Flawed Dartmouth Atlas study only catalogs dead people, but HR 3200's "efficiency" payments are based on it
Never let it be said that the scientists who publish in dry, staid medical journals lack a sense of humor. That resurrecting dead patients line is the title of an article that appeared in JAMA [Journal of the American Medical Association] a few years ago, and beyond the fact that it provided me with a snappy headline, gives me the chance to post one of my favorite lolcats [again], and is cited in another article in another journal, it has no further bearing on this post.
The another article in another journal, Looking Forward, Looking Back: Assessing Variations in Hospital Resource Use and Outcomes for Elderly Patients With Heart Failure, is monumentally less gripping than, oh, the last installment of Harry Potter, or even the labels on cat food cans, but it's nonetheless an important data point in the present health care
deform reform debate.
To back up for just a moment, the Dartmouth Atlas Project is a massive gathering of data gleaned from Medicare spending records over many years. Mapping the data has produced the realization that Medicare spending varies widely throughout the country. Peter Orszag, President Obama, and Tom Harkin, to name just a few personages, are all quite taken with it, and with the Dartmouth researchers' assertions that the patients in higher-spending regions fare no better than those in lower-spending regions.
If only those spendthrifts in Miami and McAllen could be made to behave more like those prudent paragons living in Minnesota, we could save hundreds of billions of $$$$$ in health care spending every year.
Not so fast, corpus breath. The Dartmouth Atlas only catalogs dead people. The researchers looked back over the patients' lives for the 6 months [and for some purposes, 2 years] before they died. Concluding that since they all died anyway [duh!], the ones who got more care [and therefore cost more money], didn't really need all that extra care [and therefore we don't need to be spending that extra money on them].
It's an attractive notion, but one of the things the Dartmouth researchers didn't do so much of was looking forward.
So this is what the California hospitals did, as reported in the slightly-more-readable-than-catfood-labels article on heart failure survival rates. They looked at all patients [not just the dead ones] with a particular medical condition [heart failure] and found that those who received more care [and therefore cost more $$$] were more likely to survive.
This point -- survival -- may or may not be interesting to academics, but you would think that it might have some importance in deciding public policy. You would be wrong on that count, legal-beagle breath. I'm not going to go looking it up in the Senate bills just now, but HR 3200 [from the Energy and Commerce committee website] takes the Dartmouth conclusion [less is more] and runs with it.
Regarding the 'public option':
SEC. 223. PAYMENT RATES FOR ITEMS AND SERVICES.
(a) RATES ESTABLISHED BY SECRETARY.—
(1) IN GENERAL.—The Secretary shall establish payment rates for the public health insurance option for services and health care providers consistent with this section and may change such payment rates in accordance with section 224.
(2) SUBSEQUENT PERIODS.—Beginning with Y4 and for subsequent years, the Secretary shall continue to use an administrative process to set such rates in order to promote payment accuracy, to ensure adequate beneficiary access to providers, and to promote affordablility and the efficient delivery of medical care consistent with section 221(a).
(e) CONSTRUCTION.—Nothing in this subtitle shall be construed as affecting the authority of the Secretary to establish payment rates, including payments to provide for the more efficient delivery of services, such as the initiatives provided for under section 224.
(f) LIMITATIONS ON REVIEW.—There shall be no administrative or judicial review of a payment rate or methodology established under this section or under section 224.
So far, we're only talking in general terms of 'efficiency' [which could mean anything] but wait until you see section 224.
SEC. 224. MODERNIZED PAYMENT INITIATIVES AND DELIVERY SYSTEM REFORM.
(a) IN GENERAL.—For plan years beginning with Y1, the Secretary may utilize innovative payment mechanisms and policies to determine payments for items and services under the public health insurance option. The payment mechanisms and policies under this section may include patient-centered medical home and other care management payments, accountable care organizations, value-based purchasing, bundling of services, differential payment rates, performance or utilization based payments, partial capitation, and direct contracting with providers.
(b) REQUIREMENTS FOR INNOVATIVE PAYMENTS.—The Secretary shall design and implement the payment mechanisms and policies under this section in a manner that—
(1) seeks to—
(A) improve health outcomes;
(B) reduce health disparities (including racial, ethnic, and other disparities);
(C) provide efficent and affordable care;
(D) address geographic variation in the provision of health services; or
(E) prevent or manage chronic illness; and
(2) promotes care that is integrated, patient-centered, quality, and efficient.
(c) ENCOURAGING THE USE OF HIGH VALUE SERVICES.—To the extent allowed by the benefit standards applied to all Exchange-participating health benefits plans, the public health insurance option may modify cost sharing and payment rates to encourage the use of services that promote health and value.
(d) NON-UNIFORMITY PERMITTED.—Nothing in this subtitle shall prevent the Secretary from varying payments based on different payment structure models (such as accountable care organizations and medical homes) under the public health insurance option for different geographic areas.
And not only are we going to experiment on those hapless souls in the public option based on Dartmouth dead people, we're going to experiment on the old folks [and the disabled] in Medicare too.
SEC. 1123. PAYMENTS FOR EFFICIENT AREAS.
Section 1833 of the Social Security Act (42 U.S.C. 3 1395l) is amended by adding at the end the following new subsection:
‘‘(x) INCENTIVE PAYMENTS FOR EFFICIENT AREAS.—
‘‘(1) IN GENERAL.—In the case of services furnished under the physician fee schedule under section 1848 on or after January 1, 2011, and before January 1, 2013, by a supplier that is paid under such fee schedule in an efficient area (as identified under paragraph (2)), in addition to the amount of payment that would otherwise be made for such services under this part, there also shall be paid (on a monthly or quarterly basis) an amount equal to 5 percent of the payment amount for the services under this part.
‘‘(2) IDENTIFICATION OF EFFICIENT AREAS.—
‘‘(A) IN GENERAL.—Based upon available data, the Secretary shall identify those counties or equivalent areas in the United States in the lowest fifth percentile of utilization based on per capita spending under this part and part A for services provided in the most recent year for which data are available as of the date of the enactment of this subsection, as standardized to eliminate the effect of geographic adjustments in payment rates.
‘‘(B) IDENTIFICATION OF COUNTIES WHERE SERVICE IS FURNISHED.—For purposes of paying the additional amount specified in
6 paragraph (1), if the Secretary uses the 5-digit postal ZIP Code where the service is furnished, the dominant county of the postal ZIP Code (as determined by the United States Postal Service, or otherwise) shall be used to determine whether the postal ZIP Code is in a county described in subparagraph (A).
‘‘(C) LIMITATION ON REVIEW.—There shall be no administrative or judicial review under section 1869, 1878, or otherwise, respecting—
‘‘(i) the identification of a county or other area under subparagraph (A); or
‘‘(ii) the assignment of a postal ZIP Code to a county or other area under subparagraph (B).
In the Dartmouth Atlas, the geographic areas in the lowest fifth percentile of utilization based on per capita spending are always deemed the efficient ones, with all the others indulging in wasted care, and gee, if the HHS Secretary should have trouble deciding which zip codes to assign to which 'counties or other areas' the Dartmouth Atlas is here to help.
For someone who waxes positively shrill on the proposed payment innovations [particularly accountable care organizations] to eliminate treatment variations, you should read Don McCanne.