In nursing homes, an epidemic of poor dental hygiene

From the Well blog at the New York Times:

Katherine Ford visited her father, Dean Piercy, a World War II veteran with dementia, at a nursing home in Roanoke, Va., for months before she noticed the dust on his electric toothbrush. His teeth, she found, had not been brushed recently, so she began doing it herself after their lunches together.

But after he complained of a severe, unrelenting headache, she said, she badgered the staff to make an appointment for him with his dentist. The dentist found that a tooth had broken in two, and he showed Ms. Ford the part that had lodged in the roof of her father’s mouth.

“I was livid,” said Ms. Ford, 57, a court reporter. “I’m there every day, pointing out he’s in pain — and he had dental insurance. So there’s no reason this wasn’t addressed.”

In nursing homes across the country, residents like Mr. Piercy are plagued by cavities, gum disease and cracked teeth, in part because their mouths are not kept clean. While residents now require more dental care than in the past, nursing home employees are rarely prepared to provide it. Aides are swamped with other tasks, and when older charges must be helped to the toilet, fed or repositioned in bed, brushing their teeth often falls to the bottom of the to-do list.

Even when care is available, few staff members are trained to cope with the rising numbers of residents with dementia who resist routine dental hygiene.

“I always say you can measure quality in a nursing home by looking in people’s mouths, because it’s one of the last things to be taken care of,” said Dr. Judith A. Jones, chairwoman of the department of general dentistry at Boston University. “Aides change someone’s Depends, change a catheter or turn somebody every few hours, but teeth often don’t get brushed twice a day.”

The neglect can lead to terrible pain for the residents. Worse, new studies suggest that this problem may be contributing to another: pneumonia, a leading killer of  institutionalized older people.

Read the complete post here.

Data transparency at CMS

From the Health Affairs blog:

Over time it has become very clear that health care today relies on sharing data to drive improvements in access and care delivery as well as control costs. The Centers for Medicare and Medicaid Services (CMS) has embraced the need for greater data transparency while recognizing the importance of appropriately protecting personally identifiable information (PII).

Five years ago, CMS began to actively explore opportunities to provide new avenues for accessing data in order to make data available to a broader group of users. We are proud to say that today we are routinely and safely sharing data to support the transformation of the delivery system

Sharing data with providers. We are developing a broader strategy for providing more data to providers for performance measurement and quality improvement. For example, CMS is:

    • helping to promote efficiency in performance measurement through the qualified entity (QE) program. This program creates a structure through which providers can receive a single, actionable report covering all or most of their practice. QEs combine Medicare claims data from CMS with claims data from other payers to create comprehensive reports on the performance of hospitals, physicians, and other health care providers.
    • providing Accountable Care Organizations (ACOs) with monthly claims feeds covering the almost 3 million beneficiaries being cared for by physicians participating in the ACOs. The monthly feeds include care the beneficiary receives from both providers participating in the ACO and those that do not participate. These data permit the ACO to coordinate care for beneficiaries and provide true patient-centered care in a fee-for-service system.
    • working to improve the performance reports that providers currently receive from CMS to ensure that they are as meaningful as possible. An example of such a report is the Quality and Resource Use Reports released to physicians and physician groups.
    • developing a strategy for providing more data to more providers for performance measurement and quality improvement as required by the American Taxpayer Relief Act of 2012.

Read the complete post here.

Variation in Health Care Spending: Target Decision Making, Not Geography

New from the National Academies Press:

Health care in the United States is more expensive than in other developed countries, costing $2.7 trillion in 2011, or 17.9 percent of the national gross domestic product. Increasing costs strain budgets at all levels of government and threaten the solvency of Medicare, the nation s largest health insurer. At the same time, despite advances in biomedical science, medicine, and public health, health care quality remains inconsistent. In fact, underuse, misuse, and overuse of various services often put patients in danger.

Many efforts to improve this situation are focused on Medicare, which mainly pays practitioners on a fee-for-service basis and hospitals on a diagnoses-related group basis, which is a fee for a group of services related to a particular diagnosis. Research has long shown that Medicare spending varies greatly in different regions of the country even when expenditures are adjusted for variation in the costs of doing business, meaning that certain regions have much higher volume and/or intensity of services than others. Further, regions that deliver more services do not appear to achieve better health outcomes than those that deliver less.

Variation in Health Care Spending investigates geographic variation in health care spending and quality for Medicare beneficiaries as well as other populations, and analyzes Medicare payment policies that could encourage high-value care. This report concludes that regional differences in Medicare and commercial health care spending and use are real and persist over time. Furthermore, there is much variation within geographic areas, no matter how broadly or narrowly these areas are defined. The report recommends against adoption of a geographically based value index for Medicare payments, because the majority of health care decisions are made at the provider or health care organization level, not by geographic units. Rather, to promote high value services from all providers, Medicare and Medicaid Services should continue to test payment reforms that offer incentives to providers to share clinical data, coordinate patient care, and assume some financial risk for the care of their patients.

Order a prepublication copy or read it for free on the National Academies Press web site.

New HRSA briefs on rural health

From the Health Resources and Services Administration (HRSA):

Two new health briefs have been published focusing on rural health and Medicare.

“Medicare Payments & Common Diagnoses. Review of 2009 Medicare Output Claims Data. Findings Brief #107” (ORPH00574) presents a summary profile of Medicare billing and reimbursement activity for independent and provider-based Rural Health Clinics (RHCs). It uses data from 2009 Medicare outpatient provider claims on all RHCs that billed Medicare.

