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12 posts categorized "Medical home"

May 23, 2014

The Affordable Care Act: How Provider Organizations Can Succeed Under Health Reform

The Affordable Care Act has triggered many changes in the health care delivery system. Learn about the health reform-inspired approaches to redesigning care that work (or don't work) for management of chronic conditions, including diabetes -- from ACOs to bundled payments to patient centered medical homes.

I recently had the opportunity to present to the domestic affiliates of Joslin Diabetes Center on this topic.

Continue reading "The Affordable Care Act: How Provider Organizations Can Succeed Under Health Reform" »

October 18, 2013

Health Care Innovation: Primary Care is the New Black

BEOften, when we think about innovation, we immediately think of hi-tech devices, software or platforms.

In the midst of this year's Joslin Diabetes Center's Diabetes Innovation conference, even acknowledging that many people with diabetes are joined at the hip (literally) to some pretty hi-tech tools, it was worth slowing down for a moment to consider the value and efficacy of decidedly low-tech solutions.

Earlier this year, Susannah Fox (a speaker at this year's conference) coauthored a report published by the Pew Research Center entitled Tracking for Health. This report collects survey data showing that while 60% of U.S adults track diet or exercise, and 33% track their own health -- 49% track only in their heads, 34% use paper and only 21% use technology (web, app, device) for personal tracking.

Continue reading "Health Care Innovation: Primary Care is the New Black" »

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

April 03, 2011

Accountable Care Organization (ACO) Regulations: First Look

ACO regulations and related federal issuances hit the street last Thursday, after several months of waiting -- from CMS, OIG, FTC, DOJ and IRS.  They cover the waterfront, ranging from the central regulation defining the structure and workings of the ACO, to  limited Stark self-referral ban and anti-kickback statute waivers in the fraud and abuse arena, to new frameworks for antitrust analysis, to rules governing joint ventures involving taxable and tax-exempt organizations. 

Update 11/12/2011:  The final ACO Regulations are out - follow the link to my thoughts (camel, not unicorn), links to all of the final regs and issuances, and to an archived webinar on the final ACO regs and what they mean for the health care marketplace.

I had the opportunity to discuss the proposed regs the day after they were issued on a special edition of the Blog Talk Radio show, ACO Watch, hosted by Gregg Masters (@2healthguru).  Gregg's guests included Mark Browne (@consultdoc), Vince Kuraitis (@VinceKuraitis), Jaan Sidorov (@DisMgtCareBlog) and yours truly (@healthblawg).  We are geographically diverse, and bring a variety of perspectives to the table.  I invite you have a listen -- we enjoyed the opportunity to discuss the rules, we all learned from each other, and we hope you enjoy the conversation as well.  (It runs about 90 minutes.)

Update 4/5/2011: For a collection of ACO analyses curated by Anita Samarth see:

Here are a few points to consider as part of a first look at the ACO rules:

1.    The rules were worth the wait.  There are a lot of moving parts to coordinate, and the multi-agency effort really came together.  The CMS rule also retains a fair amount of flexibility.  Some requirements are very specific, but others much less so.  (For one example of specific guidelines, take a look at the eight-part definition of patient-centeredness; an  organization must satisfy all eight in order to be an ACO.  Other requirements have no detail at all, and CMS will look to applicants to explain how they meet the requirements, without giving any hints.)

2.    This is the Frankenstein regulation:  A Medicare beneficiary must sit on the board of the ACO, CMS must approve all marketing materials before they are used ....  These requirements may be traced back to origins in CMS demonstration project and Medicare Advantage policies, respectively, and illustrate the way in which CMS took a short statute and really put some meat on the bones.  Some may balk at the weight of the requirements limiting the options of an ACO.

