Scan this code to subscribe!

03/13/2017

Does Pay for Performance Improve Care and Lower Spending? An Interview with Stephen Soumerai (March 15th)

Listen Now

Over approximately the past decade the health care industry has become increasingly committed to financially incenting physicians and other clinicians, or tying performance to reimbursement.  Commonly termed "pay for performance"(P4P), these arrangements are increasingly employed in the Medicare (i.e., under the Medicare Access and CHIP Reauthorization Act, or MACRA) and Medicaid programs and by commercial insurers, most notable accountable care models and bundled payment arrangements.   One might assume because P4P models are now common there is research evidence that demonstrates they are effective in, again, improving care quality, patient outcomes and lowering spending growth.  That is not the case.  For example, a systematic review published by Cochrane in 2011 found "there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care."  Among other examples, for all the attention the Massachusetts' Alternative Quality Contracts (AQCs) have received since they were launched in 2009, it remains unclear if they have reduced spending or spending growth.   Because P4P models have not proved out, payers and providers, for example, England's National Health Service and in the US the integrated, 12 hospital system, Geisinger Health, have substantially reduced incentive payments or are returning to paying providers straight salaries.            

During this 27 minute conversation, Professor Soumerai discusses his interest in the P4P topic, describes P4p arrangements, summarizes his and others' review of the research evidence relative to the effectiveness of P4P arrangements and suggests model designs that may be more effective.  

Stephen B. Soumerai is Professor of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care SsoumeraiInstitute.  He also co-chairs the Statistics and Evaluative Sciences concentration within Harvard University’s health policy Ph.D. program.  Dr. Soumerai recently served as International Trustee for the Canadian Health Services Research Foundation.  Dr. Soumerai has published more than 250 original scientific articles in leading scientific journal, such as the New England Journal of Medicine and the Journal of the American Medical Association.  He is well known nationally and internationally for his work on the impacts of health policies and methods to improve the quality of medical practice.  He frequently advises Congress, state legislatures and federal and international agencies on the design of drug cost containment, coverage and quality-of-care policies, evidence-based health policy and his research has been used extensively to support expanded economic access to medications in Medicaid and Medicare. He is the recipient of numerous honors including numerous article of the year awards from national and international scientific societies, named lectureships, and is the recipient of the Everett Mendelsohn Excellence in Mentoring Award from the Harvard University Graduate School of Arts and Sciences.

Professor Soumerai's 2015 and 2016 CDC articles noting in this discussion are at: https://www.cdc.gov/pcd/issues/2015/15_0187.htm and https://www.cdc.gov/pcd/issues/2016/16_0133.htm

03/07/2017

Proposed House Republican Changes to Medicaid: An Interview with Matt Salo (March 6th)

Listen Now

Late today, or within a few hours after this interview was completed, the House Republicans proposed ACA repeal or reconciliation legislation.  The legislation includes repealing Medicaid expansion under the Affordable Care Act (ACA).  More specifically, House Republicans propose repealing the  federal enhanced match rate for eligible beneficiaries on December 31, 2019 though states can keep the enhanced match rate for those Medicaid eligible before January 1, 2020 but only for those that do not have a break in Medicaid eligibility for more than one month after that January 1, 2020..  Moreover, the proposed legislation would reform federal Medicaid funding by creating a per capita cap model starting in 2020.  This means federal funding would be benchmarked to 2016 for the five Medicaid enrollee categories: the elderly; blind and disabled; children; non-expansion adults; and, expansion adults.  Year- over-year federal spending increases would be pegged to the medical care component of the Consumer Price Index (CPI).   While there is not yet a Congressional Budget Office (CBO) score for the proposed legislation, that's schedule for mark up on Wednesday, estimates by the Center for Budget and Policy Priorities (CBPP) project that if the 32 states that expanded Medicaid coverage under the ACA wanted to keep it, the cost to these states would be approximately $280 billion over the next decade.  CBPP also estimates that per capita caps will  increase the state's share of Medicaid costs, excluding expanded coverage, by another $280 billion also over 10 year budget window.   

