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 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

Advance-Care Planning

The cover story of this coming week’s edition of Modern Healthcare (subscription required) focuses on end-of-life directives. The now infamous death panels phenomenon that became coupled with fears over the Independent Payment Advisory Board (IPAB) and rationing of knee and hip replacement procedures for Medicare recipients. I first wrote about this topic in November of 2012.

So here we are going on three years later and to my knowledge there have been no elderly individuals dragged before a panel of subjective arbiters charged with determining whether or not a person shall live or die. Not to diminish the reality of systemic rationing, as I have also written upon here – and that it will increase dramatically as an issue and concern in proportion to the demand for healthcare of an aging society.

But it has and continues to seem certain that admonishing public policy that raises awareness about the challenges of rationing and end-of-life care through increased and improved communication is rather wrongheaded. Fortunately, pragmatism seems to be winning over irrationality, and there are continued efforts to recognize the realities of having to address how scarce healthcare resources are allocated.

CMS announced last week that its proposed 2016 Medicare Physician Fee Schedule would incorporate physician payment for end-of-life conversations with patients. Though Medicare already provides for advance care planning upon enrollment the new rule would create new and separate advance care planning codes. Numerous medical societies and health organizations have pushed for reimbursement of advance-care planning as a separate, stand-alone service.

In good part much of the support was a desire to be paid for work already being performed. But to some extent it also represents an incentive to provide a service. And there’s the rub: what’s being incentivized? Education and awareness – or an inherent bias to abridge care and treatment options in favor of resource conservation that could be manifested in income to the clinical practitioner?

Indeed, it’s a slippery slope, and we need to be vigilant in understanding the impact of frequently dramatic differences between how an end-of-life is planned and what actually takes place at care settings in the hands of clinicians whose primary directive is to preserve life. From a policy perspective there are multiple elements that may yet contribute more to this discussion (e.g., the apparently defunct IPAB and the Patient-Centered Outcomes Research Institute).

For now, however, there is a greater opportunity to empower patients with more knowledge and information to assist them in their personal decision making regarding end-of-life care. That’s a good thing.

Cheers,
  ~ Sparky

Image credit: Martin Kozlowski for WSJ

Chasing Population Health

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

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

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

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

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

Cheers,
  ~ Sparky

To Sleep Perchance to Die

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

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

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

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

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

Before answering, consider . . .

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

Cheers,
  ~ Sparky

Picture Credit:
Hamlet – Skull Study by PaulJulianBanks

DocFix is D O A

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

Oh, please.

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

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

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

See what I’m getting at?

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

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

Cheers,
  ~ Sparky

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