• Catch-up reading list (from readers)

    While my attention was focussed elsewhere last week, some folk sent a few things to share:

    Brad Flansbaum, in a post on ACOs, writes,

    The AHA numbers 5800 hospitals in the Unites States.  Of that total, I wondered, how many are engaged in an ACO type arrangement, or better, close to collaborating with other entities to move in a direction like those above.  I searched, and as there is no ACO professional association (although, see here, and here), and no federal registry, I could not determine numbers.  However, if references to “model systems” are any guide, beyond the usual suspects (Geisinger, Mayo, Intermountain, Kaiser, etc.), and a handful of lesser known beacons of bright lights scattered about, maybe the number of functioning ACO-oid type arrangements are a few dozen (or hundred to be generous).  Regardless, it is safe to say <1% of hospitals are living in that world, and it safer to say the rest of us are a tad few years away from getting there. …

    Almost as frustrating, and yes, sounding a bit curmudgeonly, begin any workgroup on ACO/bundling and there is an encouragingwhite cloud overhead.  Invariably though, as the group tumbles through the weeds, so many obstacles, stumbling blocks, and intangibles begin to crop up, that before you know it, you are not discussing ACO’s, but wholesale payment, delivery, provider, and patient reform.  In short, PPACA 2.0, 3.0, and 4.0.  Think I am kidding?  Just ask a group of hospitalists (or ER docs and intensivists), “who controls the money in any ACO?”  If you have half a day on your hands, listen in.

    About Wide Awake: A Memoir of Insomnia, by Patricia Morrisroe, Robert Pinsky writes,

    Nevertheless, by writing about sleep Morrisroe tells an important story, providing a specific example of a profound social and political question: the relationship between medicine and money. Precisely because concerns about sleep are both widespread and vague, and the more so because doctors themselves are legendary consumers of substances to induce wakefulness and sleep, the example is significant.

    The AEI put out a new report on geographical variation in Medicare:

    Medicare’s attempts to restrain costs center almost exclusively on reducing prices paid for medical services. Private-sector insurance companies are unable to secure similarly sized price discounts but rely more heavily on managing utilization to control costs. Studies find that Medicare spending and utilization vary considerably across U.S. regions, leading some to suggest that Medicare should look at relatively “low-use” regions as a model for decreasing costs in “high-use” regions. This policy prescription may be off the mark. In a new study, we examine spending and utilization for Medicare and private-sector health insurers. While Medicare’s market share gives it more leverage to dictate prices than private health insurance companies have, variations in service use across regions are smaller for the private sector than for Medicare, suggesting tighter management of utilization in the private sector. To reduce spending and more appropriately limit geographic variation in utilization among Medicare beneficiaries, the program should consider the utilization-management techniques employed in the private sector as a model.

    A reader also kindly shared some links to HSA/CDHP studies and information:

    • In a post about the American Academy of Actuaries CDHP research review Alex Tabarrok writes, “All of the studies the AAA reviewed used credible methodologies, controlled for selection and were based on substantial data but the major studies so far have been industry funded. It’s remarkable that in the current debate over how to control health care costs so little attention is being given to the important results of our 10-year experiment with consumer driven health plans.”
    • The National Center for Policy Analysis has a CDHP repository.
    • HSA Consulting Services has produced a handy summary of HSA-relevant provisions of the Affordable Care Act. It says that the law “will likely have a modest impact on consumer-driven health plans and their associated health care accounts.”

    Lastly, Letting Go, by Atul Gawande, seems to have gotten some attention. Aaron Carroll had a particularly personal reaction.

    • I alos had a very personal reaction to the Gawande piece. We operate on so many people who have no chance of benefitting from the procedure. No one stops the train once they get on it. I have been and remain bitter about the death panels thing. I wanted to title my own post, F*** Palin, but the wife talked me out of it. Paying for someone to just talk about end of life issues was about as a political as you can get, but it was demagogued by the right. Still pisses me off.


    • There is an article in the August Health Affairs describing a randomized Medicaid expansion in Oregon. In 2008 Oregon wanted to expand Medicaid coverage and in order to determine who would get coverage the state allowed uninsured people to sign up for a waiting list-85,000 people applied to the waiting list. The state then randomly offered Medicaid applications to 29,000 people from the list. The authors studied the population on the waiting list, and how they compared to the entire uninsured population in Oregon and the US. They then looked at the determinants of who actually applied for coverage and were accepted from the 29,000 people. The authors say they will use this experiment to look at all kinds of issues including health outcomes in the Medicaid and uninsured populations. Do you think that because of the randomization in this experiment, the results will be accurate then any other observational study?

      Link to study: http://content.healthaffairs.org/cgi/content/abstract/29/8/1498