3.    CMS has bootstrapped a law aimed at ACOs serving at least 5,000 Medicare beneficiaries each into a system of rules that effectively requires that commercial business be handled in an ACO-like manner.  This, among other infrastructure requirements (e.g., 50% of ACO docs must be meaningful users of EHRs), leads to the conclusion that there will be relatively few ACOs, at least initially.  CMS estimates 75-150 nationwide.  There are, of course, many unanswered questions about what a commercial ACO would look like.  One model I am familiar with -- here in the People's Republic of Massachusetts -- is the AQC, or Alternative Quality Contract offered by Blue Cross Blue Shield of Massachusetts to providers enrolled in its HMO Blue product.  One question is whether a slightly different financial model could apply to the commercial side of the house.  One model worth a close look is Jeff Goldsmith's proposed ACO model, which would treat primary care, emergency and diagnostic care, and episodes of specialty care in three distinct ways.

In brief, Goldsmith recommends risk-adjusted capitation payments for primary care, fee-for-service payments for emergency care and diagnostic physician visits, and bundled severity-adjusted payments for episodes of specialty care.  Primary care would be provided through a patient-centered medical home model, which would likely have a collateral effect of reducing the total volume of emergency care and diagnostic physician visits.  Specialty care would be provided through "specialty care marts," ideally more than one per specialty per market to maintain a little healthy competition.

A quick explanation of this approach to an intensivist over the weekend elicited a favorable response.

4.    Also in the bootstrapping department, CMS has shifted the ACO from a "shared savings" approach to having ACOs share risk as well as the upside.  Of course, this makes a lot of sense; a number of commentators, including the HealthBlawger, had lamented the fact that risk sharing was left out of the statute.  CMS has used its general waiver and demo authority under the ACA to move the ACO into risk sharing.  The ACO may choose: share risk from day one, and enjoy a potentially higher percentage of the upside, or defer the risk sharing to year three.

5.    The retrospective nature of patient attribution and savings calculations mean that each ACO must treat every Medicare fee-for-service patient as if he or she is "theirs."  Patients have the right to decide whether they want their data shared with an ACO; if enough patients are spooked by health care data privacy and security issues, fewer and fewer will authorize the sharing from CMS to the ACO, and the ACO will have to drive by feel -- or base its management of Medicare beneficiaries on its management of its general patient population.

6.    Organizations that dominate their local markets may be the most successful as ACOs, but they may face the most involved antitrust review at the hands of the FTC/DOJ.

7.    Scoring on 65 quality metrics in 5 domains will help determine the amount of any shared savings to be paid to an ACO.  One domain, patient experience of care, links up nicely with the patient-centeredness threshhold requirement noted above.  (For private sector attention to patient experience, see what the Leapfrog Group is doing in this domain, using some of the same measures.)  While some may bristle at the number of metrics, it is worth noting that these metrics are all drawn from existing sets of measures.

8.    All in all, the regulations represent the first stage of realizing the ACO vision expressed by Don Berwick last fall: there is a field open to experimentation (albeit a field likely limited to large networks of significant means that can underwrite the up-front infrastructure costs), and the ACO rules sketched out in the statute and further delineated in the regulations will enable CMS to incentivize the provider community to help achieve the triple aim of better care for individuals, better health for populations and reduced per-capita costs.  

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 06, 2011

Accountable Care Organizations: The Emperor Has No Clothes, Or, Jeff Goldsmith's Plan B

The current all-ACO issue of Health Affairs includes a piece by Jeff Goldsmith entitled: Accountable Care Organizations: The Case For Flexible Partnerships Between Health Plans And Providers.  It is a proposal for how private sector health plans ought to pay for services, in order to save us all from what Goldsmith sees happening in the near future thanks to the Gold Rush mentality among health care provider organizations working to become ACOs before they've been defined in regulation. 

He begins with a précis of how we've gotten into the health care market mess we're in, touching on the concentration of market power in horizontally and vertically integrated health care provider organizations, payors and providers mudwrestling over fee-for-service reimbursement rates, and the rise of the large specialty group and the growing bifurcation of in-hospital and out-of-hospital medical practice into two largely separate populations of doctors.  (He appears to be unmoved by the limited, but significant successes of some CMS demonstration projects in improving quality and reducing cost.)  He then turns to the panacea du jour, the ACO, and finds it wanting.  While one may quibble with some details, his indictment of the ACO model for Medicare is fairly convincing.  A product of the usual sausage-making approach to legislation, the ACO -- even if workable in its original conception by Fisher and others -- is a health care camel (a horse designed by committee), and Goldsmith finds it unlikely to yield any meaningful net cost savings to share in the near term.  I, for one, believe that physicians could exert greater influence within an ACO than Goldsmith would allow; while the bulk of health care costs are, as he notes, hospital-based, the most expensive piece of medical equipment is still the ordering physician's pen (or, these days, perhaps her iPad).  Still, offering providers an upside without exposing them to a downside doesn't really make them CMS's partners in the cost containment enterprise. 

