Potpourri of Health Policy Issues in June.

My cup runneth over with potential issues to explore.

June has been a busy month both locally and nationally insofar as things I like to write about. The shame-on-me is that I have not carved out enough time to do so!  In part I am still picking up the pieces after my early spring travels. Exploring how to unpack and deal with the new Medicare prescription drug data base also took a lot of time.  The truth is that I am a slow writer handicapped by a default and probably over-wordy professorial style.  I haven’t even been able to update the Institute’s Facebook and Twitter pages!  What follows is a list of things that occured during the month that I wanted to write about and hope to do so in more detail later.  These are not necessarily in chronological order or of importance.

The Supremes Rock & Rule!
We were presented with two back-to-back major decisions by the U.S. Supreme Court. The first, King v. Burwell, allows federal subsidies of health insurance premiums for low income individuals and their families to continue even if their insurance was purchased in states that chose to allow the federal government to operate their health insurance exchanges.  The lawsuit brought by Obama/Obamacare-haters to limit premium support to insured individuals in states like Kentucky that chose to operate their own exchanges would have essentially gutted the Affordable Care Act (ACA) and tossed millions back into the uninsured category. For the time being, Obamacare stands intact for at least the next year and a half, despite promises by opponents to throw up additional challenges. All our legislators should be working together to deal with a major remaining deficiency of the ACA.  The Act has been very successful in decreasing the number of uninsured people, but it makes little headway against the exploding costs of unnecessary, marginally effective, or for that matter even necessary medical care.  Continuing to forbid the federal government to negotiate over the prices of drugs is a case in point. Subsidies were deemed necessary for a reason! Continue reading

Narcotic Analgesic Drug Use By Medicare Patients: Continued

What drugs and by which specialties?
When I first looked at the recent release of outpatient prescription drug utilization by Medicare patients, I was immediately struck by how many narcotics were being prescribed by physicians and other medical providers for so many patients. The vast majority of providers prescribed a handful of different and mostly inexpensive opioid drug products to a relatively few patients, On the other hand, a smaller number of providers wrote for many different opioid formulations, some fantastically expensive, for large numbers of patients.  Is good medicine being practiced?  Is it possible to tell? Should we even care?  Of course we should. In this analysis I break down further the utilization of a subset of the most common opioid analgesics, show which medical specialties prescribe the most, and begin to highlight the vast discrepancy in narcotic use among individual providers. From the full CMS database, I extract and make available an Excel file enumerating  prescriptions of selected narcotic analgesics by Kentucky medical providers . Continue reading

Narcotized Elderly America: Diseased, Stoned, or Dealing?

pills-15The Federal Government has been releasing an avalanche of health care utilization data over the past very few years while the rest of use are still trying to figure out how to use the information.  While there exists the potential to use the data to evaluate healthcare quality and safety, to ferret out best medical practices, to more efficiently use increasingly limited healthcare dollars, or to otherwise guide good public policy; the most apparent utility so far is to identify medical fraud. It is easier to justify looking for fraud than to confront entrenched interests dug in deep in this profitable segment of the economy.

Medicare prescription drug cost and utilization data.
One month ago, the Centers for Medicare and Medicaid Services (CMS) published another data-dump. It was the first compilation of all drugs and selected supplies prescribed by physicians and other healthcare professionals to the majority of Medicare patients in 2013.  Included beneficiaries number 35.7 million and include those enrolled in freestanding Medicare Part-D drug plans, or those covered by drug plans that are part of Medicare Part-C (managed care) Advantage plans. These make up about 68% of all Medicare beneficiaries. Medicare fee-for-service patients are not included.  Recall also that a proportion of all Medicare beneficiaries are enrolled because they are disabled, not because they are over 65 years old.   Each provider has a line item for every discrete drug prescribed more than ten times by them (to protect patient privacy) including the number of unique beneficiaries receiving the drug, the number of times times prescribed or renewed, the number of days worth of of drug prescribed, and the total amount paid for the drug by the patient, Medicare, and any third party payers.  In the full data file there are 23,650,520 line items for more than 1 million individual providers prescribing 3449 different drugs or supplies. Continue reading

UofL Board of Trustees to Meet at Health Sciences Campus.

