WHCOA Regional Forum

I am delighted to have received an invitation to this Monday’s regional White House Conference on Aging forum. The fourth in a five part series and being held in Cleveland, the regional forum is designed to focus public attention on the key issues of ensuring retirement security, promoting healthy aging, providing long-term services and support and protecting older Americans from financial abuse and neglect.

The Conference on Aging has been held once a decade since the 1960s, “to identify and advance actions to improve the quality of life of older Americans.” Input and engagement is being sought from older adults, as well as a variety of stakeholders sharing an interest and passion for addressing the difficult issues of providing housing, services and care for an aging population with limited resources.

The Cleveland forum is being held at the Global Center for Health Innovation, which showcases the confluence of best practices and emerging technologies impacting how care is provided and received. Northeast Ohio is a leader in advancing innovative solutions to the challenges facing older adults navigating their way through successful aging. With organizations like the Benjamin Rose Institute on Aging and the McGregor Foundation (most proud to note that both are clients of Artower Advisory Services), Greater Cleveland has a well-respected history of supplementing the area’s world class medical care with strong community-based services that enrich and protect the lives of seniors.

It is truly an honor to share the day with individuals served by organizations such as these and to hear firsthand their expectations for successful aging in the years ahead. I promise to take good notes and report back here on the key issues being discussed and debated. And with any luck, maybe a few pub patrons will want to weigh in on those issues.

Cheers,
  ~ Sparky

Chasing Population Health

A few years back when the ACO concept was starting to gain traction as a result of the Affordable Care Act’s Shared Savings Program, Mark Smith, MD of the California Healthcare Foundation remarked that, "the accountable care organization is like a unicorn, a fantastic creature that is vested with mythical powers. But no one has actually seen one." I am starting to wonder, as are many others, whether that analogy might even more adeptly describe population health and the tidal wave of efforts now being directed toward managing same.

In a post today on the Health Affairs Blog David Kindig argues that in light of the definitional challenges that have led to confusion of what population health is – or is not – what’s now required are “multiple definitions.” Counterintuitive as that may seem, Mr. Kindig explains how the term is today being increasingly applied to populations characterized by disease state and/or chronic condition (i.e., a clinical perspective) rather than the traditional understanding of populations defined primarily by geographic origin.

The latter’s focus is rooted in public health officials’ efforts to observe, quantify, assess and understand a multitude of personal and environmental considerations that impact the health of individuals – and how that impact is manifested in health characteristics of a defined population over time. The former is a growing focus of new delivery and payment models that aim to lower costs by decreasing demand – while assumedly concurrently not affecting safety, quality or having a negative impact on outcomes.

More importantly, population health in the clinical sense is being touted as a primary means of assessing the success of those models – and in turn, providing financial reward for that success. And further, in contrast, it is being used as a disincentive to pursue activities that are not proven to improve population health.

And there’s the rub, isn’t it. One of the two obstacles that currently prevent us from being able to leverage value in healthcare as Porter, et al have envisioned as the market mechanism that will curb costs and increase performance is the ambiguity surrounding how to define a patient outcome (the other being 19th century cost accounting practices still in place in healthcare). If we haven’t yet been able to adequately define and agree upon the comparative merits of individual patient outcomes, then how the hell can we suppose to find benefit from applying that shortcoming exponentially?

Cheers,
  ~ Sparky

Health and Housing Task Force

BPC_logo2The Bipartisan Policy Center, founded in 2007 by former Senate Majority Leaders Howard Baker, Tom Daschle, Bob Dole and George Mitchell, today announced a new Health and Housing Task Force that seeks to help address the needs of an aging US population. The one-year initiative is to be led by former HUD Secretary Henry Cisneros, former Senator and HUD Secretary Mel Martinez and former Representatives Allyson Schwartz and Vin Weber.

In echoing research and observations made in the recently released report, Housing America’s Older Adults: Meeting the Needs of An Aging Population, prepared by Harvard Joint Center for Housing Studies and the AARP Foundation, the BPC notes the glaring disconnect between forecasted housing, services and care needs as compared to our current ability to meet that demand.

