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04/27/2018

"The Never-Ending Misuse of Antipsychotics in Nursing Homes" (April 27th)

If you missed my February 15th interview with Human Rights Watch's Ms. Hannah Flamm regarding her report, "They Want Docile," How Nursing Homes in the US Overmedicate People With Dementia," my related essay under this title is posted on the Health Affairs Blog.  It's at: https://www.healthaffairs.org/do/10.1377/hblog20180424.962541/full/.  

04/18/2018

Kip Sullivan Discusses the Flaws and Future of the Medicare ACO Program (April 17th)

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The Medicare Shared Savings Program's Accountable Care Organization (ACOs), created by Section 3022 of the 2010 Affordable Care Act constitutes the flagship Medicare pay for performance (P4P) program.  Though there are other P4P (also termed pay for value) models, for example two bundled payment models (Bundled Payments for Care Improvement and Comprehensive Care for Joint Replacement), they are short-lived CMS demonstrations.   If the federal government is to bend the Medicare spending curve or make the program more financially sustainable it will likely be due moreover to the success of ACOs.  Though provider participation in ACOs is substantial, this year there are 561 ACOs providing care to 10.5 million Medicare beneficiaries, the program has to date achieved marginal success.  Over four performance years (2013-2016), ACOs have saved substantially less than one percent of annual Medicare spending (now over $700 billion) - which is why the DHHS Secretary Alex Azar recently admitted candidly ACO performance has been "underwhelming" and "lackluster."  Even before the Medicare ACO program formally began there have been questions and criticism about the model's design.  Perhaps no one has written more about the model's flaws than Kip Sullivan.    

During this 32 minute conversation Mr. Sullivan discusses the genesis of ACOs including results from its predecessor, the Physician Group Practice demonstration, assumptions made in the the design of the model, e.g., the relationship between cost and quality and the effectiveness of financially incenting physicians, and moreover the problem of addressing care quantity instead of pricing.  In sum, Mr. Sullivan argues the Medicare ACO model is fatally flawed and will not achieve meaningful success. 

Mr. Kip Sullivan is currently a member of the board of the Minnesota chapter of Physicians for a National Health Program.  Mr. Sullivan began his career as a staff attorney for the New York Legal Aid Society and as a researcher for Citizens Action SullivanLeague in California.  Form 1980 through 2000 he researched universal health insurance and a single payer system for Minnesota COACT (Citizens Organized Acting Together).   He also served as a consumer representative on the Minnesota Governor's Health Plan Regulatory Reform Commission in the 1980s.  From 2000 to 2007 Mr. Sullivan was a health system analyst for the Minnesota Universal Health Care Coalition.  Mr. Sullivan has written over 150 health policy articles for the American Journal of Public Health, the Journal of Health Politics, Policy and Law, the LA Times, The Nation, The New England Journal of Medicine, The New York Times, and others.  He published 2006 "The Health Care Mess: How We Got Into It and How We'll Get Out of It."  Mr. Sullivan earned his undergraduate degree from Pomona College and his law degree the Harvard School of Law.   

Mr. Sullivan's latest essay, "Curb Your Enthusiasm," is at: http://thehealthcareblog.com/blog/2018/04/16/curb-your-enthusiasm/.

The Lawton Burns and Mark Pauly essay titled, "Transformation of the Health Care Industry: Curb Your Enthusiasm," in the the recent Milbank Quarterly, that is noted during this discussion is at: https://onlinelibrary.wiley.com/doi/full/10.1111/1468-0009.12312.

