will evidence-based medicine shift hospitals to accountable-care organizations?

from http://www.dallasnews.com/sharedcontent/dws/bus/stories/112909dnbusbaylor.3d5ccc5.html

In an accountable-care organization, doctors and hospitals share a financial incentive to control costs and improve quality by coordinating care for a defined patient group.

Today, most medical care in Dallas and across the nation is delivered piecemeal. Doctors are paid for each patient visit. Hospitals are paid for each procedure. This “fee-for-service” model rewards caregivers for how much they do rather than how well they do it.

Health economists say it does too little to ensure that the people treating a patient know what’s been done by other caregivers. Too often, the result is duplication, waste and mistakes that are both expensive and dangerous to a patient’s health.

But what sounds like a commonsense approach is full of complications. Accountable care relies on a single, bundled payment that’s spread across all caregivers dealing with a patient. In its model, Baylor, with a powerful hold on much of the North Texas hospital industry, will decide how patients should be treated and how the payment pie is sliced. Doctors, hospitals and insurers in North Texas have a hard time trusting each other. And medical professionals don’t like being told how to do their jobs.

Patients may not like it either. The last overhaul of patient care and payments on this scale took place in the 1990s, when HMOs, or health maintenance organizations, were introduced on a wide scale. Patients rebelled against insurers getting between them and their doctors on decisions about care, and they may not see much difference if it’s a hospital rather than an insurance company making the calls under accountable-care.

In 2000, 3 million Texans were enrolled in HMOs. Last year, it was 852,000.

In that decade, however, Dallas changed from an average spender for health care to one of the biggest spenders in America on a per-patient basis.

Congressional Democrats have struggled for months to write legislation that will extend coverage to more Americans, including many in Dallas who lack health insurance. Insurance might persuade some of those people to seek preventive treatments they now skip because of cost. The legislation also encourages communities to try models such as accountable-care organizations, under the theory that doing so will lead to better care at lower cost.

“I don’t think we can really afford to wait for what might happen with national health care legislation,” said health economist Mark McClellan, keynote speaker for Monday’s summit.

“It’s very clear we need to move to more preventive care, and more coordinated care. While legislation can help address that, there are certainly a lot of steps that can be taken in the meanwhile, ahead of health care reform.”

Wooing employers

Roberts said Baylor will not wait for Congress to pass a health care overhaul bill. Instead, he has been going directly to large North Texas employers with a pitch that Baylor can improve quality while lowering costs with an accountable-care model.

“I might go to a Texas Instruments and say, ‘I know you’ve been struggling with your health care costs. Can we help you bend the cost curve?’ ” Roberts said.

Early next year, Baylor will meet with the Texas Employees Retirement System and Blue Cross Blue Shield of Texas to see if it can help slow the growth of the system’s health care costs.

Those costs for the 528,000 participants are projected to be $2.1 billion by year’s end, according to the system’s records.

“We will be looking at a number of innovations in plan design and reimbursement structure, including patient-centered medical homes, clinical integration and an accountable-care organization structure,” Roberts said.

In Baylor’s accountable-care plan, Baylor would be held responsible for organizing its hospitals and physicians to lower costs. In a contract, the employer would have to agree to a number of terms, possibly changing health insurance plans, which could set up fights between Baylor and health insurers. The contract might also require the employer to hire an outside wellness program developer to get workers in shape, Roberts said.

What’s less clear, and more controversial, is whether employers would instruct workers to visit only Baylor doctors and hospitals.

Roberts said he’s unsure what employers will do. If employees are given the freedom to choose their doctors and decide not to participate in Baylor’s accountable-care system, then Baylor has limited power in controlling costs.

If workers are limited to Baylor services, the hospital system secures a steady revenue stream and leverage over regional hospital competitors.

One difficulty facing health providers that are considering accountable-care models is how to sell the idea to patients without their feeling it’s just another cost-control measure.

“The challenge with evidence-based treatment is that sometimes we don’t like what the evidence shows,” said Eduardo Sanchez, chief medical officer of Blue Cross Blue Shield of Texas. Sanchez pointed to the uproar over a federal advisory panel’s recommendations that women younger than 50 don’t need routine annual mammograms screening for breast cancer. The panel warned that early testing causes many more false diagnoses and needless procedures than life-saving cancer detections.

“Does preventive medicine have to save money to be worthwhile?” Sanchez asked. “The response has been that, clearly, it shouldn’t be driven by the idea of saving money.”

Uwe E. Reinhardt: healthcare comparative effectiveness analysis and cost-effectiveness analysis

from http://economix.blogs.nytimes.com/2009/03/13/cost-effectiveness-analysis-and-us-health-care/

With so much brouhaha over what should be thought of as basic operations research for health care, it may be well to explore what “comparative effectiveness analysis” is, and how it is related to what is known as “cost-effectiveness analysis.”

The sketch below describes the basic structure of “comparative effectiveness analysis.”

It is assumed that researchers compare two therapies aimed at the same medical condition. The researchers try to determine which of these therapies can be judged “better” in terms of the positive and negative consequences associated with them. In principle, the clinical practice guidelines promulgated by medical specialty societies to help physicians with their daily treatment decisions should be based on this type of carefully structured comparative effectiveness research.

Source: Uwe Reinhardt A diagram of comparative effectiveness analysis.

