Of Medicaid and Pork Belly’s

There is an old saying that’s been around in DC for years that goes something like,

Don’t tax you
Don’t tax me
Tax that man behind the tree.

So goes the thinking in private conversations around Washington about the duplicity of elected officials wanting to reduce constituents’ tax burdens while at the same time providing valuable public services to those constituents.

The simple reality is we will – eventually (next year? next decade?) have to pay the piper in the same way Greece has. To the extent that reality causes angst it’s understandable why a Federal budget proposing to slash millions in spending would be embraced.

The issue, of course, is whether and how spending reductions should be effectuated. With today’s release of the Administration’s “proposed” budget the gauntlet has not been laid down so much as the effort has been made to call attention to the man behind the tree.

The sad reality in our country is the Federal budget could very likely be cut by a third without touching Medicaid (might even be able to expand it). But then, at least half, if not more, of current members of Congress would likely lose their seats for failing to bring home the bacon.

Knowing their potential absence probably doesn’t bother most of us should tell you all you need to know about the huge systemic challenge we face in correcting the best form of government this world has ever seen.

Cheers,
~ Sparky

http://www.healthcarefinancenews.com/news/trump-budget-cuts-600-billion-medicaid

Let’s Take A Breath . . .

AP_17137623354997-1280x960The James Comey Oval Office conversation looks like a witch hunt to me.

Frankly, if Trump said what he is alleged to have said to Comey, I could really care less. That a sitting president should be called into question over a remark that “could” be interpreted as coercive I guess is in keeping with the 24-hour news cycle and social media landscape that now litters our country. Pragmatically, I could very well see Trump having said what he is alleged to have said without having any sense of desired influence whatsoever. 

But that’s because he is so clueless that he says whatever words he is able to muster at the time. If you listen to him enough, how could you not believe he rarely says anything with forethought – let alone malice of forethought. I listened to his commencement address to the Coast Guard Academy this morning, and it was truly sad. I think he only has three or four adjectives in his repertoire that he uses time and again.

“Really” is the big one, though technically an adjective preceeding another adjective is considered an adverb if memory serves.  Everything is really good, or really great, or really wonderful. And beyond, good, great and wonderful things fall off quickly. And of course, there’s the show stopper: “believe me.” At least George W had the presence of mind to pause and take flack for not being quick enough to get the right words out rather than just filling the void with adolescent banter.

The more you listen to Trump the more two realities become self-evident: he does not take the time or effort to gain even a basic understanding of the policy issues about which he speaks – regardless of what position he may favor on those issues. And second, he has no sense of himself outside of how he is self-actualized by his audience and the sycophants clamoring around like remoras attached to a shark. That must be why he craves those rallies so much. Without them he has no self worth nor understanding of why he ran for president.

But being obtuse and narcissistic are not impeachable offenses. Rushing to judgement on the basis of what should have been a private and confidential conversation between a president and his direct report is folly and only serves to fan the flames of political irreverence. Let’s maintain some common sense of decorum and see if we can’t still find the better angels of our nature to guide us through these troubling times.

Cheers,
   Sparky

Role of Wrongful-Life Cases In Palliative Care

 

11SPAN-master768Earlier this week Paula Span wrote in the New York Times about the increasing number of lawsuits being filed on behalf of patients being kept alive. Counterintuitive? Not when you consider they were kept alive only to endure more pain and suffering – against their known wishes.

If you’ve ever read or heard about a court case involving whether, how, why or why not an individual’s advance directive was carried out as intended by the patient, then you are no doubt familiar with the myriad circumstances and events that can lead to great confusion at the time of death. It’s an area of healthcare painted with a thousand shades of grey.

Unfortunately, an advance directive often gets twisted and manipulated nine ways to Sunday in the hands of numerous stakeholders standing bedside, whilst the person in the bed is most often unable to advocate for their own interests. This is when doctors begin envying lawyers because lawyers don’t have to practice medicine.   

I have yet to meet the physician who wants to cause his or her patient harm. They even swear an oath not to. There are other areas of the Hippocratic Oath wherein its fulfillment brings into question – absent an informed directive – to just what lengths are necessary and appropriate to save the life of a dying soul in the knowledge that such actions may cause increased suffering.

