I'm From CMS and I'm Here to Help

Writing in JAMA "online first," CMS Administrator Tavenner and colleagues offer a payment reform "framework" that includes "multipayer collaboration."  The article is wonky, so the Population Health Blog dons its universal adminispeak translator so us normal humans can better understand what CMS is up to.

According to the writers, CMS has a history of innovatively implementing reforms that were later adapted by other insurers. The most famous example is the hospital "DRG" system that, starting in 1983, paid for a diagnosis in lieu of a daily room rate.  Suddenly, hospitals had an incentive to shorten hospital stays, which is precisely what happened in the years that followed.

Buoyed by this success, the authors describe the merits of championing Medicare's transition from "category 1" fee-for-service without any link to quality to "category 4" population-based payments that are linked to quality. And, as CMS embarks on this excellent payment journey toward accountable care, they'll get other commercial insurers to mirror their efforts by:

"Being conveners" as in "working with" other insurers in a region or a state to implement large payment reforms.  Working with may include grants;

"Incentivizing," as in requiring the participation of other payers prior to funding any large pilot programs.

"Working with states" to implement additional reforms, when the state has sufficient influence over the health insurance or delivery system.

The Population Health Blog's take:

"Category 4 population-based payments" are a form of capitation that are ultimately designed to transfer insurance risk from CMS to providers. The PHB hopes the bureaucrats at CMS are aware of the risk re-introducing some 1990s-style managed care abuses. 
 
What also goes unmentioned by the JAMA article are examples of CMS payment reform unintentionally gone awry, including RVUs, regional payment variation and the SGR with lingering fraud. While CMS has had its successes, it's also had more than its share of problems.  Time will tell which track record will apply to population-based payments.

Convening was an art developed by Medicaid programs.

Ms. Tavenner implies that population-based payments (a form of capitation) are intrinsically linked to quality.  Nothing could be further from the truth, since it's possible to reward quality while also relying on a FFS methodology. 

Accountable population-based care remains a large experiment.  Ms. Tavenner implies that there is an aura of inevitability.  The PHB learned long ago that the sign of a good plan is an exit strategy in case things go south.  The PHB didn't read that here.

HAPPINESS DOESN’T JUST HAPPEN

Wouldn’t it be nice to wave a magic wand, and all of life is just how we wanted it to be?  We are blessed with the gift of life but how we live it is up to us, and that takes effort and choices.  There are consequences, hard lessons learned and happiness along the way, but ultimately it is in our choices that create the life of happiness we all desire.  Sometimes we do not even know what we want or how to create this happiness, and wander around going through some sort of life motions that we learned from healthy or unhealthy example.  Choosing the right way to create a life of happiness is quite the goal, but like anything else that takes time and effort, it is worth the journey to get there. 

I have gone through the ups and downs of not being happy in this journey of life, and have held onto the hope that God has a greater plan than I can ever imagine. Life has not been what I thought it would be as I contemplate it, but I am thankful for the life lessons of each circumstance that created an opportunity for me to learn and grow in positive ways. It took a choice for me to go to counseling during tough emotional times, to go to physical therapy during horrific physical times, and to rough up my knees in prayer during doubtful spiritual times.  All the choices to become a better person were in search of a happiness that I wanted in my life and I have always been in pursuit of all methods of work to reach that goal.

The pursuit of happiness also includes being a healthy person.  I believe that the two go hand in hand.  When we feel our best physically, it is easier to handle the emotional rides of life.  Also, when our “mental game” is healthy and our responses to life’s circumstances are handled with maturity, clarity, and good intentions this enhances our state of being healthy and happy overall. Happiness is a goal just like being healthy is a goal, and both are lifetime achievements.  There is no end to being a happy and healthy person, and each day is our chance to make choices toward being both. 

Easter seemed like the perfect time to share how important it is to be happy and healthy, and to take this opportunity to let you know that it is possible and necessary in this life.  Happiness does not just happen, but will take a commitment of self-discovery, and not being afraid to peel the onion and take a look at what is keeping you from being happy or healthy. This took years of work in my life, and I am thankful for it.  I will share that it has not always been easy, and nothing worth anything is, right?  My wish for you this Easter is health and happiness and for you to know that each day is a gift that provides a step closer to reaching those goals.  

Have a very Happy Easter from My Family to Yours

Thanks for stopping by my Blog, hope you enjoy the content, and if you have not become a follower yet, I would love to see your face on my friend's list.  If you are inspired, LIKE my entry, leave a comment and I look forward to responding!

Stay Healthy!

Darla

The Dichotomy of Medicare’s Data Release Policy: Moral Suasion and the Limits of Mass Data Transparency

The Disease Management Care Blog continues to welcome blog posts from outside authors. This is another one courtesy of Erik Tollefson, who works in the health policy field. He can be reached at erikDOTmDOTtollefsonATgmailDOTcom.

