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Highlights from #nhpc15

Here are a few highlights, in no particular order, from the National Health Policy Conference that was held in DC last week.

Elizabeth Bradley, Professor of Public Health at Yale, who co-authored The American Health Care Paradox with and Lauren Taylor of the Harvard Divinity School, talked about population-health approaches. Noteworthy stats: the US, out of 34 OECD countries, is 25th in maternal mortality, 26th in life expectancy and 28th in low birth weight. According to a 2002 Health Affairs paper by McGinnis et al, health is determined at 60% by social, environmental and behavioral factors, while health care makes up only 20% and genetics the remaining 20%.

Bradley investigates spending in (non-health-related) social services as a way to improve health. Social services include employment programs, supportive housing and rent subsidies, nutritional support and family assistance, among others. The US has one of the lowest social-to-health-spending ratios among developed countries; in the graph she showed, the OECD average is slightly over 1.50 while the US ratio is about 0.6. She also points out that, for $1 spent on health care, the US spends $0.90 and the OECD $2 on social services. (I guess the ratio shown on the graph is calculated in some different way, but you get the overall theme.) A possible reason for this discrepancy between the US and the rest of the developed world is that health care grew into a marketable commodity for purchase while social services were viewed "for the poor", as an act of charity.

She suggests incentivizing collaboration on health and gives the examples of:

  1. C-TRAIN in Portland, OR, serving families facing homelessness, poverty and addition,  
  2. the 10th Decile project, targeting the 10% of homeless people with the highest healthcare costs, who were provided permanent housing with strong medical and mental health support. This intervention led to a decrease in healthcare costs by 72% from almost $59k to about $17k.  
  3. the WIN for Asthma project, where bilingual community workers provide asthma education and referrals for housing, immigration and mental health services. This led to a 50% decrease in emergency visits and hospitalizations as well as a 30% decline in school absenteeism.

 Michael Vita, of the Federal Trust Commission, discussed healthcare mergers. (32% of the FTC's enforcement actions over 2009-2013 were in the healthcare sector. The moderator pointed out that onsolidation is a real concern since most urban areas are dominated by 1-3 very large systems, there has been over 350 mergers since 2010 and we have seen a 32% increase in number of doctors employed by hospitals over the last decade, with 20% of physicians now employed by hospitals.) In 2002, the Hospital Retrospective Task Force studied four consummated mergers and found that the Evanston-Highland Park merger had led to a price increase 11 to 18 percentage points above the price of the control group. It successfully challenged the merger, which set the stage for challenge to proposed mergers. While most transactions are approved (the FTC has only challenged less than 1% of the hospital mergers between 2002 and 2012), it has at times challenged mergers of hospitals and mergers of primary care physician practices to avoid market concentration. Vita also discussed FTC rules regarding efficiencies claimed for the upcoming merger and ended with a few words on antitrust and the ACA. ("We see no conflict between goals of ACA and goals of antitrust.") 

Eve Kerr of the VA Center for Clinical Management Research and the University of Michigan Medical School talked about patient-centered performance management, and in particular on goal definition and performance management based on patients' preferences, leading to different care pathways. For instance in the case of diabetes, it is standard practice to monitor hemoglobin A1c levels through the HbA1c test. The goal would be to keep the level below 7%; however, you can't label care as good or bad depending on whether it falls below or exceeds the 7% threshold.

For instance, if the A1c level is between 7% and 7.5%, there will probably be low benefits to expanding high efforts in trying to bring it below 7%. For high levels of A1c, say, above 9%, it is clear that care would yield very high benefits. But patients with a blood level around 8% find themselves more in a gray area in the continuum of care, where there is not a "one-size-fits-all" best care pathway and the best treatment plan would be preference-sensitive. If the patient's goal is indeed to bring the A1c level below 7.5%, he would be willing to try a medication (and thus be more likely to adhere to it); however, if the patient's goal is to keep its A1c level at 8% or less and he is currently right at 8%, he would achieve his goal with a lifestyle modification. While the amount of choice seemed a bit overwhelming and risks creating the need for significant amounts of documentation (how do you code patient preferences in medical records?), in fact this is simply about having multiple well-defined care pathways and letting patients choose the one they feel most comfortable with given their goals, making them more likely to successfully complete treatment.

Michael Chernew of Harvard made brief remarks on payment reform. He discussed traditional fee-for-service, Patient Centered Medical Home type fixed fees, bundled payment and global payment and pointed out a Brookings white paper he recently co-authored, on Medicare Physician Payment Reform: Securing the Connection Between Value and Payment

The NHPC Monday Afternoon Keynote offered many important insights. Jeffrey Kang, Senior VP for Health and Wellness Services and Solutions at Walgreens, talked about retail health, Walgreens' partnership with Theranos to offer lab testing in its stores (read more about Theranos here [Wired article about Theranos CEO Elizabeth Holmes] and here [NewYorker profile of Holmes]) and its "Balance Rewards for Healthy Change." I particularly enjoyed the short discussion about Walgreens' implementation of private exchanges. 

David Notari CEO of Innovation Health, a new insurance company that emerged from a collaboration between Aetna and Inova in the Northern Virginia market, also at the Monday Afternoon keynote, also provided a valuable perspective on the market. Innovation Health's plan is to leverage real-time information, for instance about patients having gone to the ER (instead of learning about it when they receive the claims), to deliver superior performance through an enhanced team-based care model. They also hope to use a full menu of network options to achieve optimum performance, since a key point of competition between plans (and payers) is the size of the network.

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