04/13/2018

Pediatrician Dr. Niran Al-Agba Discusses Gun Violence (Via In Part Her Columbine Experience) (April 12th)

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Including the February 14th shooting at Marjory Stoneman HS in Parkland Florida that killed seventeen students and teachers, there have now been over 130 shootings in elementary, middle and high schools in 43 states since 2000 and another 58 shootings in US colleges and universities.  Gun violence in this country is in a word, obscene.  It is, for example, 96 times higher than in Japan and 55 times higher in the UK.  It is largely explained by gun prevalence.  The US accounts for approximately five percent of the worldwide population, however, Americans own 42 percent of the world's guns.   What also explains gun violence is a federal policy that has persisted since 1996, the so called Dickey amendment, that prohibited federal funding to conduct gun violence research.   (Since 1996 there have been approximately 600,000 gunshot victims.)  The recently passed omnibus spending bill (that funds the federal government through this fiscal year) included accompanying report language stating the Dickey Amendment does not prevent federal agencies, moreover the CDC, from conducting gun violence research.  However, the spending bill included no money to conduct gun violence research.   

During this 28 minute conversation Dr. Al-Agba discusses her experience treating survivors of the 1999 Columbine High School shooting (that killed 13 and wounded 21), why the physician community has been hesitant to discuss gun safety with their patients and what can be done by the physician community to reduce gun violence, e.g., participating in student threat assessments.   

Dr. Niran Al-Agba is an a board certified pediatrician in private practice in Silverdale, Washington and is affiliated with Al-Agbamultiple hospital in the region including Harrison Medical Center and MultiCare Mary Bridge Children's Hospital and Health Center.  She is a her family's third generation physician practicing in the Kitsap County.  She is also an Assistant Professor on at the University of Washington School of Medicine and is a lead instructor at Seattle Children's Hospital for the past 15 years.  She has been voted the Best Doctor in Central Kitsap for three of the last six years.  She is the independent practice editor for the Health Care Bog, published on KevinMD and RebelMD, and pens a monthly column for her local newspaper, The Kitsap Sun.  Dr. Al-Abga received her medical degree from the University of Washington School of Medicine, did her residency at the University of Colorado School of Medicine/Denver Children's Hospital.  

Dr. Al-Abga's March 10th essay titled, "I Treated the Columbine Kids, I Have Not Spoken Before," noted during this discussion is at: http://thehealthcareblog.com/blog/2018/03/10/i-treated-the-columbine-kids-i-have-not-spoken-out-before/.

 

03/27/2018

The Reverend Patricia Lyons Discusses the Administration's Proposed Protection of Religious Beliefs and Moral Convictions Rule: March 26th

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In January the Trump administration published a proposed DHHS rule titled, "Protecting Statutory Conscience Rights in Health Care, Delegations of Authority."  For decades the federal government, via several legislative amendments, has protected healthcare providers who object to performing, or object to assist in performing, certain medical procedures based on their freedom of conscience and religious exercise.  While these protections moreover concern abortion they have been gradually expanded to include, for example, refusal to participate in assisted suicide.  The proposed rule however vastly expands these protections.  The administration is proposing a regulatory rule that would allow all health care personnel (as well as hospitals, labs, insurance companies and others) to refuse to provide any medical care to any person by claiming conscience, moral or religious objection.  For example, a pediatrician could refuse to treat a child of gay parents or an emergency room nurse could deny providing a terminal patient end of life pain management.  The proposed would also allow the health care worker to refuse to refer a patient or identify anyone or organization that in turn could refer.  Critics of the proposed say the rule would effectively weaponize discrimination and professional medical associations have expressed concerns the rule would allow clinicians to violate their codes of medical ethics.  These criticisms aside what is the theological basis, if any, that would legitimately allow claiming religious or moral exercise in denying health care? 

During this 31 minute conversation the Reverend Patricia Lyons discusses, in sum, that while Christian theological teaching supports the rights of individuals (and their obligation) to follow their conscience, doing so should neither be without consequence as the proposed would allow nor should such protection be used to undermine justice in delivering healthcare without discrimination.  The proposed she Reverend Lyons argues is not workable since it negates the providers obligation in recognizing the inherent dignity of all, undermines their commitment to their profession, erodes the state's obligation in delivering healthcare without prejudice, and altogether is a failure in addressing the common good.     

