QUALITY: A Thoughtful Critique of ACOs

In case you missed the ‘Space' section of your daily paper a few months ago, two planets -- one the size of Mercury and one the size of our Moon -- collided in a far off solar system.  The smaller planet went the way of Alderaan. The larger planet suffered a big dent.

My own worlds collided this week when former-professor-in-my-department Kelly Devers teamed up with my former boss (on a research project) and friend-of-the-blog Robert Berenson to publish a thoughtful critique of the panacea fever surrounding Accountable Care Organizations (ACOs).  As much as we have trumpeted ACOs as the best cure-all since Clark Stanley's Snake Oil Liniment, Drs. Devers and Berenson's thoughtful analysis published by RWJF is a welcome contribution to the dialogue.

QUALITY: Is Safeway's The Best Way to Promote Wellness

Residents of D.C. love to talk about their Safeways. Apparently, so do Members of Congress.

During the mark up of Senate Finance Committee's bill in September, Senators John Ensign (R-NV) and Tom Carper (D-DE) introduced an amendment that increased the financial rewards companies could offer their workers for meeting certain health goals and criteria such as losing weight, lowering their cholesterol or quitting smoking. Pushing hard for this change, were companies like Safeway which puts a great deal of stock in their efforts to help manage and improve their employee's health, as explained this week in by the LA Times:

Nationwide, 25,000 nonunion employees in Safeway's health insurance plan are eligible for the premium-reduction program, most of them in California. The company says that 74% have signed up.

Once a year, participants submit to tests of four health risk factors: smoking, obesity, blood pressure and cholesterol. If they pass all four, they receive a $780 annual discount, which is 20% of the total cost of their insurance. If they do not pass initially but make progress in some areas -- quitting smoking or losing 10% of their weight -- they can get a premium rebate.

QUALITY: Robotic Surgery Gone Awry

Shocking news from the Boston Globe's Liz Kowalczyk: minimally invasive prostate removal, often performed with surgical robots like the da Vinci, more than doubled the rates of incontinence or impotence experienced by patients compared to those who opted for traditional open surgery.

Not good.

The study, which has solid but imperfect methodology, was published recently in the Journal of the American Medical Association. Other findings: success at controlling the cancer was about the same; minimally invasive got patients home in two days instead of three, and those patients also had fewer short-term complications like respiratory problems. In a nutshell, short-term effects were better with minimally invasive; long-term effects were better with traditional surgery.

According to the Globe, the study's lead author doesn't think the surgical robot itself is the problem:

HEALTH REFORM: Evidence-Based Change You Can Believe In (Part 2)

We posted the other day on the Kaiser Family Foundation-commissioned paper on delivery system reform. In short, Mathematica's Randall Brown concluded that the ideas getting the most attention (medical homes, health IT, ACOs, bundling etc) are worthwhile and may save in the long run but aren't likely to save much in the first five to 10 years. In the promised, albeit slightly belated, part 2 of this post, let's look at how he thinks we can get results faster.

Making dramatic changes in the health care delivery system takes time. While that shift is underway, Brown writes, we have "solid evidence" on strategies for managing patients with serious chronic diseases in ways that reduce hospitalization and rehospitalization. It saves money, and keeps patients healthier.

We also have "less rigorous" but still encouraging evidence on how to address geographic disparities in the practice of medicine and use of resources. The goal is to find approaches that help doctors understand -- and  incentives to change -- the way they themselves practice and how they stack up against other doctors and other regions.

These programs and initiatives can be phased in with tweaks to the current fee-for-service system -- although Brown is not arguing that we shouldn't also make longer term initiatives to reform that system, but it's a heavier and longer-term lift. (And since we've written about a lot of these ideas before, we are feeling affirmed.)

HEALTH REFORM: To the Floor!

The fifth committee has spoken. The Senate Finance Committee led by Montana Democrat Max Baucus just passed its health reform bill, 14-9. All Democrats, liberals and moderates, backed the bill, along with one Republican moderate, Olympia Snowe of Maine.