Trustees follow on the heels of accreditation site-visit.

uofl-valveThe regularly scheduled June meeting of the UofL Board of Trustees will be held at various locations within the Health Sciences Campus this Thursday, June 4.  It promises to be a long and busy session. [Agenda here.]  In addition to its usual slate of business, Trustees will hear an update about the partnership with KentuckyOne Health from the CEO of Catholic Health Initiatives, Kevin Lofton. Interspersed with regular sessions will be walking tours to include the cardiovascular services at Jewish Hospital, the Neurorecovery Training Institute at Frazier Rehab, the Level 1 Trauma Center at University Hospital, the Center for Women and Infants within University Hospital, the UofL Healthcare Remote Physician Presence Robot Network, and the recently remodeled instructional facilities at the School of Medicine.  I do not expect to see the same fireworks launched as at the May meeting, but who would have predicted then!  Anything can happen.

LCME Accreditation Site visit.
The School of Medicine was visited in May by the Liaison Committee on Medical Education (LCME), the organization sponsored by the Association of American Medical Colleges and the American Medical Association that accredits American and Canadian schools of medicine and osteopathy– necessary for these professional schools to grant M.D. or D.O. degrees to their students. This important site visit is the first one following UofL’s School of Medicine being placed on probation last year.  I expect that Medical School Dean Tony Ganzel will give an update on what the School had done to respond to the LCME’s concerns, and perhaps something about how the site visit went.  I am unaware of the timetable for a final report and decision, but typically please things take several months. It would be nice to get things cleared up before the next application cycle and enrollment.  Letters of acceptance have already gone out for next Fall’s entering class. Continue reading

Presidential Outburst at UofL Board Meeting. 

ramsey-may2015•Only Nominally Over Executive Compensation.
•Trustee requests for information and oversight rebuffed.
•Audit called for.

Readers will note that I have not posted anything for over a month.  In truth, I was in Europe for three weeks and am just now getting over a jet-lagged recovery. This was to be an “unplugged” holiday. My long-suffering wife likes to tell the story of how I once almost missed our connection in the Amsterdam Airport waiting to upload a post over the free McDonald’s internet connection. She has other stories too! Indeed, I admit to occasionally feeling guilty of insufficient spousal attention during our travels in these hyper-connected times.

Always something to write about.
I did cheat on this good woman a little by occasionally peeking at the news.  It is not that there was nothing I like to write about!  Several updates of existing hospital quality, safety, and performance ratings were released, as well as a new rating approach by U.S. News & World Report. Flanking these stories were scholarly reports addressing the same issues I have been raising about the reliability and usability of existing rating systems.

There was new data-hacking breach of over a million members at another health insurer. No one should feel safe!  Medicare released a massive database of all outpatient drugs prescribed for those with Part-D drug coverage or in Medicare managed-care plans. The data is broken down by individual drug, healthcare provider, and cost and is already generating a flurry of attention.  For example, it turns out that many of the top prescribers of specific drugs receive monetary payments from the manufacturer. [Naturally this does not influence their professional judgments!] I started looking at the drug database on the flight home– this wasn’t really cheating–  and will have more to say future articles.

New Sunshine Act Data Release.
Entirely by coincidence, the next iteration of the federal database of payments to medical providers by device and drug manufacturers will be released in a month or so and will now list at least some payments to providers for continuing medical education (CME).  These latter payments, previously undisclosed, provide a measure of the degree that manufacturers have taken control of what physicians and other providers think and do.  If transparency and accountability is the goal of the Open Records Program (a.k.a. Sunshine Act), it was a critical error to have initially allowed payments for CME to remain hidden. The fact that such payments were exempted from disclosure attests to the lobbying power of both drug companies and the academic medical establishment.

UofL against the world (and its own Board?).
There were other items I filed away in my write-about-later folder, but the big-ticket item for Kentucky was the further unfolding, indeed explosion of nagging concerns over University governance and secrecy, fueled by revelations about executive compensation at the University of Louisville, and triggered by a recent call from a University Trustee and others for an external independent audit by Kentucky’s State Auditor of Public Accounts. The news reports of the Trustees’ meeting used words like “angrily,” “testy,” agitated,” “contentious,” “defiant,” and “lashes out” to describe the behavior or UofL President James Ramsey.  All of this was in response to quite reasonable requests by responsible board members for information that either they or the public is entitled to.  Comments to articles from the public on the three major Louisville markets were solidly against Dr. Ramsey’s positions, except for the reliable fan-boy or contract internet-troll for whom UofL can do no wrong.  I found the reports of the apparent melt-down difficult to believe until, on my return, I had a chance to view a video clip of part of the encounter— it was worse than I thought.  View it yourself. Was this justified indignity, staged outrage, or a hissy-fit?  You be the judge.  In any event, it must have been embarrassing for most of the folks present. Continue reading

Medicare Releases New 5-Star Rating System for Acute Care Hospitals.

