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50 posts categorized "Managed Care"

December 02, 2013

Narrow Networks and Medicare Advantage: The True Meaning of Managed Care?

Narrow road signUnited HealthCare and other Medicare Advantage plans are dropping numerous providers from their networks, to the consternation of members given short notice of the changes. Predictably, the story is presented as big bad insurance co. vs. grandma, but the real story is less clear-cut.

For years, Medicare Advantage plans have benefited from a regulatory structure that pays them more than the average Medicare fee for service cost for parallel populations and asks the plans to provide some addtional services to beneficiaries in return for the bonus payments. The reimbursement has been attractive enough to keep numerous insurance companies involved in Medicare Advantage.

Continue reading "Narrow Networks and Medicare Advantage: The True Meaning of Managed Care?" »

October 30, 2013

Mobile Health Apps: Pass the Secret Sauce

6029363903_0e9abdceab_mThe IMS Institute for Healthcare Informatics released a report on the ecosystem bloody mess of 40,000+ mobile health apps that are available today. Hat tip to Jane Sarasohn-Kahn for writing about it today at Health Populi.

From the executive summary:

Over time, the app maturity model will see apps progress from being recommended on an ad hoc basis by individual physicians, to systematic use in healthcare, and ultimately to an end goal of being a fully integrated component of healthcare management. There are four key steps to move through on this process: recognition by payers and providers of the role that apps can play in healthcare; security and privacy guidelines and assurances being put in place between providers, patients and app developers; systematic curation and evaluation of apps that can provide both physicians and patients with useful summarized content about apps that can aid decision-making regarding their appropriate use; and integration of apps with other aspects of patient care. Underpinning all of this will be the generation of credible evidence of value derived from the use of apps that will demonstrate the nature and magnitude of behavioral changes or improved health outcomes.

(Emphasis supplied.)

We are nowhere near this endpoint -- integration of the use of health apps into health care management -- right now, due to a number of factors.

Continue reading "Mobile Health Apps: Pass the Secret Sauce" »

June 18, 2013

Alternative Quality Contract with Blue Cross Blue Shield of Massachusetts: A model for ACOs?

Managed Care Magazine recently ran a story on the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC), which serves as a model for the ACO program under the Affordable Care Act. Check it out: Bay State Blues Combine Global Payment With Quality Metrics. The author of the piece, Joe Burns, contacted me as well as others in Massachusetts for comment.

My take, drawn from the story:

David Harlow, a health care lawyer in Newton who writes the HealthBlawg, agrees [that the early findings are encouraging], calling the AQC a significant development for two reasons. First, it is an alternative to fee for service.
“That’s appropriate because there is a need to change the incentives of health care providers in the system,” he adds. Second, the AQC is important because it has served as a model for the federal Centers for Medicare & Medicaid Services’ accountable care organizations.
“The problem with past attempts to control health care spending is that adequate quality standards were not in place,” Harlow says. “It was all about keeping costs down. While this model represents an improvement over other models, the amounts at risk are relatively trivial and, standing alone, will not bend the cost curve.
“Nevertheless, the AQC is different because no provider group can earn a quality bonus unless the physicians and hospitals achieve or exceed the quality standards.”

As I've written before, I think the focus should be on long-term planning for a wholesale shift away from fee-for-service medicine rather than trying to expose and rationalize payment levels. Global payments (a euphemism for that dirty word, capitation), a bonus structure tied to performance against quality benchmarks pegged at a level sufficient to change provider behavior, and dedicated funding within the global payment system for nurse case managers and other elements of the medical home model, are the key elements of the solution we are looking for.

The AQC is a good start. 

David Harlow
The Harlow Group LLC
Health Care Law and Consulting 

November 21, 2012

Engage With Grace

As patients, as family members, as friends, as health care providers, we have all faced end-of-life issues at one time or another, and we will face them again. And again. 

Having been through this process twice in the past year, I can only repeat that it is important to have The Talk, to help ensure that your family members' and friends' wishes about end-of-life care are clear, are documented and, as a result, are followed. If it helps to get the conversation going, use the Five Questions in the slide at the end of this post. 