As several of the committee members noted, this puts America closer to health reform than it's ever been in the nearly 100 years since President Theodore Roosevelt first demanded that we cover everybody.

Now, after the Finance and Senate HELP bill are melded (not an easy task we know, but none of this has been easy and we've come far) the full Senate will vote. And the House.

 As the director of New America's health policy program Len Nichols said, "America got better today."

QUALITY: Primary Care Innovation Goes Viral (The Good Kind of Viral)

When was the last time you looked at Wikipedia?  Chances are, if you're a blog reader, you probably read it last week, if not more recently. Many of us could write or edit something related to health policy on Wikipedia, but probably not on astrophysics.  But if we have a question on astrophysics, we know where to look.  It is a collaboration, or network, of experts and learners.

The current issue of JAMA has an important commentary that describes how primary health care innovation networks can be funded, operated, and used to disseminate best practice information.  As the article states:

HEALTH REFORM: More is Better when This American Life Does "Less is More"

This American Life devoted a whole hour this weekend -- and plans another hour next weekend -- to the health care crisis, more than it's ever spent on a single topic. Host Ira Glass, who immersed himself in health policy 101, sounded just as amazed and outraged each time he repeated some variant of the following statement: "Rising health care costs are driving everything in the economy. Half of our incomes are going to be going to health care very soon.  Unless somebody does something." (I haven't seen Ira in maybe 10 years, but half his charm was that he always sounded amazed.)

The theme of the first segment, "Dartmouth Atlas Shrugged" may be familiar to our readers, but the story was told with a punch, going back to the Jack Wennberg research that eventually gave rise to the atlas. He discovered the extraordinarily high hysterectomy rates in one Maine community in the 1970s -- a rate so high that 7 in 10 women would have the surgery by age 70, nearly three times the rate of a similar community with similar demographics in the same state.

IN THE STATES: Big Variations In Quality and Access

Earlier this week, we looked at insurance coverage on a state by state (or more precisely -- district by district) level. Based on a similar concept, the Commonwealth Fund report, Aiming Higher: Results from a State Scorecard on Health System Performance, 2009, looks at how well -- or poorly -- states are performing on health care. The report looks at a number of indicators that represent health care access, quality, costs, and health outcomes; this includes avoidable hospitalizations, healthy lifestyles (like not smoking), and preventative care, such as routine checkups and screenings.

HEALTH REFORM: Evidence-Based Change You Can Believe In

About a year ago, Drew Altman, president and CEO of the Kaiser Family Foundation, wrote an essay about "delivery system" folks and "coverage" folks. When I saw Drew soon after that, interviewing him for an unrelated magazine piece,  I said I thought the overlap in that Venn diagram of coverage and delivery was both bigger than he described it, and expanding faster than he perceived it. I thought that as health reform became something that might really and truly happen the "coverage" camp had a growing appreciation of how delivery system reform, properly done, could improve quality of care while saving money needed to pay for that very same expansion of coverage. And the delivery system camp, at least the people I knew reasonably well, certainly thought it was high time that the United States did what every other developed country on the planet (and some of the not-so-well developed ones) has managed to do: make sure that everybody has decent affordable health coverage.

So it was a pleasant surprise to find Kaiser (which I think of as more on the coverage side) publishing a very useful, worth-reading paper on what we do and do not know about delivery system reform, at least with regard to Medicare.

WORLDVIEW: Dutch Improve Care and Cost Through Competition

When the health care conversation heated up a year or so ago, a spate of articles focused on the Dutch health care system. In the Netherlands, everyone receives health coverage through a network of private insurers, and there is strict government regulation to ensure that everyone competes on a level playing field. We heard very little about the Dutch system for awhile -- but recently, there's been another round of reporting, including this piece from the NewsHour with Jim Lehrer.