Alba gu bràth!

Ian Morrison wrote an interesting piece today in H&HN Daily: Will Your Hospital Maintain Its Independence? Most anything that starts with, “My native c32f740dadef6f60188f14b376a76efcScotland,” attracts my attention, but Dr. Morrison makes some very interesting comparisons between nationalism and traditionalism that are especially insightful in understanding the current healthcare landscape in the US. More particularly, he offers some useful observations on the national referendum for independence in Scotland at a social level and resistance to change in the US healthcare industry at an individual level.

Scotland recently rejected a call for independence from the United Kingdom by a margin of 55% to 45%. From what I followed in The Times as a run up to the vote it was anticipated to be a lot closer. An emotionally charged issue as one might expect when contemplating the future fate of a nation, the debate over independence goes way (way) back. When I was in Edinburgh in mid 90s I met family there fervid about having such a referendum on the ballot. And, of course, if you’re familiar with Braveheart, you know the thirst for independence goes back to when battles were fought with spears and arrows and naked bums.

The point is, human commitment and passion run deep whenever and wherever the past is concerned. As a nation, it’s the cultural mores and traditions that bind together its citizenry into a common purpose that forms a society beneficial to the individuals participating in – and often fighting for – that society. At an individual level it’s the ability to associate with that purpose through reflection and introspection – memories as it were, whether real or perceived.

Though often positioned as an assertive claim to acquire, it is really most often a defensive maneuver to retain. And thus the desire for independence – at both a national and individual level – therefore also reflects an inherent resistance to change. And that is the parallel Morrison draws to the American healthcare system. An historical cast of passionate, empathetic caregivers – both individuals as well as the institutions to which those individuals have belonged – is being threatened by, “the relentless growth of large regional systems of care coming to dominate the landscape.”

The concern is genuine and real, and how it will ultimately play out is still far from being determined. Morrison shares a few thoughts on how individuals and organizations might best prepare for decisions affecting their own independence. He rightly points out that maintaining independence at all costs may not be prudent, but I direct you to his article (link at the beginning of this post) because it really is worth the read.

I would add to his thoughts the need for a true sense of urgency to create a market strategy that addresses the prospect of remaining independent – or not. Reactive thinking is never strategic. Very often necessary, unavoidable and critical to survival – but not strategic. Take the time now to ensure your organization’s leadership team is in alignment on how it will approach threats to independence – before that threat is manifested as a fete accompli.

  ~ Sparky

This Is Not Your Grandma’s Taxi

Having worked with numerous organizations over the years that provide services and care to seniorsDelorean_DMC-12_Time_Machine_in_San_Francisco living in their communities I know that transportation is very often a primary obstacle to expanding and improving those services and care. Whether needed for a doctor’s visit, a rehabilitation appointment, a flu shot, a socialization event, a trip to visit family – it is typically not the distance as much as the inability to coordinate the timing of demand with availability in an efficient manner that creates challenging cost obstacles.

There are organizations across the country that have been effective at tackling this obstacle by leveraging information and communication technology. For example, Senior Transportation Connection serves individuals in Cuyahoga County, Ohio by utilizing mapping and scheduling algorithms (EasyRides©). I had the opportunity to visit their “command center” a few years back and was impressed with how much they are able to do with so little financial support. Truly amazing.

Even so, seniors using STC have to schedule their travel appointments by noon two days prior to the appointed time. It doesn’t take a great deal of imagination to realize there will be many circumstances when the best efforts to plan ahead will fall well short of providing the level of access needed for many seniors still wanting to live independently.

Enter Uber. Jason Oliva writes in yesterday’s Senior Housing News that the San Francisco-based ride service company has just announced it will be expanding its transportation services into San Diego. UberWAV and uberASSIST are ride offerings specifically designed to accommodate elderly individuals living with disabilities.

For those – who until recently included myself – unfamiliar with the Uber concept, the simple genius (yeah, one of those V8 moments I’m afraid) is the development of a smartphone application that connects passengers with vehicles for hire. Not a cab for hire, mind you, but an individual who has signed up and been vetted to provide safe, reliable transportation (yes, I would like to understand that whole process better myself – but that’ not the point of this post).