In explaining the task force’s direction Mr. Cisneros noted that, “our aim is to call attention to this emerging challenge facing our nation. This challenge offers incredible opportunity in the near-term, yet is on track to become a major crisis in the coming years if left unaddressed.” Specific goals outlined by the task force include:

Find cost-effective ways to modify homes and communities to make independent living for seniors safe and viable. Identifying potential funding sources will be critical.

Highlight best practices from states and localities for integrating housing, health care, and long-term services and supports. The task force will seek out programs that work and investigate how they can be replicated elsewhere.

Identify barriers to offering home-and community-based services and supports through Medicaid.

Seek opportunities for further collaboration between the Departments of Housing and Urban Development and Health and Human Services.

The fourth goal is something that I have been scratching my head about for more than a decade now. I once even had the chance to personally ask a former HHS Secretary why the two departments couldn’t find more ways to collaborate, and that person was surprisingly candid in not knowing why either.

I know it may seem intuitive to those working in senior housing and care, but still much of the healthcare industry is only starting to recognize and understand that if services and care need to be provided “long-term,” then those individuals requiring such care need a place to live – they need a home. Further, we are learning more every day that underscores how important it is to have hospitality services provided in coordination with that care in order to achieve a beneficially holistic approach to health and wellness. Thus I believe any successful delivery model that addresses the crisis this task force sets out to address must reflect a deep understanding of four core areas:

Real estate – a place that can be called home wherever that may be

Operational & clinical performance: consistently safe and high quality services that are unique to the populations being served

Hospitality: recognizing and respecting the human spirit’s desire to live a fulfilling life

Underwriting: understanding the unique financial challenges of providing extended services and care

I would encourage the task force – and any other organizations involved in assessing and contributing to the knowledgebase that increases access and affordability of senior housing and care – to adopt these as the four pillars of any successful delivery model.

Cheers,
  ~ Sparky

To Sleep Perchance to Die

Hamlet___Skull_Study_by_PaulJulianBanksEarlier this week the French parliament acted in a compassionate – and certainly controversial – fashion by passing a law that will allow terminally ill patients to opt for “deep sleep” as an alternative to and/or palliative care. Lawmakers there believe (and by a substantial majority) the measure does not legalize euthanasia, but not everyone agrees. And the applicability of such a policy decision to America’s struggle with healthcare cost containment could not be more profound.

Depending on which study you want to believe, it is estimated that between 25% and 30% of all Medicare spending each year goes toward the 5% of beneficiaries who die in that year. Of that, approximately one-third of expenditures occur in the last month of life. If it weren’t for the realty that life is the most precious commodity on earth, it would be a rather simple fete accompli that such investment is ludicrous.

But any discussion of healthcare policies touching upon end-of-life care is rife with raw emotion and often political hysterics. Death Panels anyone? While Sarah Palin may have done more personally than anyone in history to obfuscate rational, intelligent discussion on reconciling individual rights with social responsibilities she nonetheless hit the mark in connecting the end-of-life care conversation to rationing: because that’s a core element of the policy debate – and it needs to be.

The talking points surrounding healthcare policy that affects end-of-life care are, however, spreading beyond just rationing – as the actions in France indicate. There is a shifting cultural perception of death as not so much a medical problem as it is a spiritual reality that can only be effectively addressed by one person – one moment at a time. And the quality of life vs expenditure is an emerging debate that will be owned by the Baby Boomer generation in a way this country has never seen.

Do the actions of the French lawmakers reflect a cultural awareness that is progressively ahead of where we stand in the US? Or do they reflect the further advance of progressive abandonment of respect for the sanctity of life that we must stand fast to defend?

Before answering, consider . . .

