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.

  ~ 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?

  ~ 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.

  ~ 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
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.




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.

IMPACT Act = Future of PA/LTC

IMPACT Act  1AYesterday I participated in a Special Open Door Forum on the Improving Medicare Post-Acute Care Transformation Act of 2014 (i.e., the IMPACT Act) hosted by the Centers for Medicare & Medicaid Services. This was a bipartisan bill introduced in March of last year, passed on September 18th and signed into law on October 6th.

The IMPACT Act requires the tracking and reporting of standardized patient assessment data for:

Assessment and Quality Measures
Quality care and improved outcomes
Discharge planning
Care coordination

Post-acute settings affected include home health agencies, skilled nursing facilities, inpatient rehabilitation facilities and long-term care hospitals. IMPACT Act  2AThe impetus behind the standardization, in theory, is to allow for the exchange of data using common standards and definitions, to facilitate care coordination and to improve Medicare beneficiary outcomes. More importantly, it is a directed effort to develop an informational backbone in support of care coordination across PAC settings.

Categories for which data must be collected and reported include:

Functional status
Cognitive function and mental status
Special services, treatments and interventions
Medical conditions and co-morbidities
Other categories required by the Secretary

SNFs, IRFs and LTCHs must begin reporting not later than October 1, 2018, while HHA have until January 1, 2019.

Question: If implementation is over three-plus years away, why worry about this now?
Answers: for starters, it’s a bipartisan initiative that isn’t likely to be rescinded regardless of what happens to the Affordable Care Act. Second, compliance with IMPACT is going to require a commitment of additional resources for most organizations, and spreading the effort out over a longer period will mean less dramatic of a short-term financial impact; and third – and most importantly – understanding and embracing the underlying systemic transformation that is driving these compliance requirements will accelerate organizational positioning toward integrated care delivery.

Additional information on the IMPACT Act can be found at CMS’s website on Post-Acute Care Quality Initiatives.

  ~ Sparky

A Business Case for Community-Based Care

BTBCPub Patrons:

I want to share with you a new publication that my professional colleague, Lori Peterson, played a significant role in drafting along with a member of her team at Collaborative Consulting, Sarah Milgrom. Based in good part on information generated as a result of a symposium hosted a year ago by the National Coalition on Care Coordination (N3C) this is an excellent resource underpinning the core value propositions of community-based care – and a great place to start understanding how to put integrated care delivery theory into practice.

The following is republished with permission:

New N3C Issue Brief:
Building the Business Case

The National Coalition on Care Coordination (N3C) is pleased to share our new brief, "Building the Business Case: Community Organizations Responding to the Changing Healthcare Environment for Aging Populations."

At the March 2014 American Society on Aging’s Aging in America conference, N3C hosted a half-day symposium titled Building the Business Case: Responding to the Changing Environment for the Aging Network.” With the support of The SCAN Foundation, N3C has partnered with Collaborative Consulting to create an issue brief that highlights and builds on the symposium presentations and discussions, in order to share the lessons learned with a broader audience.

The brief explores tactics for community-based aging service organizations (CBOs) to be successful in the midst of changes in the healthcare and social service sectors and increased demand for comprehensive services from the growing aging population. As more and more CBOs begin to navigate the healthcare landscape, it is important for them to learn from the experience of those who have already begun the complex process of asking critical questions of themselves and their organizational structure, crafting a strategy to lead their organizations forward, and developing working relationships and mutually-beneficial agreements with payers and health systems.

We hope that you will share this brief widely with your networks. Please
reach out to us with any follow-up questions or comments that you may have. Many thanks to Collaborative Consulting and The SCAN Foundation for their partnership on this project!

~ Sparky

National Study of Long-Term Care Providers

National Study of Long-Term Care ProvidersFor those policy wonks out there looking for resources to support your work here is a phenomenal publication that you need to be familiar with. The National Study of Long-Term Care Providers is sponsored by the Center for Disease Control and Prevention’s National Center for Health Statistics. Data, information and analysis is presented in an integration fashion that is designed to monitor trends in paid, regulated long-term care.

Five sectors are included:

Adult day service centers and participants
Home health agencies and patients
Hospices and patients
Nursing homes and residents
Residential care communities and residents

The main goals of the study are to:

Estimate the supply and use of paid, regulated long-term care services
Estimate key policy-relevant characteristics of providers and users, and practices of providers
Produce national and state-level estimates, where possible
Make comparisons within and between sectors
Examine trends over time

And not just policy wonks will benefit from the depth of knowledge and information provided by this initiative. Those in the senior housing and post-acute/long-term care business will benefit by having insights and understanding of utilization patterns, disease incidence, clinical and operational characteristics – across provider types. As the industry transcends away from its silo-based legacy toward the integration of community support, services and care across organizations having an understanding of how these provider types can work together to provide greater value will be a fundamental requirement to economic survival.

  ~ Sparky

Healthcare Reform: Join the Debate!