The Reverend Patricia Lyons is Missioner for Evangelism an Community Engagement, the Episcopal Diocese of Washington, Church House, Mount St. Alban, in Washington, D.C.  She is also an Associate Priest at the Church of the LyonsEpiphany.  Rev. Lyons was for several years chaplain, teacher and JK-12 Director of Service Learning at St. Stephen's and St. Agnes (Episcopal) School in Alexandria, VA.  Reverend Lyons has also taught as an adjunct at the Virginia Theological Seminary.  Reverend Lyons is an honors graduate from Harvard College.  She holds a Master of Divinity degree from the Harvard Divinity School.  She received her doctorate from Virginia Theological Seminary.  Reverend Lyons has published numerous sermons, articles and book chapters on moral and spiritual development theory, as well as consulted for independent schools on moral formation and service learning programs. 

The proposed rule is at: https://www.federalregister.gov/documents/2018/01/26/2018-01226/protecting-statutory-conscience-rights-in-health-care-delegations-of-authority.  

If you're interested in a related essay on this topic, THCB recently posted my essay, "HHS Conscience Rule Would Grant Providers Sweeping Rights to Deny Care," it's at: http://thehealthcareblog.com/blog/2018/03/30/hhs-conscience-rule-would-grant-providers-sweeping-rights-to-deny-care/.

03/15/2018

Author Timothy Hoff Discusses His Latest Work: "Next In Line: Lowered Care Expectations in the Age of Retail - and Value Based Health" (March 14th)

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During this 29-minute interview, Professor Timothy Hoff discusses moreover what market factors explain or are driving the degradation of the therapeutic relationship between the physician and the patient, or what he terms the doctor-patient dyad, these include the "retailing" of medicine, whether "next in line" retail medicine, where we've traded relational trust for calculative trust, is economically rationale, the (negative) effect it is having on physicians and possible solutions to save the physician-patient relationship and raise care delivery expectations. 

Professor Timothy Hoff is Professor of Management, Healthcare Systems, and Health Policy in the D'Amore-McKim School of Business and School of Public Policy and Urban Affairs at Northeastern University.  He is also a Visiting Associate Fellow at Oxford University's Green-Templeton College and a Visiting Scholar at the Said Business School, Oxford University.  Prior to Hoffhis academic career, Dr. Hoff worked for a decade as a primary care practice administrator and as a healthcare consultant.  His research has been published in Pediatrics, Archives of Internal Medicine, Journal of Organizational Behavior, Academy of Management Perspectives, Health Affairs and The Milbank Quarterly.   His research has received rewards from the American Sociological Association, Academy of Management, and the Society for Applied Anthropology.  His previous work, Practice Under Pressure: Primary Care Physicians and Their Work in the 21st Century earned an Outstanding Academic Title award from Choice Magazine in 2010.  He is also co-editor of the 2016 reference volume on transformation in the health professions workforce, it's titled, The Healthcare Professional Workforce also published by Oxford University Press.  Professor Hoff received his undergraduate degree in business administration and his Ph.D. in Public Administration and Policy from the University of Albany.  

For information on Next In Line go to: https://global.oup.com/academic/product/next-in-line-9780190626341?cc=us&lang=en&.

 

03/11/2018

Author Jonathan Engel Discusses His Recent Work, "Unaffordable: American Healthcare From Johnson to Trump" (March 9th)

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During this 30-minute interview Professor Engel discusses moreover why, as he notes, US healthcare is "uniquely dysfunctional," and "laden with profit taking" largely due to induced demand, provides an overview of efforts to contain spending growth via HMOs both in the commercial and the Medicare market, the success of Medicaid HMOs, and discusses his disappointments with the Affordable Care Act (ACA) actually making healthcare more affordable.    