Allowing for the presumption of innocence, however, doesn’t change the very real consequences suffered in those cases shared in the article. I suspect attributing the failures to a breakdown in communication is a safe bet in most of those cases since that is a phenomenon, which continues to plague our healthcare delivery system despite the investment of billions into information technology.

Of course, the broader discussion this story touches upon is addressing life and death in the context of quality of life – and who determines the subjective nature of “quality.” To that point, we have much to benefit from the continued awareness and education of the role palliative care can play in treating severe and terminal illnesses.

In this country we are culturally adamant about resisting and ignoring the realities of death. One needs look no further than the hysterical idiocy that surrounded death panels. Perhaps these cases will help advance the broader conversation we need to have on how we can best protect individual patient rights while providing them the best possible life while still on earth.

Cheers,
  ~ Sparky

Now What !?

At 7:30am on Wednesday, November 9th I received a Helen of Troy type text message: three simple words from a client that begged a thousand responses, simply asking, “now what?”

Unless you’ve been hiding under a rock for the past few Trump Winsweeks you are aware that healthcare in the United States is once again heading into turbulent policy waters with the election of a president whose political party has very different ideas about how to improve our healthcare delivery system. Or so we have been led to believe.

From what little is known to this point it is unlikely the Trump Administration will just blow up the Affordable Care Act in the first 100 days of its tenure. That is fortunate because, irrespective of your political beliefs, haphazardly dismantling the current system would undoubtedly result in unintended – and politically undesirable – consequences, potentially causing harm to millions of patients and healthcare providers.

That being said, there is no doubt substantial changes will be made and quickly by Washington, DC standards. If anything is predictable about Mr. Trump it is that he won’t be patient with bureaucratic efforts not quickly producing tangible results. Whether that impatience can be channeled into effective change management in a kingdom that literally thrives on maintaining the status quo only time will tell.

The next six months are going to be incredibly confusing and confrontational as we seek to consider and understand the potential ramifications of new health policy proposals. Speculation on the impact of such proposals will span from certain and imminent catastrophe to unbridled joy. Through it all be reminded that often in many ways the more things change the more they stay the same. To that point, in helping senior living organizations anticipate how to best position for changes in healthcare policy I think it is more prudent than ever to focus on what we know won’t change.

The accelerating demand for affordable housing, home and community-based services and healthcare resulting from the demographic realities of an aging population will not change. Underlying pressures such as technology and innovation driving up healthcare costs will not change. The growing impact of consumerism on healthcare will not change. Demand for qualified human caregiving resources outstripping supply will not change. The increasing burden chronic disease management puts on our delivery system will not change. I’m sure you can think of your own realities to add.

If you aggregate all of the environmental certainties shaping the healthcare industry today and in the future, logic dictates that value will continue to be at the center of new policy initiatives. And that means alternative payment models (APMs) will continue to garner support if not greater efforts to accelerate their adoption. Recall, the Medicare Access and CHIP Reauthorization Act (MACRA) provides substantial incentive for physicians to migrate into advanced APMs, and that legislation was passed by Congress with overwhelming bipartisanship. MedPAC, the nonpartisan legislative branch agency that provides Congress with analysis and policy advice on the Medicare program has also been very supportive of APMs.

So when answering the question, “now what?” my response is to continue developing organizational attributes that will build competitive advantage as a participant in APMs. Focus on the no regret investments that build enterprise value in the context of emerging care delivery models: e.g., demonstrating a commitment to continuous quality improvement; assess the value of specialization; improve productivity and reduce costs without impacting outcomes; develop an employee value proposition; build a robust cost accounting system; focus on beneficial referral relationships; measure and report on performance; invest in community-based downstream relationships.

A great way to learn more about what APMs entail – and to stay ahead of emerging research, ideas and discussion about their advancement – is to join the Healthcare Payment Learning & Action Network (HCPLan). This is a nonprofit organization that was launched by the Department of Health & Human Services in March of last year with a mission, “to accelerate the health care system’s transition to alternative payment models by combining the innovation, power, and reach of the private and public sectors.”

On October 25th of this year I had the opportunity of attending the fall LAN Fall Summit in Washington. The Summit brought together nearly 800 participants representing senior leaders from across the health care community, including providers, payers, employers, patients, consumer groups, health experts, and state and federal government agencies.