To be, or not to be, that is the question—
Whether ’tis Nobler in the mind to suffer
The Slings and Arrows of outrageous Fortune,
Or to take Arms against a Sea of troubles,
And by opposing, end them? To die, to sleep—
No more; and by a sleep, to say we end
The Heart-ache, and the thousand Natural shocks
That Flesh is heir to? ‘Tis a consummation
Devoutly to be wished. To die, to sleep,
To sleep, perchance to Dream; Aye, there’s the rub,
For in that sleep of death, what dreams may come,
When we have shuffled off this mortal coil,
Must give us pause.
~ Hamlet, Act III, Scene i

Cheers,
  ~ Sparky

Picture Credit:
Hamlet – Skull Study by PaulJulianBanks

DocFix is D O A

pic_related_022514_SM_A-Doc-Fix-Thats-Not-a-Fix_0Things have gotten so pitiful in Washington that political reporters – being anxious to share any news their audiences might find not depressing – are apparently falling over one another buying into the idea that a divided city can suddenly  come together and address the $174 billion political juggernaut of Medicare reimbursement for physician services. Using words like momentum, enthusiasm and optimism they report that Congress is advancing on a permanent Doc Fix.

Oh, please.

The rightwing of the Republican Party has already made clear its intent to use intransigence as the primary tactic to implement a strategy of growth through attrition in this 114th Congress.  And the only hope for securing Democratic support to bridge the voting gap left in their wake will be if those Democrats subscribe to Ms. Pelosi’s edict of not reading healthcare legislation before voting on it. Because if they actually read it, they will in all likelihood not be happy at the entitlement program cuts needed to fund the fix.

Alternatively, funding offsets could be achieved on the backs of other clinical providers and Medicare recipients. Those have always been pushover constituencies with poor lobbying representation, right? Or, to steer clear of that minefield legislators could assume funding offsets will come from expanding value-based payment models and continued implementation of other ACA reforms (e.g., lowering of hospital readmissions). That should be an even easier sell with Conservatives in Congress (yeah, more sarcasm).

And let’s not forget the public and private enterprise investments made into ICD-10 implementation, which Republican lawmakers would probably seek to delay as part of SGR repeal. That will be a contentious ideological battle separate from not having $174 billion at hand.

See what I’m getting at?

All this has to be worked through before physicians face an average reduction of 21.1% in Medicare payments in less than three weeks. Physicians who are already nearing their human capacity and ability to fight through the regulatory obstacles that impede helping their patients.

So don’t buy into the hype: 2015 looks a lot like 2002, 2003, etc. – time once again to kick the can down the road.

Cheers,
  ~ Sparky

Mental Health: Change Perception–Change Reality

Reprinted from the SAMHSA blog:

Changing the Story about Mental Health in America

blog.samhsa.gov · by SAMHSA · March 9, 2015

Today, in support of her Joining Forces initiative, the First Lady spoke at the launch of The Campaign to Change Direction, a nation-wide effort to raise awareness around mental health in America. Spearheaded by Give an Hour and co-sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), the campaign is designed to change the story of mental health across the nation by urging all Americans to learn the five signs that someone might be in distress.

While there has been much media attention on mental health in the military and veteran community, it is incredibly important to understand that mental health isn’t just a military issue — it is a human issue. Mental health conditions impact our children, our grandparents, and our neighbors. Every year, roughly one in five adults — or more than 40 million Americans — experience a diagnosable mental health condition like depression or anxiety.

"I want to encourage everyone in this country to go to http://t.co/MBYHHV44EY." —The First Lady on learning the five signs of mental illness

— The First Lady (@FLOTUS) March 4, 2015

It’s up to all of us to change the conversation by encouraging everyone to reach out when a friend, co-worker, veteran, or loved one might be struggling, and to ask for help when we need it for ourselves.

As the First Lady said today at the Newseum in Washington, D.C.:

It’s time to tell everyone who’s dealing with a mental health issue that they’re not alone, and that getting support and treatment isn’t a sign of weakness, it’s a sign of strength. That’s something that my husband believes strongly as President. Because in this country, when you’re fighting an illness — whether that’s mental or physical — you should be able to get the help you need, end of story.

Rory Brosius is the Deputy Director of Joining Forces.

Campaign to Change Direction, First Lady of the United States of America, FLOTUS, Joining Forces, Michelle Obama, The First Lady

Cheers,
  ~ Sparky

OBAMACARE: Was The Runner’s Knee Down?

NFL-REF-WATCH-BREAKING-BAD-bigger-300x211The play lasted only eight seconds out of 3,600 in the entire game. The distance traveled roughly 16 inches out of 3,600 across the field. Yet what occurred during those 8 seconds and 16 inches could make the difference between immeasurable joy or profound sadness. It all depends on how the referees view the play.