Jonthan Engel is Professor of Health Policy and Management at the Marxe School of Public and International Affairs at Baruch College, CUNY.  He has taught previously at Seton Hall University, Mailman School of Public Health at Columbia University and the School of Public Health at the University of Massachusetts.  He has been a consultant to the White House's President's EngelJonathan-2017.165tAdvisory Committee on Human Radiation Experiments, the lead author on multiple HIV needs assessments for the City of Newark and director of research at the Local Area Board for Health Planning for Essex and Union counties in New Jersey.  His published works include: Doctors and Reformers: Discussion and Debate of Health Policy 1025-1950; Poor People's Medicine: Medicaid and the US Charity Care Since 1965; The Epidemic: A History of AIDS; American Therapy: The Rise of Psychotherapy in the US; and, Fat Nation, forthcoming.   He is currently writing a book on Cold War science and policy in the US.  Professor Engel received his BA from Harvard, an MBA from the Yale School of Management and his PhD in the history of medicine from Yale.  

For more information on "Unaffordable" go to: https://uwpress.wisc.edu/books/5682.htm.

03/04/2018

Unpacking BPCI, CMS' New Bundled Payment Demonstration: An Interview with Dave Terry (February 28th)

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This past January 9th CMS announced Bundled Payment for Care Improvement (BPCI) Advanced.  This five-year Medicare bundled or episode-based payment demonstration, that begins this October 1st, will succeed the agency'a five-year BPCI demonstration that sunsets this September 30th.  BPCI Advanced, also voluntary, will be considerably less expansive than its predecessor in that, among other things, it will include just 32 clinical episodes (29 inpatient and three outpatient), and offer only a single, 90 day retrospective bundled payment under one risk track.

During this 28 minute interview Mr. Dave Terry briefly defines Archway's business model/s, posits what attributes describe successful bundled payment providers, summarizes the findings from a recent study, he coauthored, of BPCI reimbursed total hip arthroplasty surgeries, how CMS has improved bundled payments under BPCI Advanced, or moreover in financial benchmarking and in quality measurement, the legitimacy of criticisms regarding care fragmentation and competition with other pay for performance models and likely success of the demonstration.

Mr. Dave Terry is currently CEO of Archway Health.  Previously, at Partners Healthcare in Boston, Mr. Terry negotiated Terry  Daveglobal cap and pay for performance contracts with managed care plans.  Prior still at Harborside Healthcare, he led a home care agency that managed Medicare and commercial episodes of care within a single payment.  As a partner with The Chartis Group, Mr. Terry developed provider networks and risk sharing models for Medicare Accountable Care Organizations (ACOs).  Mr. Terry holds an MBA from the Harvard Business School and a BA from Columbia University.  He currently serves on the board of Bottom Line, a national educational non-profit, and is a past board member of the Harvard Business School Health Industry Alumni Association.

For information on BPCI Advanced to go: https://innovation.cms.gov/initiatives/bpci-advanced.

02/22/2018

The Trump Administration's Decision to Require Employment as a Medicaid Coverage Prerequisite: An Interview with Prof. Sara Rosenbaum (February 21st)

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In a letter last March to state Medicaid directors by then DHHS Secretary Tom Price and CMS Administrator Seema Verma telegraph the administration's intent to radically redefine the Medicaid program.  Believing the ACA's expansion of the Medicaid program was, per the March letter, a "clear departure from the core, historical mission of the program,"  administration officials telegraphed they were preparing to reinvent the program by, in part, requiring work or community engagement for abled-body adults as a precondition for Medicaid coverage.  Historically, the Medicaid program was intended to strengthen and increase coverage for the poor.  In a nine-page, January 11 letter to state Medicaid directors, Ms. Verma announced, "a new policy to assist states in their efforts to improve Medicaid enrollee health and well-being through incentivizing work and community engagement."  That there is no evidence that work improves health status, the January 11th letter stated "work . . may improve health outcomes," on January 12th CMS approved a Kentucky waiver to require employment as a prerequisite for Medicaid coverage despite state officials recognizing through the course of the waiver's implementation 15 percent of abled-body Kentuckians would lose coverage.    

