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.

Cheers,
  ~ 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?

Cheers,
  ~ 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.

Cheers,
  ~ 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
Payment
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.

Cheers,
  Sparky

 

 

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
Interoperability
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
Impairments
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.

Cheers,
  ~ 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!

Cheers,
  ~ Sparky

CCRCs As Healthcare Providers

HCG1Earlier this month Steve Maag, LeadingAge’s Director of Residential Communities, shared an insightful video presentation (a Quickcast) on environmental and industry trends that are anticipated to impact the future of continuing care retirement communities (CCRCs). If you are in any type of leadership position in an organization that owns and/or operates a CCRC with some level of responsibility for that organization’s future direction, then I strongly encourage you to find 15 minutes to watch this presentation.

There are three broad areas Steve addresses, including consumerism, healthcare reform and technology. This being a blog on healthcare public policy, a couple of years back I shared some of my own thoughts on the risks and perils that CCRCs face in assessing their role as a healthcare provider in the post, CCRCs: Healthcare Providers—Or Not.

Now having some additional data points I thought it might be interesting to revisit what I wrote back in August 2012. I then identified five major areas that CCRC organizations needed to be cognizant of as they assess strategic positioning as a healthcare provider in their market:

Healthcare delivery related cost pressures
New care delivery and payment models
Increasing demand for home and community-based services
The need for infrastructure investments
Potential future tax consequences for nonprofit organization

In considering the impact these areas could have on organizations unwilling or unable to effectively address that impact it was my opinion then that those organizations would be further ahead to get out of the healthcare business altogether than to wait on the sidelines. Fast forward 29 months and I will double down on that assessment.

Successful CCRC organizations of the future are making the requisite investments today to assess their healthcare market environment and determine how they can effectively and profitably integrate into that environment. To assist organizations with that process I recently updated my whitepaper: A Framework for Strategic Planning & Positioning in an Era of Healthcare Reform. Please feel free to download and use to help your organization with this critically important assessment.

Cheers,
  ~ Sparky

Should The Employer Mandate Survive?

Over the period January 8th through the 11th of last week the Morning Consult conducted a poll of 1,707 registered voters to understand their views regarding the Employer Mandate. The reported responses have a margin of error of +/- 2.4% (I assume that’s at 95% CI). What they found seems a bit counterintuitive at first. But it may reflect an indication of where we sit along the curve to better understanding the economics of healthcare in the United States.

Of those polled, 74% believe that a 40-hour workweek should constitute full-time employment – not 30, the definition used as part of the Affordable Care Act’s employer mandate provision. But only 58% support Congress’s effort to legislatively change that definition. Why? Dunno. And yet, 57% of respondents overall support the employer mandate provision of the Act, and 55% believe companies should provide healthcare for part-time employees.

Whether employers are required to provide health insurance for their workers at 20, 30 or 50 hours misses the broader discussion of whether the employer mandate still makes sense in light of other provisions of the Act having been enacted. And it misses the political discussion of whether it’s a reasonable and plausible giveback to a Republican Congress that’s carried around the repeal and replace bone long enough.

Even the most ardent opponents of the ACA have to admit, if they are being honest, the past few years have increased the individual and social consciousness of healthcare as a very real – and very expensive – commodity that has been more misunderstood than any other product or service in history. And despite the major early challenges of the insurance exchanges most indications now support the dawning of a new dynamic in financing healthcare delivery: the expansion of individual insurance and responsibility.

Ever since wage freezing during WW II led employers to use healthcare benefits in seeking competitive advantage recruiting workers the disconnect between what individuals pay out of pocket for healthcare – and what healthcare actually costs to produce – has been an underlying source of tremendous waste and inefficiency. Have the exchanges, coupled with the incremental increase in Medicaid expansion, made the employer mandate concept moot – or worse, an economic albatross that could stifle growth at a time when the country just might be turning a corner?

What do you think?

Cheers,
  ~ Sparky

 

Sorry Charlie: Too Many Sharks at the Trough

There is an old analogy in healthcare that refers to the largesse of national healthcare spending as the Big Tuna. Many sharks feed off that tuna – the extension of the analogy being that many individuals and organizations financially benefit from being in the healthcare industry without adding any real value to the consumers served by the industry – patients.

This is my interpretation of an article posted by Dr. Fred Pelzman on New Year’s Day, Return the clinician to the center of the health care experience, on the KevinMD healthcare system blog. Dr. Pelzman asks what I believe should be the quintessential question of the 2015 healthcare policy debate: “Are we allowing the health care system to be transformed by people who should not be transforming health care?”