Here’s the singular most important message that I would like to share from my participation there: alternative payment models are not unicorns. They exist, they are being tested, learned from and gaining increased support daily. They are transcending the ideological spectrum of political discourse. The advance toward APMs is accelerating, and as shared above I do not see that being at all abated by the results of this presidential election. I can see the opposite effect taking shape.

Sadly, I believe there will come a time in the not too distant future when many nonprofit and smaller senior living organizations that depend upon post-acute/long-term care revenue for survival will find their organizations have waited until the decision of whether or not to participate in APMs has been taken out of their hands. For profit organizations are investing millions in learning how to compete and win under alternative payment models. If your organization is not taking steps to be equally competitive, then I would focus your energies instead on building acquisition value.

The first step in determining whether and how your organization can be competitive in a world of value-based care delivery models is to perform a gap assessment: what attributes must you have to compete under APMs compared to your organizational current state – and what investments are required to bridge that gap? Do you have the financial wherewithal to make those investments? How much time do you have to effectuate change?

That’s now what.

Cheers,
  ~ Sparky

What Interested Me About Senior Living?

040111.01TearoffSheetI have written this brief essay in response to a fund-raising effort for the cure of Alzheimer’s disease. Several of us were asked by Symbria colleague, Dr. Lori Stevic-Rust, to respond to the question, how did you become interested in the senior living industry?

The Symbria Advisory Services team is sponsoring Lori’s Walk to End Alzheimer’s®, the nation’s largest event to raise awareness and funds to fight Alzheimer’s disease. Please click on the pic above to join us in sponsoring her efforts!

What Interested Me About Senior Living?

Candidly like many people, I’m not sure it was my interest that got me started.

I was a young man with a young family and just trying to make a living. What interested me most at that time was a steady paycheck and the hopeful ability to grow into a career – whatever that meant. What caused me to stay in senior living for the past 25 years – now that I think might be worth sharing.

To me, one of the greatest advantages of being a management consultant in the senior living industry is performing site visits. Being able to travel around the country and tour different communities in different geographies; seeing the good, the bad and the regrettable. Being reminded of the work direct caregivers do every day and that mine, at best, is a supporting role backstage.

On one such occasion I found myself in New Jersey at a senior living community near to the Atlantic Ocean. It was late afternoon on a clear winter’s day, and shadows from the trees outside were inching their way across the lobby floor. I sat there admiring the beauty of a crisp, amber sky, satisfied I had completed a good day’s work. I only needed to touch base with one more staff person, and I would be on my way – back to the hotel to write up my notes and then off to explore the local area.

As I was waiting there a couple was approaching from down a long hallway toward me. They were of an age where I surmised they could be (likely were) residents of this assisted living community. Maybe they were heading out to do some exploring too. I felt happy that I had some small part in this image – part of an industry that provided a secure, caring and loving environment for this couple. That they could enjoy the fullness that life had to offer together in the twilight of their lives.

They were holding hands as they came down the hall, and as they grew closer I noticed the woman had a somewhat distant expression – a mix of forlorn and bewilderment. Her partner’s expression seemed to be one of melancholy and concern, yet stoic determination. His shoulders were a bit slouched, and I don’t know why but I did not think it owing simply to an aging posture.

There were clearly some emotional undertones here that made me quickly challenge my exploration hypothesis. Then as they neared the door it dawned on me the woman wasn’t dressed near appropriately enough to be going outside on this frigid afternoon in mid-February.

That’s because she wasn’t. And then what followed was a scene that has yet to be eclipsed in my mind by any other for its sheer heartbreaking sadness and poignancy. I can still hear their words as if they were spoken only yesterday.

“Bill, take me home . . . take me home, Bill . . . Bill, this isn’t my home . . . I want to go home, Bill . . . please, Bill! Why won’t you take me home?”

“It’ll be okay, Alice . . . it’ll be okay . . . you’re going to be fine . . . I will see you tomorrow, I promise.”

The elderly gentlemen tried earnestly, with the calmest and most serene expression as tears were welling up in his eyes to explain why this was her home now. This was, “where she needed to be.” He was unable to leave without the assistance of an aide having to gently redirect his wife. I glanced over at the receptionist who, like me, had sat silently taking this all in – wondering whether she could see I was fighting back tears. Her own only made my efforts more impossible.