I would agree that the time and dollar commitment needed to set up a really humming ACO are quite significant. It could take 5 years or so; folks will be able to meet the bare-bones requirements by 2012, once we know what they are, but most provider organizations will still have a lot of work to do to reap the maximum benefit from the new organizational structure, and it is not clear whether or when the shared savings will make that investment pay off on the Medicare side.

Goldsmith notes the likely cost-shifting that will occur in order to make up the Medicare losses, as bulked-up provider organizations negotiate with commercial payors (though I must note that some states -- including the People's Republic of Massachusetts -- and now the federales, are imposing stricter controls on premium hikes for health insurance), and lays out a new approach to payment on the commercial side.  He presents a set of payment and contracting strategies that he suggests should be adopted by all commercial payors, in order to reduce the administrative costs inherent in our current system, which has every provider dealing with the billing and payment idiosyncracies of every payor.  Nice idea but, as they say, that could take an act of Congress.  (Maybe this is the right Congress to roll back the antitrust laws just far enough for payors to do this, but of course it is unlikely that all payors would sign on in any event.)

In brief, Goldsmith recommends risk-adjusted capitation payments for primary care, fee-for-service payments for emergency care and diagnostic physician visits, and bundled severity-adjusted payments for episodes of specialty care.  Primary care would be provided through a patient-centered medical home model, which would likely have a collateral effect of reducing the total volume of emergency care and diagnostic physician visits.  Specialty care would be provided through "specialty care marts," ideally more than one per specialty per market to maintain a little healthy competition.

There is a great deal of merit to this proposal, and in fact, elements of the model are already in place in a number of markets around the country.  At the same time, I don't think that it may be easily and quickly implemented as laid out, for a variety of reasons.

I've worked with specialty "centers of excellence" that function much as the specialty care marts that Goldsmith describes, providing integrated services for bundled payments.  The ones that work well, work well, but the up-front investment in determining severity-adjusted payments, defining episodes of care, contracting the network of providers, and agreeing on clinical protocols is far from trivial.  Furthermore, given the consolidation that has taken place to date, getting a good price may be difficult for payors. 

Patient-centered medical homes exist in many locales, though just through demonstration projects for now, and the philosophy may not be consonant with a capitation-only payment model for primary care.  The core approach of the Patient Centered Primary Care Collaborative (PCPCC) calls for reimbursement for patient care management, for in-office services, for cost avoidance downstream, and for quality.  I believe that some monetary incentive for prevention and quality care must be included; the devil's in the details, but perhaps incentives based on patient panel health status over time rather than solely based on avoided downstream costs could be developed.

In sum, life is not perfect, we have to play the hand we've been dealt, and we've been dealt ACOs.  They will likely be a fact of life for many Medicare beneficiaries this time next year.  Commercial payors are in the habit of glomming onto Medicare payment system innovations, so moving them -- and providers -- in a different direction will be difficult, though it may ultimately be a win-win-win for payors, providers and patients. 

Depending on how flexible the regulatory waivers -- and Don Berwick promised the federales would be very flexible -- CMS may even be able to contract with ACOs in the manner described by Goldsmith.  That could be the real win-win-win scenario.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


October 25, 2010

Connected Health Symposium 2010

I attended the Connected Health Symposium last week in Boston. I enjoyed many of the sessions (sometimes wished I could have attended two simultaneously, though the livetweeting helped on that front), and as usual enjoyed the hallway and exhibit floor conversations too.  As is often the case at conferences these days, I had the opportunity to meet several on-line connections in real life for the first time. 

(I will not attempt to give a comprehensive report of the symposium here; please see the livetweeting archive linked to above and other reports to get a sense of the rest of the event.)

