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Re: Changing Physician Incentives for Affordable, Quality Cancer Care: Results of an Episode Payment Model
Urological Survey Socioeconomic Factors, Urological Epidemiology and Practice Patterns Re: Health Spending Slowdown is Mostly Due to Economic Factors, Not Structural Change in the Health Care Sector D. Dranove, C. Garthwaite and C. Ody Kellogg School of Management, Northwestern University, Evanston, Illinois Health Aff (Millwood) 2014; 33: 1399e1406.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.01.031 available at http://jurology.com/ Editorial Comment: The good news is that there has been a slowdown in health care spending in the last 7 yearsdno one is arguing this point. The focus of debate has been regarding why this phenomenon has occurred. Proponents of health care reform contend that structural changes in the health care sector before and since the introduction of the Affordable Care Act (ACA) have had an important role in the decline in growth of health care spending. This analysis argues that, in fact, the observed changes in health care spending were due almost entirely to the economic slowdown that occurred in 2008 and had nothing to do with an early response to the ACA. Does this mean that the ACA is failing to control costs? Not necessarily, as the cost control components of the ACA did not really start kicking in until 2014. Rather, this study underscores that there are many reasons why health care costs may increase or decrease, and we should not be too optimistic that any single factor or intervention will permanently solve our health care cost problem. David F. Penson, MD, MPH
Re: Changing Physician Incentives for Affordable, Quality Cancer Care: Results of an Episode Payment Model L. N. Newcomer, B. Gould, R. D. Page, S. A. Donelan and M. Perkins UnitedHealthcare, Minnetonka, Minnesota, Northwest Georgia Oncology Centers, Marietta, Georgia, and Center for Blood and Cancer Disorders, Fort Worth, Texas J Oncol Pract 2014; 10: 322e326.
Permission to Publish Abstract Not Granted Editorial Comment: Episode groupers are effectively risk adjusted capitated payments for outpatient health care. They effectively transfer risk from the payer to the provider and mimic diagnosis related groups in the outpatient setting. I firmly believe that episode groupers are the future of payment for outpatient health care in the United States. That being said, the effects of these novel payment models might not be what policy makers expect. In this setting of 5 outpatient medical oncology groups the authors studied the impact of episode groups on total costs and patterns of care. They found that the total cost of care was considerably less than what would have been expected if a fee-for-service model had been used but that the use and costs of chemotherapy actually increased in patients in the episode grouper model. Certainly the
0022-5347/15/1935-1615/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.01.031 Vol. 193, 1615-1617, May 2015 Printed in U.S.A.
www.jurology.com
j
1615
1616
SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
capitated payment model achieved its primary goaldto reduce costsdbut at what other price? Perhaps providers were more aggressive with up-front chemotherapy in this population of patients with lung, breast and colon cancer to avoid later costs. As we continue through the era of health care reform, we have to be cognizant of unintended consequences of changes in health policy. David F. Penson, MD, MPH
Re: Association of the 2011 ACGME Resident Duty Hour Reform with General Surgery Patient Outcomes and with Resident Examination Performance R. Rajaram, J. W. Chung, A. T. Jones, M. E. Cohen, A. R. Dahlke, C. Y. Ko, J. L. Tarpley, F. R. Lewis, D. B. Hoyt and K. Y. Bilimoria Division of Research and Optimal Patient Care, American College of Surgeons, and Surgical Outcomes and Quality Improvement Center, Department of Surgery and Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, American Board of Surgery, Philadelphia, Pennsylvania, Department of Surgery, University of California Los Angeles and VA Greater Los Angeles Healthcare System, Los Angeles, California, and Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee JAMA 2014; 312: 2374e2384.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.059 available at http://jurology.com/ Editorial Comment: Surgical residency education has changed radically in the last 2 to 3 decades. In addition to increased focus on outpatient care and minimally invasive approaches, there have been stringent rules put in place that limit resident duty hours. These regulations were implemented out of concerns for patient safety. The current study explores the impact of the latest round of resident duty hour reforms on 30-day morbidity and mortality outcomes in general surgery. The authors use a differences in differences approach to compare outcomes before and after the 2011 reform. They fail to show any differences in outcomes after implementation of the new rules. Does this mean that we should abandon residency duty hour limits or at least relax the rules? I do not believe so. Even a single adverse event that results from impaired decision making due to resident exhaustion is one too many. That said, it is also time to recognize that it is unlikely that these regulations have had a measurable impact on a population level and that, if we continue to limit work hours, we ultimately will either have to extend the residency training period or accept the fact that recent residency graduates may not have been exposed to the complete spectrum of urological conditions and ultimately may provide lower quality care, at least at first. There is no right answer to this difficult decision. David F. Penson, MD, MPH
Re: Patient-to-Physician Messaging: Volume Nearly Tripled as More Patients Joined System, but Per Capita Rate Plateaued B. H. Crotty, Y. Tamrat, A. Mostaghimi, C. Safran and B. E. Landon Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Department of Dermatology, Brigham and Women’s Hospital, and Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, and Johnson Health Center, Lynchburg, Virginia Health Aff (Millwood) 2014; 33: 1817e1822.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.060 available at http://jurology.com/ Editorial Comment: The electronic health record is a blessing and a curse for physicians today. In theory the ability of patients to directly message their physicians is convenient for patients and allows physicians to respond directly to patients, with the interaction being directly entered into the medical record. On the other hand, the ease with which patients can electronically message providers may result in physicians being deluged with messages and requests that take up their time and interrupt their work flow. The current series explores temporal trends in use of a patient portal at a large academic medical center. The study shows that patients have adopted the technology during the last decade, with 37%
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.01.031 available at http://jurology.com/ Editorial Comment: The good news is that there has been a slowdown in health care spending in the last 7 yearsdno one is arguing this point. The focus of debate has been regarding why this phenomenon has occurred. Proponents of health care reform contend that structural changes in the health care sector before and since the introduction of the Affordable Care Act (ACA) have had an important role in the decline in growth of health care spending. This analysis argues that, in fact, the observed changes in health care spending were due almost entirely to the economic slowdown that occurred in 2008 and had nothing to do with an early response to the ACA. Does this mean that the ACA is failing to control costs? Not necessarily, as the cost control components of the ACA did not really start kicking in until 2014. Rather, this study underscores that there are many reasons why health care costs may increase or decrease, and we should not be too optimistic that any single factor or intervention will permanently solve our health care cost problem. David F. Penson, MD, MPH
Re: Changing Physician Incentives for Affordable, Quality Cancer Care: Results of an Episode Payment Model L. N. Newcomer, B. Gould, R. D. Page, S. A. Donelan and M. Perkins UnitedHealthcare, Minnetonka, Minnesota, Northwest Georgia Oncology Centers, Marietta, Georgia, and Center for Blood and Cancer Disorders, Fort Worth, Texas J Oncol Pract 2014; 10: 322e326.
