Tuesday, April 29, 2014

Letting ideological purity stand in the way of common sense

Health care policy is rife with fads, unsupported and analytically flawed approaches to try to influence the way care is delivered with simple--but wrong--metrics used to determine unwarranted penalties.

There, I've said it.  But please don't put me as an ally of nay-saying doctors and hospitals who really don't want to improve the quality of care.  I've been devoting many years to advocating for patient-driven care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement.

The problem is that poorly thought through interventions of government policy not only fail to improve care, but they raise levels of resentment and cynicism among the people we need to engage in making changes in the system.  Those interventions also have harmful unintended consequences.

The latest validation of the dangers of wrong-headed thinking is summarized in Robert Pear's article in the New York Times.  The lede:

Federal policies to reward high-quality health care are unfairly penalizing doctors and hospitals that treat large numbers of poor people, according to a new report commissioned by the Obama administration that recommends sweeping changes in payment policy.


The panel found that existing payment policies unintentionally worsen disparities between rich and poor by shifting money away from doctors and hospitals that care for “disadvantaged patients.”

Measures of health care quality and performance — widely used by Medicare and private insurers in calculating financial rewards and penalties — should be adjusted for various “sociodemographic factors,” the expert panel said. The panel was created by the National Quality Forum, an influential nonprofit, nonpartisan organization that endorses health care standards.

“Factors far outside the control of a doctor or hospital — patients’ income, housing, education, even race — can significantly affect patient health, health care and providers’ performance scores,” said Dr. Christine K. Cassel, the president of the organization.

Sorry, but this isn't news.  Here's a related point noted by anyone who was paying attention three years ago: 

Karen E. Joynt and Ashish K. Jha from Brigham and Women's Hospital published an article in Circulation: Cardiovascular Quality and Outcomes, entitled, "Who Has Higher Readmission Rates for Heart Failure, and Why? Implications for Efforts to Improve Care Using Financial Incentives." Excerpts:

Among 905 764 discharges in our sample, patients discharged from public hospitals (27.9%) had higher readmission rates than nonprofit hospitals (25.7%, P<0.001), as did patients discharged from hospitals in counties with low median income (29.4%) compared with counties with high median income (25.7%, P<0.001). 

Given that many poor-performing hospitals also have fewer resources, they may suffer disproportionately from financial penalties for high readmission rates.  As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care.  (Circ Cardiovasc Qual Outcomes. 2011;4:53-59.)

Look though, at the response of the Administration, as reported by Mr. Pear:

The Obama administration commissioned the study, but is not entirely comfortable with the recommendations, officials acknowledged. 

The Obama administration has championed the idea of pay for performance, with financial penalties for hospitals where deaths, readmissions or complications occur at rates above the national averages. The administration has said adjusting the data for social or demographic factors would be equivalent to accepting a double standard, with lower expectations for the care provided to low-income patients.

“We do not want to hold hospitals to different standards of care simply because they treat a large number of low-socioeconomic-status patients,” said Dr. Kate Goodrich, the director of quality measurement programs at the federal Centers for Medicare and Medicaid Services. “Our position has always been not to risk-adjust for socioeconomic status within our measures because of concern about masking disparities, and potentially rewarding providers who provide a lower level of care for minorities or poor patients.”

Sorry, but this is the response of a government that has let ideological purity stand in the way of common sense.  The issue is not about rewarding lower levels of care to poor patients.  It is about not penalizing hospitals that care for poor patients.


Brad F said...

Firstly, I agree with unfair penalties falling on those facilities least likely to afford it. Ass backwards policy.

WHat I wonder, and the evidence less clear--does risk adjustment with SES factors lessen response from those hospitals with higher burden of safety net type patients? Does leveling the playing field put blinders over the data?

NQF and others raised similar concerns--and comments reflected. We dont know. I think that point not made in your post, and its important flag.


Barry Carol said...

I agree that the government is dead wrong on this. Experts know well that socioeconomic status and environmental factors play a significant role in determining an individual’s health status and it’s not fair to hold doctors and hospitals accountable for things they can’t control. I thought one reasonable recommendation in the article was to compare a safety net hospital that treats a disproportionate number of uninsured, Medicaid and dual-eligible patients with other safety net hospitals that have a comparable share of such patients.

Just as in comparing student achievement between wealthy and low income school districts, I’ll bet that if you took the staff from a high performing hospital in a wealthy area and transferred them all to a safety net hospital with a much lower income patient population, they wouldn’t achieve the same results despite having the same people, and presumably, the same care processes.

I often get frustrated by the lack of common sense in government people and their inability to project themselves into the shoes of those who have to live under the regulations and incentive structures that they propose.

Paul Levy said...


I like Barry's construct:

"I thought one reasonable recommendation in the article was to compare a safety net hospital that treats a disproportionate number of uninsured, Medicaid and dual-eligible patients with other safety net hospitals that have a comparable share of such patients."

Anonymous said...

The really sad part is that all of this could have been avoided if the health care insiders had exhibited some leadership to begin reform from within, long ago. Instead they gamed the system to a fare-thee-well and now are whining. I agree the government is misguided, but that is entirely predictable, and they are getting NO help from the profession - neither medical nor administrative.

Now the government doesn't trust them ( with some good reason) to provide legitimate input or not to game the system again, so you get irrational attitudes like 'don't change the standards for safety net hospitals.'

Here's another idea - tax the rich hospitals and redistribute the take to the safety net hospitals. (only partly tongue in cheek)

nonlocal MD

Anonymous said...

The trouble with Barry Carol's argument is it sounds very much like having "low expectations" for the poor.

Teachers make similar arguments in schools. We can't perform as well as "rich" school districts because our students are pick one: unprepared, have little support at home, poor role models and the list goes on. But those same public school teachers choose to ignore how well charter schools do in similar socio-economic environments and even in experiments where "self-selection" played no role, high standards were achieved.

I think the goal of the Obama admin is to make it so "painful" that it will force smart hospital clinicians and administrators to find creative solutions.

I am not sure they are right, but that is what they are hoping for.

I think they will find it costs more to care for people who need additional support to ensure they take medications on time, get all the proper treatments to prevent a readmission.

But there is a "pot of gold" that can be tapped.

There was a study done a few years ago for "commercial insurers". It analyzed the cost of patients for commercial plans. So for example if patients had the same health plan, paying the same premiums, deductibles etc how did costs to care for those patients differ by zip code?

It showed that patients from wealthier zip codes cost more to treat than those from poorer zip codes. After much hoopla, the study was promptly ignored.

The results showed the additional cost for wealthier zip codes wasn't because patients were sicker but because the hospitals and doctors who treated those patients had much higher payments. In others words the "Partners hospitals" (and associated physicians), at places like Newton Wellesley, were paid much more than those in Brockton, going to Brockton hospital. And while referrals from Newton Wellesley went to high cost MGH or Brigham and Womens, referrals from Brockon Hospital more often went to less expensive tertiary locations.

Why does this matter?

If that money was "equalized", then there would be more for poorer hospitals caring for poorer patients.

Why should Blue Cross or Harvard Vanguard spend more to care for richer patients?

This wouldn't be a tax? It would just be equalizing payments to hospitals for similar medical conditions.

Does anyone know why discussion of this study has stopped?

If acted on it would solve many financial issues for poorer hospitals.

Paul Levy said...

I don't read Barry's comment that way at all.

I think your discussion of insurance rates and the like is mixing up the issue I present with a totally different set of issues. I don't see the connection you make, nor do I see any likelihood of the large money transfers you propose happening at all.

Anonymous said...

Not to detract from your point, but in re-reading your first sentence, it struck me that one could substitute 'health care delivery' for 'health care policy' and it would still be true:

"Health care [policy] is rife with fads, unsupported and analytically flawed approaches to try to influence the way care is delivered..."

as you have pointed out in recent posts on robots and such.

I don't know which is worse; ignorant ideologues or unscientific scientists.


Barry Carol said...

I can understand how one could suggest my comment implies lower expectations for poor people. I think it depends on how you define expectations and what it might cost to attempt to achieve them. If the goal is, say, to reduce hospital readmission rates, lower income people would likely need more support to ensure compliance with medication regimens and other treatment recommendations. It would mean home visits by NP’s and social workers since many lack adequate transportation and need more hand-on management generally. That would all cost more. If you define it as parity on life expectancy, I think the poor would likely continue to die sooner than higher income people due to a higher incidence of smoking, less access to healthy food, inferior housing environment including living in more dangerous neighborhoods, etc. all of which are beyond the control of healthcare providers. In the end, I think the underlying issue driving lower life expectancy among the poor is poverty, not the quality of healthcare they have access to or the lack of it.