Download your copies of the Massachusetts health care proxy form or other states' proxy or living will forms -- and add specific instructions about nutrition, hydration, and anything else that is important to you so that everything is crystal clear.  Having the conversation is a starting point; we all need to follow through and make sure that our loved ones' wishes are documented, placed in medical records, discussed with physicians and other caregivers, and honored.

And with that I turn it over to @engagewithgrace for #blogrally12 (the latest edition from a group of us kickstarted by Alexandra Drane, Matthew Holt and Paul Levy.) If you blog, consider copying the rest of this post, and putting it up now through the end of Thanksgiving weekend. 

- O -

One of our favorite things we ever heard Steve Jobs say is… ‘If you live each day as if it was your last, someday you'll most certainly be right.’

We love it for three reasons:

1) It reminds all of us that living with intention is one of the most important things we can do.
2) It reminds all of us that one day will be our last.
3) It’s a great example of how Steve Jobs just made most things (even things about death – even things he was quoting) sound better.

Most of us do pretty well with the living with intention part – but the dying thing? Not so much.

And maybe that doesn’t bother us so much as individuals because heck, we’re not going to die anyway!! That’s one of those things that happens to other people….

Then one day it does – happen to someone else. But it’s someone that we love. And everything about our perspective on end of life changes.

If you haven’t personally had the experience of seeing or helping a loved one navigate the incredible complexities of terminal illness, then just ask someone who has. Chances are nearly 3 out of 4 of those stories will be bad ones – involving actions and decisions that were at odds with that person’s values. And the worst part about it? Most of this mess is unintentional – no one is deliberately trying to make anyone else suffer – it’s just that few of us are taking the time to figure out our own preferences for what we’d like when our time is near, making sure those preferences are known, and appointing someone to advocate on our behalf.

Goodness, you might be wondering, just what are we getting at and why are we keeping you from stretching out on the couch preparing your belly for onslaught?

Thanksgiving is a time for gathering, for communing, and for thinking hard together with friends and family about the things that matter. Here’s the crazy thing - in the wake of one of the most intense political seasons in recent history, one of the safest topics to debate around the table this year might just be that one last taboo: end of life planning. And you know what? It’s also one of the most important.

Here’s one debate nobody wants to have – deciding on behalf of a loved one how to handle tough decisions at the end of their life. And there is no greater gift you can give your loved ones than saving them from that agony. So let’s take that off the table right now, this weekend. Know what you want at the end of your life; know the preferences of your loved ones. Print out this one slide with just these five questions on it.

Have the conversation with your family. Now. Not a year from now, not when you or a loved one are diagnosed with something, not at the bedside of a mother or a father or a sibling or a life-long partner…but NOW. Have it this Thanksgiving when you are gathered together as a family, with your loved ones. Why? Because now is when it matters. This is the conversation to have when you don’t need to have it. And, believe it or not, when it’s a hypothetical conversation – you might even find it fascinating. We find sharing almost everything else about ourselves fascinating – why not this, too? And then, one day, when the real stuff happens? You’ll be ready.

Doing end of life better is important for all of us. And the good news is that for all the squeamishness we think people have around this issue, the tide is changing, and more and more people are realizing that as a country dedicated to living with great intention – we need to apply that same sense of purpose and honor to how we die.

One day, Rosa Parks refused to move her seat on a bus in Montgomery County, Alabama. Others had before. Why was this day different? Because her story tapped into a million other stories that together sparked a revolution that changed the course of history.

Each of us has a story – it has a beginning, a middle, and an end. We work so hard to design a beautiful life – spend the time to design a beautiful end, too. Know the answers to just these five questions for yourself, and for your loved ones. Commit to advocating for each other. Then pass it on. Let’s start a revolution.

Engage with Grace.

Engage With Grace

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

December 05, 2011

Deja Vu All Over Again: David Harlow speaks with Gene Lindsey, MD, President and CEO of Atrius Health and Harvard Vanguard Medical Associates


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.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


HealthBlawg :: David Harlow’s Health Care Law Blog

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.

