Apr 19, 2014

Readmission for Life

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Readmissions. A term that has become ingrained in the lexicon of governmental agencies, elected officials, healthcare policy analysts, healthcare provider institutions – and even care providers. The case is made simply enough: it is far less costly to care for someone at home or in a congregate setting than in a hospital. More nuanced, the logic follows that both efficiency and quality can be maximized by utilizing the setting that costs just enough to provide quality outcomes.

And so a lot of money is being spent – by the government in the form of research and testing grants, as well as both for profit and nonprofit healthcare providers, all wanting to better understand how to keep people out of the hospital without impacting their health. Of course, Medicare’s Hospital Readmissions Reduction Program is also providing an incentive as hospitals seek to avoid up to a 3% reduction in Medicare reimbursement.

The Internet is replete with articles and stories on the how and why of reducing readmissions. I have written about the topic extensively on this blog. It has captured my attention because that is where Artower Advisory Services, positions itself: at the intersection of acute and post-acute/long-term care.

I have a growing concern that the dialogue over readmissions is becoming increasingly academic and pedantic. The measures of programming success have not been clearly defined because of the simple reality that success needs to be defined differently for each patient.

People react to environmental stimuli in different ways. Two patients with the same condition and otherwise similar health may be better served in different settings. One patient might have great comfort in being at home – to the extent where their mental state promotes healing faster than in an institutional setting. Another patient may need the real or perceived sense of security from being at the hospital where immediate attention is just down the hall.

In more than a few ways the initiative to reduce hospital readmissions has been an effort to pick the low-hanging fruit. Anecdotally, I am convinced from spending years working with healthcare providers that patients needlessly end up in the hospital because of poor communications, silo operations and the practice of defensive medicine.

There are tremendous opportunities for performance improvement. Along with reducing costs and improving outcomes, however, we must be diligent in developing outcome measures that reflect the subjective reality that every patient is unique.

Cheers,
  Sparky

 

Filed Under: Editorials & Opinions, Hospital Readmissions · Tagged: , ,
Apr 13, 2014

I Made HOW Much ?!?!

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This past week CMS released Provider Utilization and Payment Data: information on services and procedures provided to Medicare beneficiaries by physicians and other healthcare professionals. In case you weren’t following along, there has been quite a bit of controversy over the data release, including from both the American Medical Association and the Medical Group Practice Association.

Donald W. Fisher, Ph.D, MGMA President & CEO:
MGMA is troubled about the potential for unintended consequences as a result of the release of this type of data and the effect it may have on Medicare beneficiaries. This release could result in patients making decisions about their care based on faulty assumptions about physicians. Claims data are not a proxy for quality, especially when provided in isolation, from a single payer. MGMA is also concerned about the impact on physician privacy, as releasing physician’s personal financial data and National Provider Identifier (NPI) information could make providers susceptible to fraud. Physicians should have had the opportunity to review the data before it was made publicly available in order to modify or appeal any inaccuracies.

Ardis Dee Hoven, MD, President of the AMA:
Thoughtful observers concluded long ago that payments or costs were not the only metric to evaluate medical care. Quality, value and outcomes are critical yardsticks for patients. The information released by CMS will not allow patients or payers to draw meaningful conclusions about the value or quality of care.The AMA is disappointed that CMS did not include reasonable safeguards that would help the public understand the limitations of this data.

Back in February of 2013 I wrote, Pick a Price – Any Price, describing how and why healthcare provider pricing is typically both misleading while at the same time meaningless. But the focus then and there was on hospitals. People in general are a lot more envious of other people than they are buildings and groups of people working in those buildings. Thus you can easily understand why there is concern over public perceptions – particularly when those perceptions are likely to be different than reality in most instances because of not understanding how to interpret the data.

Theoretically, I weigh this concern against a belief that in most cases more information is better than less.  Obvious exceptions include issues of personal privacy and national security. Transparency and accountability should be hallmark pursuits of the Medicare system. And I think most physicians are in favor of sharing data that helps empower the patient to make more informed healthcare decisions.