During this 20 minute interview, Professor Sara Rosenbaum briefly explains Medicaid 1115 waivers, the administration's intent to, in addition to requiring employment, refashion the Medicaid program to more resemble commercial insurance, what evidence the administration posits to justify the policy change, the details of the Kentucky waiver (the first of likely several, if not many work requirement waivers), the anticipated effects of the Kentucky waiver and the legal bases for litigation already filed to challenge the Kentucky waiver. 

Professor Sara Rosenbaum is the Harold and Jane Hirsh Professor of Health Law and Policy at the Milken Institute School of Public Heath at George Washington University.  She also holds professorships at GWU's Law and Medical Schoold and at the Sara%20Rosenbaum%20Color%20Pic[1]Trachtenberg Schoolf of Public Policy and Public Administration.  Professor Rosenberg worked in the Clinton Administration where she directed and drafted the Health Security Act and designed the Medicaid's Vaccines for Children program.  She currently advises states, foundations and others on health policy and has served as a testifying expert in landmark litigation to enforce children's rights under Medicaid.  She is the lead author of Law and the American Health Care System.  Professor Rosenbaum is the Past Chair of AcademyHealth and a member of the National Academies of Sciences, Engineering, and Medicine.  She also has served on the CDC's Director's Advisory Committee and Advisory Committee on Immunization Practice.  She was the founding Commissioner of the Congress's Medicaid and CHIP Payment and Access Commission (MACPAC) and served as its Chair from January 2016 through April 2017.

Recent related writings by Professor Rosenbaum, i.e., "The Trump Administration Re-Imagines Section 1115 Medicaid Demonstration - and Medicaid" (Health Affairs Blog, 11/9/17) and "Experimenting on The Health of the Poor: Inside Stewart v. Azar (Health Affairs Blog, 2/5/18) are at: https://www.healthaffairs.org/do/10.1377/hblog20171109.297738/full/  and https://www.healthaffairs.org/do/10.1377/hblog20180204.524941/full/.

02/16/2018

Misuse of Antipsychotics Continues to Harm and Kill Thousands of Nursing Facility Residents: An Interview With Ms. Hannah Flamm (February 15th)

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In early February the Human Rights Watch (HRW) published, "'They Want Docile': How Nursing Homes in the US Over-medicate People with Dementia."  The inappropriate or misuse of antipsychotics, e.g., Haldol, Seroquel and Risperdal, in nursing facilities to chemically restrain nursing home patients, moreover frail and elderly seniors, has been practiced for decades.  The HRW report found in 2016-2017 "massive use" or abuse, i.e., the report estimated in an average week over 179,000 long-stay nursing facility patients were administered antipsychotic drugs without a diagnosis for which the drugs are indicated or approved.  Despite efforts to reduce the abuse of these medications, in part via a CMS voluntary initiative (a link to which his provided below), the practice persists, in part, because the federal government has nominally enforced regulations and enforcement measures to remedy the problem.  The use of these drugs can and does cause serious patient harm.  In testimony before the Congress in 2007, the FDA's Dr. David Graham stated, "15,000 elderly people in nursing homes [are] dying each year form the off-label use of antipsychotic medications for an indication that the FDA knows the drug doesn't work."  Listeners may recall I initially discussed this topic in December 2012 with Diana Zuckerman.   

During this 36 minute discussion Ms. Flamm explains what prompted the HRW study, the study's methodology, how widespread is the practice of misuse of antipsychotics in nursing facilities, how and why they are used inappropriately, that includes the the failure to obtain free and informed consent, the federal government's inadequate enforcement of federal laws and regulations to police the problem and how this practice violates not just US laws but international human rights agreements. 