August 15, 2011

Partners Health Care acquiring Neighborhood Health Plan: The 800-Pound Gorilla and the Fig Leaf?

Kingkong.jpg (480×320) Partners Health Care (the dominant provider network in Greater Boston) and Neighborhood Health Plan (a local mostly-Medicaid HMO) just announced that the former intends to acquire the latter, and maintain it as a separate operating entity.  No money will change hands between the parties, but an unspecified amount of money will be given by Partners as grants to community health centers where NHP members receive much of their health care services. Gary Gottlieb, CEO of Partners, graciously allowed that it would not seek to interfere with the current referral patterns of NHP members to the two local safety-net hospitals (which get disproportionate share hospital payments; Partners hospitals do not).

The deal is contingent on several layers of regulatory review, including review by the Commonwealth's Attorney General's Office, which has reported on Partners using its market power to extract high rates of reimbursement from payors that do not correlate to a higher quality of care relative to others around town.

See the NHP presser and fact sheet, and the Boston Globe story on the deal announcement.

So, is the motivation for the affiliation (a) Partners offering a helping hand to a Medicaid HMO and a network of community health centers as part of its mission, (b) a rational reaction to market forces in the face of health reform by Partners, providing a fig leaf for Partners as it faces further scrutiny in the marketplace by regulators and others, (c) an ace in the hole that may be used to win a future hand (e.g., when state, Federal or commercial reimbursement rates get cut further, and Partners can claim it's a special case) or is it (d) simply part of the Partners unified field theory of the marketplace whereby it seeks to extend its influence over payors and non-Partners providers and position itself for future success as an ACO or other as-yet-undefined new type of provider network with a payor kicker?   Probably a bit of each.  The community health center move is just the latest in a years-long chess game of CHC affiliations.  The HMO acquisition is something new, though, and will bear watching.

For more on Partners, the Massachusetts experiment and Massachusetts Attorney General Martha Coakley, see this post on global payments and earlier Massachusetts Attorney General and special commission reports and other resources linked to from the post.

This news comes on the heels of news of some fancy footwork by John Kerry that tied all Massachusetts hospital Medicare payments to a wage index related to Nantucket Cottage Hospital (a high-wage hospital on an island) which is part of Partners.  (A few other states benefited from this ACA amendment as well.)  This being a zero-sum game, the $275 million a year extra income flowing to Bay State hospitals comes out of the hides of other states' hospitals. They are less than thrilled.

The continuing question as all of this shakes out is -- or perhaps should be -- whether the Partners-NHP deal advances Don Berwick's triple aim: improving the experience of care, improving the health of populations, and reducing per capita costs of health care.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

May 18, 2011

Why do 10% of cancer patients on oral meds stop taking them?

Ten percent of cancer patients failed to fill their initial prescriptions for oral anti-cancer drugs, according to a new study published jointly today in the Journal of Oncology Practice (JOP) and American Journal of Managed Care (AJMC)[, based on data] . . . from 2007 to 2009. . . .

The study, “Patient and Plan Characteristics Affecting Abandonment of Oral Oncolytic Prescriptions,” finds that patients were primarily abandoning their anti-cancer drugs due to two key factors: high cost-sharing and higher prescription activity. For example, claims with cost-sharing over $500 were four times more likely to be abandoned than claims with cost-sharing of $100 or less. Across the sample of prescription claims studied, Medicare coverage and lower income were also related to higher rates of abandonment when each were compared individually.

The study shows that while anti-cancer medicines offer benefits to patients, access to them is difficult due to high rates of cost-sharing. While 73 percent of newly initiated oncolytic patients had a cost-sharing amount of $100 of less, 16 percent required an out-of-pocket cost of greater than $500. The study found that the abandonment rate increased with cost-sharing amounts. Claims with cost-sharing above $500 had the highest abandonment rate – 25 percent – as compared with an abandonment rate of six percent for claims with cost-sharing of $100 or less.

(Source: presser from Avalere Health, which conducted the study.)

In the bad old days, most cancer meds were delivered through infusion therapy (chemotherapy), but a sizable chunk of those now in use, and likely more of those that are in the pipeline (25-35%) are oral meds.