Policy brief “Medicare Advantage Enrollment Update (Brief No. 2013-3;  ORHP00573) examines the growth of Medicare Advantage enrollment between 2008 and 2012. It reviews the distribution of market share by the type of plan, including preferred provider organizations, health maintenance organization/point of service, non-private fee for service, and other preferred provider organization plans, and by state.

Nationwide Hospital Charges

On the heels of yesterday’s post on U-M’s analysis of its visualization activities, today’s post also touches on the impacts of visualization, although on a much broader scale. The New York Times recently released an interactive data visualization map that tells you how much hospitals charge per procedure. You can search by location (state & zip code) and see how the charges compare to national averages. Visualization is based on 2011 data collected from 3,300 hospitals and includes the top 100 common procedures (including hip replacement, heart operations, and gallbladder removal).  Naturally, there is an accompanying article.
The pricepoints that the NYT used to build its interactive map comes from the Centers for Medicare & Medicaid Services, and the full (warning: massive) dataset can be found here.
UMHS reported costs slightly above the national average, but points out that it:
doesn’t mean patients or their insurance companies are paying those charges…Patients then pay whatever’s left after the insurance or Medicare payments.
UMHS Medicare reimbursement was also high, to which UMHS Headlines responded:

The payment we receive for treating Medicare patients is set by the federal government, not us, and takes into account how sick the patient is. Since we care for some of the most acutely ill patients in the country, including transfers from other hospitals and patients with underlying conditions that complicate their care, it is not surprising that we should be reimbursed at a higher rate.

Our Medicare reimbursement also includes payments that offset some of our costs for caring for a disproportionate share of uninsured patients, and for paying for the salaries, training and supervision of more than 1,100 resident physicians.

Read the full UMHS response here, and the article here.

Immigrants Contributed More To The Medicare Trust Fund Than They Took Out In 2002-09

From Health Affairs:

In 2009 immigrants in the United States accounted for a net surplus of $13.8 billion paid into the Medicare Hospital Insurance Trust Fund, while native-born Americans were responsible for depleting the fund of $30.9 billion. This finding from a study being released today as a Web First by Health Affairs, suggests that immigrants heavily subsidize Medicare. This study is the first to quantify immigrants’ share of contributions to this fund.

The authors tabulated contributions from the Current Population Survey, data generated by the Census Bureau and Bureau of Labor Statistics, and expenditures from the Medical Expenditure Panel Survey, conducted by the Agency for Healthcare Research and Quality. They then calculated net contributions (contributions minus expenditures) for immigrants, noncitizen immigrants, and native-born Americans for each year between 2002 and 2009.

The study found that immigrants generated surpluses of $11.1-17.2 billion per year between 2002 and 2009, resulting in a cumulative surplus of $115.2 billion to the fund that primarily pays hospitals and institutions under Medicare Part A. In 2009 the final year examined in this study, immigrants made 14.7 percent of Trust Fund contributions but accounted for only 7.9 percent of its expenditures–a net surplus of $13.8 billion to Medicare, the majority of which was attributable to noncitizen immigrants.

Read the complete story here.

Medicare advantage costs often exceed traditional Medicare costs

From the Commonwealth Fund:

Health plans participating in Medicare Advantage (MA), the private insurance option for Medicare beneficiaries, have long been paid considerably more to provide coverage of hospital and physician services than what the government spends to deliver the same benefits to enrollees in traditional Medicare.

Under the Affordable Care Act, overpayments to these plans are gradually being pared back. But will private plans be able to cope with the reduced payments?

Using newly available government data, Marsha Gold, a senior fellow with Mathematica Policy Research, found that risk-adjusted MA plan costs in 2009 were, on average, 4 percent higher than those for traditional Medicare. Among plan types, only health maintenance organizations (HMOs) had lower average costs, while costs for more than 75 percent of local preferred provider organizations (PPOs) and private fee-for service plans exceeded traditional Medicare’s. According to Gold, the wide variation in MA plan costs relative to traditional Medicare suggests there is room for many of these plans to deliver care more efficiently and keeps costs down.

Visit to read more.

FAQ: Decoding The $716 billion in Medicare reductions

From Kaiser Health News:

The structure and financing of Medicare, the federal health insurance program that serves seniors and the disabled, has become a defining issue in the presidential and congressional campaigns since GOP presidential candidate Mitt Romney picked as his running mate Rep. Paul Ryan. KHN’s Mary Agnes Carey answers some frequently asked questions about the numbers and policy surrounding the Medicare debate.

 Q:  Romney and other Republicans over the past two years have criticized President Barack Obama and Democrats for cutting $500 billion from the Medicare program over the next decade as part of the 2010 health care law.  In the past couple of weeks, the number that Romney is using has grown to $716 billion? Which is right?

A: They both are.  The $500 billion figure comes from a March 2010 analysis that estimated the 2010 federal health law’s effects on Medicare spending and was put together by the Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT). It covered the budget years 2010-2019. 

Read the complete article here.

Healthcare Innovations Summit – Recap now available

On January 26, 2012, health delivery systems, physicians, innovators, policymakers, academics and venture capitalists gathered at the Care Innovations Summit in Washington, DC.

More than 1,200 individuals participated in person and an additional 3,000 joined online. Hosted by the Centers for Medicare & Medicaid Services (CMS), the West Wireless Health Institute (WWHI), and Health Affairs, this event showcased care delivery and payment solutions already working in the marketplace, catalyzing the dialogue for applying and expanding successful solutions to lower the cost of health care.

The Summit recap can be found here.

Continue the conversationby emailing or tweeting  updates: or #cisummit. Check back on for updated content and videos.