Now, it should be remembered that it was a clinician – Dr. Donald Berwick – who popularized the Triple Aim concept that came out of the Institute for Healthcare Improvement prior to the Affordable Care Act being passed. Clinicians are not exempt from thinking big thoughts and hoping to altruistically apply that thinking to achieve goals and objectives that are widely held desirable by society. So I don’t know if getting them unselectively more involved is going to lessen the incredible waste that rightly drives physicians like Dr. Pelzman crazy.

But I do know – or rather I believe, anyway – there is a finite limit of tuna available to satiate the sharks before they start feeding on the patients. It’s indignantly ironic that clinicians are being pressured to improve performance in the name of value when a great deal of the non-clinical world is only being held accountable to producing value in the abstract – and most often ex post facto.

Unquestionably, there needs to be greater connectivity between the work performed by non-clinicians and the ultimate value produced for patients. This is not going to be any easier to measure than patient outcomes’ metrics currently being explored and tested on/by clinicians. So what? Get used to it.

As I have written before, I wholeheartedly agree with those who, like Dr. Pelzman, promote the central role clinicians must play in assessing, planning and implementing healthcare public policy. But if you look at the landscape you will see there are already quite a few retired clinicians in that space, and the system is still largely a mess. So there must be more to the story.

What do you think is missing?

Cheers,
  Sparky

Is Being Ignorant Better Than Being Stupid?

In the poem, Ode on a Distant Prospect of Eton College, Thomas Gray wrote that, "where ignorance is bliss, ’tis folly to be wise." He was referring to the unfettered ability of time to ultimately win any race against human pain and sorrow – and since that race is determined before it is run, why not walk and enjoy what you may. Or something like that.

Earlier this week renowned healthcare economist, Uwe Reinhardt, wrote an editorial for the Healthcare Blog: Rethinking the Gruber Controversy: Americans Aren’t Stupid, But They’re Often Ignorant – And Why. Reinhardt reminds us that stupid implies the inability to learn, whereas ignorance is lacking information and knowledge. And when it comes to most public policy, including healthcare policy, Reinhardt points out there is no lack of ignorance caused by four contributing considerations.

First, the social and economic analysis associated with most controversial policy involves complex and (too) often complicated approaches. Then secondly, special interests representing differing positions with respect to such policy usually seek to further complicate that analysis in order to gain popular support for their individual position. And then too, considerable cause for ignorance can be attributed to the general lack of individual interest in public policy. Reinhardt writes the third and fourth contributors represent some combination of individuals lacking time and/or interest (what does not impact us directly tends not to interest us).

Whatever and however the relative causes contribute to ignorance of public policy the political maelstrom surrounding the Affordable Care Act has certainly helped highlight that disconnect. And when it became publicized this fall that Jonathan Gruber had made the now infamous remark about the “stupidity of the American voter” the nature of that disconnect became politically contentious.

Even a fundamental understanding of the majority of that Act remains elusive to most. And nearly every stakeholder with a horse in the race if you will has relied upon that reality to exploit ignorance for the purpose of individual and/or public gain. This is the crux of Reinhardt’s article: that the inherent nature of our political system necessarily involves positioning policy in ways that belie known (or unknown and unintended) consequences negatively impacting various constituencies of those stakeholders.

For example, he believes that consumer driven healthcare is a veiled means of facilitating care rationing in a market economy; individual savings that receive preferential tax treatment in lieu of a defined purpose (e.g., FSAs and HSAs) are a means of regressive taxation; and tax preferences should really be considered tax expenditures that require direct or indirect subsidization through higher tax burdens on those not receiving those preferences (burden shifting).

Reinhardt ends the post with a passage from Alexis de Tocqueville’s Democracy in America. People all too often hear what they want to hear. When the choices of those individuals represent personal benefit to others – e.g., whether through a consumer choice to purchase or a vote to elect a candidate – there is the inherent incentive to tell them what they want to hear.

Reinhardt’s post reinforces what I wrote back in November about how I would like to see this modest little blog advance in 2015, and so I thought it was a fitting end to the year. Next year ought to be fascinating with a newly Republican-controlled Congress, a refusal-to-be lame duck President and a Supreme Court that again will have its objective temerity put on trial via a challenge to the Affordable Care Act.

Through it all, I hope to continue sharing with you that which reflects honesty, integrity and a steadfast commitment to always seek the truth – even when the truth is hard to hear.

Happy New Year!
  ~ Sparky

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