With respect to education achievement, it’s one thing to compare results achieved by a charter school serving low income students with nearby public schools serving a similar population and quite another to compare their results to outcomes achieved by students in wealthy districts whose families can afford enrichment programs, tutors, travel, provide help with homework, a quiet place to study, healthy food and a host of other advantages. Here in NJ, the town of Asbury Park gets enormous educational funding help from the state as a result of the Abbott vs. Burke case in the late 1970’s. Spending in that district is now approaching $30K per child and the measurable results are still relatively poor.

Finally, the focus of my earlier comment was in treating patients who are uninsured, on Medicaid or eligible for both Medicaid and Medicare (dual-eligible). The issue of widely differing reimbursement rates paid by commercial insurers to different hospitals for similar treatment does not apply to these populations. As Paul notes, commercial payment rates are a completely separate (and also important) issue.

Anonymous said...

I am working on a project at safety-net provider in Texas who has very high readmission for AMI and heart failure. Our initial hypothesis?

We are adopting a methodology from the prison system. What the studies we found is that when parolees can name 3 individuals who will be responsible for their parole program, they were far less likely to reoffend.

We are asking patients upon discharge if they can put 3 names of individuals who will be responsible for their care plan: filling prescriptions, rides to follow-up appts, wound hygiene assistance, etc. Those who cannot put 3 are the high-risk population (from a social network perspective), those above 3 require less resources from case managers, social workers et al.

This provider is using resources in a smarter way given our hypothesis that compliance is closely linked to social network and support outside the four walls of the hospital.

The penalty system isn't equitable -- as mentioned in the article and comments -- but some safety-nets are working to get smarter about the high-risk population.

C Johnston said...

You had me until "ideological purity". Are you saying that their ideology is concern over permitting lower quality care to poorer patients due to socioeconomic adjustments? That seems to me to be a legitimate concern. You can make the argument that they are weighing this concern too heavily in their calculus, and that in doing so, they end up hurting the very patients and hospitals they are trying to help. I would agree with that argument. But it is the prescription that they are doing this from a place of ideology that I find puzzling.

Instead, I would argue that they are genuinely trying to move the country toward more value-based purchasing, with the goal of eventually achieving the triple aim. They are trying to be careful, however, to ensure that they do not allow a double-standard of care in which poor patients get worse care and these hospitals go unpunished, as this lower quality of care is written off as due to socioeconomic factors. I agree with you that their approach is currently misguided, but not that it comes from some deep-seated ideology that is inherently flawed.

Paul Levy said...

CJ --

"Go unpunished"??? You want to punish hospitals that are already underpaid because of the state and federal funding mechanisms and are dealing with a population that often doesn't have a full set set of social services and other support to do what's needed.

THAT's what I call putting ideology in the place of the facts on the ground. Meeting the triple aim doesn't mean squat if you don't provide the resources necessary. It is even more the case when you take resources away.

And, by the way, there is no evidence that the Administration is pursing the triple aim. Look at Medicare policy that supports the medical arms race, pricing and other support that encourages the purchase of high cost equipment that has not been shown to be clinically efficacious.

I guess it is all right if you don't want to call it ideology and instead call it "merely" an "inherently flawed" approach. If so, they are more incompetent that poorly motivated. Which is worse?

C Johnston said...


Thanks for your response. I guess I have two issues with the idea of ideological purity. First, it seems to imply that the person who possess it is unlikely to be persuaded by facts and that they will follow the same course, no matter what. Second, it implies that they are not interested in acting in good faith, and are more interested in achieving an ideology than achieving practical, meaningful results. If these two implications are accurate, there is no sense in trying to work with that person or persuade them of anything, as they will only pursue it if it is in alignment with their ideological goals.

I guess I just don't see that with the Obama administration. Are they doing things perfectly, or even well? Absolutely not, in certain areas. But if you characterize them as fundamentally dismissive of factual evidence and of acting in bad faith, there is no hope of improvement and no hope for dialogue. That may be exactly how you feel about the administration, and you may be right, but I just don't see it.

Paul Levy said...

Thanks, CJ. I don't think it is a matter of bad faith. I think people can behave in an ideological fashion and be of extremely good faith. I have no reason to believe that the Obama folks are acting in bad faith.

I do see them in this instances as being dismissive of factual evidence--here, of their own advisory committee--because they are overly influenced by their prior conception of the way things ought to be.