The separation we had witnessed was like what one might observe at a daycare or preschool between child and parent. I would guess the relative emotions might be quite similar too: fear, anger, regret, sadness. But when a parent or guardian shows up in the afternoon, the reunion is a joy to see: an emotional reversal, all secure in the knowledge the family will be reunited at home that evening.

Bill’s wife was not going home. She had Alzheimer’s disease, and though Bill had tried to care for her at home he was unable to do so without risking injury to her or himself. She was, “where she needed to be.” Quite obviously, she was not where anyone wanted her to be.

I once had a colleague who owned several assisted living properties share with me something he regularly explained to his sales staff. He would tell them, “never forget, that even on your most successful sale it is most likely your customer will not be getting what they want.” They want to stay home. Alice wanted to stay at home.

There are some five million individuals in the United States like Alice. This is a tough industry to work in when you take to heart the challenges these individuals, their families and caregivers face every day in the communities I am lucky enough to assist. And the challenges associated with Alzheimer’s disease are right up there at the top.

I could never do the work of the caregivers that labor tirelessly to ease whatever burden they can of those afflicted with Alzheimer’s disease and their families. So I do what I am able: try and help ensure their working environment is as unencumbered, encouraging and helpful as it might be. If I can do that, then I feel like I am contributing what I can – and that is why I have stayed in the senior living industry for the past 25 years.

Cheers,
  ~ Sparky

What Hospitals Need to Understand About Housing

Blog_Sutton_GrantThere was a post in today’s HealthAffairs Blog  (see links at the end of this post) with some helpful insights on the importance of affordable housing as a key element of being able promote and sustain healthy aging. I have written rather extensively over the years in this space on this topic, and I have long been an advocate for Affordable Housing Plus Services.

I don’t recall if I’ve shared this here before or not, but I once had the opportunity to ask directly a former Secretary of Health & Human Services why there wasn’t more effective communication and coordination of policy initiatives between HHS and HUD. The response was unflattering: that was a great idea without a plausible explanation for why it had not been actively pursued. Thus be to bureaucracy.

If I could build upon the major policy themes pointed out in the HA post, something I have learned over the past five years is that a primary reason acute care providers struggle to understand post-acute care is because post-acute care is a lot more complicated than I understood. And, of course, I make that observation somewhat tongue-in-cheek because that’s all I’ve done for the past two decades.

But this article reminded me again how complex post-acute/long-term care can be. And that’s because it’s not just about providing good healthcare. It’s very much about where that healthcare is going to be provided (in what structure does the patient live). It’s about what support services are available to assist the patient with activities of daily living (in what community does the patient live). It’s about hospitality and entertainment (who wants the sole focus of their life to be an illness?) And it’s about insurance because most often care providers and/or insurers are underwriting extended care for which it is often difficult to predict duration, complexity and cost.

The same fundamental attributes that make it a complex delivery model make it a complex policy issue. Acute care providers are being more intimately connected with post-acute care providers every day through healthcare public policy initiatives. My counsel is they would do well to begin understanding the root causes of what makes post-acute and long-term care more complex than they may have realized.

Cheers,
  ~ Sparky


Read Health Affairs article here:

Integrating Health Care And Housing To Promote Healthy Aging
Read more about the authors here:
Allyson Schwartz and Anand Parekh

Here We GO!!

And We're BackAs Joey Mack (a/k/a Jimmy Fallon) used to say on Z-105, “… we’re back!” My last post here was at the beginning of December last year. That’s just about the time I entered into serious discussions on the sale of Artower Advisory Services to Symbria, Inc.

I have to say the intervening period has been dominated a lot more by politics than policy – at least so far as the broad spectrum of media reporting have favored upon us a la the circus that is the American presidential race. Believe it or not, in spite of that depressing entertainment a lot of policy continues to be made every day – much of the action happening at the state level. The discussion and debate over healthcare policy is anything but dormant.

So where do things stand on the future of healthcare reform? If Donald Trump is elected do you think he’ll be able to withstand industry resistance to repeal & replace the Affordable Care Act? If Mrs. Clinton is elected, will she be able to use the Medicare model to expand coverage and lower costs? If Bernie Sanders is elected, would the Chinese economy ever grow fast enough to absorb all of the new US debt needed to fund his great ideas?