From a business perspective, the value proposition appears to be the ability to concurrently offer convenience and affordability on the demand side while providing income-earning flexibility and lower barriers to entry on the supply side. As you might imagine, the lower barriers to entry proposition has not played well with taxi and limousine companies – there have actually been protests staged in several countries, including Germany, France and England. I’m sure we’ll get round to it once we get by Halloween.

Now you can just see where this idea is going to eventually cause all sorts of policy issues: free market solutions to public challenges usually do, for better or worse. What are the safety risks? Who is insuring those risks? What happens after the first case of elder abuse is reported?

Having the requisite vehicle apparatus to accommodate disability is one thing – having a driver that can thoughtfully and emotionally navigate through an individual’s confusion and dementia is another. Will seniors be able to use the application in a crisis? Can it/should it be available in cases of emergency? There’s a lot to think about to protect seniors from abuse – intended or not.

On the other hand, if we follow the tried and true path of policymaking we will almost certainly regulate Uber services to the point where a creative solution becomes cost prohibitive. Without market-driven innovation we will never be able to tackle all of the challenges associated with a dramatically aging society.

What do Pub patrons think? Share your thoughts by leaving a comment.

  ~ Sparky

Photo credits:
Delorean DMC-12 Time Machine in San Francisco
CC BY-SA 3.0
Ed g2s – Own work

Moving Away From Sick Care

There is a saying that goes, “America doesn’t have a healthcare system – we have a sick-care system.” I don’t know whether that quote is attributable to an individual or not, but the connotation is that what for decades has served as a healthcare delivery system belies the underlying premise that the individuals benefitting from that system’s value proposition are, indeed, healthy.

Of course, they are not – at least at the time service is required.  They are sick, ill or afflicted by a myriad of chronic diseases and conditions. Whatever we want to call it, a system that addresses the needs of these individuals is critically important. But the study in ironic contrast serves to raise awareness of the need to address population health as the best hope of reigning in the unabated march of healthcare’s gobbling up the nation’s GDP.

Last week a new Health Policy Brief, The Relative Contribution of Multiple Determinants of Health, was released by Health Affairs and the Robert Wood Johnson Foundation that looks at factors and considerations impacting individual and population health. These are commonly referred to as health determinants and can be summarized into five major categories: genetics, behavior, social circumstances, environmental and physical influences and medical care.

Researching and understanding how specific factors and considerations within these categories impact individual and population health is very challenging because of complex, interdependent, bidirectional relationships – and because the timeframe over which meaningful measurement must take place can often be decades. But if the US delivery system is to make a paradigm shift away from having a sick care system, efforts must continue to understand whether and how health policy interventions and choices, as well as the efficient use of limited resources, can achieve better outcomes.

This, in turn, requires the adoption of a more holistic understanding of health: the roles social and environmental (i.e., nonclinical) determinants play in impacting individual health. Human behavior, for example – a primary concern in understanding poor health outcomes – must be understood and assessed, “according to multiple dimensions and at various points of intervention.”

Despite the challenges, progress continues on understanding the role nonclinical determinants play in individual and population health outcomes. The continued advancements in Big Data should accelerate these efforts. The policy brief referenced above provides a nice overview of these efforts with resources that should be noted by healthcare providers wanting to better understand how their competitors are seeking to become strategically aligned with population health management.

There are currently a lot of major healthcare providers touting in the press their foray into population health, as if the opportunity for impact is ripe for harvesting. But having recently become more educated and aware of the myriad issues and complexity of population health, I do have to wonder if their strategies are too narrowly focused on how to creatively redeploy existing assets and resources – rather than making a candid and honest assessment whether either can be productively leveraged in the context of a holistic approach to healthcare.


Healthcare’s Disruptive Innovator

Disruptive Innovation is a term widely attributed to Harvard Business School professor, Clayton Christensen. Often used interchangeably with the term, disruptive technology, there is an important distinction: the former represents not just advancements in underlying technology but the innovative application of that technology.