IV meds administered in a health care facility are, generally speaking, not subject to the same level of cost sharing by patients now common for prescription medications.  Thus, the confluence of changes in drug therapy and changes in insurance coverage has led to a dangerous drop in medication adherence for cancer patients, due to higher out-of-pocket costs, even if the total cost of a given course of treatment is lower than the cost of a comparable course of IV chemo.

This should be understood intuitively, but apparently it is not.  A couple months ago, we were treated to another study showing that as high deductible health plans become more prevalent, use of preventive services declines.

The solution being adopted to deal with this latter problem, across many commercial plans as well as Medicare, is the elimination of copays for certain primary and preventive care services.  This makes economic sense to payors, even as it makes eminent sense for individuals as well.  For short money up front, expensive care down the road may well be avoided.

While we need not return to the bad old days of infusion therapy only for cancer meds, payors should examine the results of this study carefully and reconsider coverage rules.  Reducing out-of-pocket costs for these meds will increase adherence, and would likely reduce the incidence of complications and relapses requiring more expensive care . . . good for everyone.

(While we're on the subject of cancer treatment, I would be remiss if I did not offer you the opportunity to sponsor my ride in the 2011 Pan-Mass Challenge -- the two-day, 200-mile annual bicycle fundraiser for the Dana Farber Cancer Institute.  Please follow the link and give as generously as you can.  Tell your friends and neighbors.)

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


February 14, 2011

AQC to ACO: As goes Massachusetts, so goes the nation?

About four years ago here in Beantown, survivors of the last big ill-conceived or poorly-executed (depends who you ask) wave of health care management and finance innovation were kicking around for a new approach to aligning payor and provider incentives, focusing on quality and cost containment. To hear Andrew Dreyfus, CEO of Blue Cross Blue Shield of Massachusetts, tell the story, the Blues wanted to address both quality and cost, and therefore (after looking in vain for a model elsewhere that could be transplanted to Massachusetts) developed the Alternative Quality Contract, or AQC, which features a global payment model hybridized with substantial performance incentives, plus design features intended to lower the cost of care over time.

Many of the features put in place under the AQC will allow participating provider networks in Massachusetts to make the leap to ACO (once the beast is defined by the federales), despite the difference in payment methodology (global cap for AQC vs. FFS for ACO).

I was invited to hear Andrew present the AQC story this week together with Gene Lindsey, CEO of Atrius Health, a Massachusetts multispecialty physician network of some 700 physicians that participates in the AQC.  (Atrius'  largest group is Harvard Vanguard Medical Associates, whose docs used to be employed by Harvard Community Health Plan, the pioneering staff model HMO 'round these parts.) 

After mulling over Jeff Goldsmith's "Plan B" for ACOs in the commercial sector a few weeks back -- he thinks they need a radical redesign to work well -- it was fascinating to hear from a payor and a provider who have been working together for a few years now in what is effectively a physician-led ACO.  (Keep in mind that the vast majority of discussions about ACOs are focused on hospital-led models, with the exceptions of those by Vince Kuraitis and the HealthBlawger; please feel free to point us to others in the comments.)   An important data point in Gene's presentation is the breakdown of the budget: outpatient costs exceeded inpatient costs.  In addition to that point, the fact of the matter is that the most expensive piece of medical technology remains the physician's pen.  It therefore makes sense to place physician organizations at the center of ACOs; they don't provide all care to all members, but they do coordinate all care.

Andrew and Gene offer glowing reports from the front. More of the details are in their presentations, embedded below.


Almost half of the BCBSMA HMO members have a PCP who is enrolled in the AQC program. (They have other insurance products in the market, too, but the AQC is limited to providers that participate in the HMO plan.)  The program may be distinguished from capitation in the bad old days by three key features:

  • The first year's global payment equals the prior year's payment experience for the population served.
  • Quality measures are in place to guard against undertreatment
  • Global payments are risk-adjusted to account for the health status of individual patients

The results to date have been encouraging. There is improvement in both process and outcome measures for the populations served by providers operating under the AQC, BCBSMA is on track to reducing annual growth in costs by 1/2 within five years and provider groups participating in the AQC are seeing surpluses as a result of their integrated approach to care management.