This year's exhibit floor included a diverse mix of distance health tools.  Most striking from my perspective was the fact that most of these tools do one of two things: Enable patient-clinician videoconferencing, or upload data from in-home monitoring devices.  The best of the second category also trigger alerts resulting in emails or PHR/EHR alerts to clinicians if vital signs are out of whack, or phone calls to consumers or their caregivers if, for example, meds aren't taken on time (one company had a pill bottle with a transmitter in the cap that signals when it's opened; another had a Pyxis-like auto-dispenser, that looked like you'd need an engineer -- or a teenager -- to program it).  One tool -- Intel's -- seemed to combine most of these functions, and more, into one platform, but it's barely in beta, with only about 1,000 units out in the real world.

The speakers this year seemed to return again and again to several major themes: (1) Is any particular connected health solution scalable? (2) Who will pay for connected health, or mobile health (mHealth)? and (3) Does it work?

These issues are, of course, interconnected.  With the current ACO (Accountable Care Organization) feeding frenzy, and expectations of health reform's full implementation as background, there was a palpable sense, or hope, that all this health-tech-geeky goodness will be snapped up by the ultimate payors for health care. 

Who the ultimate payors are depends on your vision of the future.  Is it health care providers, who will be squeezed by bundled payment demos and mainstream Medicare payment changes coming down the pike under the Affordable Care Act?  Providers have an incentive to save more money than they'll be losing through payment reform under the ACA (and perhaps even the implementation of the SGR [link is to a post on the subject from over a year ago; Congress still hasn't faced the music]-- the latest "doc fix" is slated to expire after the election and fall in the laps of the lame duck Congress).  Is it health care insurers, who are being squeezed by state regulators?  Consider, for example, the recent Massachusetts experience with the Connector -- the model for state insurance exchanges -- and the governor insisting on limited rate increases, with the dispute ending up in court.  Is it premium-paying or self-insured employers?  Is it consumers, or patients?

In addition, the future of ACOs and the rest of health reform implementation is a little unssettled, to say the least.  The law has been thrown to the courts in a series of constitutional challenges, and will be thrown to a new Congress in January.  So even if an investment in some of these systems could eliminate a significant chunk of a physician practice's overhead expense, who's going to invest those up-front dollars right now?

Some of the pricey hi-tech solutions raise my perennial question as well: How many childhood vaccines could we buy with that money?  Roni Zeiger of Google Health tweeted a similar comment attributed to Bill Gates during a presentation on genome sequencing: "I'll get my genome sequenced after we cure the top 20 infectious diseases."

In short, there is recognition that some connected health tools can have a positive impact on health status of individuals and populations, but the key questions center on the cost-effectiveness of those interventions.

One speaker, B.J. Fogg, of the Standford Persuasive Technology Lab, said: "Many crummy trials beat deep thinking," encouraging folks to continue to throw stuff against the wall and see what sticks.  I would take issue with this approach.  For example, the home monitoring devices I described above only upload data to their own proprietary software.  Only one vendor (Intel) seemed to be close to designing an interoperable interface to standard PHRs.  It seems to me that this is a key feature of any such system, and the sooner the vendors adopt this thinking, the sooner they will be able to demonstrate the utility of their products and grow their markets.

On the "Does it work?" front, many speakers addressed the issue of behavior change.  All of the tools discussed at the symposium are, in essence, intended to make change in personal behaviors easier to accomplish.  While much of the behavior change discussion was laced with paternalism, it had, at its core, a remarkable patient-centered orientation.  This orientation was emphasized by a discussion on process and outcome measures of the future, to be used as a means for calculating incentive payments to health care providers.  One speaker insisted that the most useful measures will be patient-centric measures: patient satisfaction, patient compliance, etc.  The difficulty lies in reaching the point where patient and consumer behavior is being changed appropriately. 

This raises the question: How do we reach consumers?  What incentives will people resond to?  What options do we need to present to individuals, and how?

