Comments for Reward Health Sciences

Comment on Health care reform with its foot on a banana peel by If the mandate is a tax, it becomes constitutional. The politically inconvenient argument could provide a way out for the Supreme Court.

Sat, 12 May 2012 14:17:53 +0000

[...] a recent blog post, I attempted to summarize the legal arguments behind the debate about the constitutionality of the [...]

Comment on Health Care Heroes: Don Berwick, MD – Adapting industrial quality improvement principles to the improvement of health care processes by Time for change in education

Time for change in education — Sun, 06 May 2012 12:27:07 +0000

[...] they can within a poorly designed system. Rather, the problem is with the system. As taught by one of my health care heroes, Don Berwick, “every system is designed perfectly to achieve exactly the results it [...]

Comment on Of 27 new ACOs named by CMS: 93% avoid downside risk, 82% avoid CMS loans, 33% use payer-based infrastructure, and average beneficiaries per physician is 106 by Dr. Ward

Dr. Ward — Thu, 03 May 2012 15:07:33 +0000

I’ve not heard which two of the new ACOs accepted downside risk. Apparently, CMS views that as confidential proprietary information.

Comment on Of 27 new ACOs named by CMS: 93% avoid downside risk, 82% avoid CMS loans, 33% use payer-based infrastructure, and average beneficiaries per physician is 106 by Warren Demurjian

Warren Demurjian — Wed, 02 May 2012 15:16:06 +0000

Is there any way to determine which two ACOs accepted the downside risk and truly put their chips on the table?

Comment on Observed over expected (O/E) analysis is commonly misapplied to performance comparisons. Please don’t. by Dr. Ward

Dr. Ward — Mon, 16 Apr 2012 17:09:09 +0000

Dr. Hunsicker, thank you for taking the time to submit your thoughtful post. I agree with your point that it would be inappropriate to try to use standardization to compare the performance of a pediatrician to the performance of an internist. But, the problem with such a comparison is not because standardization is not asking the right question. The problem is more fundamental.

Before doing any comparisons of providers’ performance, the analyst must first be comfortable that the providers being compared are from the same population. Risk adjustment is only appropriate for the purposes of adjusting for relatively small differences in the mix of characteristics of the members of the population of providers. Since pediatricians and internists focus on non-comparable populations of patients, they are different populations of physicians. It is not appropriate to use risk adjustment to try to extrapolate results from one population to another population or to draw conclusions from comparisons of different populations.

Unfortunately, there are no formal methods or established criteria (at least none that I’ve ever heard of) for make this determination of same vs. different population. This is primarily determined by human judgment and convention. However, when doing risk adjustment, I like to check the difference between adjusted and unadjusted measures. If the difference between the two is more than about 20%, it makes me suspicious that we are dealing with different populations, and not merely adjusting for different mix within the same population.

If everyone agrees that we are comparing performance of providers within the same provider population, then, I still feel that O/E analysis is not an appropriate method for the purpose of making fair, level-playing-field comparisons of provider performance, since the measured differences between providers is still potentially confounded by differences in the mix of patient characteristics, as demonstrated in the example calculations. As I pointed out in a subsequent post, methods analogous to O/E are useful to identifying and prioritizing opportunities for improvement of each provider.

Comment on Observed over expected (O/E) analysis is commonly misapplied to performance comparisons. Please don’t. by L. G. Hunsicker, M.D., Professor of Medicine, U. Iowa College of Medicine

L. G. Hunsicker, M.D., Professor of Medicine, U. Iowa College of Medicine — Sun, 15 Apr 2012 22:13:28 +0000

I am not a (formal) statistician, so I respond to this analysis with some temerity. It seems to me that Dr. Ward’s numerical analysis is correct, but that his conclusion that O-E should not be used to evaluate performance of hospitals/practitioners may not be the end of the discussion. The issue, at root, is over which patient population one wants to evaluate a physician’s/institution’s performance – the average population overall, or the average population that the physician/institution sees. The problem arises from the fact that there may be an interaction between physician performance and the characteristics of the patient population. In his conundrum, Dr. Ward’s Provider A sees mostly adults, but does less well with these patients than expected, but better with children. Conversely, Provider B sees mostly children,does less well with the children than expected, but better with adults. (This may be the reverse of what might have been expected. We might have guessed that each provider would have done better on average with the patients that he sees more of – the pediatrician with children and the internist with adults.) But we want an “overall” measure of performance, not a separate evaluation for each patient population. So we have to construct a weighted average performance – and here is the basis for the difference between Dr. Ward’s two computations. If we weight the average performance by the characteristics of the general population – asking the question how well each practitioner would do if (s)he saw a patient population typical of the population as a whole, we get Dr. Ward’s preferred answer. But we may prefer to weight the average by the patient population that the provider actually sees – in essence asking how his/her performance compares with a hypothetical/counterfactual average provider seeing the kind of patients that the practitioner being evaluated actually sees. In that case we get the evaluation that Dr. Ward doesn’t like. Two different questions. Two different answers. Which question is the relevant one? I think that many would say that the relevant question is how well does each practitioner perform in caring for the kind of patients (s)he generally sees. Consider one likely consequence of taking Dr. Ward’s point of view, and consider the likely situation with a pediatrician who sees mostly children and whose care of children is superior. But his/her care of adults (which (s)he rarely sees) is less good. Because the patient population at large has more adults than children, the pediatrician’s good outcomes with children would be down weighted and his/her less good outcomes with adults would be weighted more heavily. If the reverse is true for the internists,in this comparison the pediatricians are likely, as a class, to look less good than the internists. (Incidentally, I am an internist, not a pediatrician.) I personally think that this approach does more damage to my sense of fairness than the alternative of evaluating each provider relative to the patients that (s)he sees. I would agree with Dr. Ward that this does not permit an overall ranking of all providers without reference to special expertise. Each provider is only reasonably compared with other providers caring for similar patients. But then, I suspect that most will think it a somewhat irrelevant exercise to rate providers on their (hypothetical) outcomes with patients that they don’t actually see very often.

Comment on Mayo and Cleveland Clinic are becoming franchisers. Maybe they should focus on primary care. by Of 27 new ACOs named by CMS: 93% avoid downside risk, 82% avoid CMS loans, 33% use payer-based infrastructure, and average beneficiaries per physician is 106

Wed, 11 Apr 2012 12:52:47 +0000

[...] scale, rather than taking on the cost of creating their own infrastructure. As I described in a prior post, this can be accomplished through a franchise arrangement. It can also be accomplished through a [...]

Comment on Health care reform with its foot on a banana peel by Tim McDermott

Tim McDermott — Thu, 29 Mar 2012 12:57:37 +0000

Rick, this is an excellent analysis (but I, too, have set aside a dollar, as reading the Supreme Court tea leaves based on oral arguments is a difficult proposition) … In the event the Court follows the suggested path, I promise to put the dollar to good use: supporting my ever-increasing health care costs.

Comment on Coconut oil as an Alzheimer’s treatment? Please don’t short-circuit science. by Dr. Ward

Dr. Ward — Mon, 19 Mar 2012 00:02:43 +0000

Meg and Marty, thanks for your thoughtful comments. For patients and families, it may be desirable to try something that might work, particularly if it is not thought to be harmful and is not unreasonably costly. My point was that, for health care professionals, researchers and health care policy-makers, there is a responsibility to refrain from advocacy for a treatment that “might work” until after doing the hard work of proving that it really does work. So, my plea to avoid short-circuiting science is really not directed at patients and families. On the other hand, it is important for patients and families to be smart consumers of information — able to tell the difference between proven vs. unproven therapies. Hopefulness is a good thing, but it also has the potential to cloud good judgment.

Comment on Hans Rosling illustrates how to tell compelling stories with data by The free market is at the heart of diverse debates in health care

The free market is at the heart of diverse debates in health care — Sun, 18 Mar 2012 23:21:01 +0000

[...] is an undesirable side effect of a larger trend that has greatly benefited the third world. As described in a compelling and entertaining way by Hans Rosling, the last century has been characterized by dissemination of scientific and economic innovations [...]