This morning I am in Baton Rouge, at the Louisiana Hospital Association conference center, sharing my perspectives on ACOs and the broad range of innovation in health care delivery and financing being ushered in under the Affordable Care Act.
This morning I am in Baton Rouge, at the Louisiana Hospital Association conference center, sharing my perspectives on ACOs and the broad range of innovation in health care delivery and financing being ushered in under the Affordable Care Act.
This conference season has already been a busy one: I organized HealthCamp Boston 2012, which was an exciting one-day unconference that took place right before Medicine 2.0, where I spoke. I hope that local HealthCamp attendees can keep in touch, and maybe this time around we won't wait three years for the next HealthCamp Boston. Unfortunately, I couldn't make it to Medicine X or Health 2.0 on the left coast this year, but I hope to see some of you in Boston at the Connected Health Symposium later in October.
Here are some of my upcoming speaking engagements:
The Effect of ACOs on the Health Care and HIT Ecosystems
Let's Talk HIT Speaker Series
Scratch Marketing + Media
October 18, 2012
An informal presentation and discussion - join us if you are local.
Health Care Social Media: The Lawyers Don't Always Say "No"
MGMA 2012 - Medical Group Management Association Annual Conference
San Antonio, TX
October 21-24, 2012
Moderator of Legal Panel Discussion
Healthcare IT News and HIMSS
The Privacy and Security Forum
December 13-14, 2012
I hope to see some of you at these events - please let me know if you'll be attending.
If you'd like to learn more about my speaking, keynoting and retreat facilitation, please start with this page about my speaking.
Last week, the Massachusetts CO-OP was approved by the federales under a provision of the Affordable Care Act that was key to the Act's passage, yet not widely known. The Consumer Operated and Oriented Plan, known as the Minuteman Health Initiative, secured a startup loan as part of the approval, intended to cover operational expenses as well as state-mandated reserves. Here's an excerpt from the Minuteman presser, as published by CommonHealth:
Tufts Medical Center, its New England Quality Care Alliance (NEQCA) physicians network and Vanguard Health Systems (NYSE: VHS) are proud to sponsor the Minuteman Health Initiative, which has received an $88.5 million loan from the Centers for Medicare and Medicaid Services (CMS). This new member-governed, non-profit health insurance option for Massachusetts residents intends to offer consumers and employers lower-cost, high-quality care with unprecedented transparency, as well as increased efficiency and satisfaction for physicians, patients and employers alike. Plan members will ultimately govern this health plan via Minuteman’s unique ownership structure.
Congressional proponents of "Medicare for All" (aka the public option) took their lumps when the ACA did not include such an animal -- in part, because it did include the CO-OP requirement: one CO-OP per state, to be a nonprofit founded by providers and run by consumers, whose margins are to be plowed back into premium reductions, improving benefits and improving quality of care. (Don't confuse the CO-OPs with co-ops, which are simply group purchasing cooperatives for health insurance that manage to eke out tiny group discounts. In Massachusetts, co-ops are limited in total enrollment to 85,000, a fraction of the small group and individual market population.) CO-OPs are supposed to be operational in every state, ready to enroll members (and therefore with provider networks already in place) by 2014, so they can get started on an equal footing with other health plans on state exchanges, on offer both to individuals and to employers (though 2/3 of enrollees must be from the individual and small group markets). Founded by providers, they are required to transition to member control within a year of beginning member enrollment.
Did that political horse trade make sense? Do CO-OPs make sense?
The CO-OP in any state has the potential to become a serious competitor to existing health plans. Since there is a limit of one per state, the potential enrollment is high, and the attractiveness to providers and provider networks -- including a willingness to enter into pricing and contracting arrangements favorable to the CO-OP, such as global caps and ACOs -- is also high. In the Massachusetts example, seventeen non-founder hospitals have expressed interest in participating. (That's about 20% of the state's acute care hospitals interested in the CO-OP before it's even off the ground.) The only other insurance plan on offer statewide is Blue Cross Blue Shield, so if the CO-OP can build or rent a provider network quickly, and differentiate itself in the various markets statewide, it has the potential to become a real powerhouse.
On the downside, a CO-OP has to price its products without having historical claims data, which could be tricky, and it needs to scale up its administrative infrastructure before it has the membership base to support it (of course, it could contract for those services, and the loan from the federales is intended to cover such up-front costs). It's a big gamble: trying to break into a market dominated by a small handful of players is never easy, and trying to do so as a nonprofit that can have no ties to existing insurance companies may make it harder.
The potential difficulties ahead of the CO-OPs explain why CMS reportedly anticipates a 35-40% default rate on the startup loans and may raise an eyebrow (after all, a billion here, and a billion there, and soon we're talking serious money). Do we need CO-OPs to make the ACA work, or is this one of the throw-it-against-the-wall-and-see-what-sticks provisions?