Permission to Publish Abstract Not Granted Editorial Comment: Episode groupers are effectively risk adjusted capitated payments for outpatient health care. They effectively transfer risk from the payer to the provider and mimic diagnosis related groups in the outpatient setting. I firmly believe that episode groupers are the future of payment for outpatient health care in the United States. That being said, the effects of these novel payment models might not be what policy makers expect. In this setting of 5 outpatient medical oncology groups the authors studied the impact of episode groups on total costs and patterns of care. They found that the total cost of care was considerably less than what would have been expected if a fee-for-service model had been used but that the use and costs of chemotherapy actually increased in patients in the episode grouper model. Certainly the
0022-5347/15/1935-1615/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.01.031 Vol. 193, 1615-1617, May 2015 Printed in U.S.A.
www.jurology.com
j
1615
1616
SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
capitated payment model achieved its primary goaldto reduce costsdbut at what other price? Perhaps providers were more aggressive with up-front chemotherapy in this population of patients with lung, breast and colon cancer to avoid later costs. As we continue through the era of health care reform, we have to be cognizant of unintended consequences of changes in health policy. David F. Penson, MD, MPH
Re: Association of the 2011 ACGME Resident Duty Hour Reform with General Surgery Patient Outcomes and with Resident Examination Performance R. Rajaram, J. W. Chung, A. T. Jones, M. E. Cohen, A. R. Dahlke, C. Y. Ko, J. L. Tarpley, F. R. Lewis, D. B. Hoyt and K. Y. Bilimoria Division of Research and Optimal Patient Care, American College of Surgeons, and Surgical Outcomes and Quality Improvement Center, Department of Surgery and Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, American Board of Surgery, Philadelphia, Pennsylvania, Department of Surgery, University of California Los Angeles and VA Greater Los Angeles Healthcare System, Los Angeles, California, and Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee JAMA 2014; 312: 2374e2384.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.059 available at http://jurology.com/ Editorial Comment: Surgical residency education has changed radically in the last 2 to 3 decades. In addition to increased focus on outpatient care and minimally invasive approaches, there have been stringent rules put in place that limit resident duty hours. These regulations were implemented out of concerns for patient safety. The current study explores the impact of the latest round of resident duty hour reforms on 30-day morbidity and mortality outcomes in general surgery. The authors use a differences in differences approach to compare outcomes before and after the 2011 reform. They fail to show any differences in outcomes after implementation of the new rules. Does this mean that we should abandon residency duty hour limits or at least relax the rules? I do not believe so. Even a single adverse event that results from impaired decision making due to resident exhaustion is one too many. That said, it is also time to recognize that it is unlikely that these regulations have had a measurable impact on a population level and that, if we continue to limit work hours, we ultimately will either have to extend the residency training period or accept the fact that recent residency graduates may not have been exposed to the complete spectrum of urological conditions and ultimately may provide lower quality care, at least at first. There is no right answer to this difficult decision. David F. Penson, MD, MPH
Re: Patient-to-Physician Messaging: Volume Nearly Tripled as More Patients Joined System, but Per Capita Rate Plateaued B. H. Crotty, Y. Tamrat, A. Mostaghimi, C. Safran and B. E. Landon Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Department of Dermatology, Brigham and Women’s Hospital, and Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, and Johnson Health Center, Lynchburg, Virginia Health Aff (Millwood) 2014; 33: 1817e1822.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.02.060 available at http://jurology.com/ Editorial Comment: The electronic health record is a blessing and a curse for physicians today. In theory the ability of patients to directly message their physicians is convenient for patients and allows physicians to respond directly to patients, with the interaction being directly entered into the medical record. On the other hand, the ease with which patients can electronically message providers may result in physicians being deluged with messages and requests that take up their time and interrupt their work flow. The current series explores temporal trends in use of a patient portal at a large academic medical center. The study shows that patients have adopted the technology during the last decade, with 37%