It is not at all clear the data released last week will be able to do that any time soon. In fact, the arguments positing the data’s release will do more damage than good are persuasive. These include a lack of any data on quality; inability to track actual service levels to individuals providing those services; misunderstanding of charges versus payment; inability to risk adjust for patients treated; no adjustments for site of service differences; discrepancies caused by changes in billing codes; and – most importantly – no way of knowing how much reimbursement the physician uses to cover overhead costs, which is required in order to determine real income.

So on balance I have to side with the physician groups on this one. CMS made a very poor decision to release the data, as-is, without any real thought about releasing it with all of the disclaimers addressing the issues and concerns described above. I hesitate to say it – but I say what I think – this sure feels like another backdoor attempt to promote victimization at the expense of disinformation.

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Provider Utilization and Payment Data · Tagged: , , ,
Apr 4, 2014

SNF Value-Based Purchasing Under SGR Extension

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Earlier this week President Obama signed into law H.R. 4302, the Protecting Access to Medicare Act of 2014. The sole impetus of this legislation was to once again avert – by one year – the nearly 24% cut to the Medicare physician fee schedule that was initiated as part of the Balanced Budget Act of 1997 under the Medicare Sustainable Growth Rate (SGR) methodology. This marks the 17th time in 11 years now that the automatic cut has been averted by legislative action. Congress knows how to kick a can.

Just a few weeks back there was a fair amount of optimism the SGR might be fully repealed and replaced with a “permanent” payment methodology. There was bipartisan support in both the House and Senate, but as you might expect, wide differences in how to pay for the repeal. While Republicans sought repeal of the individual mandate, Democrats wanted to tap into unused military spending. And there you have it then.

In about 11 months from now Congress will be back to the same spot of having to deal with a pending fee cut, but it will be a different Congress.  Just how different of course should make for a fascinating late summer/fall entertainment for political wonks. In the interim, however, there are a number of non-physician related items included in this Act that are worth noting, including a delay in the implementation of ICD-10; acceleration of LTCH moratorium; changes to Medicaid disproportionate share hospital (DSH) payment reductions; limitation on the two-midnight rule enforcement; as well as other provisions.

SNF Value-Based Purchasing
In addition, the Act calls for the establishment of two hospital readmission-related measures for skilled nursing facilities (i.e., value-based purchasing for SNFs). The first measure is an, “all-cause all-condition” hospital readmission measure; and the second is to encompass, “all-condition risk-adjusted potentially preventable hospital readmission rate.”

The implementation of this program is a few years off: actual reductions in Medicare reimbursement based upon comparative readmission performance won’t take effect until FY 2019 (i.e., SNFs with fiscal years beginning on or after October 1, 2018). But when it does take effect, those organizations with relatively lower hospital readmission performance will be penalized two-percent of their otherwise Medicare reimbursement. In turn, up to 70% of the savings achieved from this penalty will be redistributed to those organizations achieving relatively better readmission performance.

No doubt the process for developing these measures will be contentious despite assertive measures to avoid bias and/or misrepresentation of care indicators included in the Act. And with penalties not starting until four-plus years from now who knows just how (or even whether) the program will be implemented.

Implications
Clearly the sentiment in Washington – at least today – is to shift reimbursement from post-acute/long-term care to acute care. And the preferred means of accomplishing this will be to focus on perceived opportunities for cost savings while improving, or at least without impacting, quality care. The value paradigm: quality divided by cost.

In advance of the value-based purchasing program will be the QAPI initiative, regulations for which are anticipated later this summer. SNF organizations will have to be able to develop quality assessment and performance improvement programs that support being able to predictively monitor and model hospital readmissions given a variety of qualitative and quantitative indicators requiring real-time operational and clinical adjustments.

For many smaller SNF organizations this is going to be a daunting task because of the investment requirements. They will be caught in the unenviable spot of having to make substantial capital investments to maintain cash flow levels that already cannot support capital accumulation. As such, within the next few years they will be faced with closing, merging or selling.

So although the revenue impact of value-based purchasing is still several years away, all SNFs would do well to begin understanding and assessing their short and long-term financial viability in lieu of these forthcoming requirements – while there are still choices available.

Cheers,
  Sparky

Filed Under: SNF Value-Based Purchasing · Tagged: , , , ,
Mar 25, 2014

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

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“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?