Disruptive innovation is something that concurrently, though at varying speeds, creates a new market while disrupting an existing market in ways that essentially had not been anticipated. Examples frequently cited include the introduction of personal computers and the impact that had on mini and mainframe computers; cellular phones’ impact on fixed line telephony; the iPod’s impact on the music industry; and most recently – retail medical clinics’ impact on traditional physician offices.

Enter The Clinic at Walmart.

Writing in the Healthcare Finance News, Contributing Editor Anthony Brino writes how Walmart is now wading into physician territory. Having already opened over 100 walk-in clinics across the country that provide access to medical care through collaborative agreements with local hospitals and/or physicians, this latest move – directly employing nurse practitioners – is part of a longer term strategy for Walmart to be self sufficiently ingrained as a primary care provider.

And of course, it’s not just Walmart that is seeking to capitalize on the increasing demand for primary care coupled with the escalating cost of that care: according to a 2013 report from Accenture Research the number of retail health clinics is anticipated to double over the next three years from 1,400 to 2,800. The core value proposition is increased access and greater convenience at a substantially lower cost than a visit to a doctor’s office.

What we are really looking at here is the commoditization of Medicine. The underlying premise is that a wide swath of fundamental and routine aspects of primary care can be automated and standardized: treatment of simple acute conditions, preventative care (e.g., vaccinations), wellness screening, diagnostic testing, etc.

There are substantial reasons to be concerned with the promulgation of retail clinics, particularly where they serve in lieu of primary care physician relationships. For starters, nurse practitioners – which undoubtedly must be a critical element in expanding primary care – simply do not have the same level of training and experience as a board certified physician. Their ability to assess, decipher and act upon the nuances of a patient’s conditions are – in general – not going to be the same.

The historical relationship of a patient and his or her physician becomes over time an invaluable knowledgebase that the physician relies upon to identify changes in a patient’s condition that may warrant investigation. And convenience can be a double-edged sword. Being prescribed an antibiotic for a virus that someone then confidently carries with them to their work environment not only prevents that individual from staying home and getting needed rest – it unwittingly exposes coworkers to that virus, which the antibiotic does nothing to control (or treat).

But what disruptive innovation is without its unintended consequences? Look at how much time we now spend in front of computers instead of outside exercising. Cell phones migrated to smart phones that people now use to text their way to oblivion: in 2012 over 3,300 people were killed in distraction-related crashes. Whether the paradigm shift in the music industry is a positive or negative I think depends a lot on  your age – but as with all other such innovations, nothing will ever be the same.

That is true for the healthcare industry and the practice of medicine: nothing will ever be the same – except our resistance to change – that won’t change.


Mental Health in Crisis

The cost of not caring: Nowhere to go ~ The financial and human toll for neglecting the mentally ill is the first in a new series of articles being produced by USA Today tackling this hugely critical issue (by Liz Szabo). Rep. Tim Murphy, R-Pa. (a child psychologist) declares that, "we have replaced the hospital bed with the jail cell, the homeless shelter and the coffin. How is that compassionate?"

Mental health services and programming has taken it on the financial chin as an unfortunate lesser of evils political choice among state programs that have traditionally provided funding. According to Robert Glover, executive director of the National Association of State Mental Health Program Directors, $5 billion was cut from 2009 to 2012, while 4,500 public psychiatric hospital beds were eliminated (a 10% reduction).

Mental illness is still not broadly well understood in a way that even starts to approximate its impact on society. The USA Today article estimates that approximately 10 million Americans with serious mental illness are not receiving care. While at the same time, individuals with serious mental illness have a probability of dying 23 years younger compared to others.

The costs to society are dramatic: in excess of $440 billion a year. And only about one-third of that total goes to medical care. Much of it reflects disability payments and lost productivity. And that amount does not include lost earnings or tax revenue spent on prisons.

The timing is not good. State budgets are already being stretched and the national focus is on how to take costs out of the system – not add more. Medicaid expansion is likely to help identify greater need for mental health services without any commensurate plan in place to address those needs.

