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We Should Channel People Into Medicare Advantage Plans Where They Won’t Have Amputations or Go Blind (Part 2)

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By GEORGE HALVORSON

Former Kaiser Permanente CEO George Halvorson has written on THCB on and off over the years, most notably with his proposal for Medicare Advantage for All post-COVID. He wrote a piece in Health Affairs last year arguing with the stance of Medicare Advantage of Don Berwick and Rick Gilfillan (Here’s their piece pt1, pt2). We also published his criticism (Part 1. Part 2. Part 3) of Medpac’s analysis of Medicare Advantage.  Now Medpac is meeting again and George is wondering why they don’t seem to care about diabetic foot amputations. We published part one last week. This is part two– Matthew Holt

We have more amputations and we have more people going blind in our fee for service Medicare program today because we buy care so badly and because we have no quality programs or care linkages for our chronically Ill patients and our low income people in that program.

We have far better care in our Medicare Advantage programs at multiple levels today, and we should be building on that better care for everyone.

The important and invisible truth is that we have major successes in providing better care to Medicare Advantage members across the entire spectrum of that package of care. The sad truth is that MedPac actually keeps those huge differences in care performance by the plans secret from the Congress and from the American public for no discernable or legitimate reason.

We have an epidemic of amputations that are causing almost a fifth of our fee for service diabetes patients who get foot ulcers to lose limbs. The number of patients in both standard Medicare Advantage and in the Medicare Advantage Special Needs Programs who undergo amputations and who have that functional and dysfunctional care failure is a tiny fraction of that number.

MedPac pretends the program does not exist. They did a lengthy study on the overall special needs dual eligible program for Medicare a year ago without mentioning the plans or describing any of the things that the plans to do make care better for those patients.

We know that in fee for service Medicare, 20% percent of diabetes patients routinely get ulcers and 20% of those ulcers to turn into amputations. There are far fewer amputations for Medicare Advantage plan members—and we have failed our overall Medicare population badly by not sharing that information more broadly at open enrollment time.

Medicare Advantage Five Star quality plans that have created a culture of quality improvement at many care sites. Those plans compete fiercely on quality goals and take pride in attaining and celebrating the highest scores.  We started with less than 10% of plans with the highest scores for the first enrollment periods. Now more than 90% of Medicare Advantage members are able to choose between four and five star plans.

The quality measurements that are missing from the set of consumer choices are the ones that relate to the most serious issues for the consumers—and that’s where MedPac should be putting the right set of information on the table to compare the two systems of care. Large amounts of data show that amputations caused by diabetes follow very predictable patterns.  

Roughly 33% of Medicare patients will have diabetes. 20% of diabetics will have ulcers. That number goes up to 30% for some patient groups—but you can count of at least 20% overall to have ulcers.  We know that the overarching pattern in fee for service Medicare is for 20% of those ulcers to end up needing and getting amputations.

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Medicare Advantage Saves Lives, Limbs, Sight, And Major Amounts of Money – (Part 1)

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BY GEORGE HALVORSON

Former Kaiser Permanente CEO George Halvorson has written on THCB on and off over the years, most notably with his proposal for Medicare Advantage for All post-COVID. He wrote a piece in Health Affairs last year arguing with the stance of Medicare Advantage of Don Berwick and Rick Gilfillan (Here’s their piece pt1, pt2). We also published his criticism (Part 1. Part 2. Part 3) of Medpac’s analysis of Medicare Advantage.  Now Medpac is meeting again and George is wondering why they don’t seem to care about diabetic foot amputations. We are publishing part one today with part two coming soon – Matthew Holt

We need to look honestly at some sad and grim realities about American Health Care and about the role that fee for service Medicare plays for too many people in our country today. 

Fee for service Medicare has the highest level of amputations and one of the highest levels of diabetic blindness of any country in the western world because it buys care so badly and so ineptly and then too often underperforms in multiple ways on the delivery of that care. 

Fee for Service Medicare only buys care and pays for care by the piece. It’s caregivers, both as a group and as individuals, actually can often make more money by performing, inadequate, unsuccessful and, far too often, even bad care, because bad care can result in more care being needed, purchased and paid for.

Many of the failures of care for the patients with the medical conditions that cause them to spend far too much time in the hospital, and in various other care settings, should not be happening—and we know that to be true because large numbers of the care failures are not happening to the patients who are enrolled in Medicare Advantage plans.   