During this 25-minute interview, Executive Director of the National Association of Medicaid Directors (NAMD), Matt Salo, discusses the mission of NAMD, his understanding of House Republican legislation to fundamentally reform the Medicaid program, the challenges with either Medicaid block grants or per capita caps, and other related policy issues the NAMD is working to resolve.  

Mr. Matt Salo has served as Executive Director of NAMD since 2011.  NAMD is a non-partisan association representing all 56 of Salothe nation's state and territorial Medicaid Directors.    Prior to NAMD, Mr. Salo spend 12 years at the National Governors Association where he  worked to forward the Association's health and human services policy agenda.   Prior still Mr. Salo worked for five years as a health policy analyst at the American Public Human Services Association.   Mr. Salo also spent two years as a substitute teacher in the Alexandria, VA public school system. Mr. Salo holds a BA in Eastern Religious Studies from the University of Virginia.

For more on the NAMD go to: http://medicaiddirectors.org/

For more on House ACA repeal or reconciliation legislation go to: 

https://energycommerce.house.gov/hearings-and-votes/markups/markup-committee-print-and-h-res-154

https://waysandmeans.house.gov/event/markup-budget-reconciliation-recommendations-repeal-replace-obamacare/

02/08/2017

Review of "Hell is A Very Small Place," (February 7th)

If you listened, or not, to my December 19th interview with Jean Casella (see below), one of the three editors of, "Hell is a Very Small Place, Voices from Solitary Confinement," here is my review of the work: http://thehealthcareblog.com/blog/2017/02/07/hell-is-a-very-small-place.

The essay begins with: 

It is well recognized that over the past several decades US prisons and jails have become the nation's largest inpatient psychiatric hospitals.  This is not surprising when you realize the majority of the US correctional population, the largest in the world at well over two million, suffers from mental illness.  Leaving aside the question of whether it is appropriate to incarcerate the mentally ill, at least those with serious mental illness, how we choose to treat a significant percent of mentally ill inmates is to place them in solitary confinement.  This means how we treat a significant percent of the mentally ill in this country is to torture them. 

 

02/07/2017

"The Case Against Sugar," A Conversation with the Author, Gary Taubes (February 6th)

Listen Now

In his recent work, The Case Against Sugar, Gary Taubes argues not all calories are alike.  Sugar, or the consumption of sugar, causes elevated levels of insulin, or hyperinsulenema, and high levels of insulin drives fat accumulation.  Rather than obesity causing diabetes, Taubes argues, hyperinsulinemia causes both.   That there's been an 800% increase since 1960 in the consumption of sugar and approximate doubling of diagnosed cases of diabetes since 1990 cannot be a coincidence.  (Per the CDC, over the past 25 years the age-adjusted prevalence of diabetes increased by ≥50% in 42 states and by ≥100% in 18 states.)   Not only does sugar consumption drive the diabetes epidemic, Taubes argues it can also be correlated to hypertension, cancer, stroke and dementia.        

During this 35 minute conversation Mr. Taubes discusses the impetus for the book, sugar's relationship to elevated insulin levels and obesity and diabetes, the problem/s with the accepted belief that a "calorie is a calorie," the FDA's determination that sugar is GRAS (Generally Accepted as Safe), the role the Sugar Association has played in encouraging and defending sugar's consumption, the difficulty in scientifically proving sugar consumption is correlated to diabetes, hypertension and cancer among other prevalent serious and fatal illnesses, how much sugar do we consume and how much is too much, or how much sugar can we tolerate safely.    

Mr. Gary Taubes is the co-Founder of the Nutrition Science Initiative, and a science and health journalist. He is the author of Gary-TaubesWhy We Get Fat and Good Calories, Bad Calories. Gary has been a contributing correspondent for the journal Science since 1993, and has contributed articles as a freelancer to The Atlantic Monthly, The New York Times Magazine, Esquire, Slate, and numerous other publications.  His 1997 book, Bad Science was a New York Times Notable Book and a finalist for the Los Angeles Times Book Awards.  He is the only print journalist to be a three-time winner of the National Association of Science Writers Science-in-Society Journalism Award.  He is the recipient of a Robert Wood Johnson Foundation Independent Investigator Award in Health Policy Research.  Gary received his B.S. in physics from Harvard University, his M.S. in engineering from Stanford University, and his M.S. in journalism from Columbia University.

