all those differences were gone.
The studies showing failure are also compelling. A study in The New England Journal of Medicine looked at 30-day mortality in the hospitals in the Premier pay-for-performance program compared with 3,363 hospitals that weren’t part of a pay-per-performance intervention. We’re talking about a study of millions of patients taking place over a six-year period in 12 states. Researchers found that 30-day mortality, or the rate at which people died within a month after receiving certain procedures or care, was similar at the start of the study between the two groups, and that the decline in mortality over the next six years was also similar.
Outlook for Medicare Trust Fund Improves, Though Shortfall Looms, Report Finds
By ROBERT PEAR
WASHINGTON
— The Medicare trust fund will be exhausted in 2030, and the trust fund
for Social Security will be depleted in 2033 if Congress makes no
change to the existing law, the Obama administration said on Monday. The
outlook for Medicare has improved significantly, mainly because
spending on hospital care was lower than expected last year, the
administration said.
The
forecasts came in the government’s annual report on the outlook for
trust funds of the two programs, which together account for about 40
percent of all federal spending.
Social
Security provides benefits to 59 million people, and an average of
about 10,000 baby boomers become eligible each day. Payroll taxes and
other revenue dedicated to Social Security would be sufficient to pay
about three-fourths of promised benefits if its trust fund runs out,
administration officials say.
With the aging of the population, the number of Medicare beneficiaries is also growing rapidly.
Reports
from the trustees — four federal officials and two public
representatives — are largely prepared by career civil servants, who
take pains to provide an objective assessment of the programs’ finances.
In
their last report, in May 2013, the trustees said that under existing
law Medicare’s hospital insurance trust fund would be exhausted in 2026,
and the Social Security trust fund in 2033. The comparable dates in the
prior year’s report were 2024 for Medicare and 2033 for Social
Security.
The
financial condition of Medicare has benefited from a remarkable
slowdown in national health spending, attributed in part to the
Affordable Care Act, which curbed Medicare payments to many health care
providers and encouraged them to find more efficient ways of delivering
care. Slow growth of wages and prices, following the recession of
2007-9, has also been cited by the trustees as a factor restraining the
growth of Medicare.
The
current trustees regularly urge Congress to shore up the finances of
Medicare and Social Security, but the politics of the programs, which
are immensely popular with voters of both parties, reduce the likelihood
of major or immediate changes.
Lawmakers
have discussed the idea of higher premiums for high-income Medicare
beneficiaries and a reduction in the annual cost-of-living adjustments
for Social Security. Such proposals often come up in the context of
efforts to negotiate a broader agreement on federal spending and taxes,
but the prospects of such a deal have shrunk to the vanishing point in
this election year.
Medicare finances improve as healthcare inflation slows, trustees say
By DAVID LAUTER
Improvements in healthcare costs have extended the life of Medicare's main trust fund by four years, the annual report of the Social Security and Medicare trustees said Monday, a further sign of the positive effect of lower medical inflation.
Medicare Part B premiums are expected to remain the same through 2015 because of that improvement, Health and Human Services Secretary Sylvia Burwell told reporters as the report was released.
Medicare is "considerably stronger than it was just four years ago," she said.
By contrast, the fund that guarantees Social Security disability payments remains in urgent need of a fix, the trustees warned. As they warned in last year's report, the trustees said the disability fund will run out of money at the end of 2016, meaning that only 81% of disability benefits could be paid unless Congress comes up with a solution.
The status of the larger Old Age and Survivors trust fund remains unchanged, with the balance projected to hit zero in 2033, after which current taxes would cover 77% of promised benefits, the report said.
In the short term, the only way to resolve the disability trust fund's problems will be to change the current rule that allocates taxes between the disability and old-age trust funds, Treasury Secretary Jacob J. Lew said.
That shift would shore up the disability system at the cost of the making the finances of the retirement system somewhat weaker.
But "there's probably no other alternative" for solving the disability problem by the end of 2016, Lew said. Congress so far has shown no desire to consider more long-term changes in the disability system.
he disability trust fund is much closer to running out of money than is the old age trust fund in large part because members of the baby-boom generation are currently hitting the age in which people make maximum use of disability insurance, noted Charles Blahous, a former advisor to President George W. Bush who serves as one of the system's public trustees.
Over time, as baby boomers move into retirement, the main pressure will shift to the retiree system, Blahous said, noting that some of that shift already has begun.
Las Vegas tries new tactic to improve city's notorious healthcare
Teresa Garcia, weak and in pain, had all but given up on doctors when she came to a small clinic next to a former wedding chapel on the Strip.
"I never thought I would get better," the 55-year-old housekeeper said, recalling years of perfunctory physician visits that generated countless prescriptions but did little to slow the dangerous advance of her diabetes.