Sheena Iyengar delivered a terrific keynote on choice, making the point that in our society we have too many choices -- about everything: breakfast cereal to jam to mutual funds in our retirement plans to Medicare Part D plans.  Research shows that the optimal number of choices to lay out before human beings is 7+2, and that more choice results in no choice at all being made -- no mutual funds selected for retirement, no Medicare drug supplement plan selected to help with prescription medication costs.

Kevin Volpp, from the UPenn Leonard Davis Institute Center for Health Incentives, spoke about how we do, and can, incentivize healthy behaviors, noting that many accepted approaches are shown through research to be ineffective -- e.g., posting calorie counts on menus, CDHPs, reducing copays.  One interesting positive note: lotteries can improve compliance with healthy behaviors in a cost-effective manner.  Volpp gave a compelling example of a medication compliance study that increased compliance by giving compliant patients the chance to win money in a lottery if they took their meds.

Overall, there was consensus that the reason we don't have all the latest tech available in service of health care is that the economic model for health care in this country is broken, thanks to skewed incentives based on the fee for service model.

To me that seems to be too facile an excuse, explaining only the failure of health care providers to adopt these tools on their own initiative.  Gary Gottlieb, CEO of Partners Healthcare addressed one plenary session and emphasized that the work of the folks in the room was critical to the success of Partners -- precisely because of the cost-saving potential of the solutions at various stages of development.  This is of critical importance to Partners as it seeks to prepare for success as an ACO and, more broadly, for success in a market less willing to see things its way than in the past.

Ultimate payors have always had the incnetive to improve health care processes and outcomes, and they are getting more and more sophisticated about it.  ACO's may be the latest (provider-centric) frame for the discussion, but the (ultimate payor-centric) patient-centered medical home frame has been around for a while, and may even prove to be a key engine for ACO success.

Back to patients. The key to success in transforming health care in this country is patient engagement, so patient-centered care, delivery of information to patients, and the enabling of patient community are the goals that health care providers and their connected health vendors need to focus on.

The concluding presentation from Joe Kvedar demonstrated that patients are more likely than we may expect to prefer interacting with computers vs. people in certain circumstances.  As symposium participants struggled with the challenge of scaling their solutions, this insight provided some comfort.  In an earlier session, Adam Bosworth described his goal for Keas as broader than scaling an individual solution.  He hopes to have his company's service act as a platform for other developers' applications -- creating an ecosystem for health apps benefiting individuals and underwritten by the ultimate payors for health care (in Keas' case, employers).

Scaling, payment, utility -- several of the challenges lined up opposite the connected health community.

All in all, this year's Connected Health Symposium showed that the potential exists for (lower case) meaningful use of a whole heck of a lot of tools and toys.  The challenge is to execute on this potential.   

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

March 16, 2010

David Harlow quoted on Electronic Health Records implementation and incentives in Mass. Medical Law Report

Just a few days before the comment period closed on the draft regulations defining meaningful use (see all meaningful use comments), the Massachusetts Medical Law Report ran a piece on the HITECH Act incentives for implementation of electronic health records systems, quoting me and a couple other usual suspects.  I highlighted some shortcomings in the proposed rule, and also noted that health care providers need to be implementing EHRs not just for the stimulus kicker ... that alone is not worth it:

[T]he regulation calls for all physicians to use e-prescribing 75 percent of the time by 2012.

David Harlow, a Newton-based lawyer and health care consultant, said that this won’t be an easy task, noting that Massachusetts is considered a leader in e-prescribing even though only 10 percent of prescriptions are submitted electronically.

At the same time, other benchmarks seem pointless in light of what many physicians – especially specialists – do on a regular basis, Harlow said.

He referred to a requirement that electronic reminders for preventative care and follow-up be sent to at least 50 percent of all patients age 50 or older.

“Why would, say, an orthopedic surgeon be sending out reminders based on age?” he asked. “That’s really geared toward primary care, yet it’s a measure that’s required in order to get an incentive payment.”

. . . 

Harlow warns that a physician practice should not even attempt to roll out an EHR system if the physicians are only in it for the incentive payments. Though an effective system should ultimately start paying for itself through the internal office efficiencies it creates, a $44,000 maximum incentive payment won’t cover the implementation costs.