As is the case everywhere, 50% of costs are incurred for the sickest 5% of the population, so intensive management of those cases will yield the biggest bang for the buck.  This is not news, yet effective care management seems to be.  Witness the recent Atul Gawande piece on "hot spotters" focusing on high-cost chronic care in Camden, NJ.   

For Gene Linsdey, long-time physician at Harvard Vanguard Medical Associates and its predecessor, Harvard Community Health Plan, and now CEO of Atrius Health, what rings true is guidance from the founder of HCHP, Dr. Robert Ebert:

The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.

Ebert said this in 1969, decades before the rise of IHI and the Triple Aim ... though of course Don Berwick must've picked up some of these ideas when he was a practicing pediatrician at HCHP.  As Lindsey demonstrated, HCHP and its progeny have been tinkering with the conceptual framework and the operating system ever since.

In order for this model to work beyond the slightly unreal laboratory of BCBSMA and Atrius, where there are many long-term physician-patient relationships (so lack of a required patient buy-in to the AQC or ACO model is not that big a deal), and there are significant numbers of covered lives, a shift in thinking is required, an adoption of the patient-centered medical home mindset, and (per Lindsey) a dedication, at a large enough scale to manage the risk involved, to promote the necessary investments in organizational culture, medical management, data reporting analysis, health information and patient engagement.

As the multitude of federal agencies potentially involved in ACO regulation work out their internal differences (the FTC-DOJ catfight over who gets to write and enforce the antitrust rules that will govern ACOs is just the latest one; Stark, Anti-kickback, IRS and other rules are implicated as well), and as the elimination of overlapping agency jurisdiction -- as promised in the State of the Union address a few weeks ago -- plays out, we may well be grappling with a seismic shift in the way health care services are organized and delivered.  Here's hoping that the shift is less about jockeying for market power, and more about delivering greater value and quality to individuals in a manner that helps achieve the Triple Aim of improved population health, improved experience of care and reduced per capita cost.  

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

January 19, 2010

Healthcare Communications and Social Media - First Anniversary Tweetchat

Sunday night, Dana Lewis (twitter handle: @danamlewis) hosted a special two-hour edition of the weekly Healthcare Communications and Social Media Tweetchat to mark its first anniversary.  There was a guest moderator -- Lee Aase (@leeaase).  There was a raft of special guests: Nick Dawson (@nickdawson), Greg Matthews (@chimoose), Jonathan Richman (@jonmrich), Liza Sisler (@lizasisler), Jeff Livingston (@macobgyn), Christine Kraft (@christinekraft) and Val Jones (@drval).

While the background and institutional interests of the speakers and the participants is incredibly broad (integrated health care delivery system to payor to digital health care marketing consultant to physician to health care IT consultant . . . ), the focus on the group has been pretty clear over the past year: harnessing the power of social media for the benefit of the patient -- providing information to patients, empowering patients and enabling patient choice.  While part of the equation is, naturally, an effort to develop outreach that results in more volume at a particular health care provider, there is great attention paid to the need for authenticity and trust in this particular sort of online relationship.  As I always say, social media is just "one arrow in the quiver," but it is a relatively new and potent one, so this sort of examination of its uses is valuable. 

Read about the history of this weekly tweetchat, known by its twitter hashtag #hcsm -- which many of us heard vocalized for the first time Sunday night, as "Hic-Sum" as the chat also took place via Blog Talk Radio (the two-hour broadcast is archived and may be heard here; beware - audio starts as soon as you open this link).

There were many participants in the discussion as well -- participating via twitter at #hcsm and on the Blog Talk Radio chat room.  The ongoing discussion owes a debt of gratitude to Tom Stitt (@tstitt) for pulling together the infrastructure and to Meredith Gould (@meredithgould) for pitching on Sunday night, in particular.