Today, under intense care from a team of social workers, nurses and a doctor who, like her, emigrated from Mexico, Garcia has learned to change her diet and closely monitor her disease. She has regular checkups. She has cut her blood sugar in half. She no longer needs to inject herself with insulin.
The model of medical care that is helping Garcia is built on a highly personal approach to patients and a high-tech system to track quality — something that is new for this city. A grim joke here long held that the best place to go for good healthcare was the airport.
Now, Las Vegas is emerging as a test of how much a community can improve chronically poor health by expanding insurance coverage and using models of medical care pioneered in healthier places.
"We are a prime example of what people see as problematic about the American healthcare system," said Larry Matheis, the former longtime head of the Nevada State Medical Assn. "That makes a lot of the ideas in health reform very attractive. … The challenge is going to be figuring out how to make it all work."
Starting this year, the Affordable Care Act guarantees insurance to tens of thousands of Las Vegas residents once effectively shut out of the health system. And leading hospitals, physician groups, unions and businesses are seeking to improve care by taking advantage of the coverage expansion.
The clinic Garcia visits has already inspired a similar facility in nearby downtown. And the Culinary Health Fund, a union health plan that runs Garcia's clinic, plans to build three more across the city.
Under another initiative in the city, a team of highly trained nurses is working to enhance medical care in nursing homes so fewer residents end up in the hospital.
Poverty and obesity are not as widespread here as in some of America's other least healthy communities. Nevertheless, improving care in Las Vegas is an immense task.
Before Nevada expanded its Medicaid program under the new health law, nearly 30% of working-age adults in greater Las Vegas lacked insurance. By comparison, in U.S. communities with the best health outcomes, fewer than 1 in 10 are uninsured.
The area also has a critical shortage of primary care doctors — half as many relative to the population as healthier regions of the Northeast and upper Midwest.
Las Vegas residents are far less likely than people in healthier communities to get cancer screenings, immunizations, blood-sugar tests and other recommended preventive care, even when they have a serious illness, according to data gathered by the Commonwealth Fund, a research foundation that studies healthcare systems.
They also are nearly twice as likely to die from illnesses that can be averted or controlled with timely medical care, including childhood measles, diabetes and colon cancer.
Outcomes here match those in the poorest parts of the Deep South and Appalachia, according to a review of healthcare data The Times conducted with help from public health researchers and visits to communities from Maine to Hawaii.In a system shaped by low levels of coverage, the city's for-profit hospitals historically have sought paying patients for more lucrative care. Freeways are lined with billboards advertising short wait times at emergency rooms, a profitable way for hospitals to cash in on patients with coverage.
One doctor would call his insured patients "little ATMs," according to a physician who asked not to be identified in candidly describing a mindset he said is widespread in Las Vegas.
Employer health insurance mandate a political orphan
When President Obama signed the Affordable Care Act, its requirement that large employers provide health coverage or pay a penalty seemed to many supporters a key pillar of the effort to guarantee health coverage to Americans.
Four years later and after repeated delays, the so-called employer mandate has become something of an orphan, reviled by the law's opponents and increasingly seen as unnecessary by many of its backers. Twice in the last two years, the Obama administration has put off the penalties, citing difficulties enforcing the mandate.
House Republicans plan to sue the president, largely over his suspension of the mandate, saying he has broken the law by failing to enforce a requirement that they bitterly oppose.
That's only one of the ironies in the debate over this part of the health law: The center of a potential constitutional clash between the House and the White House is a program that many in both parties would just as soon see go away. The House could vote to approve the lawsuit as early as this week.
Backers of the Affordable Care Act list the employer mandate as among the provisions of the complex law that they hope could be revised when healthcare becomes less politically explosive.
"A few years down the road, there may be opportunities to revisit parts of the ACA and improve them. That would be nice to contemplate," said Paul N. Van de Water, senior fellow at the Center on Budget and Policy Priorities, a left-leaning Washington think tank. "We are not there yet."
The employer mandate is designed to prevent businesses from dropping health benefits now that the government provides subsidies to help low- and moderate-income Americans buy coverage. Democrats who wrote the law worried that companies would be tempted to stop offering coverage, shifting the cost to taxpayers.
With New Obamacare Rulings, One Thing Is Certain: We Need Medicare for All for Life
by
It makes me crazy to see the latest news about a Federal Court striking down the tax credits (subsidies) offered on the Federal Affordable Care Act health exchanges because I know the media commentators will go crazy analyzing the politics of it all. The Republicans are celebrating; the Democrats are scrambling. And the people who hate the ACA/Obamacare as well as those who are pushing to achieve a longer term solution through single-payer reform will claim victory. The camp that will once again be completely ignored in this whirl of political analyzing will be the patients and the caregivers whose lives and security are threatened once again.