Yet we simply cannot afford to continue down the care delivery path we have forged. Mental illness is often a root cause for various physical illness and chronic conditions. Tragic events like Sandy Hook Elementary, Virginia Tech and Fort Hood remind us of the potential incident costs of untreated mental illness – but a fitting analogy of those events to the broader problem might be comparing the tragedy of an airplane crash to the number of traffic fatalities across the country each year.

Recently in true Washington partisan fashion Republicans and Democrats illustrated their shared compassion for those suffering from mental illness by drafting legislation designed to promote political distinctiveness rather than policy progress (though it should be noted that in this instance the Democratic initiative has to be viewed as politically reactive). Here’s hoping maybe someday that will change and this country can start having the very serious and much needed conversation on how to address this terrible crisis.


Pressure Mounts on SNF Performance

As a follow up to my post this past Friday, some additional political pressure aimed at assessing and improving safety and quality of care in America’s nursing homes has come in the form of a letter from Senators Bill Nelson (D-FL) and Charles Grassley (R-IA) to CMS chief Marilyn Tavenner. In that letter, dated April 2, the senators reference the now much discussed OIG report – Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries – and challenge the CMS Administrator to reconcile the reported performance weaknesses with the current certification and survey process for nursing homes.

They went on to request an understanding of what steps CMS is taking to address the identified weaknesses in the survey and approval process. As has already been discussed, a primary means of response that CMS is counting upon is implementation of the long-awaited QAPI initiative, which will require SNFs to self-assess and critique their existing operational and clinical performance while developing a comprehensive plan to address and remedy identified performance gaps. And the resulting QAPI program of those facilities will then become subject to the state survey process.

The letter also referenced an IG report from November of 2013, Medicare Nursing Home Resident Hospitalization Rates Merit Additional Monitoring. The key finding of that report on which the senators focused was the noted variation in readmission rates across geographic areas (i.e., the associated hypothesis being that following existing best practices of better performing facilities could yield overall lower rates of readmissions – and thus lower costs to Medicare and Medicaid).

The upshot here is that SNFs now have giant targets on their backs. Provider advocates and trade associations now probably wish even more so that the QAPI regulations had not been so long delayed, as there might now be at least some political cover from being able to report work was already underway to assess these issues and challenges. Now when then QAPI regulations are released there will be heightened attention, focus and expectations of organizational compliance.

Bottom line for SNF organizations: if you haven’t started to familiarize yourself with QAPI, yesterday would be a really good time to start.


The Future of Medicine is Now: Can We Afford It?

“Imagination is more important than knowledge. For knowledge is limited to all we know and understand, while imagination embraces the entire world, all there ever will be to know and understand.” ~ Albert Einstein

Writing about healthcare public policy is never far removed from contention and conflict. It just comes with the territory. So it’s a treat on occasion to share something that can be appreciated and enjoyed without being debated (that being said, stand by). But first, please enjoy these two videos – in order, starting in the late 23rd century with the original crew of Star Trek.

“What is this, the Dark Ages?”

Now fast forward back to the twenty-first century.

InSightec is an Israeli-based company that has pioneered MR guided Focused Ultrasound, which provides a personalized non-invasive treatment that can replace invasive procedures and offer therapeutic alternatives to millions of patients with serious diseases. Jackob Vortman, PdD, the President of InSightec, shares the remarkable advancements he and his colleagues are achieving.

Future of Noninvasive Outpatient Surgery

Policy Implications

The future of medical technology is indeed exciting. As with many innovations over the course of history what once was only imagined is now becoming a reality. At the same time medical technology is recognized as a fundamental driver of healthcare costs and, in turn, affordability. From a social and political perspective what makes this driver so acutely felt today is the demographic impact on escalating demand for core primary care.

Invoking Star Trek again, the relative merits of individual versus social needs pervade several film episodes with the key line being, “the needs of the many outweigh the needs of the few – or the one.” Of course pragmatists will recognize that’s really more a matter of perspective than any metaphysical reality: i.e., depending on whether you are the one or the many and your personal belief system.

