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2011 Potpourri XXIII

By June 10, 2011Commentary

The accountable care organizations initiative in the “reform” law and the rule implementing the initiative proposed by HHS have come under widespread criticism by providers and provider organizations on a variety of grounds.  The American Hospital Association piled on by releasing a study showing that the implementation costs would be far higher than CMS has estimated.  CMS said it would cost on average $1.8 million to start up and operate an ACO in the first year.  The AHA paid for an analysis by a consultant who said for a 200 bed single hospital it would cost $11.6 million and for a five hospital system with 1200 beds, the cost would be $26.1 million.  It doesn’t look like the ACO concept is going anywhere fast, so maybe we shouldn’t put all those savings in our calculation of reform’s effects.   (AHA Release)

A couple of other provider groups have also expressed dissatisfaction with the ACO rules.  The AMA suggested changes in the reimbursement structure, including being able to share savings without sharing losses; more flexibility in beneficiary assignment, such as it only being voluntary; participation in more than one ACO by a doctor; simplifying the performance measures and reporting; and waiver of fraud and abuse laws.  (AMA Comments) The Cleveland Clinic generally said the rules were too prescriptive and inflexible in ways that had nothing to do with improving outcomes and that imposed additional expense on the ACO.  The Clinic also expressed concern about the beneficiary assignment and risk-sharing provisions.   (Cleveland Clinic Comments) The Medical Group Management Association similarly expressed concerns about the cost of the rule and its potential effect as a deterrent to participation.     (MGMA Comments)

An interesting study in the Archives of Surgery explores whether making physicians aware of the costs of a service might make them more careful in ordering its use.  The test for this was daily phlebotomy services.  The hospital where the study was done made a weekly announcement to staff about the dollar amount charged to non-ICU patients for lab tests in the prior week.  Daily charges per patient for phlebotomy services dropped from $147.73 before the intervention to $108.11 after.  Presumably there was no change in patient outcomes.  A very simple step that saved almost $55,000 in eleven weeks.   (Archives Study)

Hospitals often market on their websites and patients often go to such websites for information and tend to trust what they see.  Robotic surgery is very expensive, adding over $3000 to the cost of an operation, and studies have found no benefit in patient outcomes.  Yet hospitals are marketing their expertise in such surgery on their websites.  Researchers looked at whether the information presented was complete and accurate.  Many hospitals are highlighting robotic surgery on their home page, most are describing it in misleading terms and making claims not supported by sound research and not presenting risks which may be associated with such surgery.   Most are using manufacturer supplied materials and data.  Hopefully they have considered the additional malpractice exposure they are creating.   (JHCQ Article)

Research published in the New England Journal of Medicine looked at the effect of concentrating volume for surgical procedures in fewer hospitals, which has been touted as a way to improve quality and potentially lower overall spending.  The “centers of excellence” notion is founded on this belief.  Eight somewhat common but difficult procedures were examined for trends over the last ten years.  Hospital volumes did increase for most of the procedures, due both to more cases and more concentration of cases.  Mortality declined for all procedures, but only for three of them did the increase in hospital volume explain a large portion of the decline.  (NEJM Article)

The Journal of the National Cancer Institute published research comparing end-of-life care for patients suffering from lung cancer in the United States and Canada.  Patients in both countries consumed substantial health resources, but Canadians were more likely to be admitted to a hospital and to use ERs and US patients more likely to be on chemotherapy.  More than twice as many patients in Ontario died in the hospital as did patients in the United States, although most patients preferred to die at home.  The research indicates that the US isn’t the only country having trouble elucidating and complying with patient preferences.  It also appears that while physicians in America may be aggressive in treating cancer with drugs, they also are doing a good job keeping patients treated in an ambulatory setting.   (JNCI Article)

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