Much has been said and written about the dearth of new commercial health insurance plan enrollees on the federal and state exchanges and, by contrast, the excessive numbers of Medicaid expansion enrollees, the death spiral signified by the absence of Young Invincibles from the exchanges, etc.
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.
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.
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.
I am on the organizing committee for HealthCamp Boston, which will roll into town on Friday, September 14th. You should be there!
HealthCamp Boston is a forum for people with interest in all areas of health and wellness to gather, to generate ideas, and to take practical steps towards building the future of health care. HealthCamps are different from traditional conferences where speakers talk at you. At HealthCamp Boston, an “unconference,” attendees set the agenda, and all contribute to the event according to their interests.
The Boston area is a center of innovation for all aspects of health care, so you can be certain that people at HealthCamp Boston will be discussing things like:
- Big Data in health care
- Improving engagement and outcomes through mobile devices and social media
- Personalized medicine and translational medicine
- Empowered patients
- Practical impacts of health care reform
- and more...
Join us on September 14th and be part of the conversation with academics, industry experts, innovators, investors, analysts, and engaged patients.
We are looking for sponsors that may be interested in presenting "4x4" sessions -- 4 slides, 4 minutes, presenting a current issue or problem, which, along with a "firestarter" panel, will help get the juices flowing.
This year's HealthCamp Boston is scheduled as a lead-in to Medicine 2.0. If you are coming to town for Medicine 2.0, come a day early and join HealthCamp. If you are local and would like to join in the fun, come to HealthCamp.
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.
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.
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.
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.
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.
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.
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.
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.
Health Insurance Exchange regulations were released by HHS yesterday -- in a DC hardware store, for local color and homespun truths -- with a go-live date of January 1, 2014, per the Affordable Care Act, and a key interim approval deadline of January 1, 2013, by which date each state needs to demonstrate that it has its act together and is on a glide path to the go-live date. Despite the rancorous opposition to the ACA (consider, for example, the views of the Virginia Attorney General -- who is leading a multi-state charge against the individual mandate -- expressed at the American Health Lawyers Association Annual Meeting last month, where he was an invited keynote speaker, and later tweeted a tone-deaf assessment of the audience and an unkind skewering of a questioner who didn't share his perspective), 49 states, D.C. and four territories have accepted health insurance exchange planning grants. Thus, it seems unlikely (for now) that the federales will have to make use of the "Do I have to do everything for you?" clause which would allow HHS to step in and set up an exchange for a state.
Here in the People's Republic of Massachusetts, the health insurance exchange established by the Commonwealth's 2006 health reform law has been up and running for quite some time now. As a Visitor from the Future I have to remember that the exchange -- or as we call it here, the Health Connector, or just the Connector, does not exist in every state. It is a boon to the people of Massachusetts, who have availed themselves of this tool, among others, in achieving near-universal coverage. (I'd encourage you to check out the Connector website, and see how it works.)
Since passage of the ACA, folks 'round these parts (and in other states ahead of the curve) have wondered whether the federales would write rules that would require the early adopters to rip out what they've built and start over. The issue has even risen to the level of a bill that would amend the ACA to let the early adopters alone. (See discussion of Wyden-Brown bill.) The regulations address this issue head-on, in a fairly reasonable manner. Subject to certain exceptions,
a State operating an exchange is presumed to be in compliance with the standards set forth in this part if: (1) the exchange was operating before January 1, 2010; and (2) the State has insured a percentage of its population not less than the percentage of the population projected to be covered nationally after the implementation of the Affordable Care Act.
CMS Office of the Actuary says 93.6% of the population will be covered in 2016; CBO says 95%. Comments are invited. Massachusetts would meet either standard. Such a "deemed" state is also supposed to "work with HHS to identify areas of noncompliance" with the exchange standards. Unclear what we're supposed to do with this understanding of noncompliance.
Stepping back from the details, the naysayers will say that the state subsidies built into the exchange for eligible residents will break the camel's back -- universal coverage is a pipe dream we can't afford. The counter-argument, of course, is that we can't afford widespread uninsurance. While the Massachusetts experience is not necessarily representatitive, so we can't extrapolate success from Massachsuetts to the US, there's much to be learned from the experience here as implementation of the ACA continues.