For more information on The Case Against Sugar go to: http://www.penguinrandomhouse.com/books/213737/the-case-against-sugar-by-gary-taubes/9780307701640/.

To learn more about the Nutrition Science Initiative go to: http://nusi.org/

01/26/2017

The Health Benefits of Marijuana and Related Regulatory Policies : A Conversation with Paul Armentano (January 24th)

Listen Now

This past November, voters in seven states legalized marijuana either for medical or for recreational use.  Twenty-nine states have now legalized cannabis for medicinal use (and of these eight, along with the District of Columbia, for recreational use).   Despite growing state legalization, the debate concerning marijuana's health effects continues.  Recently, the National Academy of Sciences (NAS) published an extensive scientific review of research literature published since 1999 to reach nearly 100 conclusions about its therapeutic benefits including in the treatment for chronic pain in adults, chemotherapy-related nausea and vomiting and Multiple Sclerosis-related spasticity.  Despite state approval and demonstrated health benefits, at the federal level, marijuana is still classified as a Schedule I controlled substance (along with, e.g., heroin), and its use illegal.  

Mr. Paul Armentano is the Deputy Director of NORML, the National Organization for the Reform of Marijuana Laws.  He is Armentanoalso a faculty member at Oaksterdam University in Oakland, California.  His is the author of over 200 publications including more than a dozen contributions to textbooks and anthologies.  His most recent book-length work is, The Citizen's Guide to State-by-State Marijuana Laws (2015) and he is co-author of the 2013 volume, Marijuana is Safer: Why Are We Driving People to Drink?  Mr. Armentano was the principle investigator for the defense counsel in US v Schweder, the first federal evidentiary hearing since 1973 to challenge the constitutionality of cannabis as a Schedule I controlled substance.  He also served as an expert in a successful Canadian constitutional challenge, Crown v. Allard, preserving qualified patients right to grow cannabis at home.   Among other awards Mr. Armentano was the 2013 Freedom Law School Health Freedom Champion of the Year.  

The National Academy of Sciences' report, The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research is at: http://nationalacademies.org/hmd/reports/2017/health-effects-of-cannabis-and-cannabinoids.aspx.

For more information regarding NORML go to: http://norml.org/.

01/24/2017

"ACA Repeal and the Ethics of Belief," by David Introcaso (January 24th)

In 1877 William Clifford published an essay titled, The Ethics of Belief."  The essay became a seminal work in the field of ethics because Clifford posed a central question in life.  Is it wrong to believe something based on insufficient evidence? Is it wrong to oppose or support repeal of the Affordable Care Act absent "patient investigation" or based on "insufficient evidence"?  Are those, like the ship owner in Clifford's essay, then responsible for any and all adverse consequences resulting from repeal?

"ACA Repeal and the Ethics of Belief" is at: http://thehealthcareblog.com/blog/2017/01/23/aca-repeal-and-the-ethics-of-belief/.

01/07/2017

NIDCD's Efforts to Reduce Noise-Induced Hearing Loss: A Conversation with Dr. James Battey (January 6th, 2017)

Listen Now

While there is evidence noise-induced hearing loss among adolescents has increased due to the use of smartphones and other mobile devices, the evidence to date is not compelling or is still the subject of scientific debate.  Nevertheless, noise induced-hearing loss is a legitimate concern and therefore a topic in need of health education to combat, particularly since exposure is frequently voluntary, the consequences are cumulative and because the effects typically do not manifest until years later. Already, it is estimated 12 to 15 percent of school age children have some hearing deficits attributable to noise exposure and in adults, 15 percent of 26 million Ameeicans between the ages 20 and 69 have noise induced hearing loss.  The consequences can be significant.  In children, for example, hearing loss can delay language development, reduce educational achievement, produce social isolation and compromise quality of life.   

