Farzad Mostashari Profile picture
Sep 23, 2020 12 tweets 6 min read Read on X
1/ How can we reduce Medicare spending without harming patients?

What we do @AledadeACO is transformative, but hard.

There are some low hanging fruit. This was one of them

Prior auth for repetitive, scheduled non-emergency ambulance transportation

cms.gov/newsroom/press…
2/ When CMS first released their public use files, I ran some analyses looking for aberrations-

One thing that jumped right out was...Repetitive non-emergency ambulance runs- often for the same person going back and forth to dialysis 3 times a week.

3/ In my blog @BrookingsInst back in 2014 I wrote:

"Medicare and law enforcement officials will need to create new processes for dealing with a potential flood of outlier reports from amateur sleuths like me."

But prevention >> fraud enforcement

brookings.edu/blog/up-front/…
4/ Later in 2014, @CMSinnovates launched an experiment to see if prioir authorization for these repetitive scheduled non-emergent ambulance transports (RSNAT, natch) would reduce costs without harming beneficiaries.

(private insurance companies do this as a matter of course)
5/ They started in the areas known to be problematic. I'm sure the mob is somehow involved in the NJ shenanigans, they are so brazen. Also PA and SC.

Over a quarter of all RSNATs had been improper, according to the @OIGatHHS and unsurprisingly, putting in controls worked!
6/ Another demonstration with prior auth for durable medical equipment also found significant savings without patient harm.

Medicare needs to be able to do reforms like this, and @CMSinnovates gives it the ability to implement them without special interest lobbying blocking them
7/ so...only 6 years later, we have the second interim evaluation showing cost savings in the initial plus expanded demonstration states, and CMS is expanding this nationwide.

I wish it could happen faster, but this is why @CMSinnovates need to stay

innovation.cms.gov/data-and-repor…
8/ So here's the data you came for.

When you have large effect sizes you don't need very fancy analytics, though they did them anyway,

The high outlier initial states fell down immediately to below comparison states.

The second wave also dropped, albeit they had less to shed Image
9/ So what was the compensatory care (there is *always* a put for every take)?

More home health services. Turns out a lot of those patients didn't need to be put on an ambulance 3x a week. Care could go to their home (including home dialysis)

I will take that. Image
10/ But inevitably people will say "limiting care must have tradeoffs! someone is going to be harmed if we don't keep paying for these without question."

Maybe @tradeoffspod will do an episode on this, cause you have to squint hard to find it.

LOWER prob of ED/Hospital use Image
11/ Also interesting that this didn't create an ongoing large burden of bureaucracy.

About half of the ambulance companies, esp those that depended on these routine transports went out of business.

The rate of denials went down back to baseline after a few quarters. ImageImage
12/ In conclusion,

There are lots of little things we can do to reduce waste in Medicare, and we should do them

CMMI is a good thing

I wish it wouldn't take so long to go from pilot to policy.

(but nice job on the eval @kcontreary)

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More from @Farzad_MD

Apr 30
1/ When Walmart enters any business you can expect that they will leverage their massive scale to get better economics, create value for customers- and drive out local mom and pop competitors

Thats what many assumed would happen w primary care clinics

but it didn't

why not?
2/ The first thing I have to acknowledge is to rule out "execution"

They aren't perfect (their Athena and Epic EMR travails show that) but Walmart knows how to execute, and they won't scale something until they've figured out how to make it profitable.

They couldn't
3/ To their credit, they tried a lot of permutations over the past 10 years, and strictly as an operator, you have to give them respect that they could be a force

- Third party vendor
- Walmart Health clinics
-Oak St Health
- Own clinics + telehealth

Read 16 tweets
Nov 2, 2023
1/ Final rule for Physician Fee Schedule is out.

let's see how the Medicare Shared Savings Program provisions played out compared to the proposed rule.

(tl;dr mostly as proposed- incremental improvements to the nation's most mature, and most successful value based program)
2/ risk adjustment should be updated to the new "v28" approach for performance and benchmark years.



my only complaint is that it's only applied moving forward- if it's good policy why not allow existing contracts to update?

3/ Fixing the glitch where ACO risk scores and regional risk scores weren't treated equally (ACO gets a cap, now region does too)



(again, why not have a simple single approach for all contracts instead of only applying it moving forward?)

Read 12 tweets
Sep 11, 2023
1/ What are the factors driving the mysterious slowdown in Medicare cost growth?

It's been a longstanding dinner conversation among health policy folks, and I have one idea to add to the mix that I haven't seen discussed yet.. Image
2/ There were lots of theories batted around in the article and the followup from @sangerkatz

My fav: "Talk Therapy Actually Works" (@ZekeEmanuel)

Policymakers setting expectations of cost control inhibit investments and behaviors that drive cost growth
nytimes.com/2023/09/09/ups…
We saw similar unexplained slowdown in healthcare costs during the *ultimately unsuccessful* Clinton health reform efforts.

The slowdown happened almost immediately in 1992, even though nothing had happened yet, other than campaign talk

(@jrovner can prob give history on that) Image
Read 8 tweets
Dec 24, 2022
1/ Warning!

nerdy Medicare payment deep dive

OMNIBUS EDITION

You've read the headlines ("Medicare pay cuts partially averted") but to understand what led us here--and what's to come-- we need to go deeper

Also, some cool tangents on effective/ineffective financial incentives
2/ let's walk through the weeds of

"a temporary patch on an expiring pandemic patch for the unintended consequences of a good-will effort to fix pay imbalance between primary care & specialists, made worse by a failure to predict future inflation, w a sop to value-based pay"
3/ The "failure to predict medical inflation"

remember the annual "doc fix" scramble? it was because the "sustainable growth rate" was indexed to inflation, which was near zero for years. So Congress had to constantly step in to reverse its own past efforts to control costs. 😧
Read 27 tweets
Dec 22, 2022
1/ Medical Debt- a holiday story

A few years ago, I found myself poring over a printout of ED frequent fliers with a PCP in Mississippi.

The office manager knew why they were going to the ED.

“They’re not going to show their faces here. They all owe us money.”
2/ Because of the Emergency Medical Treatment & Labor Act, the ED would see them even if they owed money

But thousands more dollars would have been added on top of the prior debts

His bills will climb. His credit score will drop. Collection agencies will start hounding him
3/ When I was in college I got dehydrated at a crew meet and an ambulance took me to the ER. A couple of liters of fluid later I was fine

But I couldn't figure out what to do when the bills started coming

For years I carried the stress and shame of being sent to debt collection
Read 17 tweets
Nov 1, 2022
1/ Let's flip through the Physician Fee Schedule Final Rule just out, w shared savings focus

Here's a little trick to get past all the pesky comments (that people spent 1000's of hours developing and submitting), and right to the meat of the matter:

CTRL-F "we are finalizing"
2/ First up: we want to increase participation!

strong evidence for providing upfront capital, especially to rural, underserved, low income ACOs (see AIM)

Good idea to expand it 👍

Lots of comments about eligibility criteria, repayment, etc etc.

"finalized as proposed"
3/ We want to increase participation!

Let's allow folks to stay in one sided risk for longer, especially lower income (no hospital) ACOs

Makes sense 👍

Lots of comments about who, how, when, etc etc

"finalized as proposed without modification"
Read 23 tweets

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