On the positive side, there are certainly reasons for moving forward with EHR implementation -- as you can read (or hear) in my recent interview with Partners Health Care CIO John Glaser -- though not all health care providers are able to absorb the costs as Partners can.  In the long run, however, there are certainly many strong arguments on a variety of fronts about the value of EHRs.  I heard some of those arguments this morning from folks in the patient-centered medical home camp who I saw at a Mass. Technology Leadership Council event -- including Paul Grundy, patient-centered medical home evangelist from IBM, who I interviewed last year.  Time will tell whether the widespread adoption of EHRs will truly fulfill their promise, but we are certainly well on our way to finding out. 

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

October 26, 2009

Connected Health Symposium 2009 Wrap-up

I attended the Connected Health Symposium last week in Boston and got a healthy dose of the past, present and future in health care connectivity, connectedness and connections.  As always, I enjoyed connecting in person with a whole host of folks I know online -- including those who know my twitter handle, @healthblawg, better than my name.

The conference was kicked off by Stuart Altman, who regaled us with tales of his days with the Nixon Administration, and made a couple of key points:

  • The health care spending crisis is cased by rising prices, not rising utilization
  • Any federal health insurance reform will cause cost-shifting to the privately insured, the states, the young
  • Therefore the key to successful reform lies in reforming the payment system as well as the delivery system; otherwise we're "trying to grow flowers in a toxic environment."
  • Value-based purchasing (P4P), gainsharing, global payments are reasonable options for payment reform
  • Incentives for providers to use home-based systems will help heal the system at large, and promote connected health, which in turn promotes quality and efficiency
(But n.b.: while remote monitoring and home care will improve quality and reduce cost overall, it is not necessarily cost-effective for every patient.)
The conference closed the next afternoon with the official launch of the Journal of Participatory Medicine, presented to the group by members of the editorial board, re-emphasizing the need expressed in the intervening two days of sessions for clinicians to include patients in all aspects of managing their own care.  (On this theme, see the JOPM kickoff on-line conference from earlier in the week, including e-Patient Dave's webcast How Great EHRs Empower Participatory Medicine; free registration required). 

In between these two sessions, we heard from a wide range of speakers, panelist and vendors.  I offer here an idiosyncratic sampling of some of the many overlapping sessions.  (Please see the archived tweetstream from the conference, a couple of audio recordings of panel discussions on EHRs and PHRs, and please post links to other blog posts about the conference in comments below.) 

Ed Markey, via videolink from DC, preached to the converted that the health care system needs CPR - connectivity, privacy and research (as the Center for Connected Health's Director, Joe Kvedar, tweeted, Markey has a terrific speechwriter).  Markey has been delivering, having had a hand in building the national broadband network from his seat on the telecom committee, and in beefing up HIT privacy and security in the HITECH Act.

Jim Mongan, CEO of Partners, made the poignant comment that liberty, on the one hand, and justice for all, on the other hand, may be at odds with each other, and the unsurprising comment (from his perch atop a large IDS)  that large IDS's are the way to go.

"It's the Network." Verizon's Rajeem Kapoor pitched his company's big entry into health care connectivity, noting that of 100,000 preventable errors per year in the US, 20% are due to the lack of immediate access to patient data.

A recurring theme: health care plans are designed by negotiation between payors and providers ... they need to include patients

Tom Lee, also from Partners, said that payors and providers are engaged in co-evolution, and that they need to work together or else chaos will result.  Lee also said: Global payment isn't about bending the cost curve, it's about enhancing value -- a different perspective than Altman's, but not unexpected from a large delivery system representative.  The "alternative contract" offered by Blue Cross Blue Shield of Massachusetts is a global payment contract with risk adjustments, quality bonuses, and other bells and whistles, per Andrew Dreyfus (from BCBSMA) designed to fairly compensate and avoid perverse incentives for providers.  The global payment system to be rolled out in Massachusetts over the next five years (maybe) is intended to separate insurance risk (not to be passed onto providers as it was in capitation's bad old days) and performance risk, or quality risk, which lies appropriately with the providers.