Of less substantial consequence in the minds of most Americans, starting tomorrow the Supreme Court will begin hearing arguments over 6 words of the Affordable Care Act – out of roughly 382,000: “through an exchange established by the State.” In November of last year when the Court determined (or at least four Justices did) to hear King v. Burwell I wrote, Does Legislative Negligence Trump Legislative Intent? I discuss there the background and ramifications of this case.

Here I am more interested in briefly sharing some thoughts on the relative influence of sociopolitical factors in SCOTUS’s review and consideration of this case. Whereas our historical view of the Court is one of great reverence and respect – the last bastion wherein ethics and morality trump politics – I think the image I chose for this post today more accurately reflects public opinion of that institution today – right or wrong.

I am not about to argue that politics has only recently become an unsightly element of the Court. Justices are appointed and approved by those who are elected, and they don’t get to the position of being considered by living out an apolitical professional career. From accusations against President Grant for court packing to FDR’s proposal to add members (conjectured to dilute a conservative bench) to more recent skirmishes over presidential nominees (e.g., Bork and Thomas) the Court has been steeped in political undertones for decades.

But what we are witnessing today is beyond just the politicization of appointees and the legacy influences of political ideologies. Like all things touched by our modern media the Court is engulfed by a sea of opinions and editorials in anticipation of a “wrong” decision – having not even heard one word of oral argument. How can the justices not hear the deafening crowd noise any less than the referees on the field looking under the video replay monitor. What influence, if any, will that carry on how they view King v. Burwell?

Regardless of how you hope the case is adjudicated you must see the irony in 8 million lives potentially being negatively impacted by 9 individuals out of 320 million based on the arbitrary interpretation of 6 words among 382,000.  Welcome to 21st century democracy in America.

Cheers,
  ~ Sparky

Does Measuring Quality Drive Value?

businesswoman drawing diagrams on wallThe Centers for Medicare and Medicaid Services today announced release of the 2015 Impact Assessment of Quality Measures Report. Designed to relate the performance on quality measures over time, it includes research on 25 quality programs and hundreds of quality measures from 2006 to 2013.

Key findings of the report include:

Overall quality measurement results demonstrate significant improvement over time.

Race and ethnicity disparities present in 2006 were less evident in 2012.

Provider performance on CMS measures related to heart and surgical care saved lives and averted infections.

CMS quality measures impact patients beyond the Medicare population.

CMS quality measures support the aims of the National Quality Strategy (NQS) and CMS Quality Strategy.

There is an old management adage that goes, “what cannot be measured cannot be managed.” It is from this vantage that CMS advocates for the role quality measurement plays in achieving the desired goals of improved access, better outcomes and lower cost (the infamous Triple Aim liberally interpreted by me). While the data may support improvement in performance indicators, that does not necessarily translate into value.

And value is (or ought to be) the universal currency of the Triple Aim

Recall, I have shared here often that value in healthcare is defined as outcomes divided by cost – and that measuring outcomes is a bit like trying to nail Jell-O to the wall. Measuring and reporting on quality in other industries has proven to be a useful endeavor that underpins market efficiencies. It’s not the availability and use of information derived from such endeavors that I wonder about – but who uses it and how.

Consumers that are armed with information on product and service quality from organizations like Consumer Reports are better able to navigate the value paradigm and reconcile their wants and needs against affordability. But in healthcare, consumers (patients) largely still don’t get to do that regardless of how much Big Data is collected, analyzed and reported on by CMS.

Will future efforts to capture all of the nuances that influence how individuals determine the value of an outcome ever be adequately captured by Big Data analytics in a fashion that such knowledge can supplant the simple effectiveness of personal decision making in a free market? CMS is banking on it.

What say you?

Cheers,
  ~ Sparky

Health Care Payment Learning and Action Network

Back view of businessman drawing sketch on wallAs shared here in the Pub at the end of January (Value-Based Payment: The Rush Is On) HHS has set a goal of migrating 30% of all Medicare payments to alternative payment models by December of next year – and 50% by the end of 2018. Overall the goals of having all payments tied to quality or value are 85% and 90% during the same periods, respectively.