Cheers,
  Sparky

Filed Under: Advancements in Medical Technology, In the News · Tagged: , , , , ,
Healthcare & IT: Oil & Water?
Feb 28, 2014

Healthcare & IT: Oil & Water?

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I don’t think it has to be that way, but the history of IT adoption and implementation in healthcare might lead many to believe otherwise. True, there have been major advancements just over the past decade, but from a public policy perspective, have federal policy initiatives helped – or hindered – that progression?

I think most everyone would agree that information technology holds great promise in improving the value of healthcare delivery. And by greater value I mean assisting caregivers and clinicians produce better outcomes at lower cost. Except that in many instances it’s not working that way.

Practical Experience
Courtesy of the healthcare policy-oriented site, KevinMD, I recently came across a blog post by Dr, Christine Sinsky that made me decide it might be a good time to bring this topic up again with you. Dr. Sinsky’s blog post, Hazards of Poorly Designed Decision Support, is an anecdotal yet nonetheless compelling reality of IT utilization in healthcare. The decision support system in question is Trinity Health’s mandatory DVT Advisor.

DVT stands for deep venous thrombosis, which in laymen terms means a blood clot that that forms in a vein deep inside a part of the body. DVTs are most common in adults over age 60 but can occur at any age. If the clot breaks off into the bloodstream, it is called an embolism, which can get stuck in the brain, lungs, heart, or other area, leading to life threatening situations.

DVT Advisor was implemented in response to Meaningful Use requirements. You can read Dr. Sinsky’s post if you would like to understand the practical frustrations she found in using it, but for the purpose of this post I will summarize the key points.

Shortcomings
From her perspective (my interpretation now) there are two key areas of the system that are counterintuitive to facilitating value creation as I describe above: unnecessary input requirements and decision tree logic rigidity that was unable to capture and reflect the patient’s situation (i.e., usability challenges). In essence, the system created more work – and more importantly, introduced a new level of potential risk – than would not have existed without its use. Now that, Pub patrons, is what’s known in laymen terms as, “stupid.”

In the interest of fairness and disclosure I want to note that Dr. Sinsky was complimentary of certain elements of the system; e.g., “the information in the DVT Advisor can be a useful reference if a physician is uncertain about anti-coagulation, but its intrusive and insistent characteristics are based on hope and belief, rather than evidence.”

Policy Issue
And so here’s the policy issue: you have an IT decision support tool that has the potential to add value but for the fact that its design has actually lowered it. Now, I have been an ardent proponent of supporting advancements in HIT as a primary means of improving productivity and efficiency – and thus lowering care delivery costs. I have been less enthusiastic about the top-down approach of HIT policy the federal government has employed to advance those efforts. I have also believed, however, there is the need for an active role of government in helping advance health IT adoption. The what and the how of that role is less certain today.

So for me, Dr. Sinsky’s post is not the needle-in-the-haystack that generated an intellectual epiphany on my part regarding the effectiveness of HIT policy efforts. There is more than enough research and literature supporting logical skepticism for the open-minded to consider. Rather it was more of the straw within the haystack that broke the camel’s back. I am looking for some pub patrons that understand this subject-matter much better than me to weigh in here.

There are some of the most brilliant minds in the world working in HIT – in the clinical and nonclinical arenas – but I sometimes wonder if they can’t get out of their own way to understand the pragmatic nature of value creation. And I wonder if federal policy and governmental agencies haven’t been just willing abettors counting more on hope than evidence as Dr. Sinsky points out.

Please, prove me wrong – show me the evidence where HIT public policy has been more effective than not.

Cheers,
  Sparky

P.S. Please click on the hyperlink above associated with Dr. Sinsky’s name. This will take you to her website where there is a wealth of information on HIT based upon her and her husband’s professional contributions.

Filed Under: Editorials & Opinions, Healthcare Information Technology · Tagged: , , , ,
Challenges of Episodic Payment Bundling
Feb 22, 2014

Challenges of Episodic Payment Bundling

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Last week the New England Journal of Medicine included this Perspective: Post-Acute Care Reform—Beyond the ACA by D. Clay Ackerly, M.D. and David C. Grabowski, Ph.D. The article describes the case of what I believe is a hypothetical patient: Mrs. T., an 88-year-old woman who was admitted to the hospital following a trip to the emergency room.

