Going Below the Surface E-newsletter: October 2018

Going Below the Surface

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Digging Deeper

Relying on topline findings — or seizing on conventional wisdom — is one of the great obstacles to going below the surface, and this month’s news highlights those risks. What seemed like good news in the insurance realm, reasonable premium growth, actually hides a looming crisis. Likewise, a year-old cardiology trial held enormous promise for changing practice — and health spending — for the better, but new perspectives on the trial lay bare the challenges of realizing that promise.

Employer-provided Health Plans: Moderating Premium Growth, Skyrocketing Sharing

A new survey from the Kaiser Family Foundation out this month shows that premiums are rising only modestly for employer-provided health plans: the average single premium is up 3 percent and the average family premium is up 5 percent. While that’s still more than average wage growth last year (2.5 percent), Kaiser characterized the trend as a “period of stability and relatively low cost growth for employer-provided coverage.” That’s the good news. The bad news is that the premium dollar is buying less. The same survey found that over the past five years, the average deductible has risen 53 percent, meaning that a quarter of those with employer insurance plans face annual deductibles of more than $2,000.

Why It Matters: Moderating premium increases doesn’t come without a cost, and Kaiser suggested that the trend of pushing more and more of the cost burden to consumers may be coming to a head, concluding that “employers may find it increasingly difficult to impose higher cost sharing.” That suggests that other systemic adjustments will have to be considered.

Hard Lessons From A Groundbreaking Trial

Almost exactly a year ago, the Lancet published the results of the ORBITA trial, which found that — in patients with stable angina — patients who received a stent did no better than patients who received only optimal medical therapy. The results largely overturned conventional wisdom and identified not only an area of medicine rife with unnecessary treatment, but rife with unnecessary and expensive treatment. Health Affairs ran a series of pieces this month teasing apart the impact of ORBITA, and the prognosis is not encouraging. Cardiologist William Boden suggested, “Likely medical practice will not change in response to ORBITA” because of the firmly held biases of specialists. Shannon Brownlee, the senior vice president of the Lown Institute, argued that ORBITA should prompt a rethinking of how we provide and pay for care, demanding more research before an intervention becomes standard practice and stopping reimbursement for inappropriate care.

Why It Matters: Decades of stent use in stable angina has set cardiology on a course that will be difficult to reverse, and ORBITA is a stark reminder that it is harder to stop doing something than it is to start doing it. Investing — and investing early — in comparative effectiveness research that spans the gamut of interventions will be critical to identifying and stopping wasteful care before it begins.

What We’re Reading in the Journals

Accountable care organizations (ACOs) were a hot topic during the past month, with several peer-reviewed journals taking a closer look at whether ACOs, particularly those in the Medicare Shared Savings Program (MSSP), have produced savings for the U.S. health care system. Studies consider the driving factors behind those savings and what policy levers are needed to encourage continued success in these programs.

  • Medicare Spending After 3 Years of the Medicare Shared Savings Program. McWilliams JM, Hatfield LA, Landon BE, Hamed P, Chernew ME. The New England Journal of Medicine. September 20, 2018. After three years of the MSSP, “participation in shared-savings contracts by physician groups was associated with savings for Medicare that grew over the study period, whereas hospital-integrated ACOs did not produce savings (on average) during the same period.”
  • Half A Decade In, Medicare Accountable Care Organizations Are Generating Net Savings: Part 1 and Part 2. Bleser W, Muhlestein D, Saunders R, McClellan M. Health Affairs Blog (Part 1 and Part 2). September 20 and 21, 2018. In this two-part series, study authors offer a detailed, data-oriented look at MSSP ACO performance, including savings, quality measures and other benchmarks, and consider policy changes to further improve the programs.
  • Medicare Shared Savings Program Produces Substantial Savings: New Policies Should Promote ACO Growth. Mechanic R, Gaus C. Health Affairs Blog. September 11, 2018. National Association of ACOs leaders suggest addressing three issues that “would be a major step towards promoting both new entrants and continued ACO participation in the MSSP.” These include continuing certain shared savings rates, lengthening the time for new ACOs to remain in a shared savings model without downside risk and allowing variations in the beneficiary risk score.

Dialogues on Health Care Spending

Since Halloween is almost upon us, we have to ask: Do you have a haunting health care tale or a spooky spending story you’d like to share with us? Pass it along by email or tweet using #GoingBelowTheSurface. For now, we’ll treat you to the following:

  • A webinar hosted by AcademyHealth and the National Pharmaceutical Council (NPC) delved into new research aimed at getting to the root of two vexing health care spending challenges — what could we do in the United States to better allocate our resources, and how can we ensure those resources are not wasted on low-value care. Check out the summary now, and come back later this week for the archive.
  • The Health Affairs Blog continues its ongoing series, Considering Health Spending, with some edgier articles this month. Among them: Michael L. Millenson, president of Health Quality Advisors, LLC, considers why the U.S. is still in a health care spending crisis, and what we should do about it. CVS Health and NPC spar over value and formulary benefit design. And a new research consortium plans to take a holistic look at health care spending. Read these articles and more on the Health Affairs Blog (note: funding for the series is provided by NPC and Anthem).

    About Going Below the Surface

The Going Below the Surface initiative was launched by the National Pharmaceutical Council in 2018 to broaden and improve the conversation around how health care resources are used in the United States. The initiative is aimed at better understanding the roots of the nation’s health spending and investments by promoting a discussion that is firmly based in health policy and systems research. Our goal is to provide clarity on how best to optimize health care spending so that patients receive the right care while simultaneously providing the right incentives to sustain next-generation innovation to improve patient well-being and health system efficiencies.

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