Commensurate with these initiatives CMS today announced the establishment of the Health Care Payment Learning Network, to provide a forum for public-private partnerships to help the U.S. health care payment system (both private and public) meet or exceed recently established Medicare goals for value-based payments and alternative payment models.”

The Network will perform the following functions:

Serve as a convening body to facilitate joint implementation of new models of payment and care delivery;
Identify areas of agreement around movement toward alternative payment models and define how best to report on these new payment models;
Collaborate to generate evidence, share approaches, and remove barriers;
Develop common approaches to core issues such as beneficiary attribution, financial models, benchmarking, quality and performance measurement, risk adjustment, and other topics raised for discussion; and
Create implementation guides for payers, purchasers, providers, and consumers.

CMS is asking for payers, providers, employers, purchasers, state partners, consumer groups, individual consumers, and others to join the network in order to participate in the discussion and debate on how to transition toward the aforementioned goals via alternative payment models. The Network is to be convened by an independent contractor that will help ensure it operates independently of HHS, CMS and other governmental entities while supporting the efforts of Network participants.

A Guiding Committee made of participants from the Network will be created to act as a clearinghouse of topics and ideas and to help prioritize discussion topics based upon the input they receive from Network participants. The frequency of meetings is to be determined but it is intended that most will be held virtually via teleconference and/or webinar. A kickoff event is being scheduled for Wednesday, March 25th.

I have signed up as a network participant to follow the activities and information provided from the Network and will share more on this blog down the road.

Cheers,
  ~ Sparky

What’s Your Quality Strategy?

04AThe Agency for Healthcare Research and Quality (AHRQ) announced today that slides are available from the February 4th National Quality Strategy Webinar, entitled Using Payment to Improve Health and Health Care Quality. Payment models is one of nine strategic levers (see below) AHRQ recommends using to drive strategic quality improvement.

The National Quality Strategy is an initiative that was established pursuant to the Affordable Care Act to, “improve the delivery of health care services, patient health outcomes and population health.” The first strategy was published in 2011; this initiative represents a nationwide effort of public and private stakeholders to align quality measures with quality improvement activities.

There are six national quality strategy priorities that NQS asserts affect most Americans:

Patient Safety
Person- and Family- Centered Care
Prevention and Treatment of Leading Causes of Mortality
Affordable Care
Health and Well Being
Effective Communication and Care Coordination

The NQS offers nine Quality Strategy Levers (core business functions that organizations can use to pursue improvement across the aforementioned priorities):

Measurement and Feedback
Public Reporting
Learning and Technical Assistance
Certification, Accreditation and Regulation
Consumer Incentives and Benefit Designs
Payment
Health Information Technology
Innovation and Diffusion
Workforce Development

The webinar presentation discusses how the ability to economically benefit from value-based payment models is negatively impacted by the inability to create outcome measurement alignment. More calls for standardization and evidence-based practices.

Making the connection between payment and quality is indeed a slippery slope and the most contentious non-access aspect of the Healthcare Reform debate. Financial reward is the most expedient means available to align incentives. But because of the inherent structural weaknesses of our current delivery system those incentives can be counterintuitive to patient welfare. If you’re in the business of serving patients, it’s critically important that you understand the nature of this debate and how it continues to play out in policy and regulatory decision making.

Cheers,
  Sparky

 

 

The slides and transcript from the February 4 National Quality Strategy Webinar entitled “Using Payment to Improve Health and Health Care Quality” are now available on the Working for Quality Web site. This Webinar focused on how using payment, one of the nine National Quality Strategy levers, can help organizations align to the strategy and promote the three National Quality Strategy aims.

 

An updated National Quality Strategy toolkit is also now available.  The toolkit includes updated graphic icons, templates for social media, newsletters, and blog content that organizations can use to share their alignment to and support of the National Quality Strategy.

 

If you have a story or case study you would like to share with the NQS audience, please email NQStrategy@ahrq.hhs.gov.

Policy Prescriptions ®

The Evidence-Based Health Policy™ Experts

ChangingAging.org

By Dr. Bill Thomas

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