Medicare Advantage plans all have basic care plans and approaches  for their patients that are linked to care related care processes of care—and a very high percentage of those processes do not exist for far too many of our fee for service Medicare enrollees  

The sad and unfortunate reality is that fee for service Medicare has no quality standards, no quality expectations, and that it is, in aggregate, a very expensive way to buy care because bad care often costs more money at several levels than appropriate care.  

Those accusations are easy to prove and they are easy to demonstrate.  

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What Could Possibly Go Wrong? Outbreaks of Injustice Linked by Two Different Dobbs.

BY MIKE MAGEE

Under the definition for the noun, epidemic, there are two main (and distinctly different) definitions. I know this fact because it was the beginning point of my preparations earlier this summer for a Fall course on “The History of Epidemics in America” at the Presidents College at the University of Hartford. 

The entry reads:

Epidemic noun

ep·​i·​dem·​ic | \ ˌe-pə-ˈde-mik  \

Definition of epidemic (Entry 2 of 2)

1: an outbreak of disease that spreads quickly and affects many individuals at the same time : an outbreak of epidemic disease

2: an outbreak or product of sudden rapid spread, growth, or development; an epidemic of bankruptcies

In my course, sessions 1, 2, and 4 will be devoted to the first (and classical, microbe-centric) definition. But my third session will focus on “manmade” epidemics which fall under definition two.

I thought long and hard about this choice. The deciding factor was reading New York Times best selling author, Adam Cohen’s book, “Imbeciles.” It details the shameful story of “The Supreme Court, American Eugenics, and the Sterilization of Carrie Buck.”

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It’s Time for No

BY KIM BELLARD

We all – well, most of us – try to be agreeable.  It’s usually a better social lubricant to say “yes” than “no.”  It’s widely considered to be better for your career to be the one who always says “yes” instead of being the troublesome worker who often says “no.”  “Yes, dear” is a safer marital strategy than “no” or “not again.”  But, like most conventional wisdoms, these deserve to be challenged. 

I’ve read several articles recently where “no” is the suggested strategy, and I think there’s something there.  Especially for healthcare.  

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Amazon’s Coitus Interruptus: In or out?

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Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

Meanwhile, it’s time for Matthew’s tidbits and of course given their recent news-making I am going to focus on Amazon in health care. The news is of course that they are in health care in a big way, buying One Medical. The news is also of course is that they are out–shutting down Amazon Care.

This reminds me of the famous criticism delivered in the British parliament by one MP about another back the last time (in the 1970s) there was a vote about leaving the EU. “The Honourable gentleman can’t make up his mind. First he’s in, then he’s out. In, out. In, out. This is the politics of coitus interruptus.” After a moment a voice from the backbenches shouted “Withdraw.”

So is Amazon in or out?

They are out of their 4 year effort to build a hybrid telehealth-to-home medical group that helps mainstream employers manage their costs. This is despite stating their intent just a few months back to add new clinics and this year adding a decent number of employer clients including Hilton hotels–before that they only really had a few of their own employees as clients. Interestingly enough, it was the development of this platform that convinced Amazon that they didn’t need Haven–their alliance with JP Morgan and Berkshire Hathaway which was developing a similar offering.

They are in to the business of One Medical to the tune of a $3Bn acquisition as well as putting in $300m extra cash so far, and likely a lot more later. Like Amazon Care, One Medical has a hybrid telehealth and clinic approach (though no home visits as yet). When Amazon said they were killing Amazon Care, they suggested that a lack of employer uptake was the biggest problem. One Medical does have employer clients. But these aren’t mainstream low or medium wage employers to whom they are delivering capitated care at a worksite. In One Medical terms that means an employer pays their employees’ $200 per member annual fee, after which the employee can see a One Medical doctor. And curiously enough by far their biggest employer client is Google.

One Medical says that they lower overall costs for their employer clients, but to use another British political line, “they would say that wouldn’t they.” In reality One Medical does very little specialty or hospital care management, and via its relationships with local high-priced health systems is able to charge insurers very high prices for primary care which they seem to actually pay! (And yes I have lots of personal experience here..). Putting aside the fact that One Medical somehow is contriving to still lose loads of money–a big reason why it put itself up for sale–it is not an organization trying to manage costs for employers in value-based care arrangements, unlike say Firefly Health or even Crossover Health (of which Amazon is a big client for its lower paid workers).