Ms. Hannah Flamm is currently an immigration lawyer at The Door's Legal Services Center in New York. FlammIn 2016-2017, Ms. Flamm was New York University's School of Law Fellow at Human Rights Watch where she researched and wrote, "They Want Docile."  She interned with the Southern Poverty Law Center, South Brooklyn Legal Services and Schonbrun DeSimone, an international human rights and civil rights firm.  She is a graduate of NYU's School of Law and the Harvard University Kennedy School of Government.  As a student she participated in NYU's Family Defense Clinic and the Harvard International Human Rights Clinic.  Prior to attending law school, Ms. Flamm worked for the International Rescue Committee in Haiti. 

The Human Rights Watch report is at: https://www.hrw.org/report/2018/02/05/they-want-docile/how-nursing-homes-united-states-overmedicate-people-dementia.

Two related 2012 and 2011 DHHS Office of the Inspector General reports are at: https://oig.hhs.gov/oei/reports/oei-07-08-00151.pdf and https://oig.hhs.gov/oei/reports/oei-07-08-00150.pdf.
 

 

02/11/2018

Mitigating the Opioid Crisis Via Abuse Deterrent Prescribing Practices: An Interview with Dr. Steven Passik (February 9th)

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Fatalities related opioid use now account for over two-thirds of all drug overdoses annually, over 60,000, in the US.  Approximately 115 Americans die every day from an opioid overdose.  This number represents a five-time increase over the past two decades.  Opioid-related fatalities have become so prevalent, according to the National Center for Health Statistics, they have caused a decrease in US life expectancy for the past two consecutive years.  (The last time life expectancy dropped was in 1993 due to the AIDS epidemic.)  While the amount of prescription opioids sold to pharmacies, hospitals and doctors has quadrupled in the recent past, Americans are reporting on reduction in the amount of pain they suffer.  (Ironically, we are over prescribed and under treated.)  To date the federal government's response to the epidemic has been poor although this past week, the Congress appropriated $6 billion, an amount experts believe beyond inadequate, over a two year period to address the crisis.   

During this 28 minute interview Dr. Passik discusses the numerous causes contributing to the opioid epidemic, policies and practices in pharmacology that may be contributing to the problem, strategies used in pharmaceutical prescribing, or in the use of abuse deterrent formulations, to reduce addiction or abuse and the role other reforms in the clinical practice setting and in reimbursement can play in reducing harm and opioid-related fatalities.  

Since 2017 Dr. Steven Passki is currently the Vice President of Scientific Affairs, Education and Policy at Collegium PassikPharmaceuticals.  Prior to joining Collegium, Dr. Passik was Director of Clinical Addiction and Education at Millennium Laboratories.  Prior still, he spent 25 years in academia and clinical care at Memorial Sloan Cancer Center, at the University of Kentucky and at Vanderbilt University.  His research has focused on the psychiatric aspects of cancer and non-cancer pain and symptom management and the interface of pain management and addiction.  He has served as on the editorial board of the Journal of Pain and Symptom Management and as a reviewer for multiple journals including The Clinical Journal of Pain.  He has been a member of several scientific and medical societies including the American Psychological Association and the American Society of Psychiatric Oncology/AIDS.  He has written extensively on the interface of pain management and addiction. He is a clinical psychologist and has areas of expertise include the general psychological aspects of cancer including palliative care and symptom management with an emphasis on pain, depression, nausea and fatigue.  Dr. Passki was named a fellow of Division 28 of the American Psychological Association (Psychopharmacology & Substance Abuse) and awarded a Mayday Fund Fellowship in Pain and Society. An author of more than 120 journal articles, 60 book chapters and 59 abstracts, he speaks nationally and internationally on pain, addiction and the pain/addiction interface.  Dr. Passik received his doctorate in clinical psychology from the New School of Social Research in New York City.

I noted during the interview Dr. Passik will be keynoting a DC-area abuse deterrent formulations meeting in March, information on the meeting is at: http://www.cbinet.com/conference/pc18298.