Alas, in practice most of the currently promulgated guidelines lack that kind of rigorous scientific foundation. For example, as the science reporter Ronald Winslow recently reported in The Wall Street Journal “just 11 percent of more than 2,700 recommendations approved by cardiologists for treating heart patients are supported by high-quality scientific testing, according to new research.”

That circumstance alone justifies spending billions more than we traditionally have on operations research for an industry that now absorbs $2.5 trillion or close to 17 percent of our gross domestic product. Why anyone would oppose that kind of research challenges one’s imagination.

Early drafts of the economic stimulus bill, however, referred not only to “comparative effectiveness research,” which keeps the analysis strictly in the clinical realm, but also to “comparative cost-effectiveness analysis,” which brings economics into the inquiry. That analysis seeks to establish which of several alternative therapeutic strategies capable of achieving a given therapeutic goal is the least-cost strategy. It seems a sensible form of inquiry in a nation that is dismayed over the rising cost of its health care.

Indeed, in recent years most industrialized nations have begun to subject clinical practices in their health systems to this type of analysis, as have private insurers in the United States (see, for example, the American Journal of Managed Care).

In Congress, however, the word “cost” in this connection remains anathema. This is despite the fact that that same Congress rings its hands in despair over the millions of American families priced out by the ever-rising cost of health care, and over the bigger chunk of the federal budget taken up by Medicare and Medicare.

So, in the end, the offensive term “cost-effectiveness analysis” was stricken from the bill.

The opposition to cost-effectiveness analysis in health care comes from two distinct groups that work closely together and reinforce one another.

The first group includes individuals or enterprises that book other people’s health-care spending as their own health-care income.

The manufacturers of pharmaceutical and biotechnology products or of medical devices are often found in that group, even though in some instances the greater economic transparency provided by cost-effectiveness analysis might help them market their health products or health services. Also in this group are physicians who thrive economically from highly resource-intensive medical treatments, even if some of its components are of only marginal clinical benefit.

The second group among the opponents of cost-effectiveness analysis includes individuals who sincerely believe that health and life are “priceless” — for them, cost should never be allowed to enter clinical decisions. It is an utterly romantic notion and, if I may say so, also an utterly a silly one. No society could ever act consistently on such a credo.

Harvard law prof: HIPAA “dismantled the longstanding moral and legal tradition of patient confidentiality”

from  www.accessmylibrary.com/coms2/summary_0286-35587036_ITM

“The HIPAA paradox: the privacy rule that’s not.

HIPAA is often described as a privacy rule. It is not. In fact, HIPAA is a disclosure regulation, and it has effectively dismantled the longstanding moral and legal tradition of patient confidentiality. By permitting broad and easy dissemination of patients’ medical information, with no audit trails for most disclosures, it has undermined both medical ethics and the effectiveness of medical care.

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Most physicians, patients, policy analysts, and journalists believe that the HIPAA “privacy rule” protects medical confidentiality. They are mostly incorrect. The Health Insurance Portability and Accountability Act creates medical records rules that tighten internal practices, like hiding computer screens and not talking in elevators, and these protections are an improvement over previous practice, but they are limited. (1) Perhaps because the enabling legislation called for a “standard for privacy of individually identifiable health information” and the original final rule in 2000 required patient informational consent, there is a belief that the Department of Health and Human Services rules provide strong privacy protections for medical information. Unfortunately, that belief is a misconception. (2) In fact, the amended final HIPAA rule (for simplicity, hereafter referred to as “HIPAA,” or “the HIPAA rule”) provides much less privacy than the term “privacy rule” suggests.”

political debates on “comparative effectiveness research” of medicine and treatments

The New York Times is reporting on an emerging political debate tied up with the February 2009 stimulus bill about comparative effectiveness research of medicine and treatments:

www.nytimes.com/2009/02/16/health/policy/16health.html?hp

“The $787 billion economic stimulus bill approved by Congress will, for the first time, provide substantial amounts of money for the federal government to compare the effectiveness of different treatments for the same illness.

Under the legislation, researchers will receive $1.1 billion to compare drugs, medical devices, surgery and other ways of treating specific conditions. The bill creates a council of up to 15 federal employees to coordinate the research and to advise President Obama and Congress on how to spend the money.

The program responds to a growing concern that doctors have little or no solid evidence of the value of many treatments. Supporters of the research hope it will eventually save money by discouraging the use of costly, ineffective treatments.

The soaring cost of health care is widely seen as a problem for the economy. Spending on health care totaled $2.2 trillion, or 16 percent of the nation’s gross domestic product, in 2007, and the Congressional Budget Office estimates that, without any changes in federal law, it will rise to 25 percent of the G.D.P. in 2025.

Dr. Elliott S. Fisher of Dartmouth Medical School said the federal effort would help researchers try to answer questions like these:

Is it better to treat severe neck pain with surgery or a combination of physical therapy, exercise and medications? What is the best combination of “talk therapy” and prescription drugs to treat mild depression?

How do drugs and “watchful waiting” compare with surgery as a treatment for leg pain that results from blockage of the arteries in the lower legs? Is it better to treat chronic heart failure by medications alone or by drugs and home monitoring of a patient’s blood pressure and weight?

For nearly a decade, economists and health policy experts have been debating the merits of research that directly tackles such questions. Britain, France and other countries have bodies that assess health technologies and compare the effectiveness, and sometimes the cost, of different treatments “