You can read the article to get the specifics of her case. The thrust of what is shared by the authors has to do with how existing Medicare payment methodologies and regulations impact clinical decision making in ways that are not necessarily in the patient’s best interest. And how payment bundling—particularly across acute and post-acute/long-term care providers—faces challenges that simply aligning financial incentives of those provider types will not adequately address.

In theory, the core precept of episodic payment bundling is that if otherwise historically disparate healthcare providers treating the same patient can be financially incentivized to better coordinate care for that patient, the costs attributable to inefficiencies, redundancies, productivity, etc. will be reduced.

Of course, underscoring this precept is the notion that human beings acting in their self interests (i.e., in pursuit of income and wealth ~ Adam Smith’s Invisible Hand) will create valuable external benefits. The counter to this belief could be found in Garret Hardin’s Tragedy of the Commons, which argues that those self interests can lead to depleting common resources to the disadvantage of wider interests – e.g., the community or society.

Economic theory aside, what the authors argue for is additional governmental intervention to remove obstacles they cite as impeding the benefits that payment bundling might otherwise achieve. These include addressing regulations impeding patient transfers between settings (e.g., the 3-day rule); research into various care delivery models that facilitate more effective care transitioning – particularly those elements outside of the clinical setting; and third, increased investment into comparative effectiveness research to help providers better determine appropriate post-acute/long-term care setting for their patients.

So here’s the irony: though many critics of the Affordable Care Act either disbelieve or refuse to accept that it was in many ways an attempt to thwart or at least delay the movement toward a national healthcare system, concepts like payment bundling, insurance exchanges and capitation are theoretically dependent upon market-based solutions. Provide the financial incentive and just watch market-driven forces create valuable solutions.

Now we are being advised in this article that’s not enough. We have to also regulate away the challenges and obstacles that market ingenuity was supposed to overcome. Sorry – but isn’t that somewhat counterintuitive?

Here’s the challenge. We recognize that individuals’ productivity – in terms of being able to create value – is closely correlated with their desire to pursue individual needs and wants (back to basic Economics). And so if we want to maximize value it follows that we need to maximize individual incentive. In a free market that is most effectively accomplished by allowing individuals to make their own choices, unfettered from governmental interference except for ensuring fairness and safety.

What we are trying to do in healthcare—with initiatives such as ACOs—is create hybrid free market models that leverage the value production ability of individuals while at the same time intentionally and unintentionally interfering with their ability to make unfettered choices. So if healthcare shared common characteristics with other industries, it would be easy to argue that government should just get the hell out of the way.

But here’s the rub. Government is already so deeply entrenched in our healthcare delivery system – at a time where demand is just beginning to grow exponentially – that I fear any serious effort to move backward toward market-based delivery would be like throwing a track switch on a runaway train. And beyond that I remain unconvinced that healthcare is not uniquely different than other industries. Thus we plod along.

What do you think?

Cheers,
  Sparky

Filed Under: Medicare, Payment Bundling · Tagged: , , ,
SGR Repeal & Replacement Act
Feb 8, 2014

SGR Repeal & Replacement Act

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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

Funding
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

Cheers,
  Sparky

Blog Photo: www.modernhealthcare.com

Filed Under: In the News, SGR Repeal and Replacement Act · Tagged: , , ,
What’s Next for the Tea Party?
Oct 17, 2013

What’s Next for the Tea Party?

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550px-Remove-a-Stuck-Tongue-from-a-Frozen-Surface-Step-3One might think the graphic accompanying this post was leaked from Sen. Ted Cruz’s political strategy playbook: the next chapter in The Tea Party’s Fight to Repeal the Affordable Care Act. It’s not. Could be though, right? The metaphor holds of doing something foolish to gain popular attention and then suffering the individual consequences of that foolishness.