The CO-OPs may well play out as the Medicare for All / Accountable Care Organizations for All sleeper cell of the ACA. A well-managed CO-OP in a state with the right market conditions could end up as a significant player. In Massacusetts, if Minuteman picked off half of the individual and small-group subscribers through its likely more attractive pricing, and the maximum number of larger-group subscribers to go along with them, it could be looking at 375,000 subscribers (and some multiple of that for covered lives) in not too long from now. Let's say, for argument's sake, 1 million covered lives in a state with a population of around 6.5 million. Not too shabby for a startup. While some may say that Massachusetts is a bad example as a poster child for this initiative, because the "big three" health insurers here are all nonprofits and we don't have a significant uninsurance problem thanks to state health reform, there is still room for improvement here -- nonprofits still have highly-paid execs and other elements of high-cost structures that may be different in a member-controlled CO-OP, and there are rural parts of the state that would benefit from the innovations that could be brought to bear by a high-functioning CO-OP partnering with ACOs and PCMHs. And if there's room for improvement here, I think there's room for improvement in most states.
The CO-OPs have the potential to be the tail that wags the dog -- larger insurance companies may well adopt the commercial market pricing and provider network contracting and benefits strategies of the CO-OPs in order to remain competetive. And in an era of legislated medical loss ratios (and the CEO of Aetna saying that he sees his company as a health information company rather than as an insurance company), that dog seems ready to be wagged.
The Massachusetts legislature is voting today on "An Act improving the quality of health care and reducing costs through increased transparency, efficiency and innovation" reported out of conference committee at the eleventh hour, last night. (Update: The law was passed by both houses and sent to the Governor for signature this evening.) The headlines include:
1. The health care cost growth rate may not exceed growth of the "gross state product" (GSP) for five years, and must be between the GSP and .5% below the GSP for the next five.
3. Transparency and accountability for cost and quality.
4. Investment in wellness and in community hospitals.
5. Med-mal reform including a 6-month coooling off period and inadmissibility of medical apologies in court proceedings.
The full text of the bill, and a summary, are set forth below. It's been a long haul, and this Part III of Massachsuetts health reform was kicked off by Governor Deval Patrick almost 18 months ago.
A return to central health planning? Not quite, but certainly more heavily regulated than things are at the moment. Is that a bad thing? Well, consider how the free-market approach has been working out: overall, we've seen a high-cost, low-quality experience (relatively speaking) that could use some help. Is this new law the panacea we need? Too soon to tell. But we surely cannot stick with the status quo.
While the HealthBlawger is generally loath to republish press releases, the source for the presser reproduced below is, well, the HealthBlawger himself. With such impeccable provenance, we need make no further apologies ....
HealthCare SocialMedia Review - A New Blog Carnival - To Launch In April
On April 4, 2012, the inaugural edition of a new blog carnival, HealthCare SocialMedia Review, will be posted on HealthWorks Collective by HWC curator Joan Justice, one of the co-founders of HCSMR. “We were inspired by other blog carnivals, including Grand Rounds and Health Wonk Review, and decided it was time to bring the blog carnival treatment to the world of health care social media,” said Justice.
The #hcsm tweetchat moderated by Dana Lewis and the community built by Lee Aase through the Mayo Clinic Center for Social Media are two examples of the many ways in which those of us who are involved in health care social media are able to interact, share best practices and new developments, and learn from each other. By adding a blog carnival to the mix, we hope to increase the sharing of long-form thoughts on the opportunities and challenges associated with health care social media.
Justice noted, “All are welcome to submit blog posts for consideration to each edition’s host. HCSM will be posted every other week -- alternating weeks with Health Wonk Review. And for the uninitiated: a blog carnival is an anthology, an on-line journal club for bloggers, hosted by a different blogger each time.”
Details on hosting, submission guidelines, Justice and Harlow bios and more are available on the HCSMR home page.
Connect with HCSMR on Facebook, Google+ and Twitter to keep up to date.
For further information contact:
Joan Justice joan AT socialmediatoday.com or @healthcollectiv
David Harlow david AT harlowgroup.net or @healthblawg
# # #
Health care social media is of consequence in its own right, but also as a tool to implement or leverage other initiatives, across the spectrum of health care innovation today, including participatory medicine, accountable care organizations, mHealth and others. We look forward to your participation in the HealthCare SocialMedia Review blog carnival as contributors, hosts and engaged readers/commenters. See you April 4, at the inaugural edition, on HealthWorks Collective.
Recently, I had the opportunity to speak with Gene Lindsey, President and CEO of Atrius Health and Harvard Vanguard Medical Associates. Atrius is a 1000-physician allliance of six medical groups in eastern and central Massachusetts; Harvard Vanguard is the largest of those groups. We discussed some current developments in the health care regulatory landscape and marketplace, and Atrius' approach to positioning itself for success -- as well as its definition of success -- in the current environment, in domains ranging from improvinmg medical education to achieving the Triple Aim.
Gene is a student of the history of his organizations (he's been a part of their operations, and those of their predecessor, Harvard Community Health Plan, since the 1970s), and he traces current discussions about health care quality and cost back to the thinking and writing of HCHP's founder, Dr. Richard Ebert. He described delving into Ebert's papers in "the bowels" of Countway Library at Harvard Medical School (Ebert was Dean there when he founded HCHP) and is clearly committed to the framework of collaborative, physician-led efforts to manage health care and control costs. He's taking his organization through a Lean process of cost-cutting, and is working to further Atrius's early successes under the proto-ACO Blue Cross Blue Shield of Massachsuetts Alternative Quality Contract (AQC). Atrius Health's first year's results under the AQC look promising, though researchers writing in the New England Journal of Medicine concluded that further study is needed. Gene says he has another two years' data, and the results continue to look good.
