2011 Potpourri XXXXVII

An article in Health Affairs discusses the early experience with a bundled payment model called Prometheus.  The pilots got off the ground much more slowly than expected and haven’t delivered benefits.  As would be expected from past experience with capitation, it is very hard to engage providers and to work out details of what the rate should be and what services are covered.  Physicians are naturally risk-averse to the potential losses.  The availability of data to help them track utilization and costs and to identify where they could make changes is poor.  And the research doesn’t really support the notion that bundled payment by itself results in large cost-savings.  (HA Article)

The federal employees health plan is run by the Office of Personnel Management, which regularly reports on the state of health information usage by the covered employees in the various plan options.  This year’s report indicates that almost all FEHBP plans have taken steps to educate their members on the value of HIT and 97% make a PHR available, but in the majority of plans, less than 5% of the members use a PHR.  Most plans also have online provider cost and quality comparison tools available to members and 75% have enabled physicians to order prescriptions electronically.     (OPM Report)

A Perspective in the New Journal of Medicine looks at geographic variation in the physician response to changes in Medicare cancer drug reimbursement.  The drugs at issue are covered under Part B and physicians bill for, and make money off of, the use of these drugs.  Medicare’s change substantially cut both what it paid for these drugs and what physicians could make by dispensing them.  The variation in change of use of the drugs was highly variable across states, from a 7% increase to a 5% decrease.  Overall the use increased.  This might reflect physicians attempting to make up in volume what they lost in unit margin, or the opposite effect, some physicians not being willing to use a treatment they couldn’t make as much money on.  It might also be that the lower drug cost meant lower costs for patients, so doctors and patients were more willing to use the compounds.  What is frightening is that there was such a change, which clearly can’t reflect actual clinical judgments about what was best for a patient.  (NEJM Perspective)

A premise of value-based insurance is that for proven treatments, lower copays can encourage patient use and adherence.  Several pieces of research have shown that in the cases of drugs, copay level can have a marked effect on prescription filling and adherence.  A new study in the New England Journal of Medicine found that adherence to medications prescribed after a heart attack, which is often poor, increased greatly when copays were completely eliminated.  While the primary health outcome was not affected, overall rates of major vascular events or need for revascularization were reduced and spending was actually lower.  The study shows the power of cost-sharing to inappropriately affect patient decision-making, or for the lack of cost-sharing to improve health.   (NEJM Article)

The Employee Benefit Research Institute published findings from its recent consumer Health Confidence Survey.  About 57% of employees are very or extremely confident that their employer will continue to offer health benefits.  People who are healthier, have more education, are higher-income and are more satisfied with their coverage are more likely to be confident about benefits being available.  On the other hand, only 20% of respondents had a high level of confidence that they could afford to purchase health benefits for themselves, even if their employer helped provide funding, although most people said they would try to obtain coverage if they didn’t keep employer-based benefits.  About 38% of employees are highly confident they can compare and choose among benefit options.  (EBRI Release)

A Center for Studying Health System Change report prepared for the National Institute for Health Care Reform looks at physician visits after hospital discharge.  The report finds that one in three adults did not see a physician within 30 days after discharge.  These people, however, were on average healthier than those who did see a doctor and were less likely to have a chronic condition.  These people were no more likely to go to an ER and were just as likely to have home care after the discharge.  Being uninsured or only insured for part of a year was associated with a higher likelihood of no follow-up visit, but insurance type seemed unrelated to likelihood of seeing a physician.  The authors of the report seem unaware that research has pretty well established that there is no relationship between having a post-discharge physician visit and readmission rates.    (CSHSC Report)