PictureBack in the day, before Al Gore had even understood the full impact of his new invention, the Internet was raw and without form. It took the efforts of early technology pioneers who could envision the scalability and acceleration of historic processes. Eric Thomas was an engineering student in Paris back in 1986 when he invented a software program that automated the management of email lists: LISTSERV.

LISTSERV facilitated the ability of an individual to send an email to a list address that would then transparently resend that message to all of the members on the list. Now for those of you under 45 please note that TCP/IP was only introduced four years earlier, so this was at the time an important step in the evolution of social media. One might argue all that has really changed since 1986 via text messaging, Facebook, Twitter, et al are the means and acceleration of transparent communication.

It’s the latter which has probably had a more dramatic impact on the popularity of email discussion groups. The process is slower and more often void of the drama and hyperbole associated with in your face communication we so much enjoy today (yeah, tongue planted firmly in cheek).

Sometime back in the early 90s, I believe, I came across such an email discussion group: HEALTHRE, which was hosted out of the University of Kentucky’s LISTSERV service. The discussion group attracted a wide variety of stakeholders in the healthcare space: nurses, physicians, patient advocates, think tank analysts, university professors – all with a shared interest in discussing and debating healthcare reform – back before it became really fashionable.

For me, what I found incredibly valuable about HEALTHRE was the varied insights from different perspectives – of often challenging and difficult topics to understand. In today’s world where each media outlet is desperate for even modest increases in attention it is nearly, if not, impossible to gain a meaningful and useful understanding of healthcare reform. You never really understand until you’ve challenged your thinking to the point of accepting how little you know about anything.

A few years back that list outlived its usefulness and ability to attract new participants. But a few of us banded together to create a new list – HCPolicy. Unfortunately, the list has not grown and continues to limp along only by the shared refusal of its participants to let go of the hope to what it could become again. Our firm, Artower Advisory Services, has continued to underwrite the list as an open, free and non-commercial email discussion group.

Over the next six months we are going to put forth a renewed effort to grow the list back to where it was in the high days of HEALTHRE. If we can’t, then we will close it down and submit to defeat at the hands of the expression over thought paradigm that pervades more popular forms of social media. Please consider joining us in keeping our list alive by simply clicking on the link below.

Sign Me Up

  ~ Sparky

Value-Based Payment: The Rush is On!

The most opportune time to jump off a bandwagon is just before the next person jumping on tips it over. If the accelerating movement toward value-based payment (VBP) models in healthcare could be metaphorically thought of as a bandwagon, then its passenger weight increased dramatically this week with two major announcements.

First, on Monday HHS Secretary Slyvia Burwell announced that within four years half of all Medicare spending will be VPB oriented (e.g., bundled payments, ACOs, capitation models). Then yesterday several of the country’s largest healthcare systems and insurers announced the creation of a Health Care Transformation Task Force whose stated goal is to shift 75% of their business to VBP type contracts by 2020 (as in 5 years).

I have been an acknowledged student and disciple of Michael Porter’s work on value in healthcare and have written about that subject here in the past. Porter and colleague Elizabeth Teisberg wrote the seminal work, Redefining Healthcare, which buttresses much of the practical theory that has been espoused in support of VBP. In my study, however, I came to believe the underlying structural challenges of our current delivery system would take a great deal of time and effort to overcome before value could work the magic as intended. And so when I read these two announcements I had to wonder whether fools are rushing in where angels fear to tread.

In other words, it’s not the direction of the bandwagon I find concerning but the pace of acceleration. There is so much unknown and so much to be learned regarding the organizational dynamics of healthcare delivery that putting deadlines on the pace of that knowledge-building is pure folly. To illustrate, let’s just look at Porter’s strategic agenda for creating a value-based healthcare delivery system and consider each in context of what we are witnessing today.

1. Organize care into integrated patient units around patient medical conditions.
Porter has travelled the world lecturing and observing healthcare delivery systems in other countries. He provides examples of structural reorganization for patient conditions (e.g., the West German Headache Center) that have achieved substantial improvements in patient outcomes at lower cost. The concept isn’t entirely new (e.g., MD Anderson Cancer Center reorganized its outpatient care services in the early 90s under the auspices of an IPU), but still rather rare and so not very well understood.

2. Measure outcomes and cost for every patient.
Another way of saying this is be able to measure cost and quality/satisfaction at the patient level. This is without a doubt the most difficult and controversial aspect of Porter’s agenda.
In June of last year I wrote a post that addresses the inherent subjectivity of patient outcomes and its impact on the value equation. If this cannot be worked out in a manner and fashion that achieves broad understanding and acceptance across patients, providers and insurers – well, see bandwagon discussion above.

3. Reimburse through bundled prices for care cycles.
When Porter talks of bundling his focus is on tying the bundle definition to the value achieved on behalf of the patient – e.g., the patient’s experience, impact on family, lifestyle functionality, etc. What I hear about mostly are efforts to define, articulate and divide up processes and procedures related to a diagnosis and/or condition, put some probability bookends around that understanding and then compare projected average payment to cost. The ability of value to be successful as a catalyst for aligning incentives has already been lost because the focus is on process – not the patient.