The audio file of my interview with Gene Lindsey is available for download/podcast. It runs about 25 minutes. A full transcript is at the end of this post (and in the linked Gene Lindsey, CEO, Atrius Health, interview transcript).
In thinking about how to create a high-performing health care system, Gene observed: "as Atul Gawande says, the issue is that we’re not without knowledge, we’re just inept in applying that knowledge." He predicts that the next several decades will be devoted to figuring out how to apply the knowledge we already have.
He wrapped up our coversation by tying his work at Atrius to the IOM's six domains of quality, making a strong statement about his organization's commitment to patient-centeredness:
We have constructed our organizational activities around what the IOM called the six domains of quality, the most important of which is patient-centricity. We need to design the system to be a benefit to the people who come to us for care - they are our reason for existence. That’s not been true in the past. In the past we’ve designed it for a lot of other reasons, but not always and specifically to benefit the care of people. Sometimes it’s for the convenience of physicians, sometimes it’s for the perpetuation of august institutions - whatever it’s been, but it’s not always been that the patient’s been at the center of it. Lucian Leape, whose name you introduced earlier, focused us on safety. The other issues . . . care needs to be timely if it’s going to be safe and patient-centered, it needs to be efficient and effective if we’re going to have a society that continues to exist, and the last and most important of the domains is it’s got to be equitably delivered -- and probably that has been the biggest conundrum for our country. How do we get the last 15% of our citizens covered in a fashion that doesn’t destroy the economics for the rest of us? [T]hat in and of itself is the most compelling reason to look hard at why and how we waste resources.
During our conversation, Gene jokingly called me an anarchist, due to my hyperbolic characterization of the Lucian Leape Institute's recommendations about re-inventing medical education in the US. The truth is, we need to put a little bit of the anarchist in each of us to work if we want to achieve meaningful change to our broken health care system.
Keep an eye on the man with the bowtie.
Interview of Dr. Gene Lindsey, President and CEO of Atrius Health
and Harvard Vanguard Medical Associates
November 30, 2011
David Harlow: Hello, this is David Harlow on HealthBlawg and I have with me today Dr. Gene Lindsey, President and CEO of Atrius Health, an alliance of 6 medical group practices in Eastern and Central Massachusetts with over 1000 physicians at 50 locations. Dr. Lindsey also serves as President and CEO of Harvard Vanguard Medical Associates, the largest of the groups. He started practicing at Harvard Vanguard’s predecessor, Harvard Community Health Plan, over 35 years ago and has held a variety of leadership positions in these and related entities through the years. Gene, thank you for joining us today.
Gene Lindsey: I’m glad to be here David, thank you very much for inviting me.
David Harlow: My pleasure. So you’ve had some firsthand experience practicing in the early days at one of the country’s leading HMOs - in fact, working with our soon-to-be-former CMS administrator Don Berwick. How are those days and that experience similar to the current environment where so many folks are focused on accountable care organizations and new payment systems? Many have said these look a lot like capitation - though we’re not allowed to say capitation these days, and of course we have some new bells and whistles. I wonder if you could speak to some of the similarities and differences and, since we didn’t fix the healthcare system for good back in the ’70s, what’s different this time around?
Gene Lindsey: Well, that’s one of my favorite questions, David. It is déjà vu all over again for me in many ways, in that there is certainly a sort of a pioneer spirit that’s associated with our organization now that feels very reminiscent of the spirit that existed when I joined the organization in 1975. In fact, the term “capitation” was not a term that we used back then. Dr. Robert Ebert, who was the dean of the Harvard Medical School and through whose vision Harvard Community Health Plan evolved, used the phrase “prepayment” and it was his concept which we still share today: that fee-for-service medicine led to a fragmentation of care that was deleterious to the concept of wellness and to the preservation of health. And so some of the terms that were popular at that time really focused more on health maintenance and so we call them HMOs, Health Maintenance Organizations - it’s too bad that these three-letter acronyms became four-letter words. But I think that that was because of the fact that the larger market that wasn’t driven by Dr. Ebert’s vision of wellness but was more economically focused on institutional bottom lines sort of took the spirit of the process and diverted it in a different direction; but the early days of Harvard Community Health Plan included not only Don Berwick, but other people who have gone on and made huge contributions like Glenn Steele who was a surgeon here - he is now the CEO of Geisinger. Glenn was a surgeon at Harvard Community Health Plan from the mid 70s through the late 80s. There was Glenn Hackbarth, who is the current chair of MedPAC, who was one of my predecessors as the CEO of Harvard Vanguard. So our organization has always been focused on the future and always been focused on what we can do in the moment to improve the health of the individuals who come to us for care.
David Harlow: So you said the word “pioneer,” so I wanted to ask you about what you’re doing in the pioneer arena as we’re moving towards ACO development, and my understanding is that you’re moving in that direction on behalf of the organization. I’d like to get your thoughts on the Pioneer ACO structure and how that relates to your present activities, or activities over the past year or so under the alternative quality contract with Blue Cross Blue Shield of Massachusetts.
Gene Lindsey: Well I certainly am in support of the Affordable Care Act, in particular the part of the Affordable Care Act that’s looking at the development of new practice models through CMMI, and on various occasions we have had conversations with people at CMMI and CMS - they’ve asked us for our input in how to create programs that will be potentially successful. Their goal is obviously to simultaneously reduce the healthcare spend while improving the quality of the care that’s provided, and our organization literally has adopted as a major portion of its reason for existence the success of what the IHI has called the triple aim: better care for individuals and better care for communities at an affordable cost.
The ACO movement, I believe, is the national extension of Dr. Ebert’s ideals. We’ve been looking for an economic model that actually supports the fact that care that’s going to be most effective will probably be care that’s delivered in a variety of environments that are difficult to harness in a fee-for-service way. I think that we have sort of gotten as far as we can get in terms of health improvement and efficiency paying for care only in a hospital or in an office, and the advantage that Dr. Ebert saw 42 years ago was prepayment, was that many programs that utilize time and energy of clinicians outside the office and hospital environment were going to be the fulcrum of what we could accomplish with patients. Now in this moment that means trying to take care out of the office into the space where the patient lives, and our organization does that through things like a patient portal on our website that allows them to have direct communication with their physician or with other caregivers in our system. We’d like to have programs of wellness, behavior modification, things of that sort, that go beyond the scope of the 15-minute appointment, and actually often take our clinicians into the home for the homebound elderly in ways that are very difficult to support – again, if there’s a turnstile in front of the office that a patient has to walk through to economically support the system.
So those ideas all feel to me like they’re exploratory and in that regard the concept of it being a pioneer effort seems very appropriate. I think in the commercial area - you referred to the AQC, I believe - we’ve learned a lot over the last 3 years because what the AQC contract had as a very laudable direction was moving from volume-based reimbursement to value-based reimbursement. And when it started for us we didn’t know for sure how to begin that journey but what we did quickly learn was – and I know that you have a prior relationship with Marc Bard – Marc preaches that the whole success will be on the basis of moving from a concept of individual effort to group effort. He talks about moving from I to WE and that’s exactly what was necessary to be successful within the AQC - to begin to assemble groups of clinicians and healthcare professionals to look at rosters of patients, to look at results in a collective fashion, to put together programs that would allow outreach to people whose health needed particular attention in one area or another - congestive heart failure and diabetes have been certainly big areas of focus, we’re beginning to try to put together programs that help with mental health issues and also with the new epidemic of obesity. So all of these programmatic approaches to problems that are shared by patients is what we refer to as population medicine and you can do more, and do more effectively, if you approach it in terms of programs - and those are all not possible to support very effectively in a fee-for-service system. But if you can group the budgets from many patients together as a resource then in fact you can very efficiently fund programs that do promote wellness which, over a series of years, will reduce the total spend on healthcare because it’ll be avoiding a lot of long term complicated problems that are otherwise going to be an individual drain on the collective healthcare spend. So we’re learning a lot - it’s a fun time - my only regret in this is that I’m old as I am and I don’t have that many more years left to go because I think the next 20 years of healthcare is going to be a really fantastic place to be.
David Harlow: Yes, we are certainly in interesting times. You said a couple of things I wanted to follow up on. One is on the question of seeing results and system savings from the approach that you describe. There was a recent piece in The New England Journal of Medicine looking at initial experience under the AQC which basically said, if I remember correctly, looks good, looks like we’re moving in the right direction, but further study is needed. Is there any information that you could bring to bear on that observation from prior experience with Atrius, with Harvard Vanguard, with Harvard Community Health Plan, that would tend to support the idea that this is actually going to work?
Gene Lindsey: Yes, in fact that article was based on just the very earliest results from the first year and I’m aware of the results of the next year already and almost two years’ more data, and the data has continued to improve. We’ve learned a lot, our initial efforts for instance in the quality areas led to what I would say is the reproduction of a typical dose-response curve. You had a sharp improvement that then began to plateau off, and that’s not a surprise because I think that each time you do something new it has an effect, and the effect will carry you so far towards the goal, but then you have to come up with what’s next that’ll get you a little further so it’s a very interesting concept of continuous improvement. And in fact much of the results that we’ve achieved have been through the adoption of continuous improvement in the form of Lean process management so that the results that we’ve achieved so far are the results of a very fledgling organization with Lean and I’m very excited that as our process improvement skills increase, our ability to yield results within the AQC-type payment mechanisms will improve as well.
What we’re really driving for is improved health. We talk about outcomes, and ultimately, to get the sort of outcomes we need and want, we have to go through a process of creating professionals who know how to affect behavior. And then we have to have those skills connect with patients in such a fashion that the patients begin to be involved in improving their health. And that is a series of adaptive changes that takes time and so I think that it’s a long climb, but we’re well on our way, and it is a good example of the phrase that you sometimes hear, which is “act your way into learning.” We really, every time we do something, whether it works or not, it clarifies to us what will lead to more success - and that’s really the adventure of it. I think physicians by nature are heuristic, they like to solve problems, the people who work with us - our other healthcare professionals - have found that this adds a new meaning to their work; they all went into healthcare because they have strong empathetic tendencies, they want to see improvement, it’s been frustrating for them to be embedded in systems that don’t deliver results, and the hope of being involved in something that actually approaches what they dreamed of when they went into healthcare - I think it’s been a personally regenerative sort of process for a lot of folks. It’s sort of exciting to be around.
David Harlow: It sounds like it. I’m wondering as you’re talking a lot about retraining and redirecting and refocusing folks who have been practicing clinicians for a while, and earlier this year or last year the Lucian Leape Institute issued a recommendation to blow up medical education and start again, basically saying – look, we haven’t really addressed the issues of medical errors and cost and to do so we really need to reinvent medical education. Do you see that as a reasonable approach? An organization like yours is of a size that can afford, in the scheme of things, to engage in this sort of reinvention, but most medicine is still practiced in smaller settings and folks can’t really do that.
Gene Lindsey: I think you’ve thrown me enough to talk about for maybe 3 hours right there, in that last little soliloquy. Let me just begin with a first thought. The core of the reason for the formation of Harvard Community Health Plan was to do just that - to change medical education. Dr. Ebert envisioned it as a teaching practice. I’m a student of history, in a way, and I’ve gone to the Countway library archives, with permission of his wife, and gone down into the bowels of the building where all of his papers are stored and actually read what he wrote back in the ‘60s. And he imagined then that much of the problem lay in medical education, in the fragmentation of the education that residents and interns and medical students received, where they learned about the kidney and then they learned about the heart and then they learned about the lungs, but they never learned about the whole person. And he didn’t believe it that was possible in a hospital environment, which is very artificial in a way and he felt that the education needed to move into the ambulatory environment where people could actually see their patients closer to where they lived and closer to where the behaviors that created disease actually occurred. So that’s not a new thought, and I think it is true that we need to be continuously redesigning medical education - in fact I read recently that some of our medical schools across the country, the one that I remember reading about, Jefferson Medical School for instance in Philadelphia, I think, has a program where they actually admit medical students to the hospital overnight so they can have the experience of being in the hospital to understand what it’s like from the point of view of the patient. And I think that there’s been a lot of activity towards trying to introduce into the lives of medical students how to assess readiness for behavioral change and things of that sort. So the progress is slow but it’s not non-existent - I do believe that it needs to continue. I can tell you that every medical student who graduates from Harvard Medical School now has some sort of experience within Harvard Vanguard. So it’s not as if we’re at zero; we may not be up to full speed but there is progress towards the issue of retraining, and revamping medical education, and I think Dr. Leape’s Institute is correct that process needs to - I assume that they’re using a lot of hyperbole in their statement and trying to --.
David Harlow: I don’t think they said they’re going to blow it up - that was me -
Gene Lindsey: That was you, okay -
David Harlow: That was me -
Gene Lindsey: Okay, so you’re the anarchist, okay - but it does need to continuously improve, that’s for sure, in this direction. So I think that’s also a part of what’s encouraging in the moment. The term that I’ve really come back to again and again and again are the issues of adaptive change both for patients and also for healthcare professionals. The ways in which we have worked have created a lot of understanding scientifically and yet, as Atul Gawande says, the issue is that we’re not without knowledge, we’re just inept in applying that knowledge. So I see this period of time, over the next 20 years, as the way in which we develop the systems that actually bring the fruits of the bench science and the medical technology that’s developed over the last 30 years to the benefit of more and more people in a more and more efficient fashion. And that’s about organization and that’s about teamwork and that’s about redeployment. It’s certainly true that as in many other industries we’re still shackled by the fixed investments that we have and so it’s about a process of, as a society, moving away from nonperforming assets and all of that is difficult because there is a sense of loss that’s associated with it, and that’s got to be balanced by a continuous reminder to ourselves of what it is we’re trying to achieve because that’s the only way that you can find the emotional energy to do the hard things that are necessary to get to a better level. I don’t believe you can do it for money; I think you have to do it because you believe that it will be better for the community - for the same reasons that you plant flowers around your home: because you want it to look better and to be aesthetically something that provides you a gratification that just a focus on finance can’t ever bring.
David Harlow: Well, hopefully, it has some of these desired results because otherwise we’re going to bankrupt ourselves. I heard an interesting figure last month, or earlier this month, where somebody said that in order to support our expanding healthcare spend at the federal level, by 2050 our marginal tax rate will have to be 93%.
Gene Lindsey: Absolutely.
David Harlow: So we do have to focus on costs.
Gene Lindsey: I was in a conversation recently with Jay Gonzales who is the Secretary of Administration and Finance for our State, Massachusetts. Right now we’re spending 41 cents of every dollar that the state collects as taxes on healthcare. You don’t have to be an economist to know that that’s probably not a good idea; it doesn’t leave us much left over for roads, for public safety, for schools, for the cultural things that add meaning to our lives. It pretty much just makes it about supporting a hospital-based system and that’s really -- I don’t think, I can’t think of anyone who would prefer to go to the hospital versus the symphony. It’s just not right – now, so let me clarify something: all of the stuff that I’m talking about is not in my mind a sense of adding more dollars to the system, I think that I’m a total proponent of the concept that we have allocated enough of our economy to healthcare we’re just not spending it effectively and efficiently. If there is any phrase that reverberates through my mind on a daily basis it’s efficient, effective, and that’s the thing that’s appealing to me and if you remember those are two of the six domains of quality. We have constructed our organizational activities around what the IOM called the six domains of quality, the most important of which is patient-centricity. We need to design the system to be a benefit to the people who come to us for care - they are our reason for existence. That’s not been true in the past. In the past we’ve designed it for a lot of other reasons, but not always and specifically to benefit the care of people. Sometimes it’s for the convenience of physicians, sometimes it’s for the perpetuation of august institutions - whatever it’s been, but it’s not always been that the patient’s been at the center of it. Lucian Leape, whose name you introduced earlier, focused us on safety. The other issues - just quickly - care needs to be timely if it’s going to be safe and patient-centered, it needs to be efficient and effective if we’re going to have a society that continues to exist, and the last and most important of the domains is it’s got to be equitably delivered -- and probably that has been the biggest conundrum for our country. How do we get the last 15% of our citizens covered in a fashion that doesn’t destroy the economics for the rest of us and that in and of itself is the most compelling reason to look hard at why and how we waste resources.
David Harlow: Well thank you Gene. I think I’d like to end it there wrap it up there and you’ve given us a lot to think about today and again I thank you for joining me on HealthBlawg.
Gene Lindsey: Thank you David. I really appreciate this opportunity.
David Harlow: I’ve been speaking with Dr. Gene Lindsey, CEO and President of Atrius Health and Harvard Vanguard Medical Associates. Thanks again, Gene.
Gene Lindsey: Thank you David.
On my way to the annual two-day blowout health law seminar put on by Massachusetts Continuing Legal Education (MCLE) on Monday -- I was second in the lineup, speaking about post-acute care and some of the innovations in that arena for dual eligibles, among other things -- I heard a fascinating piece on NPR on one of the ideas floating around the supercommittee charged with cutting $1.2 trillion from the federal budget. The idea: increase the minimum age for Medicare eligibility from 65 to 67, and save a bundle for Medicare in the process.
The problem with this deceptively simple idea (Social Security eligibility is migrating from 65 to 67, too, so it seems to be a sensible idea on its face), is that while it would save the federales about $6 billion, net, in 2014, it would cost purchasers of non-Medicare coverage (employers and individuals) about $8 billion, net. Why? The 65 and 66 year olds are the spring chickens of Medicare -- they actually bring Medicare average costs down, because they're healthier than the Medicare population as a whole. However, when compared to the working population, they are the older, sicker cohort, so they would drive costs up if insured in the commercial market.
Monday's post in this space was on the 2012 MPFS (Medicare Physician Fee Schedule) and the continuing Sustainable Growth Rate (SGR) debacle, and it prompted an email from a reader pointing to a predictable but ultimately unsympathetic plea to please not cut THAT program, because it's Important.
They're ALL important, folks.
The cold, hard truth is that we need to figure out how to do more with less -- in every program, for every worthy cause. We need to learn how to work collaboratively, tear down the silos, and activate every other cliche in the book. Collaborative thinking, inspired by changes in the economic drivers -- i.e., reimbursement models -- that have led to more siloed thinking in the past, is hard to do, but actors in the health care economy need to get better at it - and fast.
The Bundled Payment Initiative, ACOs and sons of ACOs, the Medicare-Medicaid Coordination Office, and more innovations coming out of CMS, driven by the ACA, are all encouraging developments, pushing providers in the direction of collaboration, and while we may have to deal with some unintended consequences a long the way, these are some important experiments that must be conducted. And the people are with Washington on this one: An RWJF/Harvard School of Public Health survey released this week found that most folks want the federales to grow their role in the health care system. Not what we might have expected, but an encouraging sign that folks understand that the problem before us is a big one, requiring significant resources in working towards solutions.
The final Accountable Care Organization regulations are out, the initial flurry of commentary is out (including my own ACO webinar with simultaneous #ACOchat tweetchat - available for replay; slides here : "ACOs, Bundled Payments and the Future of Health Care"), and we can now all catch our collective breath and contemplate the draft vs. final ACO regulation comparisons, the meaning of this new, final set of regulations, guidances and statements from CMS, FTC, DOJ, OIG, and IRS on ACOs and Medicare Shared Savings Programs, and all of the attendant antitrust, antikickback, Stark, and other fraud and abuse matters, and of course tax issues.
So, now that these final regulations are out, and the mythical characteristics of the ACO will soon be dispelled (see under: unicorn), I propose a new animal kingdom metaphor for discussion of Accountable Care Organizations:
The Camel's Nose is in the Tent.
The definition of a camel, as those of you who tuned into my ACO webinar already know, is a horse designed by a committee. And, given the nature of the legislative and rulemaking processes, that's exactly what we have before us - a camel.
The clincher, though, is the way in which the final regulations have been engineered.
CMS would have ACOs, by virtue of participating in the MSSP, diffuse all the ACO goodness of care management, quality and cost control, etc., into the broader Medicare population. This conclusion is inescapable. CMS is focused on the question of how to do more with less, and the ACO conceptual framework, if not the details, will permeate many arenas across the health care lansdscape.
ACO assignment is still retrospective (even if there is a nod to prospective assignment, that nod is provisional, and reconciliation must be done after the close of the contract year). Since an ACO never knows for sure which patients' experience will form the basis of its gainsharing or risksharing, it must behave as if each Medicare benefiicary who receives care form its providers will ultimately be attributed to the ACO.
In addition, the slimmed-down set of 33 ACO quality measures focus in part on "better care for individuals" (through CAHPS scores for patient/caregiver experience, also care coordination/patient safety measures, too), and in part on "better health for populations" (vaccinations, screenings, diabetes management).
These are just two examples of the ways in which CMS is leveraging its MSSP authority to engineer provider focus on improving population health.
Another "proof text," if you will, is the fact that at most, CMS anticipates that no more than two million Medicare beneficiaries will be seen by no more than 270 ACOs in the initial three to four years of the program. (Compare those figures to the roughly 47 million Medicare beneficiaries and 6000 hospitals, and you will quickly get the sense that the MSSP / ACO is a test probe, not a wholesale shift.) Even if the maximum anticipated ACOs are established and beneficiaries are served, projected savings to Medicare will top out at less than $1 billion over four years. In a $2.5 trillion a year health care economy, this is bupkes (a technical term).
So, the idea of the ACOs under the MSSP is the camel's nose in the tent -- the forerunner, the disruptive innovation that is intended to set the rest of the system off-kilter until it reaches a new status quo on the other side of the Triple Aim.
Given the emphasis on a wholesale departure from fee-for-service payment (even if it's done through workarounds thanks to the inertial forces of the "assets in place" of existing law and the systems built up around it), which will reverberate throughout Medicare and the rest of the health care system, it is critically important for health care providers to begin now -- if they have not already begun -- to take a broader view of the patient encounter, to get a firm grasp of their own costs and the costs of their partners, and to start thinking about the power of collaboration. Physicians, hospitals and all other sorts of health care providers need to think about episodes of care, bundled payments, care management, cost control and the path forward to a win-win-win for patients, providers and payors in a blown-up-and-put-back-together high-performing health care system.
Oh -- camels spit, so be prepared!
I am presenting two webinars this week, one on health care social media and the other on accountable care organizations, or ACOs.
(Title links to registration information)
Webinar: Tuesday, October 25, 2011
Time: 12:00 p.m. to 1:30 p.m. ET
Health care organizations, professionals and patients alike are embracing the social media movement with vigor as online tools like blogs, Facebook, Twitter and YouTube grow in popularity. It is no longer a question of whether you should be using social media tools to promote your practice and institution and connect – effectively, legally and ethically -- with patients and referral sources; it is a question of when, and how.
A skilled user of social media has the opportunity to become a trusted source, a convener, an influencer; and can effectively and efficiently utilize these tools for reputation enhancement and building strong relationships with existing patients and referral sources while “expanding the sales funnel” to attract new patients and referral sources. However, the use of these tools requires interaction and engagement at a level that many health care organizations find uncomfortable. Balancing the inherent tension between transparency and privacy, openness and control, can be difficult. While the legal land mines are there, you can make your way through and emerge unscathed if you have a clear understanding of HIPAA and other relevant rules – and how they apply to social media initiatives.
Learn more during this interactive 90-minute webinar about the value of social media tools, the range of issues they present, and some key strategies for using these tools effectively while steering clear of trouble by social media expert and charter member of the Advisory Board of the Mayo Clinic Center for Social Media, David Harlow. Become comfortable with social media for your facility!
(Title links to free registration information)
Webinar: Thursday, October 27, 2011
Time: 1:00 p.m. to 2:00 p.m. ET
In the future (starting tomorrow!) health care providers will have to do more with less. Total reimbursement by both public and private sector payors is dropping, and the metrics for success are changing. Instead of thinking about this as a zero-sum game, payors and providers are moving away from fee-for-service payment systems to bundled payment systems. The health reform law spells out one such program in detail -- the ACO, or shared savings, program -- and created the CMS Center for Innovation, and funded it with $25 billion. The Center for Innovation’s mandate is to run experiments on how to do more with less, and to scale up successful experiments quickly.
In this webinar, noted attorney, consultant, blogger and speaker David Harlow will describe the future contours of the health care market, defined by emerging federal and private sector programs in a post-fee-for-service environment, and identify ways in which provider organizations should be preparing themselves in order to succeed in this brave new world.
Join the simultaneous tweetchat at #ACOchat.
See you later this week.
Today, CMS released the final ACO regs, after many months and after reviewing something north of 1300 comments filed. For now, I wanted to share the CMS presser and links. Analysis and discussion to follow.... For background, the draft regs, and commentary on ACOs over the past few months, please see all HealthBlawg posts on Accountable Care Organizations.
I will be presenting a free webinar on ACOs and other CMS initiatives next Thursday, October 27, 2011, 1:00 p.m. ET via HCPLive. You may learn more about it and register here: ACOs, Bundled Payments & the Future of Health Care.
Reproduced below is today's CMS presser with links to today's government publications -- including regulations and fact sheets -- on Accountable Care Organizations (aka Medicare Shared Savings Program) and the Advance Payment Model for physician-owned and rural providers who need assistance with start-up costs associated with ACO / MSSP participation. You should read CMS Administrator Don Berwick's perspective on the ACO final regulations, too.
If you'd like to, you can jump right in to the full text of the final ACO regulations, or take a quick look at a table comparing the final ACO regs to the proposed regs.
The helping hand extended by the federales through the Advance Payment Model is encouraging to me, because -- as I've written before -- I believe that having physicians lead in this arena is of critical importance in order to achieve the Triple Aim and to effectively bring costs down in an era of constrained resources.
I hope you can join me for the webinar. If you have any specific questions you'd like me to address in the webinar or otherwise, please note them as comments to this post on HealthBlawg and/or in the course of registering for the webinar.
For Immediate Release: Thursday, October 20, 2011 Contact: CMS Office of Public Affairs
HHS ANNOUNCES NEW INCENTIVES FOR PROVIDERS TO WORK TOGETHER THROUGH ACCOUNTABLE CARE ORGANIZATIONS WHEN CARING FOR PEOPLE WITH MEDICARE
New tools help doctors and other health care providers improve quality of care
People with Medicare will be able to benefit from a new program designed to encourage primary care doctors, specialists, hospitals, and other health care providers to coordinate their care under a final regulation issued today by the Department of Health and Human Services (HHS). Created by the Affordable Care Act, these final rules on Accountable Care Organizations add to the menu of options for providers looking to better coordinate care for patients and will make it easier for providers to deliver high quality care and use health care dollars more wisely.
The initiatives announced today are just two of several efforts made possible by the Affordable Care Act to help bring better health, better care and lower costs not just to Medicare beneficiaries, but to all Americans. For example, the Bundled Payments for Care Improvement Initiative and Comprehensive Primary Care Initiative offer alternatives to coordinate and improve health care.
“Today we have taken another step to improve health care for people with Medicare,” said HHS Secretary Kathleen Sebelius. “We are excited to give doctors, hospitals and other providers the flexibility and support they need to work together and focus on making sure patients get the care they need.”
“This model of delivering care may not be right for everyone, but it provides new incentives for doctors, hospitals, and other health care providers to work together in new ways,” said Secretary Sebelius.
The two initiatives launched today – the Medicare Shared Savings Program and the Advance Payment model – will help providers form Accountable Care Organizations and reflect the significant input provided by stakeholders as well as lessons learned by innovators in care coordination in the private sector.
- The Medicare Shared Savings Program will provide incentives for participating health care providers who agree to work together and become accountable for coordinating care for patients. Providers who band together through this model and who meet certain quality standards based upon, among other measures, patient outcomes and care coordination among the provider team, may share in savings they achieve for the Medicare program. The higher the quality of care providers deliver, the more shared savings the providers may keep.
- The Advance Payment model will provide additional support to physician-owned and rural providers participating in the Medicare Shared Savings Program who also would benefit from additional start-up resources to build the necessary infrastructure, such as new staff or information technology systems. The advanced payments would be recovered from any future shared savings achieved by the Accountable Care Organization.
“As a physician I understand the complexities of caring for a patient who may have multiple providers,” said Donald M. Berwick, M.D., administrator of the Centers for Medicare & Medicaid Services (CMS). “This opportunity to coordinate care among providers could greatly improve the quality of care Medicare beneficiaries receive.”
Both the Medicare Shared Savings Program and Advance Payment model create incentives for health care providers to work together to treat an individual patient across care settings – including doctors’ offices, hospitals, and long-term care facilities.
Unlike a managed care plan, Medicare beneficiaries will not be locked into a restricted panel of providers. Rather, a determination of whether an Accountable Care Organization was responsible for coordinating care for a beneficiary will be based on whether that person received most of their primary care services from the organization.
“We listened very carefully to the more than 1,300 comments we received on the proposed rule released this spring, and this final rule includes a number of improvements suggested by those comments that will strengthen the program,” Dr. Berwick said. “For example, the final rule will increase the incentives and streamline the Shared Savings Program, extending the benefits of the new program to a broader range of beneficiaries.”
Other changes from the proposed rule include making the one-sided model truly one-sided, expanding participation to Rural Health Clinics and Federally Qualified Health Centers and organizations where specialists provide primary care, and providing a flexible starting date in 2012. Federal savings from this initiative could be up to $940 million over four years.
To aid organizations interested in becoming Accountable Care Organizations, CMS offers a number of learning opportunities for providers, including the third Accelerated Development Learning Session on November 17-18 in Baltimore. This free session will offer providers the opportunity to learn more about this option for providing care. For more information, visit https://acoregister.rti.org/.
People with Medicare have received information about what an Accountable Care Organization could mean for them in the annual issue of “Medicare & You” and if their current health care provider is participating in an Accountable Care Organization, they will receive additional information from their provider.
The Shared Savings Program final rule is posted at: www.ofr.gov/inspection.aspx.
The Advanced Payment solicitation is posted at: http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/advance-payment/.
For more information, fact sheets are posted at: http://www.HealthCare.gov/news/factsheets/2011/10/accountable-care10202011a.htmland http://www.cms.gov/ACO/.
The joint CMS and Department of Health and Human Services Office of Inspector General (OIG) Interim Final Rule with Comment Period addressing waivers of certain fraud and abuse laws in connection with the Shared Savings Program is posted at: www.ofr.gov/inspection.aspx.
The Antitrust Policy Statement is posted at:
The Internal Revenue Service (IRS) Fact Sheet, Tax-Exempt Organizations Participating in the Medicare Shared Savings Program through Accountable Care (FS-2001-11), will be posted at: http://www.irs.gov .