We won't hear the patient and caregiver stories unless and until some of the politicians decide it would benefit them to prop us up in front of a camera in support of their particular position on health reform. While there are some very limited efforts going on to record stories, it has been since before the ACA/Obamacare was passed since anyone really cared to hear what happens to average people about their struggles with the profit-driven, dysfunctional US health system. No, Michael Moore will not be making another updated version of SiCKO and gathering stories for it as some have suggested to me -- the original version still holds up well, sadly.
In the current matter, it will be months before people really know if the tax credits/subsidies they thought they would have to help pay insurance premiums will stay in place or go away. The hardships are not tough to imagine. And thinking that my fellow Americans in another state may suffer more than I because of some decision their elected officials made about creating a state exchange is troubling, to say the least. The consequences in terms of the overall viability of the ACA/Obamacare are also probably predictable, though a bit less so. Politicians will argue this well into the next Presidential election season. Those who thought health care would be a back burner issue should now know without doubt that health care will stay front and center.
What I know for certain is that so long as the US health care system is based on trying to keep the market-based model for profiting off suffering and illness, we will continue to have these push-me, pull-me changes in how much it costs to get and keep health coverage, who is eligible for coverage, and who benefits politically or economically from the current whim of the courts, Congress, the President, media ratings or readership, religious beliefs claim by corporate persons, and many other changeable forces. That's no way to handle the health and well-being of our society and communities.
The forces needed to move this country away from this horrible system of changing fortunes and misfortunes in health policy will have to be those of us who can best speak to the real consequences of this continual uncertainty. And unless we have joined forces with one another to gather our stories in the post ACA/Obamacare period, we won't be able to demand the kind of stability an improved and expanded Medicare for all for life system would bring to us all. If only a few highly educated, predominantly white, socially and economically well-positioned, largely middle-aged and older, self-elevated spokespersons for health policy change continue to speak for us and about us but largely without us, the movement to achieve transformational change in the health system will not be able to overthrow the powerful, wealthy forces we all know are against putting people before profits.
Dana Milbank: North Carolina Republicans put ideology above lives
On July 1, the hospital in rural Belhaven, N.C., closed — a victim, in part, of the decision by the state’s governor and legislature to reject the expansion of Medicaid under Obamacare.
Six days later, 48-year-old Portia Gibbs, a local resident, had a heart attack. The medevac to take her to the next-nearest hospital (as many as 84 miles away, depending on where you live) didn’t get there in time.
“She spent the last hour of her life in a parking lot at a high school waiting for a helicopter,” Belhaven’s mayor, Adam O’Neal, said outside the U.S. Capitol on Monday, holding a framed photograph of Gibbs.
A week after Gibbs’s death, O’Neal began a 15-day, 273-mile walk to Washington to draw attention to the outrage in Belhaven, which he blames on the combination of an “immoral” hospital operator and the failure of Republican leaders in his state to accept the new Medicaid funding the hospital needed to stay afloat.
What makes the mayor’s journey all the more compelling is he’s a white Southerner and a Republican officeholder who has conservative views on abortion, taxes, guns — “you name it,” he told me. But ideology and party loyalty have limits. “I’m a pretty conservative guy, but this is a matter of people dying,” he said.
Republicans nationwide have abandoned any consideration of offering an alternative to the Affordable Care Act, figuring that their complaints about President Obama’s selective implementation of the law, and lingering unease about the legislation itself, will be enough to motivate conservative voters in November. But as O’Neal points out, this political calculation has a moral flaw.
HSA holders don’t understand accounts
Sure, as evidenced by the growing numbers, consumers love theirhealth savings accounts. Problem is, they just don’t really know much about them.
A new survey from Alegeus Technologies says most consumers, and even account holders specifically, do not fully understand account-based health plans, including HSAs, flexible savings accounts and health reimbursement accounts.
Only 30 percent of HSA holders passed a basic HSA proficiency quiz — which included nine true/false questions such as “I can have an FSA and an HSA at the same time,” “Contributions that I make to an HSA are tax-free,” “I can contribute to an HSA regardless of which health plan type I’m enrolled in” and “My employer owns my HSA.”
Meanwhile, only 50 percent of FSA holders passed a FSA proficiency quiz. The health care and benefit payment firm polled more than 1,000 consumers and 500 employer health benefit decision-makers.
Research continues to show the growing popularity for HSAs. This week America’s Health Insurance Plans said that health plans that include health savings accounts continue to rise in popularity — experiencing double-digit growth over last year.
No comments:
Post a Comment