During this 21 minute conversation Dr. Battey discusses the effects of being deaf, the physiological causes of deafness, the evidence for noise induced hearing loss and moreover the impetus for the NIDCD's "It's a Noisy Planet" and the educational program's goals, targeted audiences, activities and success or impact to date.  

Since 1998 Dr. James Battey has served as Director of the NIH's NIDCD.  Previously he served as the Institute's Director of Battey_7486Intramural Research.   He has also served as an Investigator and Section Chief at the NIH's National Cancer Institute and the National Institute of Neurological Disorders and Stroke.  Dr. Battey received his undergraduate degree in physics at the California Institute of Technology and his MD and Ph.D. in biophysics at Stanford University School of Medicine.  He did his residency training in pediatrics also at Stanford and did postdoctoral training in genetics at Harvard Medical School. 

For information concerning NIDCD's "It's a Noisy Planet" go to: https://www.noisyplanet.nidcd.nih.gov/.

For a review article concerning noise induced hearing loss among children, see, for example, Robert V. Harrison, "The Prevention of Noise Induced Hearing Loss in Children," International Journal of Pediatrics (2012) at: https://www.hindawi.com/journals/ijpedi/2012/473541/

12/20/2016

Solitary Confinement: the Least Discussed & Most Unknown Public Health Crisis in America: A Conversation with Jean Casella (December 19th)

Listen Now

On any given day US prisons and jails hold between 80,000 and 120,000 men, women and children in solitary confinement.   A significant percent of these individuals enter solitary with a mental disease and a similar percent of those held in isolation for extended periods of time develop severe psychiatric illnesses that include self amputation and suicidality.  (US prisons and jails constitute the largest psychiatric hospitals in the country.)  The UN Special Rapporteur on Torture and Other Cruel, Inhuman or Degrading Treatment and Punishment, Juan E. Mendez, has concluded solitary confinement for more than 15 days constitutes torture.  In Hell is a Very Small Place, Voices from Solitary Confinement," edited by Jean Casella, James Ridgeway and Sarah Shourd, 16 former and current solitary confinement inmates discuss their experience in solitary and  two physicians and three professors (in law, political science and philosophy) discuss its physical and psychological effects and legal justification. 

During this 32 minute conversation, Ms Casella provides an overview of Hell Is a Very Small Place.  She explains why inmates are placed in solitary confinement, for how long and describes conditions under confinement.  She provides an overview of the psychological effects of solitary noted by contributing authors Dr. Stuart Grassian and Dr. Terry Kupers.  She addresses whether solitary confinement constitutes torture, explains how inmates attempt to keep their sanity, explains to what extent private sector profit making contributes to the practice and discusses what continued progress, if any, may be made under a new, incoming administration. 

Ms. Jean Casella is co-director of Solitary Watch, a web-based watchdog project that investigates, documents, and Caselladisseminated information about solitary confinement in US prisons and jails.  Prior to co-founding Solitary Watch in 2009, Ms. Casella managed several mission-driven book and magazine publishers including Thunder's Mouth Press and the Feminist Press.  Jean's writing has appeared in The Nation, Mother Jones, The Guardian, Al Jazerra, and other publications and media outlets.  The Hell is a Very Small Place anthology edited was published by The New Press in February.  For her work on solitary confinement, Jean was awarded a Soros Media Fellowship in 2012. 

For more information concerning Hell Is a Very Small Place go to: http://thenewpress.com/books/hell-very-small-place.