Since the current health care system is straddling the past and future, fee for service reimbursement in an age where a more holistic approach to care is recognized as preferred, Partners is paying physicians participating in a medical-home-like program a management fee to replace some of the lost FFS income.  A panel on patient incentives yielded the observations that silos within health insurance companies lead to irrational decisions: a cost to one division could yield a many-times-larger savings to another division, but the first has no incentive to incur that cost.

In a panel discussion called The Futurists, Jay Sanders of WellDoc said we need to bring the exam room to where the patient is, and to personalize medicine (i.e., normal for me is not normal for you).  Roy Schoenberg of American Well described his company's next step, plans to allow PCPs to bring specialists into the in-person patient visit; he also cited a Gartner prediction: By 2013, 25% of all health care encounters that can happen virtually, will.  We also heard about implantable wireless sensors that will be able to transmit a stream of data and household robots from Microsoft. 

In an interesting back-to-the-future answer to the question: What's the killer app? we heard this answer from Paul Williamson of Cambridge Consultants: Family-provided, wireless-enabled care.  This vision of the future was echoed later in the day by Joe Kvedar, who posited as an ideal a world in which the patient coordinates self-managed care with a clinician as coach and an employer as enabler.  A related recurring theme: The need to move to more of a team approach to care.

Some of the toys in the exhibit hall (some called it vaporware) seemed more geared to the futurists (e.g., Intel's offering, a wired home hub for communication among providers, case managers, family members and patients, now being put through its paces in a few demos), but some are ready to go now, sporting tags signifying their compliance with Continua connectivity standards (the Continua Alliance is a standards organization jump-started by Joe Ternullo, assistant director of the Center for Connected Health, who, along with director Joe Kvedar and the Center's staff, put on a terrific conference) -- and some are positively old warhorses already in widespread use, like Honeywell's offering, with interfaces for automated home monitoring and communication of data directly into interoperable EHRs or standalone software.
The Myca/HelloHealth presentation highlighted the robustness of the Myca platform (employee health programs -- Qualcomm was featured at length; are there others?), medical home programs for small physician practices with "fractional use" of physician extenders -- a new twist on the Vermont and South Carolina medical home pilots), PHR integration already there or on the way, lab results integration coming soon (Quest); reiterated the slow rollout of HelloHealth (12 practices so far); and demonstrated (in part via BCBS Ventures' investment in the company) that Jay Parkinson & Co. may not be able to put as much space between themselves and third-party payors as they may like.  (This issue is not limited to HelloHealth, of course; the retail clinic sector, also founded on the premise of dissociation from third-party payors, has had to retrench; and some of the speakers also pointed to insurance companies as players not to be overlooked, due to the Willie Sutton factor . . . that's where the money is.)

Linda Magno, head of demonstration projects at CMS highlighted experiences with some demos and shared the podium with a couple of physician demo sites.  Key takeway from her presentation was that payors (beyond government payors) are just not willing to pay more for improved quality.  (Putting the Medicare managed care program / fiasco in the best possible light, her comment is consistent with the dismantling of that program, which pays higher prices, theoretically in exchange for more comprehensive care, because it was costing more than traditional FFS Medicare.)

Mark Bard, of Manhattan Research, shared some of his data re: physician internet use (doubled on-line work hours in past five years, and 2/3 of docs use smartphones in their practices -- using apps 15-20 times a day), and patient use of "Health 2.0" tools (doubled to 80 million in past two years).  This demonstrates that moving health care to the cloud will not leave all providers and patients behind. 

More than one speaker concluded that we need to subsidize healthy choices as well as tax unhealthy ones (e.g., tax the Big Mac and subsidize the salad). 

John Halamka and John Glaser presented interesting personal counterpoint on the issue of changing behavior, Halamka saying he easily chose diet and exercise over putting "poison" (Lipitor) into his body, Glaser saying he went for the stent and still enjoys his hamburgers.

Other keynoters:

Nicholas Christakis (looking at obesity as a social network epidemic, using Framingham Heart Study data - see NY Times magazine treatment), offered a couple of terrific analogies: First, carbon makes coal, graphite and diamonds - the difference depends on the interconnections between carbon atoms.  Second, the form of the network yields its function: are you finding the mastodon, or killing the mastodon?  As Christakis was winding down, I tweeted: "Unanswered Q: How do we design health care interventions to leverage IRL social networks?"  The immediate, slightly tongue-in-cheek, response from @cascadia (Sherry Reynolds), tweeting from the Pacific Northwest: "Ask women with actual friends."

