The Affordable Care Act: Day 3 at SCOTUS

By Gregg A. Masters, MPH

It’s deja vu all over again!

The theater circa 2010 at the Senate Finance Committee via the reconciliation process that delivered unto us the Patient Protection and Affordable Care Act, the framework enabling the accountable care industry, is in play again this time at the Supreme Court of the United States (SCOTUS).

[Editor’s note: For a comprehensive and politically agnostic resource c/o @CSPAN, click here].

Day 1 dealt with the Anti Injunction Act (AIA), an arcane Federal law that would have deferred consideration of the constitutionality of ACA, was both interesting and curious in substance and contribution to ‘sentiment meter’ of the individual justices.

Day 2 took a rather problematic turn, at least for those who favor the Act (a long list of supporters) vs. Florida AG Clement, et al , who are determined to ‘restrain’ the relationship between the Federal Government and the people via at times simple minded bright lines of markets v. commerce inherent in the intent of the ‘commerce clause’. Many pundits concluded the Solicitor General arguing the Government’s position grossly mismanaged the message, and lost control of a compelling narrative during his argument and subsequent lively questioning by the court.

Now comes the finale, Day 3, with the focus on the question of ‘severability’ of the individual mandate. While a rather boiler plate clause typical of most contracts, the severability of the mandate alone (in whole or part) vs. the Act in it’s entirety, is the question before the court. The omission is a rather curious fact in it’s own right, and will no doubt be grist for the ‘Congressional intent mill’.

I’ve drawn a line between the process associated with the passage of the Act as it played out via the theater of the Senate Finance Committee hearing in 2010. Apparently, I am not alone as reported this week by Bloomberg 75% of the public believe politics vs. merits will drive the consideration process:

So yes, here we go again. This law has had a hard time in the public sphere, see Pew piece ‘Public Remains Split on Health Care Bill, Opposed to Mandate‘, mostly misunderstood in the aggregate due to its complexity, yet embraced when you consider it’s line item nature, i.e., eliminating benefit caps, pre-existing conditions, requiring a minimum of medical loss ratio of 80%, extending dependent care coverage up to the age of 26, the establishment of health insurance exchanges to assist in the standardization, evaluation and purchase of health insurance plans, an oversight role of the unrestrained nature of the individual insurance market and more.

Today’s proceedings will add content to the odds makers and pundits’ calls on which way the court will decide. For a setup piece, watch this clip from the Wall Street Journal:

For audio analysis of the proceedings to date, check out the higlights from SCOTUSblog here.

SCOTUS and the ACA: Day 1

By Gregg A. Masters, MPH

Perhaps the hearing of the new century thus far? The Supreme Court of the United States takes up the challenges submitted with respect to the Patient Protection and Affordable Care Act.

From the social media ‘journalism domain’, two hashtags received the predominant volume of tweets tagged to the event; they include: #SCOTUS, and #ACAhearings (both are partial digital footprints representing the last 50 tweets only, including the accounts reached and impressions generated).

For complete realtime coverage collapsing both #ACAhearings and #SCOTUS hashtags, click here.

Several blogs were tweeting contemporaneous commentary on the proceeding, two notable sources include:

The Wall Street Journal and the SCOTUSblog.

With some color and tea leaves interpretation, check out Dr. Jaan Sidorov’s blog for the bi-partisan common theme extraction on The Disease Management Blog via ‘Showdown at the SCOTUS Corral‘.

Useful context pieces include:

For those of you healthwonk junkies, C-Span is airing the replay of the event here (check for schedule).

Finally, the complete transcript from Day 1 is available here.

ACO Deep Dive Session at this Year’s Health Datapalooza

By Gregg A. Masters, MPH

This just in from the Centers for Medicare and Medicaid Innovation and HDI Forum III:

The CMS Innovation Center is helping plan one session of this two-day event. An ACO “deep dive” will demonstrate how Accountable Care Organizations can make effective use of claims data through innovative software services and analytics. Surgeon and author Atul Gwande will be leading a discussion between the audience and a diverse set of stakeholders from data analysts to a number of the Pioneer ACOs.

‘This year’s event will feature keynote addresses and panels, breakout sessions, apps demos and action beat announcements. Make sure you stop by the Data & Apps Expo to talk with data producers and the developers that use that data to create innovative tools and services to improve the health of individuals and communities. See an overview of the agenda below, and click through to find a detailed schedule of the events on Day 1 and Day 2.’

Thought leader and major disruptor of the health plan gene pool, Mark T. Bertolini, (aka @mtbert), Chairman, CEO & President, Aetna aka, @Aetna, to deliver Day 1 keynote address.

Welcome and opening remarks:

Matt Miller, aka @mattMillerNow, Host, “Left, Right & Center,” NPR (moderator)
Bob Kocher, aka @BobKocher Partner, Venrock (HDI Forum III Co-Chair)
Dick Foster, Venture Partner, Lux Capital (HDI Forum III Co-Chair)

For complete program details, click here.

Aetna teams with Hoag Orthopedic on bundled payment initiative

By Gregg A. Masters, MPH

Leveraging up from the Integrated Healthcare Association’s (IHA) work (and others) in the bundled payment domain, @Aetna announced yesterday that in association with partner health information technology vendor @McKesson_HIT, their work with Hoag Orthopedic Hospital (aka @HoagOrthopedic) in Newport Beach, California.

Bundled payment a child of the DRG payment system and long employed in service of managed care contracts for select high cost services including cardiovascular and orthopedic surgeries, holds promise to reduce costs, while promoting quality, patient safety and integrated care. Perhaps one of the least controversial elements of the Patient Protection and Affordable Care Act, an expanded bundled payment model is clearly in service of the Triple Aim (better care, better health, lower cost).

Per IHA:

according to one estimate [the bundled payment model], could reduce U.S. health expenditures as much as $300 billion between 2010 and 2020

For the complete announcement, click here.

They Shoot Horses’ Don’t They?

By Gregg A. Masters, MPH

Some may remember the movie ‘They Shoot Horses’ Don’t They‘ [caution: a rather graphic depiction of an exit]. The plot borrowing from the humane ‘taking them out of their misery’ [post injury] if you will, albeit in the context of certain determined dance partners ‘desperate to win a Depression-era dance marathon and the opportunistic MC who urges them on to victory’, strikes a contemporary cord.

Some might extend this desperation metaphor to our rather creatively change resistent healthcare industry, aka ‘healthcare conundrum‘, given decades of serial failure [or success depending upon your interest]. Yet, with Dr. Eric Topol’s recent publishing of ‘The Creative Destruction of Medicine‘ where among his many insights, he acknowledges with the weight of history on his side that:

innovation must come from outside the profession [of medicine].

Fast forward the frame and consider where we are in the health reform, re-design or collective business model or technology leveraged innovation theater. At best it’s a mixed bag of industry voices, direction and results. The first series of ‘tea leaves’ can be traced to the consideration process (aka theater} over the Patient Protection and Affordable Care Act afforded by the Senate Finance Committee hearing process. An excruciatingly painful event to witness, yet the battle lines where being drawn at that time.

Next came the release of the ‘Notice of Proposed Rule Making’ to implement the broad brush provisions in the Act (yes, it passed over the wishes of the ‘Hatch Enzi Gang of 42) specific to Accountable Care Organizations’. While some 1,300 comments where filed by healthcare industry stakeholders [can you imagine a more iterative public/private exchange?], the rule was then finalized incorporating many of the substantive objections submitted to CMS. Yet, even with the ‘adjustments’ to the proposed rule, the fact that AMGA, arguably one of the centers of excellence in medical group consciousness and therefore coordinated care delivery, remained on the sidelines was a puzzling and somewhat disturbing turn of events.

So here we are. The Supreme Court (see briefs here) is about to take on the series of constitutional questions posed with respect to the Act. None directly speak to the provisions of ACOs per se, other than the underwriting implications of undoing the mandate, we remain in a very much bi-furcated, if not divided reform minded community.

Yet whether the Act is struck down in part or whole, the horse [no pun intended] is out of the barn. The only question which remains, who will lead and from what ‘book of business’ or marketplace vantage point? Judging from activity in the private (commercial) market where announcements of payor/provider partnerships are announced seemingly with regularity, it’s pretty clear that whether the codified rules on Medicare ACOs and derivative programs (Pioneer, MSSP, etc.), remain in the custody of legal or regulatory detention or not, the market will march on.

Bundled Payment: A Gateway to Accountable Care?