To put a finer point on the issue: how can we possibly continue to fund the types of advancements of organizations like InSightec here in the US and allocate sufficient resources to provide a baseline level of care for a dramatically aging population while not being more direct, more candid and more transparent in how medical care is rationed?

There has always been rationing of care. But it has always been a de facto situation that is for better or worse woven into the fabric of our care delivery system. Can we continue that way without anticipating some real tragedies?


Medicaid vs Education

In The Hill yesterday, Dick Morris, one-time Republican strategist and advisor to President Clinton beginning with the 1994 midterm elections, wrote about the looming social battle between state funding of Medicaid v. Education

Even in those states that have chosen not to expand Medicaid through the Affordable Care Act’s benefit opportunity Morris believes they will be, “unable to provide decently for education without cutting back on the ambitious Medicaid expansion” as insurance exchanges provide coverage to individuals already eligible for Medicaid without the ACA.

He points out that Medicaid’s recently modest spending trajectory is set to increase substantially with increases in enrollment (spending is projected to rise 12.2 percent in 2014, 7.9 percent in 2015 and 2016, and 6.6 percent per year thereafter). But with state budgets overall not increasing commensurately, that means Medicaid spending must take a bigger share of the budget pie – and something else must get less.

Morris believes that will be education and has issued this dire warning: “we cannot afford both [education and Medicaid]. Of course, states can still raise taxes and join jurisdictions like Detroit into their slow spiral to oblivion.”

What really puts this suggested tradeoff on the razor’s edge is the evidence of failure that Medicaid expansion efforts have generated. Of course the Oregon Health Insurance Experiment is both timely and top of mind here. If you haven’t already, I encourage you to take the time to at least survey that research. In a nutshell, the experiment found that expanding Medicaid resulted, “in no measurable health benefits in the Medicaid group for several chronic conditions, including hypertension, high cholesterol and diabetes.” It did result, however, in a significant increase in ER utilization, where relative costs are substantially higher than primary care settings.

Expanding healthcare coverage to those who cannot otherwise afford it is both a noble and moral obligation of a progressive society. But making choices to pursue noble pursuits with limited resources is a reality that becomes more urgent every day in the face of what we have seen  happen in other countries due the lack of fiscal responsibility.

Mr. Morris has pointed out an important and challenging debate that states will have to wrestle with in the years ahead. It’s hard to make the argument for defunding children’s educations to support a program that has so far not achieved the desired ROI. But while we’re focused on relative social ROI we might also want to look critically at the success of state investments into educational programs.


Blog image from The Hill ~ Jenny Francis

SGR Repeal & Replacement Act

AR-307319997If there was any truth, whether by design or default, to Nancy Pelosi’s infamous quote regarding the Affordable Care Act – i.e., that Congress would have to pass it to find out what’s in it – then she could have been alluding to the reality that the ACA is much more of a framework for creating future policy through regulation than it is prescriptive on the means of enactment.  And for that – and for many of those who did read the ACA – it has taken a fair share of plausible criticism.

Now comes the SGR Repeal and Medicare Beneficiary Access Improvement Act of 2013 (introduced on December 10th of last year).  As of my writing this blog post it has overall received pretty broad support, including from two of the largest and most respected physician trade associations (e.g., the AMA and AMGA) that if you weren’t familiar with the politics behind it would be truly dumbfounding.

Without expressing an opinion on the merits of the legislation, I believe that if you have found core concepts of the ACA unacceptable, then you sure as hell can’t be comfortable with many of the concepts contained in the SGR Replacement bill. I can only guess that most folks know about as much about the latter as they do about the former – and that they take their lead from media interpretations. Or the country is so desperate to have a Congress that works constructively on anything instead of being at war, they read "bipartisan" and jump off the cliff.

My areas of experience and expertise have never included consulting to physician practices, so if I am out of my league here, I apologize in advance. But from what I do understand provided below is a summary of the bill’s key components.  You can decide whether you favor these ideas based upon what’s already been debated regarding the ACA.

