Episode based payments (3)

 Medicare's Bundled Payment Initiatives for Hospital‐Initiated Episodes: Evidence and Evolution

The Impact of Medicare’s Alternative Payment Models on the Value of Care

Bundled payments have been promoted as an alternative to fee‐for‐service payments that can mitigate the incentives for service volume under the fee‐for‐service model. As Medicare has gained experience with bundled payments, it has widened their scope and increased their duration. However, there have been few reviews of the empirical literature on the impact of Medicare's bundled payment programs on cost, resource use, utilization, and quality.

Main messages:

•  Evidence suggests that bundled payment contracting can slow the growth of payer costs relative to fee‐for‐service contracting, although bundled payment models may not reduce absolute costs.
• Bundled payments may be more effective than fee‐for‐service payments in containing costs for certain medical conditions.
• For the most part, Medicare's bundled payment initiatives have not been associated with a worsening of quality in terms of readmissions, emergency department use, and mortality. Some evidence suggests a worsening of other quality measures for certain medical conditions.
• Bundled payment contracting involves trade‐offs: Expanding a bundle's scope and duration may better contain costs, but a more comprehensive bundle may be less attractive to providers, reducing their willingness to accept it as an alternative to fee‐for‐service payment.

Both articles reflect the current situation on payment systems in US. The effort to change fee-for-service is more difficult than expected. There is a lot of money at stake.

 

The Gossips by Norman Rockwell

Atul Gawande on this pivotal moment

 Atul Gawande on Taming the Coronavirus

Can a vaccine be distributed fairly? What will be the impact of a large number of people not taking it—as they say they won’t? Atul Gawande, a New Yorker staff writer who was recently appointed to President-elect Joe Biden’s covid-19 task force, walks David Remnick through some of the challenges of this pivotal moment

 And in FT:  "I do think that the fundamental disaster of the United States is tying where you get your healthcare to where you work,"

Agree

 Podcast in The New Yorker radio:

Unwarranted variation in clinical practice

 Understanding unwarranted variation in clinical practice: a focus on network effects, reflective medicine and learning health systems

Variation is not bad or unwarranted per se. To some extent, variation should always exist, because patients are unique and different. Care could be called appropriate when decisions reflect such differences, especially differences in informed patient preference [1].

Variation may be unwarranted when it cannot be explained by sensitivity to patient characteristics or well-informed preferences. In this perspective, we propose alternative hypotheses for mechanisms underlying unwarranted variation in healthcare and  propose new target points for research to better understand, reduce and improve unwarranted variation in care quality in daily medical practice.

 A key element in this new focus in research should be on the complex cohesion of network effects, reflective medicine, patient beliefs and objective criteria for treatment choices.

After all these years and the large amount of research on variations in medical practice, it's time to act. 

Shara Hughes

 

The social media industrial complex and the tiranny of trends

 The hype machine

From the book:

We’ve constructed an expansive, multifaceted machine that spans the globe and conducts the flow of information, opinions, and behaviors through society. This Hype Machine connects us in a worldwide communication network, exchanging trillions of messages a day, guided by algorithms, designed to inform, persuade, entertain, and manipulate us.

The object of this machine is the human psyche. It was designed to stimulate our neurological impulses, to draw us in and persuade us to change how we shop, vote, and exercise, and even who we love. It analyzes us to give us options for what to read, buy, and believe. It then learns from our choices and iteratively optimizes its offerings. As it operates, it generates a data exhaust that traces each of our preferences, desires, interests, and time-stamped, geolocated activities around the world. It then feeds on its own data exhaust, refining its process, perfecting its analysis, and improving its persuasive leverage. Its motivation is money, which it maximizes by engaging us. The more precise it gets, the more engaging and persuasive it becomes. The more persuasive it becomes, the more revenue it generates and the bigger it grows. This is the story of the Hype Machine—the social media industrial complex: how it was designed, how it works, how it affects us, and how we can adapt to it.

 

 

What is the alternative to Friedman’s capitalism?

 Milton Friedman 50 Years Later

Angus Deaton says:

“Milton Friedman was one of the foremost thinkers who challenged the post-war Keynesian consensus. He was immensely successful in arguing the pro-market case, and questioning the ability of government to improve on market outcomes. Today, we need to reopen these questions, using new economic thinking and new evidence; is the market bringing the unalloyed benefits that Friedman thought it would? This book is an important contribution to that reevaluation,”

And this is the capitalism that Martin Wolf expects:

“in which companies would not promote junk science on climate and the environment; it is one in which companies would not kill hundreds of thousands of people, by promoting addiction to opiates; it is one in which companies would not lobby for tax systems that let them park vast proportions of their profits in tax havens; it is one in which the financial sector would not lobby for the inadequate capitalisation that causes huge crises; it is one in which copyright would not be extended and extended and extended; it is one in which companies would not seek to neuter an effective competition policy; it is one in which companies would not lobby hard against efforts to limit the adverse social consequences of precarious work; and so on and so forth.”   

 

The largest global public-health initiative

 The COVID-19 vaccines are here: What comes next?

From McKinsey:

As vaccine availability nears, communities and consumers will want answers to many questions, including:

• Is the vaccine effective and safe?
• Who will get vaccinated first?
• Which vaccine will we receive, especially if multiple vaccines are available?
• Where and when can we get vaccinated?
• Will we have to pay?
• Above all, what do we need to worry about?

Although the scale of the task may seem daunting, countries benefit by starting end-to-end planning immediately. Our 6A framework lays out a structured approach to ensure vaccines are available, administrable, accessible, acceptable, affordable, and accountable while taking into account strategic considerations associated with uncertainty (for example, vaccine clinical and technical profile) and building system capabilities (Exhibit 2). We have developed, in granular detail, the individual activities and considerations behind each component of the framework. Through the collective initial effort of the pharma industry, the scientific community, global health institutions, and governments, most elements of the “available” segment of the 6A journey are being addressed

 

Paul Strand

 

Platforms as essential services

Essential Platforms

Competition in Digital Markets 

Imagine you own a company, and you see millions of potential customers for a new product. But there is a problem: all these customers live on the other side of a river and the only way to reach them leads over a privately owned bridge. The owner of that sole bridge either prevents you from passing altogether or charges excessive fees. Long story short, if that is the case, this product line and, potentially, your entire business are doomed.

 Digital platforms can behave in that manner because they do not face serious competition. The platforms’ monopoly power mainly stems from network effects—that means the participation of additional users almost exponentially increases the utility of the network and creates enormous market entry barriers for potential competitors. The characteristics of data and algorithms further foreclose the markets.

 Google, Amazon, Facebook, Apple, and others behave just like the railroads did 100 years ago. Instead of physical infrastructure, like bridges and tunnels, the digital platforms leverage network effects that shield them from effective competition. 

To define the suitable remedies and to open the digital economy for competition, we can learn from the past. In the early twentieth century, the railroads controlled critical infrastructure and excluded competitors from crucial markets. The railroad monopolies rested on enormous investments in physical infrastructure that could not be replicated.

After all these years, a clear message, while the regulator is still on vacation.