Medicare has had an interesting few weeks: Not only did Congress manage to pass another one-year “fix”  to the (unsustainable) sustainable growth rate reimbursement scheme, but planned Medicare Advantage cuts magically turned into a marginal increase (at least for some insurers) after deftly applied political pressure. This behind-the-scene politicking set the stage for CMS’s second massive release of provider data last Wednesday. Although the data release may further codify extant evidence of some specialists being more richly compensated than their primary care colleagues, coupled with the potential pursuit of fraudulent claims, unfiltered transparency reveals Medicare’s weakness in providing useful transparency for beneficiaries. 

CMS formally released data detailing the 100 most common inpatient services, 30 most common outpatient services, and all physician and other supplier procedures and services performed on 11 more Medicare beneficiaries. The data included information on the doctor who performed the procedure, as well as the city and zip code where the procedure was performed. The biggest related take away seems to be a rather intuitive one: specialists, particularly cardiologists, ophthalmologists, and oncologists, are the biggest recipients of Medicare reimbursements: The three groups of specialists accounted for 7% or $5.6 billion of reimbursements in 2012.

Some in the medical community have responded to the perceived public scorched earth exercise circumspectly: hell hath no fury like scorned ophthalmologists. Valid questions, however, have emerged not only regarding the veracity of released data, but also the lack of context: some individual provider numbers may serve as a pass-through for entire practices, and a longitudinal release of data might allow for a more accurate picture of how service and drug utilization has changed as the country’s demographic profile has grown older. 

In response, CMS and politicians have responded that the benefits of “transparency” would likely drive more cost-effective care with less waste. Putting aside concerns of what transparency actually means in this context, an economist might ask a more apposite question: while the literature shows that public excoriation (in limited doses) may be effective in reducing price variance in an established legislative framework on the supply side, where are equivalent measures to empower consumer (demand–side) decision making?

To perhaps put a finer point on it: while variance in the pricing of procedures by hospitals and providers is certainly a problem, an equal problem is the variance in treatment across patients using non-cost effective treatments and medical devices that add little or no value to outcomes.  On this critical point, CMS and their data are silent. While further data releases may address this critical lacuna in consumer information, it is not likely: statute prevents the agency from making drug and procedure approval decisions explicitly based on costs.  Thus, an odd dichotomy has emerged in Medicare’s transparency campaign: exposure of the downstream cost equation (doctors), while leaving the curtain back on the furtive upstream costs including the RUC committee and other important input prices that would help consumers to make more informed decisions. 

The conflation of releasing big data with transparency is not a fatal error. Numerous useful data products may ultimately be developed as a result of CMS’s efforts.   A bigger problem, however, may be the asymmetrical use of moral suasion to expose doctors to the glare of public scrutiny without giving consumers information on the cost and outcomes related to technology and drugs use. If transparency does not result in more informed decision making, some would argue it is not transparency at all.

Sculpted Ab Routine (Just 3 Exercises)

As I mentioned yesterday when I shared my meal plan, I'm currently 12 weeks out from my first bikini competition and this week, I start doing my ab exercise routine everyday.  I have definitely seen improvements in the last two weeks in the toning/tightening of my stomach. I'm sure it's a combination of my clean meals, workouts/cardio, ab exercises, and perhaps this cream I've been using.  The picture below was snapped on Monday morning (April 15, 2014).  

Now that I'm 12 weeks out, I'm doing my ab exercises every day.  I do 3 exercises in a row, and repeat them 4 times.  These exercises can be done in the comfort of your own home too.  

1.  Leg Raises- 20 reps

When I'm at the gym, I do leg raises on the roman chair.  

via

At home, you can do them lying on the floor.  

via

Watch the video HERE.

2.  Medicine Ball V-Ups- 15 reps 

These are really hard, but I'm getting better at them.

Watch the video HERE.

3.  Russian Twists- 20 reps

I don't use any weight, I just sit on the floor and touch my hands to the floor on either side. 

Watch the video HERE.

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Seven Things You Need to Know About The Overt Fun and Covert Benefit of Health Gamification

Channeling all this energy for
health and wellness?

The networked Population Health Blog got an alert about this just-published article on the "gamification" of health from the Games for Health Journal

The PHB was only vaguely aware of the growing medical literature that uses humans' love of gaming to promote healthy behaviors, increase prevention and mitigate chronic disease.  And it certainly wasn't aware that there was a entire journal dedicated to the topic.

In this particular article, author Brian Landwehr introduced the PHB to the term "gamification." Using "overt" fun to achieve "covert" benefit, gameplay is combined with virtual or real rewards to engage patients in behavior change. 

Examples include using:

~ videogaming, wireless mats, smartcards and monitors to increase and reward physical activity in children;

~ email/text to remind expectant mothers about appointments and healthy behaviors that are paired with incentives such as gift cards, baby toys and health and safety gear;

~ mobile health apps that track exercise and nutrition choices to earn discounts on merchandise.

What seven things did the PHB learn after reading the manuscript? 

The technology is

1) in its infancy, but it's already being launched in settings that involve thousands of people;

3) utterly scalable, since it can be offered today to entire school districts or fully-insured books of business;

3) very modular, using a surprising amount of "off the shelf" technology that are adapted and combined to build "prototype" products

4) creates products that can also quickly become obsolete thanks to the creation of better and cheaper replacement prototypes;

5) very entrepreneurial, which is one of the drivers behind gamification's surprising growth

6) substitutive when it replaces in-person education, or synergistic when paired with live health coaches

7)  cool because "gamification" is innovation jargon that the PHB cognoscenti can use in meetings and emails to impress their colleagues and stymie their opponents.