Repeal of the Sustainable Growth Rate
This one’s rather easy and hard to imagine will face much controversy. Everyone I have ever met in healthcare wanted to see the SGR formula repealed in favor of a stable, sustainable approach that wouldn’t push uncertainty of physician income to the cliff on a continual basis. Economic uncertainty due to congressional inaction has been the single greatest shortcoming of Congress over the past decade.
Purpose: Create a permanent fix to the Medicare physician payment approach
Risk: It actually fails to control costs and gets debated all over again in five years

Fee Updates
From 2014 through 2018, annual updates will be 0.5%. From 2019 on the 0.5% update would continue – but there would be incentives and potential penalties under a new Quality Incentive Program.
Purpose: Recognize the need to reflect impact of very modest cost inflation
Risk: Medical inflation substantially outpaces 0.5% a year, and the alternative payment models described below fail to provide adequate compensation

Reporting System to Improve Accuracy of Relative Values
Based upon existing data, patient scheduling systems, cost accounting systems, etc., payment incentives would be provided for reporting groups (i.e., physicians across specialties and setting). While this doesn’t appear to be a mandatory requirement, to the extent compensation is available to subsidize cost reductions it will become a de facto requirement.
Purpose: Creation of a data set that can be used to incentivize and reward productivity based upon comparing relative costs and outcomes
Risk: The cost of collecting and analyzing the data far outweigh any long-term cost benefits achieved

Adjustments for Misvalued Physicians’ Services
What will the reporting system above be used for? To identify services whose relative value adjustment would result in a reduction in spending up to 1%. And, of course, this would not be a budget neutral proposition: funds would be removed from the pool of spending for Medicare physician services.
Purpose: To achieve meaningful cost savings where value being produced isn’t commensurate with cost of production
Risks: Historical measures may not be reliable indicators of true cost and methodologies for determining value could be harmfully arbitrary and/or subjective

Quality Update Incentive Program
A new QUIP reporting system would begin triggering payment incentives and penalties beginning in 2019, unless a physician or other eligible professional is already in an alternative payment model. The QUIP quality measures would replace those of the existing PQRS reporting and penalty program, though that program would remain in force. The QUIP would be used to adjust payment rates +/- 1% (or zero) based on scores relative to peer groups, and as an incentive to report there will be a 5% reduction in cost reimbursement for failure to participate.
Purpose: Provide financial incentives to improve quality while reducing costs
Risks: See above

Advancing Alternative Payments Models (APMs)
$2 billion is being advanced from the Medicare Trust Fund for the evaluation, approval and implementation of APMs. A unique bent is the Secretary of HHS must contract with an independent entity to do this rather than CMS (i.e., a privatization of the process – though certainly not beyond the realm of politicization). But the underlying idea is consistent with the ACA’s effort to incentivize innovative new payment models that lower cost and improve quality outcomes, while underwriting the means of education and ability to replicate successful models.
Purpose: To use alternative payment methodologies to incentivize greater provider collaboration and coordination
Risk: Payment incentives become misaligned with provider incentives resulting in practice choices that are not in the patients’ best interest

Encouraging Care Coordination and Medical Homes
CMS has to develop new HCPCS codes and begin reimbursing for care provided under those codes in 2015 for, “complex chronic care management services.” Of great significance here is that PAs and NPs will also be able to bill Medicare under these codes if they are able to meet criteria equivalent for physicians participating in a medical home model or similar model.
Purpose: to provide a means and mechanism to reimburse the work effort involved in providing care coordination and transitional care services
Risk: The financial incentive to push care coordination onto PAs and NPs results in overburdening and leads to worse overall patient care

Expanding Availability of Medicare Data
The bill increases access and use of Medicare claims data. This allows “qualified entities” to to sell claims data or analyses to authorized users for non-public purposes and allows qualified clinical data registries (QCDRs) access to claims data. Purpose: Streamline access, utilization and analysis of claims data that could provide valuable insights into physician practice patterns
Risk: The wrong type of data ending up in the wrong hands and thus putting patient privacy at risk