4. Integrate care delivery across separate facilities
The many challenges of integrated clinical care notwithstanding, improved performance through specialization is really the key concept here. Research has shown that volume in a particular medical condition is positively correlated with patient value. This runs counter to the notion that all healthcare is local. While every day we culturally become more comfortable with this notion – e.g., international medical tourism – there are still substantial social and political obstacles to overcome.

5. Expand areas of excellence across geography
We are seeing systems like the Cleveland Clinic, Geisinger and the Mayo Clinic exporting their knowledge and expertise across geographies. But the expansion has been primarily revenue-driven (relatively more patients with the financial ability to afford services). If value is to be the driver of alignment, then eventually those organizations will also have to demonstrate how knowledge exporting not only improves outcomes at the local level but also lowers costs (much harder to achieve).

6. Build an enabling information technology platform
Hoo boy, right? The challenge here, of course as I have written before, is properly utilizing IT to facilitate and enhance the productive value of human processes. If the underlying organizational structure and processes aren’t in alignment with the goals and objectives manifested through the five agenda items above, then all we will be doing is automating a system that we said we wanted to change.

I realize some of these concepts are above my pay grade, and I continue to believe the value concept – Patient Outcomes/Cost – is the key fundamental principle of structural system reorganization. But when I step back and compare the payment and care delivery models being pursued in the name of “value” against the strategic agenda that Porter laid out I worry greatly that we are not willing or prepared to take the time or effort to understand and address fundamental areas of concern.

It’s like building a pyramid. The more time you take to create a solid and expansive foundation, the higher you will ultimately be able to build. As much as I have supported the value driving structural change paradigm I would encourage all industry stakeholders and participants to be both pragmatic and cautious in advancing on VBP models. Take the time to observe, learn and adjust – and don’t let your timeline be driven by outside sources with no vested interest in your organization – or your patients!

  ~ Sparky

Standing At The Gates of Hell

Je Suis Charlie? That all depends. Am I Charlie, a faceless Parisian joining with thousands of others along the Avenue des Champs-Élysées in candlelit vigil mourning a national tragedy? Or am I Charlie, a major newspaper like the New York Times having to carefully weigh my support of free speech – however rancor and callous that may be – against my potential complicity in unwittingly embracing and spurring additional tragedy? Either way, it’s no fun being Charlie.

Unless you have been hibernating through the cold of January or living under a rock you have some knowledge of the tragic events that unfolded in Paris on January 7th. At approximately 11:30 that morning two men armed with Kalashnikov rifles and other assault weapons entered the offices of Charlie Hebdo – a French satirical weekly newspaper – and slaughtered 12 individuals, including its popular yet controversial editor, Stéphane Charbonnier. The perpetrators were subsequently killed following a massive manhunt, as was their wont, being self-proclaimed Jihadists whose attack they claimed was vengeance for Hebdo’s cartoonish portrayal of the Prophet Muhammad.

Charlie Hebdo’s historical agenda of satire reflects an equal opportunity offensive. Charbonnier said two years earlier that, “we have to carry on until Islam has been rendered as banal as Catholicism." Anyone with a working familiarity of history will recall the Catholic church’s legacy is anything but banal. But whereas Christianity has by and large been secularly assimilated into a separation of church and state, radical elements of Islam seem increasingly intent on remaining more than a few centuries behind. Thus be to tyrants and zealots and their expedient interchangeability in the name of power and control.

In the aftermath of the events in Paris columnists, pundits and editorialists have taken to whatever venue will have them to let us all know who’s at fault, what could have been done to prevent it and what we absolutely, positively must do next to prevent further aggression. They write and speak with such authority that it truly is amazing they have either been silent up to now or just recently had the epiphany that will save us from the gates of hell.

The reality is there are so many different ways to theoretically and intellectually slice the myriad social and political challenges of extremism in the name of religion that even the Whitehouse is afraid to use the term, Radical Islam.  Obama ne résiste avec Charlie? If there is a war against that extremism who or what exactly are we fighting against? A religion? An idea? Criminals? A nation-state? The aforementioned experts believe it’s somewhere between one of those and all of the above. Brilliant, right?

All I know, or what I think I know in any event – if you’ve followed my blog, you know this is a substantial subject-matter departure – is that terrorism will never go away as long as it can have the effect desired by its perpetrators.  And I know that in the long run it will never achieve its desired purpose. Never has. What I believe is that terrorism or violence of any type in the name of a religion wanes in proportion to the ability of that religion’s followers to achieve prosperity and happiness.

And so eventually, the power and control held by the few under the guise of religious fundamentalism will crumble under the weight of the many who become educated and enlightened to how they have been manipulated for centuries into oppression and  subservience. We have seen this taking shape already, and electronic communications are helping to accelerate the process. In the meantime, I am afraid, there is going to be a lot more hell to pay no matter what course of action is chosen.

  ~ Sparky



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