Eyeworld

EW NEWS & OPINION 14 April 2015 Insights by J.C. Noreika, MD, MBA executive vice-president enthusias- tically endorsed prospective global payment models "which promote value over volume." There's that pesky problem of correlation and causation again. In "How Not To Be Wrong: The Power of Mathematical Thinking," Jordan Ellenberg, professor of math- ematics at the University of Wiscon- sin-Madison, paraphrases Prussian military theorist Carl von Clausewitz by positing "mathematics is the ex- tension of common sense by other means." The math is revealing. Mr. Ellenberg cautions against linear thinking. Ms. Burwell writes, "there were 1.3 million fewer ad- verse events between 2011 and 2013 than there would have been if the rate of such events had remained un- changed" (my italics). Social planners like linear thinking. If policymakers were to treat patients who suddenly lose vision, they might realize that the quality/cost curve is brutally non-linear and "big" is an indepen- dent variable. But non-linearity has its own mysteries. One example is the Laffer curve. Economist Arthur Laffer infamously proposed that the government's tax revenues are non-linearly related to the tax rate. However, when he was questioned by members of Congress in regard to the optimal tax rate, he demurred, "I cannot measure it frankly, but I can tell you what the characteristics of it are." And that's the troubling part about Ms. Burwell's conceit. Confi- dent of design, viz., big and bureau- cratic, the plan lacks insight into the Extending common sense by other means Advancing CATARACT SURGERY LenSx ® © 2015 Novartis 2/15 CNT15013JAD CENTURION ® VISION SYSTEM IMPORTANT PRODUCT INFORMATION CAUTION: Federal (USA) law restricts this device to sale by, or on the order of, a physician. 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Cautioning against linear thinking T his month's conclave of the American Society of Cataract & Refractive Surgery animates ophthal- mology's finest minds to assess the state of their profession. The clairvoyance of Nostradamus, the prophesy of the Cumaean Sibyl, and the mysticism of iridology ar- en't necessary to perceive this year's concerns to be more ACO than PCO, SGR than SLT, medical home than surgery center. Urged on by Congress and the White House, the Department of Health and Human Services (HHS) is resolved to unwind the mainspring of American medicine, fee-for- service payment. In so doing, it threatens to make private practice a retronym like snail-mail and land- line phones. On Jan. 26, HHS Secretary Sylvia M. Burwell announced an ambitious program to tie 50% of Medicare's outlay to alternative payment models by 2018. She proposes to do this by fostering quasi-innovations like accountable care organizations (ACOs), medical home models and bundled payments. In her address to payers, employers, Medicaid directors, consumers, and providers, the argot was familiar: "transfor- mative change," "accountability," "measurable improvement," "man- age and track progress." Quality of care will improve and costs low- ered "by spending our healthcare dollars more wisely." Incentives and penalties prodding physicians to embrace these new programs were not addressed. The process is well underway. Meaningful use, generating "Big Data" by connecting physicians, hospitals, pharmacies, insurers, and patients, is best implemented by large organizations that can absorb its technologic costs by sleight of balance sheet tactics that small prac- tices can't afford. ICD-10 and the Physician Quality Reporting System (PQRS) impose disingenuous taxes best absorbed by not-for-profits. Tort reform's absence in the Affordable Care Act was not solely the slick work of 1-800-lawyers. Unlike other businesses such as financial—and legal—services, these costs cannot be passed along to consumers. Balance billing is proscribed. Government has little use for cottage industries. Only massive, too-big-to-fail organizations pro- vide the efficiencies to preserve the American way of life including its consumption of healthcare. The architects' scatter-plot clearly sug- gests that consolidation inexorably pushes the curve into the coveted quadrant of low cost, high quality care. Hence, the ACO and the medical home. Represented at Burwell's an- nouncement, the American Medi- cal Association endorses a system of high-quality and efficient care "while reducing the administrative and regulatory burdens of physi- cians." How it and the government propose that happens awaits the sequel. Characteristically, the Amer- ican Academy of Family Physicians, the country's fervent admirer of Britain's National Health Service, called for the end of fee-for-service medicine. Quaffing the Kool-Aid, its J.C. Noreika, MD, MBA

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