The UN Special Rapporteur's report is at: http://solitaryconfinement.org/uploads/SpecRapTortureAug2011.pdf

For another physician's review of solitary confinement, see, for example, Dr. Atul Gawande's essay titled,"Hellhole," in the March 30, 2009 issue of The New Yorker.  At: http://www.newyorker.com/magazine/2009/03/30/hellhole

12/06/2016

Will the Republicans Repeal the Affordable Care Act and Be Able to Replace It: A Conversation with Chris Jennings (December 5th)

Listen Now

With the election of Donald Trump Congressional Republicans are poised to repeal the Affordable Care Act (ACA) within the first 100 days of the 115th Congress via the budget reconciliation process.  (At some future date they are pledging to draft ACA replacement language or legislation.)  The expectation is repeal would have an effective date of 2018 or 2019, or after the mid-term Congressional elections.  However, many if not most health policy experts agree the simple act of repeal would cause such instability state insurance marketplaces would collapse long before repeal would, legally, go into effect.  Congressional Republican leadership is also promising to move major Medicare, via premium support and major Medicaid legislation, via block grants or per capita caps, though the upcoming Congress.       

During this 23 minute conversation Chris Jennings discusses whether, and moreover how if at all, Congressional Republicans can repeal the ACA with an out-year effective date without fatally damaging state insurance marketplaces, the likely consequences of a simple repeal (without replace), when and how will Republicans will replace the ACA and whether that effort would garner any Democratic interest or support, what substantively explains Republican opposition to the current law and what might Republican leadership do to reform the Medicaid program and its likely effects.

Chris Jennings is currently Founder and President of Jennings Policy Strategies, a DC-based policy firm where he consults Jenningswith foundations, purchasers and other aligned stakeholders on policies to ensure higher quality, more affordable health care for all Americans.  Previously, Mr. Jennings served as Deputy Assistant for Health Policy to President Obama and for eight years as White House Health Care Adviser to President Clinton.   Prior still he served for a decade in the US Senate for Senators Glenn, Pryor and Melcher where he worked on Medicaid CHIP, HIPAA, PDUFA, major Medicare reforms in the 1997 Balanced Budget Act and related work concerning long term care, prescription drug coverage, rural healthcare and other related issues.  Chris has been a campaign adviser to six Democratic presidential campaigns and is a frequent contributor on health reform issues to the New England Journal of Medicine and numerous other scholarly journals, periodicals and newspapers.   

 

12/01/2016

The Pros and Cons (or Imperfections) in Rating Hospital Care Quality: A Conversation with Consumer Reports' Doris Peter (November 30th)

Listen Now

Though comparatively late to adopt quality ratings, many health care products and services are today quality rated.  For example, CMS rates hospital, nursing home and home health care care quality along with Medicare Advantage insurance and prescription drug, or Part D plans.  Quality performance is a factor in calculating rewards and penalties in Medicare pay for performance agreements, for example, in scoring earned shared savings for Accountable Care Organizations.   Though today common, rating care quality is not without criticism.  For example, researchers question the validity of how component or domain scores are weighted or clustered, the absence or inadequacy of risk adjustment, meaningfulness to patients, patient literacy/numeracy limitations and unintended negative consequences.     

During this 21 minute conversation, Dr. Peter discusses why Consumer Reports rates hospital care quality, the methodology used in scoring hospital care quality, specifically types of care quality, for example prevalence of hospital-acquired infections, the response to ratings by hospitals, use by patients or consumers, the imperfections or limitations in rating hospital care quality, unintended negative consequences and how Consumer Reports intends to improve upon its work in the near term.

Dr. Doris Peter is the Director of Consumer Reports Health Ratings Center, a part of the nonprofit organization, Consumer Doris Peter Reports.   Beyond hospitals her team rates other health care services including physicians and insurance plans and as well health care products, e.g., drugs.  Dr. Peter is also the Principal Investigator of a grant from the Consumer and Prescriber Education Grant Project that helps consumers understand safety, effectiveness and the cost of prescription and over-the-counter medications.  Prior to joining Consumer Reports Dr. Peter was an editor and then publisher of the nonprofit organization, The Medical Letter, and then North American editor for an international evidence-based medicine journal.  Dr Peter is a neurobiologist by training, earning her Ph.D. at UCLA.  She completed a postdoctoral fellowship in cellular biophysics at Rockefeller University.

For more on Consumer Reports hospital quality ratings efforts go to: http://www.consumerreports.org/cro/health/doctors-and-hospitals/index.htm