A minor detail. Means of providing revenue to fund provisions of the RSGR haven’t been thought out – or perhaps considered may be more appropriate. One idea being touted is to use the claimed savings from the Better Care, Lower Cost Act, which proponents claim will save as much as $25 billion a year. This bill also has attracted bipartisan support, but the CBO has not scored it yet – so there isn’t anything to hang your hat on there just yet. Short of something like that, however, funding will become another partisan and special interest charged debate that easily threatens to derail the RSGR bill.
Purpose: To provide the revenue need to cover costs of implementation
(HUGE) Risk: In a Robbing Peter to Pay Paul fashion Congress takes even more funding away from post-acute/long-term care providers


Blog Photo:

Better Care, Lower Cost Act

MHLast week, Sen. Ron Wyden, D-Or, together with co-sponsors Sen. Johnny Isakson, R-Ga., and Reps. Peter Welch, D-Vt., and Erik Paulsen, R-Minn introduced the bipartisan Better Care, Lower Cost bill (S. 1932/H.R. 3890).

Wyden is broadly thought to have the inside track to succeed Senator Baucus – who has been nominated as the US’s next Ambassador to China – as the successor chair of the Senate Finance Committee. But despite the bill’s referral to that committee and its bipartisan support it is unlikely to reach the Senate floor anytime soon. Thus, Congress.

Consider that according to CMS 68% of Medicare enrollees suffer from two or more chronic conditions and account for 93% of Medicare spending ($487 billion). And 98% of hospital readmissions involve beneficiaries with multiple chronic conditions. Consider that today the Medicare system creates barriers preventing healthcare providers from building on successful integrated care delivery models.

The core concept of this bill – a Better Care Program – isn’t new. BCPs have been developed in various states as teams of doctors, nurses and social workers working together under a capitated payment arrangement. In seeking to monetize the success of those programs, the Better Care, Lower Cost bill has elements of the accountable care framework promoted under the Affordable Care Act, but there are important differences:

                      1. The underlying incentive for care coordination of an ACO is the belief that such coordination will lower costs (i.e., utilization) and result in shared savings. Under a BCP, care coordination is germane to the program (though the troublesome utilization disincentive seems to me to remain).
    1. BCPs are not impacted by the ACO attribution rule, which prevents providers from actively targeting and enrolling the sickest patients.
    2. BCPs can use pricing incentives to encourage participation in high-value care and patient activation, whereas patients covered under an ACO are not limited by where they can seek care nor particularly incentivized to engage in care management.
    3. Every beneficiary of a BCP receives an individual care plan, whereas ACOs are not required to create a plan for every beneficiary.
    4. BCPs are specifically designed to target the chronically ill with the intent of effectively managing those conditions as efficiently as possible, whereas the ACO attribution rule prohibits differentiation of patient condition or need.
    5. In theory, BCPs lack the volume-driven incentives of a FFS payment system that characterizes ACOs.

    Coordinating care across healthcare providers is intuitively beneficial to a patient – in much the same way that coordinating parental responsibilities is to a child. But where this bill falls short from my reading is its tight focus on the clinical and pharmaceutical aspects of chronic disease/care management. Long-term care, though not defined, is specifically excluded from a BCP’s requirements, though some provision is made for coordination of Medicaid long-term care benefits.

    If we are serious about wanting to utilize care coordination as the silver bullet to lower Medicare costs associated with treating beneficiaries with chronic diseases, then we will have to recognize taking a holistic approach that extends beyond doctors, nurses and drugs is necessary. It does little good to provide affordable therapy when the patient has no means of transportation. It does little good to prescribe a beneficial diet when they have no stove to cook. It does little good to prescribe medications when the patient cannot remember when and if they took the prescribed dosages.

    A successful caregiving team under a capitated payment arrangement must also include the housing and community-based services and supports necessary for individuals with chronic disease to effectively manage their own care. The thinking behind the Better Care, Lower Cost Act is headed in the right direction, but it just seems to me whomever was responsible for drafting it doesn’t really understand chronic care delivery very well.




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