Image from Wikipedia

Garden Update: A Banner Year

Things are warming up here in Seattle and the flowers are blooming.  I just planted my first crops of the year-- potatoes and strawberries.

2013 was a banner year for my 500-square-foot urban vegetable garden, including my first experience growing and processing a grain.  I never got around to posting about it last year-- so here it is.

Interbay mulch technique

The bed on the right has been mulched with leaves, spent coffee
grounds, and burlap sacks ($1/sack at the local hardware store).
The beds on the left were planted with a rye-clover-vetch-pea
cover crop.  Paths are mulched with wood chips.

In the fall of 2012, I tried a new technique for improving the soil called "Interbay mulching".  This is a variation on sheet mulching, which involves placing uncomposted organic matter directly onto the garden soil in fall and letting it compost until the next growing season.  To Interbay mulch, you simply cover your sheet mulch with burlap.  This keeps everything moist, protects earthworms from bird predation so they can munch freely, and suppresses weeds.  I used leaves (carbon) and spent coffee grounds from a local coffee shop (nitrogen) for my organic matter.

When I pulled back the burlap last spring, I was initially disappointed.  The coffee grounds had disappeared completely, but there was still a lot of leaf matter left on the soil, indicating that it had only partially composted.  However, I later decided that it had worked well, because the soil structure underneath was improved and it seemed to be enriched with significant organic matter as well as a large population of fat earthworms.  The mulch suppressed weeds remarkably well, and the beds remained mostly clean for the rest of the season.

Those observations, combined with huge yields from the mulched beds, convinced me that it was worthwhile.

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12 Weeks Out // My Bikini Contest Meal Plan

This week we're turning it up a notch in both the workouts and meal plan.  I still have fat to lose so, right now, there will be no fat in my diet, no sugar, no dairy.  I have to say that the meal plan is not very exciting, just a balance of lean protein, carbs, and veggies - 5 times a day.  

This is similar to how I've been eating, but there are things I'm cutting that I previously had been enjoying:  coffee with creamer (I can have coffee but don't like it without a lot of creamer, so I'm trading it for black unsweetened tea), peanut butter and syrup (on my protein pancake), peanut or sesame oil, egg yolk, low sodium soy, salt-free seasoning (in my stir fry), and milk (in my cheerios), nuts.  

Keep in mind that this meal plan was given to me for my specific goal of competing in a bikini contest in 12 weeks, and based on where I am in my fitness journey.  I'm sharing it with you partly to document my process and partly to just give you an idea of what these "fitness girls" eat like if you're curious. 

Here are some examples of lean proteins and carbs:

Protein:

• Tuna or most any fish.
• Cottage cheese.
• Eggs (especially the whites).
• Chicken breast (boneless skinless).
• Turkey breast (boneless skinless).
• Lean beef.
• Low fat or no fat cheese.
• Low fat pork.
• Milk protein isolate.
• Whey protein.
• Soy protein.
• Essentially most any other source of protein so long as it is low in saturated fat and carbohydrates.

Carbohydrates:

• Sweet potatoes.
• Oat meal, oat bran, oat bran cereal (i.e. cheerios).
• Bran cereal.
• Brown rice.
• Wheat bread (try to limit to 2 slices per day).
• Beans.
• Low fat popcorn (low fat butter spray makes this a delicacy).
• Fruits (limit to 2-3 servings per day).
• Malto dextrin (during workout).
• Dextrose (during workout)
• Vegetables.
• Stay away from refined grains and anything that says “enriched” or “high fructose corn syrup” on the label

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My breakfast (egg whites and oatmeal) will be made into a pancake and eaten dry (no PB or syrup)- boo. 

Meals 2 and 3 look something like below, on a smaller (9-inch) plate.  It is actually so much food.  This is 5 oz. boneless, skinless chicken breast, 6 oz. sweet potato, and 1 cup veggies. 

I'm still eating on the go a lot.  

Meal 4:  3/4 cup egg whites, 3/4 cup brown rice, and 1 cup mixed veggies cooked in a skillet with nonstick cooking spray, but no seasonings 

Meal 5:  Protein shake with one scoop of protein, 6-8 oz water, 2 ice cubes.  I make it like this because it doesn't make a huge drink. 

I'm now buying bags of frozen veggies and frozen chicken because it's so much food to keep preparing.   

And I bought a food scale that I really like so I can get the measurements exact. It's super easy to use and lightweight.  I poured through all the reviews and think this was a great choice- well worth the money.  

I think I will get one cheat meal a week and I'm already craving my iced tall 2-pump mocha from Starbucks.  But, I'm so excited to see the changes in my body.  I can't say I LIKE to eat this way, but I've never done it so cleanly or consistently and I have been wanting to cut sugar for a long time, so here we go.  Since the beginning of this journey I just keep thinking, "Do the work. Trust the process." 

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