Set aside what influence, if any really, these presidential hopefuls might have on future healthcare policy and all we are left with are the same difficult issues we’ve been facing for the past few decades:

  • Will this new era of industry consolidation do anything to help achieve the Triple Aim goals espoused by supporters of the Affordable Care Act? Or just create greater monopsony power?
  • What, if any, should be the role of government in addressing escalating drug prices and Pharma’s insatiable appetite for capital?
  • How do we even begin to build a qualified workforce to care for our aging population with stagnated economic growth?
  • More evidence daily shows the promise of mental/ behavioral health integration; what’s the most effective way to accomplish this?
  • New payment and care delivery models have so far shown mixed results, at best; should we continue to invest or stop trying?
  • Will we be able to build the requisite community infrastructures ultimately needed to support population health and the benefits that portends?
  • Where and how should public policy most effectively intersect with health technology?
  • What’s the point of chest-thumping on transparency in healthcare when we are still unable to provide meaningfully basic cost data?
  • Big Data? Big security risks. What can be done to protect patient medical records when it seems nothing electronic is protected?

These are a few of the topics I have been mulling around in my mind over the past five months. These are a few of the topics I would like to start writing about again.

I hope if you are still out there signed up as a follower of the PolicyPub you will think about getting engaged again discussing and debating these issues. As we move through the summer and head toward the two political parties’ national conventions healthcare is going to become a hot topic for debate again. I will do what I can here to help keep you informed and energized.

Cheers,
  ~
Sparky

 

Value Isn’t Working

HC FrustrationVALUE. I have written quite a bit in this space over the past three-and-a-half years on the role of value in healthcare and how it has been purported to be used as an effective public policy tool. Just type in, “value” on the search box to the right and 10 such posts will appear for your reading pleasure. But I haven’t written about value in the context I am about to now.

Earlier this week Paul H. Keckley, Managing Director of the Navigant Center for Healthcare Research and Policy Analysis, posted The Meaning of “Value” in Healthcare to the Health Care Blog.  In that post he argues rightly that the significant shortcoming of value as a driver of anything in healthcare is that it is not being defined by end users – i.e., patients, or consumers as it were. In stark contrast to what I have advocated in the past I would go beyond that.

Keckly muses of a system where consumer-driven healthcare is manifested in the dissemination of knowledge and information that empowers rational decision-making and the efficient allocation of resources. Where he stopped short – whether by omission or design – was to suggest the best means of achieving that nirvana. I will pick up the ball and take it a little further.

It is not enough to advocate for consumer-driven empowerment as the means of leveraging value in our healthcare system.  We must also recognize the stark reality that current healthcare policy – and in particular, the Affordable Care Act – is a tremendously effective impediment to achieving that empowerment.

I remain as convinced as ever that value – Porter’s axiomatic assertion that outcomes over cost will drive achievement of the IHI’s Triple Aim – is key to delivery system improvement. But I am terribly disillusioned that value can be effective in a system that is controlled in such a manner that it is determined artificially and arbitrarily by the likes of academics, bureaucrats, administrators and consultants.

Alternative payment models – and the care delivery models that are being developed in response to the artificial financial incentives they are offering – are doomed to ultimately fail because they lack the inert ability to leverage value as it is perceived by the individual consumer, one person at a time. By failure I do not mean they will be soon to go away – but they will not achieve the shared goals referenced above. Disagree?

Cheers,
  ~ Sparky

Principles of Alternative Payment Models Framework

HCPLANGreetings PolicyPub patrons. I would like to take a moment and share with you a whitepaper recently published by the Health Care Payment Learning and Action Network. The purpose of the whitepaper is to provide a roadmap to measure progress and establish a shared language and common set of conventions to help facilitate discussion and debate regarding alternative payment models (APM).

A group that I have actively participated in since its inception back in March of this year, HCPLAN was established by the Department of Health and Human Services, “to help achieve better care, smarter spending, and healthier people.” It’s primary purpose is to serve as a convener and facilitator (as well as catalyst) in pursuing HHS’s stated goals of:

  • tying 30 percent of Medicare fee-for-service payments to quality or value through alternative payment models by 2016 and 50 percent by 2018; and
  • tying 85 percent of all Medicare fee-for-service to quality or value by 2016 and 90 percent by 2018.