Of course, Tea Party advocates will no doubt claim I am being foolishly satirical and hypocritical for not recognizing my own ignorance in understanding the dramatic importance of standing up for liberty, fiscal responsibility and apple pie. If they truly believe those were Senator Cruz’s motivations, well then what can I say – they must see a political reality in this country different than the one I see.

Even if we were to believe the efforts of Senator Cruz and other Tea Party congressional enthusiasts – to hold the country fiscally hostage for over two weeks in an effort to defund the ACA – were nonpolitically motivated, the overall reaction of the American public can hardly be what they were hoping for. According to a Pew Research Center poll released yesterday, the Tea Party is less popular than ever, even among many Republicans, with nearly half (49%) of survey respondents having an unfavorable opinion. This is up from 37% in June of this year.

On the other hand, Senator Cruz’s popularity among Tea Party respondents has risen from 47% to 74% since July. I’m not sure how well that bodes for his future political aspirations (at least outside of Texas, if that was of interest), but I am being sincere when I say that I respect the all-in approach of any elected official because it represents a refreshing departure from governing by opinion polls.

My view of the Tea Party, for better or worse, is largely based on the individuals I know personally who are either sympathetic to, intellectually aligned with or proud to be members. I find them to be generally well informed on political issues and passionate about protecting individual liberties. Things go downhill when we start debating who gets to define which liberties should be protected and by whom, which I interpret as the Tea Party being discerningly different than many Libertarian viewpoints.

They are very concerned – and I think rightly so – with the economic future of our country and seem to understand more than most that both political parties are guilty of sustaining special-interest budgeting despite whatever expressions of concern we may hear to the contrary. That’s where a large part of the inherent challenge to the Tea Party’s future lies. As shown in the Pew Research poll, there is a lot of confusion, disagreement and debate over whether and how well the Tea Party “fits” within the Republican Party.

I personally hope it finds its national voice apart from the GOP. If it has something meaningful to offer in the nation’s political discourse – it could hardly do worse – then it should seek to do so through the existing construct of our democracy and not by resorting to Machiavellian tactics whereby it seeks to bend the will of a majority to its beliefs (again, I refer you to the Pew Research poll).

I admit, there is a real attraction to a grass roots political movement in an age where electoral helplessness – whether learned or systemic – has become anathema to a democratic form of government. But waxing nostalgic for the 18th century and expecting that same apathetic electorate to embrace the social and cultural norms of men in wigs and women in hoops is a very tough sell.

And that’s where I find the greatest difficulty in accepting my Tea Party colleagues’ personal political platform. To me it feels like hidden below the surface of, “strike a blow for liberty,” “defend the Constitution” and “balance the budget” is an observable pattern in their logic and debate that belies a commiserate longing for the good old days.

I think all of us over a certain age find ourselves quite often reflecting on a past that was less stressful, less fearful, less threatening and certainly less complicated. Today we live in a world of constant change that just one generation removed couldn’t possibly have imagined. In his book, Managing at the Speed of Change, Daryl Conner talks about the Beast: a metaphor of the challenge each of us faces in adapting to constant change in our environment. It takes incredible resiliency to maintain good mental health in the 21st century.

I do not believe effective public policy – including Healthcare policy – can or should be based on what worked in the good old days. As Don Henley wrote, “those days are gone forever – [we] should just let ‘em go but…” Today we live in a society that is aging at an accelerated rate, that is growing in ethnic and cultural diversity and is inundated on a 24-7 basis with technological advancements that introduce hope and terror in equal measures.

With that understanding of reality, my primary concern with the Tea Party is the perceived sense of moral intransigence and impractical political dogma that transcends their beliefs. We should be focusing our efforts on how best to practically adapt a constitutional style of government to the world we live in today – not expecting today’s society to mirror that of the 1700s. I think I share just as much angst and anxiety over our nation’s future as do my Tea Party colleagues. I just don’t believe that going backwards offers much hope in addressing the problems we face today and tomorrow.

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Tea Party · Tagged: , , ,
Sep 26, 2013

It’s About Value, Stupid

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The title of this post is a reminder to myself and not intended to offend the millions of other participants in healthcare to whom its application may or may not apply. I remind myself of this assertion quite often – primarily because I believe it provides the singular most important connection between the practice of healthcare and the business of healthcare. It also has the theoretical advantage of transcending many of the political realities of public policy because it reinforces commonly held beliefs regarding individual liberties, morality, as well as social consciousness.

That is why I am very excited about a new initiative I wanted to share with Pub visitors: last week, the New England Journal of Medicine announced a new collaborative publishing initiative with Harvard Business Review. Beginning on September 17th, new articles are being shared daily via the Insight Center for Leading Health Care Innovation.  Over an eight-week pilot period new articles will be posted daily, “from numerous experts across health care and business communities.” The content shared will be free during this pilot phase, so I strongly encourage you to at least take a few minutes to peruse the variety of information and insights offered there.

One of the most prominent initial contributors, Michael Porter, has written and spoken at length on Value in Healthcare. In fact, he and his coauthor, Elizabeth Olmsted Tiesberg, published Redefining Healthcare in 2006, in which they argued that historically health care systems have competed to shift costs, accumulate bargaining power and restrict services – rather than create value for patients. To address this shortfall Porter and Tiesberg have offered specific policy recommendations they believe can help reposition the potentially positive effects of market competition from between health plans, networks and hospitals to where it would be a lot more effective in producing value: i.e., at the level of diagnosis, treatment and prevention of high cost illness and conditions.

I should also note (and recommend) Porter’s latest article featured in the October issue of HBR and coauthored by Dr. Thomas Lee (CMO at Press Ganey), The Strategy That Will Fix Health Care. Porter and Lee rightly argue that healthcare providers are the only ones who can ultimately reframe the US healthcare delivery system into one that delivers high value. They discuss six interdependent components:

1. Organizing around patients’ medical condition
     rather than  physicians’ medical specialties
2. measuring costs and outcomes for each patient
3. developing bundled prices for the full care
    cycle
4. integrating care across separate facilities
5. expanding geographic reach and
6. building an enabling IT platform

I think they purposely left off #7, pushing the camel through the eye of a needle. Please don’t take my sarcasm for lack of interest and support, but I am of an age where I tend to be a realistic chap. Between the theory espoused on the pages of HBR and the practice that is often manifested in care providers’ growing frustration with the obstacles they face in caring for their patients lies the enormous ball of yarn, which has been healthcare public policy in the US for the past 50 years.

I do believe, however, the value paradigm offers great promise in building a healthcare system where lower cost and higher quality are not viewed as a diametric choice but rather complimentary results of market competition. But there are indeed miles to travel before any such paradigm shift can be realized.

Value is not a foreign concept to healthcare, so I want to be wary of conveying the sense that a silver bullet exists, just waiting to be found so that in a single shot our delivery system can be cured. But value – whether seen through the prism of a patient’s ability to assess a surgical procedure, an insurer’s ability to assess the quality of an outcome or a nurse’s ability to assess the fairness of his or her employment contract – is way too often obfuscated to the point where it cannot serve the purpose of driving competitive performance.

I am hopeful the contributors to the new Center will be mindful of this observation as they seek to promote the potential benefits of a value-driven healthcare system.

Cheers,
  Sparky

Filed Under: In the News, Value Driven Healthcare · Tagged: , , , , , ,
The Realities of Defunding
Aug 29, 2013

The Realities of Defunding

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obamacarefingerbitingLG-300x158Last week the once relevant political operative of right wing influences, Karl Rove, wrote an editorial in the Wall Street Journal, Republicans Do Have Ideas for Health Care. In case you were concerned that defunding the Affordable Care Act would leave the country’s healthcare system in chaos and peril you can now rest easy – the Party of No has a plan. Except they don’t if you go by Mr. Rove’s article.

Before I continue I should note that high hopes of defunding the ACA may reflect a personal perception of authentic patriotism but for most those hopes belie an understanding of our healthcare delivery system, the Affordable Care Act – and most pragmatically, political realities. At the request of Tom Coburn (R-OK), the Congressional Research Service recently published Potential Effects of a Government Shutdown on Implementation of the Patient Protection and Affordable Care Act.

As discussed in that memorandum, defunding of the ACA via government shutdown would not have the intended consequence of stopping much of its implementation while risking the consternation of various constituencies that the Republican party has yet to alienate. Of course, that won’t stop Senators Cruz (R-TX), Lee (R-UT) and Rubio (R-FL) from making political hay out of an issue that strikes a harmonious chord with their conservative bases, and why should it. Those who look for sincerity in the motivations of either (any) political party fail to accept the realities of campaigning and democratic elections in the 21st century.

I should also note that Mr. Rove is on record of disagreeing with these senators. He believes defunding the Affordable Care Act through a government shutdown would give the President, "a gigantic stick with which to beat [Republicans]." I tend to agree and would hope the Republican party could spend more time on developing new ideas that reflect the realities of our current delivery system instead of just being against the ideas of others (and sometimes their own).

In his editorial, Mr. Rove points out several Republican policy initiatives that taken one by one have some merit – both within the context of ACA implementation and under the unlikely hypothetical assumption of its outright repeal. But it is beyond a stretch to suggest that even taken together those several examples he cites constitute a legitimate alternative to the comprehensive approach of the ACA. And therein lies the challenge that many (most?) political wonks, talking heads and sound bite artisans face when discussing healthcare policy. Our healthcare delivery system is complicated and complex beyond reason, and certainly way beyond necessity. But you have to play the game on the field you’re given not on a chalkboard.

Several of the policy initiatives Mr. Rove cites deal with health insurance: portability of policies, employer risk pooling and selling premiums across state lines. I think these are plausible modifications and/or addendums to the ACA approach that are worth circumstantial testing.  But part of the recognized challenge up front is that these approaches are dependent upon employer-based insurance, which most policy experts agree was never a good idea to begin with. And they leave out a wide swath of the population that doesn’t receive employer-based health insurance. If we didn’t think there was merit in providing healthcare benefits to those unable to afford such coverage, then these would be top of mind ideas.

Another initiative cited, medical liability (or tort) reform is a bit like the weather: everyone complains about it but nobody really ever does anything to change it. Perhaps that’s because of the preponderance of Congress who are also lawyers. But there is another line of thought that believes increasing quality and safety might also be a pragmatic approach to lowering malpractice liability. What would we rather have: the forbearance of frivolous suits that also risk restricting justice to individuals – or the reduction in the basis upon which such suits are brought. In reality, we probably need both.

Of the several reform initiatives Mr. Rove shared transparency has to be the weakest example of meaningful policy. Pulling the cover off of the Invisible Man won’t change your view of him. And mandating that meaningless provider charge rates (prices) be published won’t enable better decision making by consumers (patients). I addressed this back in February in a post I entitled, Pick a Price.

Moving on, allowing Medicaid patients to apply their governmental benefits toward private insurance sounds reasonable enough. Unfortunately, it would be bad policy. Although there are already a number of states seeking to leverage private insurance capitation models as a hybrid compromise to Medicaid expansion within the context of the ACA, those models still maintain control over risk pooling so as to address adverse selection.  While allowing funds to be indiscriminately repurposed may sound like an idea promising to partner individual choice with market efficiencies, as Naomi Freundlich addressed in her Healthcare Blog post, the reality of implementing such an idea is another matter entirely.

Finally, Mr. Rove writes that, “the president and his liberal posse have a fundamental, philosophical objection to conservative ideas on health care. They oppose reforms that put the patient in charge rather than government, that rely on competition rather than regulation, and that strengthen market forces rather than weaken them.”

Disingenuous assertions like this do little to advance meaningful healthcare policy discussion. This is no different than liberal talking heads claiming that conservatives seek to advance healthcare policies that benefit (or are structurally biased toward) the wealthy at the expense of the poor. More generally, asserting that the ACA’s hidden agenda is to abscond personal liberty in favor of governmental control misses the point of the real debate entirely. Both the theoretical and practical debate is not over whether the government knows better than the individual what is best for the individual. The debate is in how public policy can best balance the protection of personal liberties while morally advocating for the rights of those individuals with far less ability to secure affordable, quality healthcare. Some feel healthcare is a basic right secured by the Constitution. Others do not. What do you believe?

Cheers,
  Sparky

Filed Under: Affordable Care Act, Editorials & Opinions · Tagged: , , , , ,
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