Why CCO's may not fail like HMO's

In response to @ChargerJeff, who asked why CCO's would fare any better than HMO's:

HMO's did succeed at cost control, which is a primary purpose of CCO's.  Where HMO's failed was in working cooperatively with doctors and patients, CCO's if they are to last will have to do better.

Reasons to think they will:

• We already have managed care, particularly in OHP.  The distance between where we are and where CCO's are going is shorter than the distance between indemnity plans and HMO's.

• The distance between doctor patient interactions and financial authority is shorter, you're less likely to see the kinds of coverage conflicts for which HMO's were notorious. 

• There is more cost awareness among providers now than there used to be.  Concepts like variation and evidence-based medicine are gaining growing acceptance, even if they are not entirely mainstream.
• Maybe most important, providers have no choice.  CCO's are an attempt to control costs by empowering providers, if they fail the alternative is to control costs by disempowering providers and stripping them of authority over treatment.  Think about the ER restrictions that Washington considered (and that for-profit hospitals have implemented), or more direct interventions in provider pricing.

None of this is to say that CCO's are a sure thing, there's a reason the feds made their funding contingent on results.  But the cost of trying in my view is much smaller than the cost of doing nothing and hoping that a 40 year history of medical inflation will somehow reverse on its own.

Emergency Rooms

Last week Kaiser ran a Phil Galewitz story on for-profit hospitals that were screening emergency room patients.  Patients deemed to have non-emergency conditions were required to make a pre-payment, as much as $150 in HCA's case.

This week Kaiser noted a Wall Street Journal article on a Washington state Medicaid plan to stop reimbursing emergency rooms for providing non-emergency treatment.

Is there a meaningful difference between these policies?  For-profit corporation and state program alike, they both utilize financial incentives to prevent emergency rooms from being used for non-emergency care.  They demonstrate the point that rationing care isn't really optional, it is already happening.

What is optional is how much discretion and transparency we allow in the process of rationing.  The for-profits and Washington are opting for rote standards where care givers have no flexibility in distinguishing what care is necessary (and reimbursable) from what is not.  Contrast that with Oregon's CCO plan, which goes the opposite way in trying to find savings by empowering providers.  I don't know which approach will prove the better, but I know which one I'm rooting for.

What Opt-In Does

Nick Christensen does a write-up on how Metro councilors view Opt-In, a registration-required online survey tool.  I think this gets at what this service really does, and what it replaces:

Metro spent $76,000 on Opt In in 2011, generating  more than 20,000 responses – about $4.50 per completed survey.

By comparison, said a staff report for Tuesday's work session, Metro spent about $400 per open house attendee during the 2010 roll-out of then-Metro chief operating officer Michael Jordan's growth and policy recommendations; those numbers soar to $2,800 per completed survey at each of those open houses. The agency also spent $35 per attendee at the dozens of stakeholder meetings Jordan attended.

Opt-in is a new way of connecting with citizens, in a way that allows two way communication- both Metro and citizens learn from the interaction.  And look at the number of people reached, a recent survey had 4,000 respondents.  How many public meetings or open houses have you seen that attracted 4,000 people?  How about a meeting where 4,000 people got to get up individually and express their view?

Some councilors expressed concern that their hands would be tied by the surveys.  How could they justify a vote that went against "majority opinion?"   Even aside from concerns about the opt-in demographics, councilors have a pretty solid excuse:  Voters elected them, not a survey.

The people who should be nervous are the interest groups who make up most of the participants at conventional public meetings.  They are the people most motivated to attend, and most likely through pooling and coordination to have a representative available to attend a meeting at 9am on a weekday.  Most individuals don't have the time or interest for that.  That dynamic gives interest groups a dominant role in reflecting "the public", quite independent of how much popular support their positions actually have.  As Metro President Tom Hughes said,

"Public hearings are an avenue for getting public input, but they're imperfect at best," Hughes said. "They're usually repetitive, not very helpful and usually the people who show up are the people who are absolutely directly involved – you don't get a sense of what the public wants."

Opt-in offers a potential check on interest groups, it creates an opportunity for a truer test of the popular will.  Whether it fulfills that potential depends on participation.  If the only people who sign up are the same people who would otherwise be represented by interest groups, nothing changes.  So if you're a Metro resident not already signed up, please consider it.  Especially if you disagree with me.

Passages I like

From Cringely:

My kids go to the best public school in Sonoma County. I know that because I chose my house based on that research. But when Cole finishes his math problems in a quarter the time it takes anyone else in the class, his teacher has him insert a wait state by putting his head down on his desk.  Conversely, when some other kid never quite gets the problem set finished, ever, well he/she never gets a rest and never masters the material, either.

The current system is unfair to both kids.

The only solution I can see is one teacher per student. And the only way something close to that is going to happen is through technology.  And it’s coming.

 A followup passage that I don't like but agree with:

My conclusion, then, is that schools serve a limited social and cultural function but our kids mainly learn despite them. My own experience is that I learned a lot about learning from half a dozen teachers in my life, so those relationships are both rare and essential. But are they reliable enough to even justify modern schools?  I don’t know. What I do know is that if I want to improve the educational environment for my children in the next year or two, I’ll probably have to come up with my own solutions.

Disclosing Drug Payments

The ACA was derided in part because of its length and complexity.  Funny thing is, the more we see of the health care reform the better it looks.  Here is one small measure packed into it that means a lot:  mandatory disclosure of payments to doctors from drug companies regardless of how it is accounted for.  Sales, research, kickbacks, whatever.  All of it will be subject to public review, so you can judge for yourself how closely your doctor's interests coincide with your own (at least when it comes to prescription drugs).  That might not seem like a lot until you realize you can't do that now, efforts of ProPublica not withstanding.

One of many ways the ACA reforms healthcare in America.

Implants: An object lesson in Ineffectiveness

Via the NY Times, an Australian study shows how newer models of joint prostheses fail at higher rates then older more established models.  The failure rate may not be the worst aspect of the newer style implants.  They also pose risks due to breakdown of the metal rubbing on metal, releasing metallic particles into surrounding tissue.  Resulting inflammation can make replacement surgery "far more complex and can leave some patients with lasting complications."  Some questions:

• What drove physicians to use the newer implant style over the old one?
• What disclosure was made to patients about the relative risks?
• Do we really not keep an implant registry?  Getting information second hand from Australia is the best we can do?

Things I like: Portland Police Edition

I was impressed with a recent speech by Portland Police Chief Mike Reese to City Club.  A former counselor with Boys and Girls Club with an educational background in psychology and public administration, he seems as suited to run a non-profit as he does a metro police force.

A story in today’s paper suggests his influence on the department, and I like it.