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2012 Potpourri XXXVIII

By December 14, 2012Commentary

Accountable care organization experiments are well underway at a number of public and private payors.  An article in Health Affairs discusses early results in a Cigna collaboration with ACOs in Arizona, New Hampshire and Texas.  The program uses a shared savings model and was begun in 2008 or 2009 with the three practices discussed in the article.  Altogether Cigna has 42 practices in the program and it is not clear why only the results from these three are discussed.  Cigna provides infrastructure and data support and pays an incentive fee to the practices.  In 2010 All three practices performed slightly better on quality standards.  Two showed modest cost savings and one more significant decreases in cost.     (HA Article)

The efficacy of disease management continues to be debated.  A new study published in Population Health Management examines a chronic disease management program in Australia.  The analysis was a retrospective, matched comparison of managed and unmanaged patients.  After 12 and 18 months of the study, those patients in the disease management program had significantly fewer hospital admissions, readmissions and a reduced length of stay.  The more calls conducted to a patient, the greater the reductions in utilization, although there is a plateau effect.  No data was presented on the cost of the program or cost savings, so the net return, if any, is unclear.   (Pop. Hlth. Mgmt. Article)

As more payers explore bundled or global payments, a Perspective in the New England Journal of Medicine describes lessons that  might be learned from past similar reimbursement approaches, particularly as CMS rolls out its latest bundled payment demonstration.  The authors find that participating hospitals could have 10-20% of their volume covered by the program.  Because the number of episodes in each category might be relatively small, however, the hospitals can be exposed to large variation in spending caused merely by random occurrence of high-cost cases.  This is a common danger of any program which deals with relatively small numbers of patients.  The authors suggest all such episode or bundled payment methods need to account for this issue.   (NEJM Article)

A Research Letter in the Journal of the American Medical Association reports on trends in the compensation of health care professionals from 1987 to 2010.  The overall percent change from a 3 year period of 1987-90 to a three year period from 1995-2000 was about 20% for doctors, but from there to 2006-2010 there was actually a decrease in real earnings.  By comparison, every other group of health professionals, such as nurses, PAs and pharmacists had higher earnings growth, both in absolute and on a median hourly wages basis.  Interestingly, health and insurance executives have one of the lower rates of income growth, especially on a median hourly wage basis.   (JAMA Research Letter)

Another article in Health Affairs discusses whether it is really likely that ACOs can yield the results proponents suggest.  The authors draw on lessons from the last big attempt at having providers be financially and clinically responsible for patients, the capitated IPA or other provider network of the 1990s.  The information technology and staffing infrastructure necessary for successful care and risk management are expensive and difficult to implement.  Having all of an ACO’s patients, who come from a diverse set of public and private payors, covered by the same type of financial arrangement and other requirements is highly unlikely and very problematic.  Our concern has always been whether these organizations will become, as many capitated IPAs did, just a vehicle for demanding higher reimbursements and leveraging market power of health systems.   (HA Article)

An opinion piece in the Annals of Internal Medicine discusses issues around lung cancer screening, which are applicable to other screening programs.  Based on very large trials, particularly for high-risk individuals, three rounds of CT screening reduced the relative risk of lung cancer by 20%.  The risk reduction, or benefit, of the screening varies dramatically depending on an individual’s risk factors.  But the article also discusses the difficulty in effectively communicating the benefit and risks of screening in a way that is easily understandable to patients.  Some physicians also struggle to understand the statistics of these studies and clearer methods of presentation would help them discuss the issues with patients.    (Annals Editorial)


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