Not everyone is happy, but Kentucky doing better than the rest!

Yesterday, the Centers for Medicare & Medicaid Services (CMS) released its first iteration of a new and simplified method of presenting the results of the awkwardly named HCAHPS survey that is administered to patients after their discharge.  The survey is intended to capture the patients’ own perceptions of their hospital experience and it is now part of the larger CMS Hospital-Compare initiative. As with previously released quality and safety initiatives, the reaction of individual hospitals is mixed.

Background.
The survey of 32 questions is administered to randomly selected adult patients who are between 48 hours to 6 weeks after being discharged alive from acute-care Medicare hospitals.  Unlike most other quality and safety programs managed by CMS, individual patient participants are not limited to the Medicare or Medicaid programs.  Hospitals attempt to reach a target of 300 surveys per year by telephone or mail, but some smaller hospitals struggle to do this.  Additionally, hospitals that are exempt from having to submit the more objective Medicare process and outcome measurements (including Medicare’s Critical Access Hospitals) can participate voluntarily in this patient experience program.

Hospitals have been submitting this information voluntarily since 2006, it has been mandatory since 2007, and the results have been reported publically since 2008.  A similar program for nursing homes and a few other healthcare providers already exists.  Future plans are to include these patient experience scores with the other more blood-and-guts process and outcome measures to provide a single global star-score for all Medicare hospitals. Proprietary quality and safety organizations are already doing this. Continue reading

Catholic Health Initiative 2d Quarter Report Showing Better Numbers.

chi-2d-quarter-2015-200pxCHI’s report shows immediate favorable impact of acquisitions on current financials. Productivity and sustainability of existing operations harder to ascertain.
Catholic Health Initiatives (CHI), the parent company of KentuckyOne Health, released its most recent quarterly financial report earlier this month covering the three months ending December 31, 2014.  The company’s press release stressed “improved second-quarter financial results as the organization continues a comprehensive program of operational improvement, revenue enhancements and strategic expansion in key markets.”  Raw earnings in this second quarter were $290.5 million compared to $132.1 million in the same quarter a year earlier. Operating income moved into the black following the losses of the first quarter.  These gains were attributed to “additional business acquisitions, clinical and operational improvements as well as other internal cost-saving programs to reduce expenses.”  However, these “turnaround” earnings are entered before being reduced by a variety of adjustments including interest, depreciation, amortization, business combination gains, and “restructuring.”  This makes it difficult for the uninitiated such as myself to judge whether this apparent reversal of fortune represents on-the-ground improvement in existing competitive markets, or the untested effects of an expanding acquisition bubble. The bond market that supports the considerable debt of the organization, and CHI’s continuing success in a rapidly changing healthcare environment will provide a more definitive judgment. The full report is available here. Continue reading

Faculty Senate Meeting Updates— Or Lack Thereof!

I attended the April 1 meeting of the University of Louisville’s Faculty Senate hoping for updates in a number of areas of both faculty and community concern that we have been following. These included the politically motivated grants to the Business School, compensation packages for senior UofL executives, and Board of Trustee concerns about University governance.  In all honesty, I came away disappointed.

Koch/Schnatter Foundation Grants.
Last month, Pres. James Ramsey signed linked contracts on behalf of the University and the University of Louisville Foundation accepting a potential $6.3 million dollars but which carries with them tight restrictions on the kind of thoughts allowable in the minds of recipients.  Others and I found the restrictions impermissible in the academic setting but I expressed my opinion why University Administration would have no objection, indeed, no option except to accept both the money and the outside control.  In accepting the grant, the University violated its own rules about requiring faculty approval before new centers or programs were applied for.  In the faculty Senate meeting of March, representatives of the relevant faculty Academic Program Committee pointed out that no such approval had been requested.  The Provost made much of the great value the administration placed on the input of its faculty but what else could she say?  The fact is, that as of the April 1 Senate meeting, the Committee had not met to consider the matter and there was no further discussion offered from the assembly. In contrast, in his March newsletter to the community, President Ramsey makes acceptance of the grant sound like the done-deal that skeptics in the community like myself believe has occurred.  Certainly there was no mention in the update of any contingency upon faculty approval. No doubt faculty other than myself are feeling steamrolled. Continue reading