Adding the fun factor, 340B reform, Kavanaugh and health care, & Medicaid value-reform sui generis 
July 12, 2018
For change, increase the fun factor
Health care, fun? Seems nigh impossible.

But "making it fun" is one of the seven things that health care providers and insurers should do if they want people to change their behavior, according to Kevin Volpp, University of Pennsylvania's behavior change and health incentives guru.

"If we want these programs to be engaging, if we want participation rates to be high, it can't feel onerous to participate," Volpp says in NEJM Catalyst piece this week. 

Of course people have been talking about gamification of health care for years now, and there are some interesting examples out there. 

Some of the other items on Volpp's to-do list are hard to argue with (simplifying complicated processes, using technology in supportive ways). Others are fraught with political and other problems (raising taxes on unhealthy items, reducing out-of-pocket expenses).
340B reform on the menu
The 340B program is classic health care inside baseball with hospitals on one side, pharma on the other, and big dollars at stake.

A House subcommittee held a hearing on Wednesday about the controversial drug discount plan. Grist for that mill was a GAO report that criticized lack oversight of the program.

The hearing came two days after HHS Secretary Alex Azar gave a speech to a trade group for 340B hospitals. Azar called for two kinds of 340B reforms, according to Joyce Frieden's account for MedPage Today: greater transparency about the discounts and narrowing the gap between the discounted prices and reimbursement. 

Azar seems likely to make some changes to 340B through regulation. Meanwhile, several different pieces of legislation have been introduced in Congress. One, dubbed the " patient definition" proposal, would rein in the program by restricting it to certain patients. Another would impose a variety of reporting on hospitals. Whether anything will get through Congress and on to President Trump's desk is questionable with the midterms three months away and all the hospital opposition, Susannah Luthi at Modern Healthcare noted this week.   
What would a Justice Brett Kavanaugh mean for health care?
In a dissenting opinion, Kavanaugh said the now-defunct individual mandate should be viewed as a tax, the same position that Chief Justice John Roberts took in NFIB v. Sebelius, the 2012 case that upheld the mandate but unraveled the ACA's Medicaid expansion requirement. 

The Washington Post headline hedged the bet: " Kavanaugh may not completely gut Obamacare if he makes it to the Supreme Court." 

But conservatives are latching on to another part of that opinion seems to signal strong misgivings about the mandate and perhaps the ACA in general. 

Politically it is far more important that many believe that Kavanaugh will vote to overturn Roe v. Wade, and he may have tipped his hand in a speech he gave at the American Enterprise Institute last year about William Rehnquist in which he lavished praise on Rehnquist's dissenting opinion in Roe v. Wade. 

The legality of abortion will become a state-by-state proposition if Roe is overturned. Kaiser Health News reported this week that 22 states are likely to ban abortion if that happens.
Medicare no model for value-based reform in Medicaid
Joshua Liao, Benjamin Sommers, and Amol Navathe make a fascinating argument this week in a New England Journal of Medicine perspective piece about value-based reform in Medicaid and how it needs to be tailored to the program.  

A large proportion (68%) of Medicaid patients already have their care managed by organizations that receive incentives for controlling costs, they point out; this is not virgin fee-for-service territory that value-based reforms are entering. Liao, Sommers, and Navathe also note the problems posed by Medicaid populations that include large numbers of people with high-cost conditions like hepatitis C. 

They don't throw in the towel, though.  Their message is that Medicaid value-based reform efforts can't just take some pages from the Medicare playbook and apply them to Medicaid. Instead, they say, Medicaid value-based efforts need to focus on nonfinancial incentives and encourage coordination between ACOs and bundled payment programs. ACO programs in Minnesota and Colorado are good examples to follow, they say. They are also intrigued by a hepatitis C bundled payment program in New York.
Medicaid resists the quick fix
Speaking of Medicaid, two articles in this month's Health Affairs examine the effects of ACA changes to the program. The results can't be seen as encouraging.

Hannah T. Neprash and her colleagues found that Medicaid expansion didn't change by very much the proportion of primary care physicians who see adults covered by the public payer. After expansion, it was still 20% of the physicians who participate in Medicaid seeing 60% of the adult beneficiaries. The percentage did go up a bit more in expansion than in nonexpansion states.  

The inertia makes sense given the administrative hassles of taking on a new payer and where physician offices are concentrated (not in the heart of poor neighborhoods). But these findings show that merely expanding coverage is just one dimension of the multidimensional problem of making health care more accessible to disadvantaged people. 

The second study by Sandra L. Decker also shows that Medicaid shrugs off the quick fix. She found that the ACA fee bump in 2013 and 2014 had no effect on primary care physicians participation. Part of the problem, she speculates, is that the bump was presented as being temporary. 
Quick takes

Erasing the ACA. HHS has scrubbed mentions of the ACA from its Medicaid pages, according to the Sunlight Foundation.

Meh on adding CVD tests. USPSTF said this week there is insufficient evidence to assess the risks and benefits of adding the ankle-brachial index, the high-sensitivity C-reactive protein level, and the coronary artery calcium score to traditional risk factors when assessing the CVD risk of asymptomatic patients. An accompanying editorial in JAMA argues that a clinical trial of coronary artery calcium scoring would, yes, be expensive but also a wise investment. 

EHRs getting in the way. How value-based care is playing out in oncology was discussed this week at meeting in Philadelphia. Apparently, legacy EHRs gum up the works. No surprise there. 

More doubts about skin in the game. High deductibles were supposed transform Americans into smart, value-seeking health care shoppers. But it isn't working out that way, according to a speakers from right- and the left-leaning think tanks at a meeting yesterday hosted by the National Coalition on Health Care. 

Peter Wehrwein
Upcoming Meetings
5th Annual Patient Support Services and HUB Design
Philadelphia, PA
July 23-25, 2018

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Philadelphia, PA
July 23-25, 2018

Patient Services Compliance Summit
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July 23-25, 2018

Copay Summit
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July 23, 2018

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2018 Star Ratings & Quality Management Forum
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July 23-24, 2018

Chief Nursing Officer Summit 2018
Las Vegas, NV
September 13-14, 2018

2nd Biosimilar Market Access and Commercialization Strategies Summit
Boston, MA
September 17-18, 2018

2nd National Opioid Crisis Management Congress
Washington, DC
September 27-28, 2018

2018 Medicaid Managed Care Summit
Washington, DC
September 27-28, 2018