    The whitepaper identifies seven Key Principles for the APM Framework that all healthcare providers should be aware of and understand:
  • Principle 1: Changing the financial reward to providers is only one way to stimulate and sustain innovative approaches to the delivery of patient-centered care. In the future … it will be important to monitor progress in initiatives that empower patients (via meaningful performance metrics, financial incentives, and other means) to seek care from high-value providers and become active participants in clinical and shared decision-making.

    Principle 2: As delivery systems evolve, the goal is to drive a shift towards shared-risk and population-based payment models, in order to incentivize delivery system reforms that improve the quality and efficiency of patient-centered care.

    Principle 3: To the greatest extent possible, value-based incentives should reach providers who directly deliver care.

    Principle 4: Payment models that do not take quality and value into account will be classified in the appropriate category with a designation that distinguishes them as a payment model that is not value-based. They will not be considered APMs for the purposes of tracking progress towards payment reform.

    Principle 5: In order to reach our goals for health care reform, the intensity of value-based incentives should be high enough to influence provider behaviors and it should increase over time. However, this intensity should not be a determining factor for classifying APMs in the Framework. Intensity will be included when reporting progress toward goals.

    Principle 6: When health plans adopt hybrid payment reforms that incorporate multiple APMs, the payment reform as a whole will be classified according to the more dominant APM. This will avoid double-counting payments through APMs.

    Principle 7: Centers of excellence, patient-centered medical homes, and accountable care organizations are delivery models, not payment models. These delivery system models enable APMs and, in many instances, have achieved successes in advancing quality, but they should not be viewed as synonymous with a specific APM. Accordingly, they appear in multiple locations in the Framework, depending on the underlying payment model that supports them.

    HCPLAN is open to anyone interested in being kept informed of and joining the conversation on HHS’s efforts to  develop new payment models intended to be structured around all of the buzzwords you’ve heard over the past five years now: e.g., value, quality, transparency, patient activation, evidence-based, and so on.

    What it is not, based on my experience, is a veiled promotional vehicle to evidence broad-based support of new payment models that go largely unchallenged. To the contrary, there is a great deal of practical concern being expressed supported by real life experience having already pursued new payment models – the good, the bad and the ugly. To participate in HCPLAN, just visit the registration web page.

    Cheers,
      ~ Sparky

National Health Expenditures Data Released

Money in syringeAccording to a report released today in Health Affairs by the CMS Office of the Actuary healthcare spending growth is projected to average 5.8% over the period 2014 through 2024. In the three decades leading up to 2008 the average annual growth rate was 9%.

So let’s see. Demographics will really begin to swell Medicare participation in the decade ahead. It is likely that more states will politically have to embrace Medicaid expansion. Diagnoses and treatment innovation is still being largely driven by private investment seeking high-risk returns. Industry consolidation on both the provider and insurer sides is eliminating market price competition. And we’re only going to see 6% annual cost increases they say . . . you buying it?

Here are some highlights from the CMS press release:

Spending in 2014 is projected at $3.1 trillion, or $9,695 per person, an increase of 5.5 percent over 2013. Prescription drug spending increased 12.6 percent but private health insurance increased at 5.4 percent, Medicare at 2.7 percent and Medicaid at 0.8 percent.

Medical price inflation was 1.4 percent, while hospital, and physician and clinical services increased at 1.4 and 0.5 percent, respectively.

Per-capita insurance premium growth in private health plans is projected to be at 2.8 percent in 2015 based upon the assumptions that there will be an increase in relatively healthier enrollees and a greater prevalence of high-deductible health plans offered by employers.

Is is estimated there will be 19.1 million new enrollees in Medicare over the next 11 years.

While per capita Medicaid spending is projected to have decreased by 0.8 percent in 2014 (owing to new enrollees being relatively healthier), overall spending is projected to have increased by 12.0 percent due to Medicaid expansion.

The rate of insurance coverage in the US is projected to increase from 86.0 percent to 92.4 over the next 11 years.

The full OACT report is available online via the CMS website.

Cheers,
  ~ Sparky

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