I was tickled to be included in the #hcsm timeline: The legal #hcsm tweetchat in June featuring Mayo lawyer Daniel Goldman (@danielg280) and the HealthBlawger, David Harlow (@healthblawg), "reaches 1000+ tweet per hour intensity and is nicknamed the 'fire hose' #hcsm chat."  (See my post on the legal #hcsm chat.)

Here's to another year of interesting discussions online . . . and otherwise, as connections made via twitter leak into that parallel universe we call real life.  I look forward to making more of those connections as time goes on, and I encourage those of you not already following the health tweets mentioned in this post to start following them on twitter; and who knows, maybe we'll hear from you at the next #hcsm tweetchat.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

January 14, 2010

HIPAA enforcement by state attorneys general: The shape of things to come

Shape OTTKConnecticut Attorney General Richard Blumenthal entered a brave new world yesterday, as the first state AG to file a HIPAA enforcement action under the "Son of HIPAA" amendments found in the HITECH Act.  Among other HIPAA changes made in the new law (all of which should be of concern to health care providers, health care payors, health care clearinghouses  -- "covered entities" or CEs -- and their "business associates" -- vendors who touch electronic protected health information or ePHI), there is a provision that permits state attorneys general to file HIPAA enforcement actions on behalf of the people of their state, in order to protect their interests, and to seek injunctive relief and/or money damages.  See Sec. 13410(e) of ARRA (p. 160 of HR 1 PDF)

The basic facts of the case are not unfamiliar:  A hard drive gone missing from a health insurance company's offices, this one with unencrypted information about 250,000 plan members.  The insurer, Health Net, failed to promptly notify data subjects that the data had gone missing, taking six months to issue a notice and letters to affected individuals and offer credit monitoring and repair for anyone affected.  Unfortunately, data breaches are all too common.  See, for example, my post on the Virginia health data breach last year, and the recent Chilmark Research post asking, in essence, whether we can reasonably expect a breach-free world.

While asserting a HIPAA claim is new territory for state AGs, the crux of the claim is really a consumer protection claim, one of the state AGs' mainstays.

The Connecticut AG (ONC chief David Blumenthal's brother, by the way) said in a press release:

Sadly, this lawsuit is historic -- involving an unparalleled health care privacy breach and an unprecedented state enforcement of HIPAA. Protected private medical records and financial information on almost a half million Health Net enrollees in Connecticut were exposed for at least six months -- most likely by thieves -- before Health Net notified appropriate authorities and consumers.
These missing medical records included some of the most personal, intimate patient information -- exposing individuals to grave embarrassment and emotional distress, as well as financial harm and identity theft.

The staggering scope of the data loss, and deliberate delay in disclosure, are legally actionable and ethically unacceptable. Even more alarming than the breach, Health Net downplayed and dismissed the danger to patients and consumers.

Failing to protect patient privacy blatantly violates federal law and Health Net's public trust. We are seeking a preliminary order to protect patients and consumers, and will fight for civil penalties.
The press release continues:
Despite its own policies and requirements of federal law, Health Net failed to encrypt this private and protected information or promptly notify Connecticut residents whose personal information may have been compromised.

. . .

Blumenthal's lawsuit alleges that Health Net failed to effectively supervise and train its workforce on policies and procedures concerning the appropriate maintenance, use and disclosure of protected health information.

It is unclear from published reports what Blumenthal is seeking to accomplish that Health Net has not already committed to do.

The takeaway point for other covered entities and business associates:  An ounce of prevention is worth a pound of cure.  Get into full compliance -- and stay there -- so that you don't become a test case (or an opportunity for a state AG to get some press for being tough on HIPAA scofflaws).  Not only do you need to adopt the policies and procedures called for under the Son of HIPAA rules -- encryption, breach notification, beefed-up business associate agreements, and monitoring of business associates' policies and procedures -- you need to be sure that the policies and procedures are tailored to your business processes, that your personnel are fully-trained on the content and the importance of these policies and procedures, and that they are actually being followed in real life.

I've been talking to a lot of folks about these sorts of reviews as February compliance dates are upon us for some of the changes outlined above ... Nobody wants to be remembered as the Son of HIPAA test case.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting