Is Medicare delivering consistent messages to hospitals on quality?

An interesting descriptive analysis by Meddings et al. (2018) finds that CMS is delivering somewhat different messages on quality based on whether the message is conveyed to patients (via Hospital Compare) or to hospitals directly (via the hospital readmissions reduction program [HRRP]).  They find the following:

Of the 2956 hospitals that had publicly reported HF [heart failure] grades on Hospital Compare, 91.9% (2717) were graded as “no different” than the national rate for HF readmissions, which included 48.6% that were scored as having excessive HF admissions, and 87% received an overall readmission penalty. Of 120 (4.1%) hospitals graded as “better” than the national rate for HF, none were scored as having excessive HF readmissions and 50% were penalized. AMI [acute myocardial infarction] data yielded similar results. Among 2591 hospitals penalized for overall readmissions, 26.6% had only 1 condition with excess readmissions and 27.5% had 2 conditions.

Although this result may be seen as inconsistent, statistically, one can view this as simply a different definition. Hospital Compare reports grades based on a risk-adjusted 95% confidence interval that the hospital’s unplanned readmissions differ from the 30-day national average.   On the other hand, 
the hospital readmissions reduction penalty (HHRP) program uses the actual risk-adjusted readmission rate–rather than the 95% confidence interval–to determine payment. 

Why would these similar programs use different methods?  

I would argue that they aim to answer different research questions.  For HHRP, the goal is to retrospectively evaluate how well a hospital did on readmissions.  Here, there is no statistical uncertainty–all readmissions are observed and they prior performance is known with certainty.  It may be the case that small hospitals had a year with bad luck, but the though is that if that is the case, these penalties would even out over the years. 

The research question asked for Hospital Compare by consumers, on the other hand, is likely not how well a hospital has done in the past but how well they are likely to do in the future.  Consumers use Hospital Compare to measure past quality only in able to predict future quality.  Although future quality is not known, there clearly is more uncertainty and Hospital Compare takes this into account.  

Thus, while the headline of this article may make it appear that CMS is doing something non-sensical, the respective approaches do make sense conceptually.  How CMS makes these predications (e.g., should they have used a Bayesian approach for Hospital Compare using the national average rate as the prior to create credible intervals and reported those?) I will leave for another post.  


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The end of Obamacare?

As reported in NPR:

A federal judge in Texas issued a ruling Friday declaring the Affordable Care Act unconstitutional, apparently setting the stage for another hearing on the health care law by the U.S. Supreme Court.
The ruling by U.S. District Judge Reed O’Connor invalidates what’s commonly referred to as Obamacare nationwide, and casts into doubt the survival of the law on the eve of the deadline for tens of millions of Americans to sign up for health care coverage in 2019.

So are the Obamacare health insurance exchanges closed?  The answer is, not yet.  Kaiser Health News reports:

Seema Verma, the administrator of the Centers for Medicare & Medicaid Services, which oversees those insurance exchanges, said in a tweet: “The recent federal court decision is still moving through the courts, and the exchanges are still open for business and we will continue with open enrollment. There is no impact to current coverage or coverage in a 2019 plan.”

Clearly, more to come on this story.

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What evidence does NHS need for reimbursement of digital health technologies?

This week, the UK’s National Health Service (NHS) and National Institute for Health and Care Excellence (NICE) released a document titled Evidence standards framework for digital health technologies.  An accompanying piece in The Lancet by Greaves et al. (2018) aims to describe the goals of the document at a high level.

The authors state that key principal used to inform these guidelines is that the level of evidence that should be required is proportional to the risk to the patient. 

For example, digital tools that provide diagnosis or treatment are in the highest level for which the minimum evidence requirement will be a high-quality experimental or quasi-experimental study with comparative data on patient outcomes. Support services and technologies designed to simply communicate information are lower in the hierarchy and the requirements are therefore designed around the credibility and accuracy of the content, including whether they meet established standards for the quality of the information provided.

Greaves et al. 2018.

The authors note that because digital health technologies tend to be iteratively developed, new techniques may need to be used such as Multiphase Optimisation Strategy (MOST) and sequential, multiple assignment, randomized trials (SMART) [see Collins et al. 2017]

Yet in general, the guidelines impose a similarly high standard of evidence on digital as compared to conventional technologies. 

However, there should be no lowering of the quality bar and experimental or quasi-experimental studies using traditional or innovative methodologies need to conform to high standards, including transparency of methods, a-priori analysis plans, and full publication of all results.

Greaves et al. 2018.

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Americans End 2018 Worried About Healthcare Costs

Nearly one-half of Americans are quite concerned they won’t have enough money to pay for medical care, according to the latest Gallup poll.

Health insurance in-security is mainstream as of November 2018, when Gallup polled U.S. adults about views on healthcare costs. It’s a major concern among six in ten people that their health plan would require they pay higher premiums or a bigger portion of their healthcare expenses. It’s also a big concern for four in ten people that someone in their family would be denied health insurance covering for a pre-existing condition, or that they might have to go without health insurance at some point.

Gallup conducted this survey among 1,037 U.S. adults in early November, as American voters headed to the polls and voted Democrats into the majority of the House of Representatives.

Gallup notes their October 2018 poll learned that voters were most concerned about healthcare, immigration and the economy as key midterm voting issues.

The second chart details responses to the survey by demographics. See that women are overall more concerned about healthcare finances across the different categories than men are: paying higher premiums is a major concern to 67% of women compared with 56% of men, for example.

Paying higher premiums is also of major concern to more Independents and Democrats that Republicans.

But those premiums are also a major concern to majorities of people at all income categories, even those earning over $75K a year.

Not having enough money for health insurance is a major concern for most people with lower incomes, and people enrolled in Medicaid or Medicare.

Having to go without health insurance is a major concern for nearly one-half of Democrats and Independents, but only 29% of Republicans.

Health Populi’s Hot Points: New data from the Center for Financial Services Innovation (CFSI) profiles Americans’ financial health at the end of 2018. Only one in four people say they’re financially healthy, with another half just “coping” financially. 42 million people, 17%, believe they’re financially vulnerable.

By income, even 50% of folks with over $100K a year in earnings are just financially coping or vulnerable, CFSI learned.

Nearly one-half of Americans are spending more than or up to their income, and over one-third are unable to pay bills on-time. Nearly one-half also don’t have enough savings to cover three months of living expenses, and a third have more debt than they can manage.

Healthcare costs as a basic need take a toll on financial wellness in America. People who struggled to afford healthcare were nearly ten times less likely to be financially healthy.

And that lack of affordable healthcare leads to self-rationing behavior: in the past year, someone in the respondent’s household did not get needed healthcare because they couldn’t afford it: 50% said this happened often, and one-fourth said “sometimes.”

Reflecting back on the Gallup Poll results, it’s clear why voters brought their financial health care stress to the voting booth in November 2018. With greater financial burden forecast on healthcare consumers in 2019, no doubt we’ll see healthcare rank highly on voters’ minds in the 2020 Presidential election.

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ACA Individual Market and State Re-insurance programs

A number of states have re-insurance programs to support the Affordable Care Act (i.e., Obamacare) marketplaces in the individual and small group markets.  Re-insurance occurs when the state offers to pay a percentage of patient costs if they exceed some threshold.  This may lead you to ask a number of reasonable questions.  For instance:

Why do states have reinsurance programs?

According to Schwab, Curran, Corlette (2018), the answer is: 

  1. Stabilize individual market premiums and mitigate future rate increases;
  2. Increase consumer enrollment;
  3. Maintain insurer participation and attract future competition; and
  4. Generate federal savings to fund state-level innovation, while ensuring a financially sustainable program.

Do reinsurance programs actually reduce premiums?

The answer seems to be yes. 

The reinsurance programs in all three states have directly reduced individual market premiums…One insurer noted that the program had a “tremendous immediate impact,” allowing them to reduce their proposed rates by over 20 percent. In Alaska, the state’s only insurer initially proposed 2017 rate increases of over 40 percent, on average, prior to approval of the [reinsurance] 1332 waiver.

Do reinsurance programs increase the number of health plans entering the individual market?

The answer to this question is unclear.  Practically speaking, if the government guarantees to pick up a share of your cost, entry is bound to happen. In practice however, none of the states saw additional insurers join the individual market after the reinsurance program was introduced. However, current market insurers did not that reinsurance decreased their chance of exiting the market. 

Will reinsurance programs continue?

Insurers like them because they reduce business risk.  Patients like them because they subsidize insurance premiums.  The key question, however, is whether States will continue to pour money into these re-insurance programs.  If there is an economic downturn and state budgets sour, then re-insurance programs may soon be at risk. 

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How good is your mental health care? Depends where you live

Access to physician services and pharmaceuticals is vital–particularly among patients with serious mental illness–to insure patients receive the care they need. However, the likelihood patients receive this care depends on where they live. A paper by Manchester (2018) examines a cohort of patients eligible for both Medicare and U.S. Social Security Disability Insurance (SSDI) and finds: 

The number of services for SSDI beneficiaries ranged from almost 48 per capita in Minnesota to 23 in Arkansas. Services for musculoskeletal impairments averaged 4.6 per capita, ranging from 6.7 in Minnesota to 2.5 in Hawaii. The greatest variation occurred in services for mental disorders, averaging 3.2 for the U.S. but ranging from 9.1 in Massachusetts to 1.4 in Alabama.

As the saying goes: location, location, location.

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