Jason Hwang (co-author of The Innovator's Prescription, applying principles of disruptive innovation to health care) spoke about technology as enabling decentralization in health care as in other industries, through commoditization of historically valuable and expensive expertise, and the need to replace the hospital-centric model with new types of networks.  This shift is already under way, of course.

Bottom line: Given the crushing cost of hospital-based health care services, the current and growing primary care physician shortage, and the expectation of high-quality health care services accessible to all, the Center for Connected Health is letting us all know that the road to the future is the information superhighway, paved with intelligent payment reforms -- but that the nodes in the network will always be human beings.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

October 05, 2009

Massachusetts health care payment reform hearings set to begin this week

For the health wonk going through legislative hearing withdrawal now that the Senate Finance Committee has wrapped up hearings on its bill, there is hope: The Massachusetts legislature will turn to global payment legislation later this week. 

The Massachusetts health reform legislation enacted last year tasked a special commission with coming up with a recommendation on payment reform (earlier health reform legislation brought near-universal coverage to Massachusetts but did not directly address cost or quality), the commission issued its report over the summer, and legislation based on its recommendations is now coming up for hearing.  The press release accompanying the July 2009 report of the Special Commission on the Health Care Payment System reads in part as follows:

The Commission recommended phasing in a global payment system statewide over five years and anticipates that, when fully implemented, global payments in Massachusetts would include the following key features:
  • A global payment system in which providers would receive a payment per person, adjusted for patients' health status and other factors to ensure that they are compensated fairly for their patients' health care needs.  Payments would also be based on meeting common core performance measures to ensure high quality care.
  • An emphasis on patient-centered medicine, with doctors and other providers providing coordinated, evidence-based, high-quality care for patients.  In addition to providing more effective care for patients, this approach will also help to reduce health care costs in the longer term.
  • A careful transition to global payment within five years, during which "shared savings" would serve as an interim payment model to help some providers become more familiar with global payment with no or reduced exposure to risk.  There would also be infrastructure support for providers to facilitate the transition to global payments, including technical assistance and training and information technology. 

Lynn Nicholas, Executive Director of the Massachusetts Hospital Association, served on the Commission and voted in favor of the recommendations, with the caveat that implementation had to be examined more closely.  This week, Nicholas highlighted several areas of concern that MHA membership would like to see addressed in legislation, and suggested that five years would not be enough time to design and fully phase in the new payment system.  The Boston Globe reports:

The hospital association wants legislators to include health care providers on the oversight board; shield providers from financial risks they can’t control and don’t have reserves to cover, such as a swine flu outbreak; change insurance plans so that patients are encouraged to stay within their accountable care organizations for all of their medical needs; provide extra compensation for providers who treat low-income patients and for teaching hospitals that have extra costs associated with training residents, research, and 24-hour trauma services; and offer incentives for providers to jump in and test the global payment system.

The full report linked to above is worth reading.  It lays out an approach to paying for health care services that could potentially "bend the cost curve" and improve quality -- and not by simply paying providers less to do more.  The idea is to pay providers for the services to be used by patients -- not to saddle providers with "insurance risk."  Providers do, however, have "performance risk."  In other words, the providers are held to a standard of quality.  For example, a preventable hospital readmission does not generate another payment if it was within the provider's power to prevent the readmission.  There's a great deal more packed into the report and, as always, the devil's in the details.

The reaction of the provider community is both unsurprising and surprising.  On the one hand, it is natural to seek to prolong the life of what is perceived as a more beneficial reimbursement scheme for as long as possible.  On the other hand, I would expect to see hospitals and other health care providers, as a group, working proactively to implement new systems and approaches, including for example the medical home.  Why?  Because significant -- if not radical -- change is inevitable, and providers and "accountable care organizations" that are ahead of the curve will be well-positioned to benefit from the changes to come.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting