Aug 18, 2014

Population Health Needs A Brand Positioning Strategy

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Population Health (PH) is a term that has become ingrained in the Healthcare Reform lexicon over the past decade. It’s one of those politically gravitational conveniences that allow candidates from different parties to embrace a common goal with little risk of being criticized for holding beliefs different than their opponent. And that is precisely because it is difficult, if not impossible, to prove someone believes in something that does not have a consistent and agreed upon definition.

Just What is Population Health?
What PH enjoys in broad political support it lacks in definitional credibility. A good treatise on variations of contemporary definitions can be found in Academy Health’s Population Health in the Affordable Care Act Era by Michael Stoto, Ph.D. Without wanting to deliberately adulterate that work, Stoto highlights conceptual commonalities and differences in definitions from several sources that I will try and very briefly summarize below.

A focus on health outcomes – the subjectivity of which notwithstanding – and the distribution of outcomes (i.e., how do outcomes vary across comparative stratifications, such as geographic residence, ethnicity, age, etc.)

The impetus of achieving healthier outcomes is through encouraging healthier lifestyles, better nutrition, preventative care, avoiding behavioral risks, etc.

Measurement of health status indicators as well as the factors that are correlated with those indicators (e.g., socioeconomic conditions, physical environments, childhood development, etc.)

Utilization of data and analytics to develop a conceptual framework for understanding and explaining differences in population health indicators – and how that knowledge impacts research agendas, resource allocations and public policy.

Often discussed (or confused, depends on your perspective) with public health, though the latter also typically connotes a governmental influence of some type (e.g., a municipal health department).

Policy Perspectives
From a policy perspective, there are two ways to look at PH: altruistic and pragmatic. From an altruistic perspective policies that promise to improve population health are most often framed in cost—benefit analyses: the benefits, if achievable, are easy to agree upon (who doesn’t want to be healthier?). The ROI is the challenge and most often the subject of political contention.

From a pragmatic perspective – particularly as PH has been manifested in the Affordable Care Act – what we are really talking about is cost control. Healthier people demand less healthcare services. Individuals with chronic conditions that more effectively manage those conditions need less healthcare. Economics 101: if we can reduce demand while maintaining or increasing supply, costs should decrease.

Parallel to this latter perspective is the growing base of knowledge that indicates improving the quality of care can achieve both lower costs AND better care. So if population health is a vehicle through which quality can be improved, it benefits from that additional policy advocacy.

Population Health Perceptions
Population Health means different things to different people. A good part of that difference can be explained in the inherent subjectivity of the concept of health outcomes. Some other portion can be explained by academic exercises seeking to cut the Gordian Knot. Still another by political extrapolations that seek to gain favor by equating improved population health with an appreciative electorate.

Whatever the feasible explanation(s) may be, Population Health suffers from an identity crisis. Beyond just a definitional problem, however, it fundamentally lacks in having been able to achieve a shared understanding of its meaning and purpose at a level that resonates with the very “population” whose health is of concern. In short, PH could use a brand positioning strategy.

Perceptual Positioning of Population Health
One of my favorite books on branding is Brand: It Ain’t the Logo: It’s what people think of  you™ by Ted Matthews. Matthews argues that,

“a brand is the sum total impression and memory of every remarkable, every so-so and every negative experience with any and all pieces of an organization. A brand is the personality of [that organization] . . . and is judged and assessed a value by everyone it touches, whether inside the [organization] or outside. These perceptions of value may, or may not, be what you want them to be. Which suggests a fact that may surprise you: your brand isn’t really yours (emphasis added). You don’t own it – all the people thinking about you do.”

It’s not a leap to borrow or migrate these concepts of perceptual brand positioning to PH. Many proponents of PH take an interventional approach as a means to advocacy. Their focus is on modifying individual behaviors, inducing health screening, creating artificial employment incentives and imposing restrictions and/or impositions on environmental elements. This is not a sustainable approach to PH brand positioning simply because it fails to recognize that the perception of PH is owned by the individual – and not the advocate.

What to do Differently
When I was giving presentations across the country a few years back on the newly passed Affordable Care Act, I made it a point to say that I believed if we were somehow successful in increasing access to healthcare services, in improving quality, in lowering costs, in enhancing efficiency and productivity – that none of that would matter long-term because the forecasted demand from an aging demographic would atomize those gains.  The only escape from a tragic gap between demand for quality healthcare and the ability to meet that demand will come from lowering innate demand.

Population health, however one wants to define it, is therefore a critical component of any strategy that seeks to address the looming care gap. But the underlying concepts of what make improving population health mutually beneficial cannot be thrust upon individuals for their own good. Nobody ever bought a Macintosh computer because Steve Jobs told them they should. If you are an advocate of PH, then it’s time to start looking at how to perceptually position its brand benefits differently.

Look at the most valuable brands in the world, and look at how they were built: such as Apple, Microsoft, Coca-Cola, IBM, Google, Disney. Marketing and advertising played important roles, but it has ultimately been each organization’s ability to offer something of value to individuals that drove sustainable perceptions. What can be learned from the branding strategies of organizations like these that can turn the perceptual positioning of Population Health on its head to achieve the long-term benefits that we believe can be achieved?

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Population Health · Tagged: , , , , , ,
Aug 13, 2014

Depression, Addiction & Mental Health Policy

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Pic For BlogThe last time I remember feeling as badly about a celebrity passing has to be December 8, 1980. I remember exactly where I was and what I was doing when a radio disk jockey (people that used to play and broadcast what were known as records on electronic turntables) broke the news over a song that John Lennon had been shot. About two minutes later, the music was stopped – and the sad news announced that he had been shot – and killed.

Queue up round the clock Beatles music and millions of tears across the world.  The next day in the Rock n Roll capital was damp and dreary. A cold mist just seemed to hang in the air. One of those days where ironically it would feel warmer if it would have just snowed. There are a lot of days like that in early December in Cleveland, Ohio. But this one so fit the mood.

Nobody saw that one coming. Whereas we all know now what only a few knew all to well before Monday: that Robin Willams’ mental demons were probably always only a few steps behind. Shadowing him like the inescapable darkness of a night in the forest, depression is a disease that lurks, pounces, retreats and then stalks – taking in turn at random how it chooses to haunt its victims.

Addiction, on the other hand, despite the cultural shift in attitudes over the past few decades, is not a disease. Writing in the Psychology Today blog a couple of years back, Dr. Lance Dodes explains how addiction has little in common with other diseases and cannot be explained by any disease process. But as he also astutely points out, neither is it the purview of individuals lacking in discipline and morality,  just being selfish and self-centered.

But to understand addiction is to understand the mental state of an individual leading up to and perpetuating its hold on that person.  Dr. Lance writes, “addictive behavior is a readily understandable symptom, not a disease.” In Williams’ case the connection between depression and resulting behavior leading to addiction is something that should continue to build awareness and understanding.

I realize it’s a sensitive line here because the last thing we want to do is roll back the progress made fighting stigmatization and the barrier and obstacles that has created in affecting treatment access. On the other hand, from a public policy perspective it is crucial that we continue to dig deeper: to understand mental health – and mental illness – as a critically holistic element impacting all varieties of personal well being, not just as a precept to alcoholism and addiction.

Robin Williams’ wife has asked that we remember her husband by not focusing on his death, “but on the countless moments of joy and laughter he gave to millions.” As the emotional pain subsides I am certain we will be able to do that. Before we get to that place, however, it is natural to question and seek answers on how this tragedy might have been avoided.

For millions of Americans suffering from, or affected by a loved one suffering from, a mental illness, alcoholism or addiction, Robin Williams’ death is a painful reminder of the fear and vulnerability they live with every day. And they are right to be questioning what might be done to help address that suffering. Yesterday, Rep. Tim Murphy (R-Pa) noted that, “Williams’ greatest gift to us, if we choose to accept it, is a focused determination to help those with brain illness and finally take real action to stop the loss of one more precious life.”

In December of last year, in response to the 2012 elementary school shooting in Connecticut, Murphy – a clinical psychologist – introduced H.R. 3717, The Helping Families in Mental Health Crisis Act. One of the most important initiatives in the bill is to address the Institutions for Mental Disease (IMD) Exclusion, which limits Medicaid coverage for inpatient mental health and addiction treatment.

The bill is complex, comprehensive and has faced a significant amount of criticism. Good coverage of this can be found in a blog post from Gary Earles, LICSW, writing last year for the Morning Zen on the Children’s Mental Health Network. Very doubtful that even with this latest tragedy the bill will move anywhere before the next Congress is installed. But what might now happen is the debate will move from the purview of policy wonks, trade groups and special interests into the real world where those aforementioned suffering can have a voice. We can only hope.

Cheers,
  Sparky

Filed Under: Depression & Addiction, Editorials & Opinions · Tagged: , , , , , , ,
Jul 22, 2014

As the ACA Turns

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So now what?

If the Affordable Care Act was a soap opera – and who’s to say it’s not – I think even Susan Lucci would have lost faith by now in the merits of a plot leading to any type of long-term resolution, clarity or certainty.

The U. S. Court of Appeals for the D.C. Circuit ruled today in the Halbig v. Burwell decision that the IRS had incorrectly allowed the subsidization of insurance premiums to millions of Americans covered under the Act’s health insurance exchanges. Then about an hour later, the U.S. Court of Appeals for the Fourth Circuit, in Richmond, argued that the IRS was within their legal power because the subsidies they provided were, “a permissible exercise of the agency’s discretion.”

Following along?

The Act provides that subsidies be provided to “state-run” exchanges, but whether through political objection or inability, 27 states opted to have the federal government establish and operate their exchanges while another 9 states opted to have their exchanges jointly ran by state and federal agencies. So by an interpretation of the letter of the law subsidies are unavailable to individuals living in those 36 states.

In writing the 2-to-1 majority opinion on the Halbig decision, Judge Thomas Griffith noted that, “we reach this conclusion, frankly, with reluctance.” Why? Because according to the Robert Wood Johnson Foundation an estimated 7.3 million people — about 62 percent of those expected to enroll in federal-run exchanges by 2016 — could lose out on $36.1 billion in insurance subsidies. Over 7 million individuals could be losing an average of $4,400 in annual subsidies (based on Congressional Budget Office estimates for the current year).

What each court had to wrestle with was whether it was Congress’ intent to provide expanded access to healthcare insurance through premium subsidization irrespective of whether the exchanges are ran by state or federal governments. Judge Griffith wrote that, “the fact is that the legislative record provides little indication one way or the other of congressional intent, but the statutory text does. Section 36B plainly makes subsidies available only on Exchanges established by states.”

And there’s the rub. Looking back to the summer of 2010, the legislative process leading to passage of the Affordable Care Act was ridiculously chaotic, incredibly politically charged and fraught with misinformation being spewed in all directions by nearly every stakeholder who could find a media outlet. All (as in both) parties being equally complicit in disinformation

John Earnest, White House press secretary noted, “you don’t need a fancy legal degree to understand that Congress intended for every eligible American to have access to tax credits that would lower their health care costs, regardless of whether it was state officials or federal officials who were running the marketplace. I think that is a pretty clear intent of the congressional law.”

I think he is wrong. It’s not clear because the legislative process leading up to and through passage was anything but. In fact, it can be effectively argued that lack of clarity was a direct result of favoring political expediency over legislative pragmatism. The Act is very poorly written and is fraught with these types of examples where implementation wasn’t very well thought through. But that lack of clarity – and legislative ambiguity in particular – is not grounds for overturning legislative intent.

Writing today in The New Republic, Brian Beutler argues that applying Supreme Court Justice Antonin Scalia’s concept of “overall statutory scheme,” that, “the words of a statute must be read in their context,” it is unambiguous that it was Congress’ intention through the ACA to provide insurance subsidies a priori of the means and mechanisms of the exchanges. Even if the argument could be made that it was ambiguous, Beutler notes that there is still the need to determine whether the law has been interpreted plausibly. In either case, it seems unlikely this latest attempt to derail the ACA will ultimately succeed.

But let’s assume that it does. I think it could easily be a case of be careful what you wish for because you might just get it for republicans. By the time this issue would make it through the Supreme Court there will be at least over 7 million individuals that are going to be told they will suddenly lose what then could reasonably be a $5,000 a year benefit. All that would be required to maintain the benefit would be an administrative language modification, which republicans could refuse as a plausible effort to cripple the Affordable Care Act. They would be in a politically very difficult spot – but then that seems to be a self-inflicted level of comfort they’ve grown accustomed to.

So stay tuned, as they say . . .

Cheers,
  Sparky

Picture credit: Time Magazine

Filed Under: Affordable Care Act, Editorials & Opinions · Tagged: , , , ,
Jul 16, 2014

The Lunacy of Our Mental Health Policy

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MEDICAID1-master675An institution for mental diseases (or, “IMD”) is defined as, “a hospital, nursing facility, or other institution that is primarily engaged in providing diagnosis, treatment, or care of persons with mental illness, including medical attention, nursing care, and related services” (42 U.S.C. §1396d(i)).

Last week the New York Times ran an article addressing the infamous Medicaid IMD exclusion: the culmination of state and federal policies dating back to the 19th century up to and including the Medicare Catastrophic Act of 1988, in which an IMD was infamously defined as a facility with more than 16 beds.

The apparent intent at that time was to promote small, community-based group living arrangements as an alternative to large institutions. But what has resulted is that Medicaid covers mental health treatment for a large percentage of people with Medicaid, but that coverage is excluded for inpatient treatment of adults aged 21 to 64 in any acute or long-term care institutions with 17 or more beds that are primarily engaged in providing treatment for mental illnesses. This is what is known as the Medicaid IMD exclusion.

Another indirect consequential reality of the IMD exclusion is what’s known as psychiatric boarding. The 1986 Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals participating in the Medicare program to provide a medical screening examination of any person presenting to its emergency department regardless of the ability to pay.  For psychiatric emergencies, an individual expressing suicidal or homicidal thoughts or gestures, if determined to be dangerous to themselves or others, the hospital must either provide treatment until their condition is stabilized – or transfer that person to an inpatient facility where the person can be treated until the condition is stabilized.

But there’s the rub: since so many individuals with mental illness (and addiction is considered a mental illness) are Medicaid patients there are very often limited alternatives for transfer.  Thus those patients tend to stay in emergency departments longer than necessary – an expensive consequence because of the cost intensive nature of ED’s. Communities work hard to develop informal diversion relationships to try and address the issues and challenges this creates: but their time could be better spent – like on improving patient care.

Section 2707 of the Affordable Care Act, Medicaid Emergency Psychiatric Demonstration, is a three-year pilot program that permits non-government psychiatric hospitals with more than 16 beds to receive Medicaid payment for providing EMTALA-related emergency services to Medicaid recipients aged 21 to 64 who have expressed suicidal or homicidal thoughts or gestures, and who are determined to be dangerous to themselves or others.

But this only addresses specifically-defined crises and will take a long time to be tested, evaluated and debated. It does not address the epidemical crisis we face as a nation with heroin addiction. So even though 26 states have willingly or unwillingly embraced Medicaid expansion under the ACA, many of the individuals needing inpatient treatment for addiction will be unable to receive that treatment.

A recent study published by researchers at the Boston Medical Center in the JAMA Internal Medicine Journal  reaffirmed the importance of combining inpatient and outpatient treat of heroin addiction. From the NYT article: for many suffering with heroin addiction, “there is an undeniable and essential need for residential treatment,” said Allen Sandusky, the South Suburban Council’s chief executive in Chicago.

Study after study has demonstrated that substance abuse treatment and rehabilitation is less expensive than incarceration as an alternative to addressing individual addiction and alcoholism. At the same time, economies of scale driving greater efficiency and lower program costs in facilities that allocate overhead over a larger number of beds is just economically intuitive.

When all these considerations are taken together with the skyrocketing costs associated with increasing crime and the burden being placed on community first responders as a direct result of the heroin epidemic it would seem like the biggest no-brainer in the history of earth is to legislatively repeal the IMD exclusion. Thus be to the ignominious wasteland that is Washington, DC.

At a time when communities across the country are scrambling to address a heroin epidemic that is literally destroying those communities and the families living there Congress is focused on a lawsuit against the president (the House) and an irrationally urgent need to reverse the Supreme Court’s innocuous Hobby Lobby decision (Senate). Shameful, truly shameful. Even more so than usual.

Cheers,
  Sparky

Photo credit: Armando L. Sanchez for The New York Times

Filed Under: Editorials & Opinions · Tagged: , , , , , , ,
Jun 28, 2014

Changing Our Perspective on Mental Health

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On Thursday I shared the post, Don’t Make Mental Health Policy About Stigma. Jessica Dawson, the brave woman who was one of several individuals featured in the USA Today article I reacted to in my post commented that she was, “discontented [her] photo is being used on [my blog] to discredit the impact which stigma has on government policies.”

I took that personally pretty hard as I had a sense I was betraying someone because of my ignorance on a subject that I am very passionate about and for which I have advocated here in the Pub. But I have to stick with what I wrote: not because I am sure I’m right – but because it’s what I wrote. In my response to Ms. Dawson I noted that I didn’t believe we had different goals but rather different beliefs in how to most effectively achieve those goals.

And then this morning I came across an article from earlier this week by Judith Solomon for the Center on Budget and Policy Priorities that is thematically consistent for what I was advocating: the pragmatic role that research and evidentiary support should play in advancing policies supportive of mental and behavioral health access and affordability – relative to (i.e., not exclusive of) the role fighting stigmatism can play in our current economic and political environment.

The article, The Truth About Health Reform’s Medicaid Expansion and People Leaving Jail, presents evidence that facilitating Medicaid enrollment in states participating in expansion under the Affordable Care Act, “can enable more of them to avoid returning to jail or prison by connecting them to needed mental health, substance abuse, or other treatment.  This is why many state corrections agencies and county governments are collaborating with state Medicaid agencies on projects designed to enroll low-income people being released from jails or prisons.”

On average, approximately 75% of the US prison population consists of nonviolent offenders, many of whom have a myriad of mental and behavioral health challenges and/or are fighting addiction. According to Solomon, “alcohol plays a role in over half of all incarcerations, and illicit drugs are involved in over 75 percent of jail stays.” But only 11 percent of inmates receive any type of treatment, while comorbid conditions are prevalent.

I haven’t taken the time to explore the cites and research that Solomon provides, so I want to be careful not to be advocating for something that obviously needs to be carefully considered, debated and vetted. My point is simply this: we should be investing more to determine – and evidence – whether and how this type of policy intervention can help achieve a stronger, more accessible, more effective mental health system.

We need to change our perspective on mental health. Fighting stigmatism – yes, important. I get that. But I believe we should be investing more heavily to educate the country about how intervention and treatment works – and how it can lower costs to families, communities and the country in the long run. There is a much better chance of redirecting funding from other sources than securing funding for new initiatives. That’s the political reality – like it or not.

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Medicaid · Tagged: , , , , , , ,
May 14, 2014

Why Can’t Healthcare Innovate?

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Whether viewed as paradox or conundrum, the healthcare industry’s relative inability to innovate has long been a source of both fascination and frustration. In the May 8, 2014 edition of the New England Journal of Medicine,  David A. Asch, M.D., M.B.A., Christian Terwiesch, Ph.D., Kevin B. Mahoney, B.A., and Roy Rosin, M.B.A. write about this phenomenon in Insourcing Healthcare Innovation.

Describing the understandable resistance of healthcare professionals to embrace problem-solving techniques from unrelated industries because the complexity of healthcare delivery is most often not well understood, those professionals are by definition usually most interested in exploring new ideas, new approaches and the pursuit of new knowledge. This apparent irony, the authors believe, might be effectively synchronized if a different approach could be taken to reconciling innovation with contextual understanding.

The approach they share is a four-stage design process they believe can achieve this reconciliation. The four stages include: contextual inquiry (understanding the processes currently in place); problem definition (ensuring the right problem has been understood and defined); divergence (exploring alternative approaches) and rapid validation (ability to move from theory to implementation).

If these sound familiar, it is because the general direction of proceeding from understanding where you are to achieving where you would like to be in an orderly fashion is the foundation of many approaches to strategic planning. So from that vantage there isn’t anything particularly revolutionary about the process described.

But understanding the core resistance to such processes – that the way in which healthcare practitioners are educated, trained and practice is frequently counterintuitive to innovation techniques successfully utilized in other industries – is an important distinction. What this translates into is making the requisite investment to understand the unique attributes and complexity of healthcare delivery – its distinctive product offerings, its highly dependent reliance upon personal relationships, its unbelievably complicated regulatory environment – as a necessary component of any planning effort.

It takes time and effort to build the needed understanding of the unique challenges that healthcare practitioners face. You have to ask probing questions and not hesitate to admit your lack of understanding: a fair balance of humility and curiosity can go a long way to building key relationships and creating the requisite knowledgebase necessary to innovate.

In other words, individual egos often create barriers to innovation processes that are attempted to be imported from other industries. More so than representing a different way of approaching innovation in healthcare, what this article does is reinforce a tried and true means of any planning effort: listen and learn before you lead.

Cheers,
  Sparky

 

Filed Under: Innovation · Tagged: , , , ,
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: , , , ,
Jan 28, 2014

Once More Unto the Breech

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Ah yes, here we go again. Yet another attempt by the Republican Party to repeal and replace the Affordable Care Act. This time, as reported by Sarah Kliff in the Washington Post’s Health Reform Watch, Republican Sens. Richard Burr (N.C.), Tom Coburn (Okla.) and Orrin Hatch (Utah) last week released, “…what is arguably the most complete Obamacare replacement plan offered by their party to date.”

Entitled the Patient Choice, Affordability, Responsibility, and Empowerment Act (abbreviated as the “Patient CARE Act”) – it has a familiar ring to it, but read on – it is in certain enough ways similar to the Affordable Care Act that I was reminded of several works by Shakespeare. The first of course is the comedy, Much Ado About Nothing. The second is a quote from Hamlet: “the [Party of No] doth protest too much methinks.” And the third was a quote taken from Henry V, which I invoked as the title of this post.

Both Ms. Kliff’s piece as well as a Forbes’ magazine article written by Avik Roy provide excellent coverage in comparing and contrasting the two pieces of legislation, and I refer readers there for better explanation than I can offer here. To be sure there are marked differences in the way key concepts of healthcare reform are addressed in the Patient Care Act. But where the hypocrisy is laid bare is in noting the overarching points of likeness.

For starters, the Patient CARE Act is said by its own sponsors to have little impact on the federal deficit (i.e., budget neutrality) over a 10-year period following enactment. So much for conservative austerity.  It maintains the insurance restrictions on pre-existing conditions and benefits, though it shifts more risk back to the individual for maintaining coverage prior to such conditions. There is the concerted effort to expand coverage to poorer Americans, though less emphasis is placed on Medicaid while abandoning insurance exchanges.  It also recognizes the importance of attracting healthy individuals into insurance pools to thwart adverse selection.

The most significant difference has to do with financing. The Patient CARE Act would repeal most of the industry taxes on insurance companies, hospitals and medical device makers and replace that lost revenue by limiting the tax exclusion for employer-sponsored insurance to 65 percent of the average health insurance plan. This is a favored approach by many economists because of the regressive nature this historic tax preference, but given the impact it would have on millions of employed workers it’s not likely to gain much political traction even if Republicans do gain control of the Senate.

Despite key differences, however, what is interesting – or perhaps remarkable – to note is that the Affordable Care Act was used by Patient Care Act’s authors as the baseline upon which to develop healthcare policy. This is in marked contrast to claims of the Affordable Care Act being illegal, unconstitutional and/or socialistic. It almost appears as if there could have been a constructive and compromising effort for the two parties to work together in crafting the ACA, rather than the Republican Party being fixated in denying President Obama any modicum of political success.

For all of the cajoling, haranguing and caterwauling we’ve endured from the likes of Ted Cruz, Bobby Jindal, Marco Rubio and Rand Paul, this latest effort to appear politically constructive and contributing something meaningful to the healthcare policy debate comes off dreadfully sublime in comparison to the political rhetoric of the past several years. And its well placed timing only days before the State of the Union Address is of course par for the course in electoral hypocrisy.

When it’s all said and done I am left wondering whether we should retrospectively view the politial machinations and hijinks the Republican Party has wrought upon this country over the past several years as comedy or tragedy. Perhaps both. A number of Shakespeare’s best works after all were tragicomedies: Hamlet, Macbeth, Othello and King Lear. I only wish watching the Republican Party’s performance of political implosion would have been as entertaining.

Enjoy the SOTU Address! Could be some real fireworks in the great hall tonight.

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Patient CARE Act · Tagged: , , ,
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