You’ll notice that I am conveniently ignoring the Iora Health part of One Medical which they inexplicably bought last year. Iora focuses on capitated services for Medicare Advantage plans, and it is trying to manage costs. Though given the amount it’s losing, that effort isn’t going so well either.

It’s possible that Amazon is going to surprise us and try to turn Iora + One Medical into a capitated giant to work with and steal the margin of the big Medicare Advantage plans. Then later, move that strategy into mainstream employers.

But if they were going to try that it would probably have been easier and more culturally aligned to merge Iora with Amazon Care. My suspicion is that Amazon means what it says and is finding it too hard to manage costs for employers. My guess is it will jettison Iora, keep using Crossover and others to manage costs for its own lower-paid employees, and try to turn One Medical into a Whole Foods-like national brand for the cost- unconscious top 25% of Americans….and somehow make it profitable.

If they manage that it would be great for Amazon’s business. But it would be very disappointing for those of us hoping that Amazon was going to have a serious go at providing a low-cost, innovative service that was trying to lower overall health care costs for employers and make a serious dent in the market power of America’s high priced, under-delivering hospital systems.

#HealthTechDeals Episode 43 | Happy Ring, Upfront, PatientBond, Nitra, Digital Diagnostic, Ubie

On this episode of HTD, Jess and I check out Akili Interactive: at least it’s still worth more than Pear Therapeutics. And by the way, what do we think will happen between Amazon and Signify? Tune in to find out! We also look at some new deals in health tech: Happy Ring raises $60 million; Upfront buys PatientBond, raising $20 million; Nitra raises $62 million; Digital Diagnostic raises $75 million; Ubie raises $26.2 million.

-Matthew Holt

“Virgin-Soil Epidemics” Covers a Multitude of Sins

BY MIKE MAGEE

Epidemics don’t appear in isolation of geography, social status, race or economics.

In a recent Kaiser Family Foundation article, the authors reviewed case numbers and death rates organized by race/ethnicity. It will come as no surprise that the most vulnerable populations death rate is nearly three times greater than the least vulnerable. But what may surprise you is that the population at greatest risk was neither self-identified as Black or Hispanic, but Native American.

Sadly, this is not a new story, but in the analogs of American history, it has been papered over by a partially true, but incomplete, narrative. That storyline was largely popularized by the book, “Guns, Germs, and Steel.” Published in 1997, author Jared Diamond explained that European colonists, arriving in the Caribbean islands in the late 15th century, carried with them a variety of diseases like smallpox and measles, and transmitted them to indigenous people that had no prior exposure to these deadly microbes.

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The Shocking Impact of an Ancestor’s Secret Abortion

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BY MICHAEL MILLENSON

When my siblings and I were young, we were fascinated by my father’s Uncle Byron. Handsome and confident, he drove a big, 1960s-era Chrysler Imperial, had a glamorous job — an executive at a Baltimore radio station — and radiated panache.

He also was part of a small family mystery. His father, Louis, was married three times, and Byron was raised by Wife № 3. But he was the biological child of Wife № 2, who died just a few years after his birth from an unknown cause.

Thanks to some persistent genealogical research, I recently discovered that cause: Annie Millenson had a botched abortion, and it killed her. It also destroyed her surviving family.

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Zap Away

BY KIM BELLARD

Speaking as a sometimes forgetful “senior citizen,” when I found out that non-invasively zapping brains with electricity can result in measurable improvements in memory, that’s something I’m going to remember.

I hope.  

In research published in Nature Neuroscience by Grover, et. al., a team lead by Boston University cognitive neuroscientist Robert Reinhart produced improvements in both long-term and short-term (working) memory through a series of weak electric stimulation – transcranial alternating current stimulation (tACS). The authors modestly claim: “Together, these findings suggest that memory function can be selectively and sustainably improved in older adults through modulation of functionally specific brain rhythms.”

The study provided the stimulation using something that looks like a swimming cap with electrodes, applied for twenty minutes a day for four days.  The population was 150 people, broken up into three separate experiments, all ages 65 to 88.

The results were amazing.  “We can watch the memory improvements accumulate … with each passing day,” Dr. Reinhart marveled.  

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