By Gregg A. Masters, MPH

Advisory Board senior consultant and talented speaker (I might add), recently penned a blog post titled: ‘Bundled Payment: A Stepping Stone for ACO’s? I Don’t Buy It.’ I read this well constructed piece, but came to a rather different conclusion.

In his set up Rob posits:

As I have previously written, hospitals can realize a range of strategic benefits by developing carefully crafted bundled payment programs. And for many leaders who want to begin experimenting with new payment models, bundling presents an attractive entrance into the accountable care landscape, enabling innovation without fundamentally disrupting the current hospital business model. As they think about longer-term accountable care strategy, many of these leaders also assume that bundling offers a helpful foundation for ultimately becoming ACOs.

Then pivots to:

Unfortunately, I do not buy the argument that bundling provides a stepping-stone for ACO development. I certainly understand the genesis of the argument: line up all of the emerging payment models by degree of financial risk and assume a linear evolution from pay-for-performance to bundled payment to shared savings or capitated models. I even admit there are some areas of overlap across models, such as focus on readmission reduction, but closer comparison reveals that bundled payment and the shared savings model have fundamental differences. There are still plenty of valid reasons to explore bundling—but preparing to become an ACO is not on my list.

Using the same math plus decades in the managed healthcare industry contracting for hospitals, health systems, medical groups, physician networks and health plans including setting up IPAs, PHOs, and MSO infrastructure leads me to the opposite conclusion.

The point is not to contrast and compare indicia of bundled payment to probable elements of ACO compensation arrangements from ‘risk lite’ to global capitation, but rather to understand the compelling case for engagement of stakeholder physicians in the consideration process. To say this journey is a rather complex and high risk transformation to enable let alone discuss is an understatement. Yet, the opportunity to grasp and develop a complete understanding of the dynamics of bundled payment, and its impact on traditional practice arrangements is unquestionably a critical path in the journey to accountable care or an ACO.

Without a doubt, the ability to understand and process how bundled payment (as a proxy for the volume to value shift) will impact medical and surgical specialties especially hospital based physicians (under any ACO scenario) are high impact opportunities to co-create the culture and values essential to birth a successful enterprise.

The likely impact on hospital based physicians will be dramatic. Bundled payment will drive consolidation of minimally the traditional hospital based ‘franchises’ of radiology, pathology, anesthesiology and emergency medicine. Historical silos with little incentive to collaborate will likely be pulled into conversations as to equity of allocation of payment, let alone the ability to receive and distribute. How will that go over? When physician peers are put in the position of deciding the value of certain services in relation to the level of effort contributed we will witness a whole new ball game in the ‘input’ (pricing) domain.

Bottom-line, bundled payment is an essential part of the accountable care if not ACO conversation. It is an opportunity not to be avoided. Bridge the divide!

A 6th Difference Between ACOs and “AC-Like” Arrangements

By Vince Kuraitis

The post originally appeared on the e-caremanagement blog.

Last week I wrote about five key differences between formal ACOs (mainly care providers contracting with Medicare)  and informal Accountable Care-Like (AC-Like) arrangements between care providers and commercial health plans.

  1. Transaction costs
  2. Timing
  3. Incrementalism
  4. Flexibility
  5. Capital cost

There’s an important  6th  difference worth noting:

Visibility

Elephants

Formal ACOs will be visible from miles away — think elephants on the Serengeti.

An ACO that wants to contract with Medicare must establish itself as a corporation. The Medicare ACO models have substantial disclosure and reporting requirements. We won’t know everything about formal ACOs, but we will know a lot. ACOs cannot hide.

Chameleon

AC-Like arrangements between care providers and commercial payers could be much more difficult to spot and categorize — think chameleons in the jungle.

These informal AC-Like arrangements can be made through private contracts — therefore not necessarily publicly identifiable. Some AC-Like arrangements have been visible and have been announced with press releases and confetti — but it’s also forseeable that there will be circumstances where deals will be quietly negotiated without fanfare.

Chameleons can choose to blend in, or they can change their colors.

Physicians Surveyed Gloomy About Healthcare Reform

By Patricia Salber

Editor’s Note: Article originally published at The Doctor Weighs In.

Recently, The Doctors Company, aka @doctorscompany, the country’s largest insurer of physician and surgeon medical liability, decided to survey doctors to determine what they are thinking and feeling about health reform.  The results are pretty gloomy.

To put this in context, it is important to understand a bit about how TDC conducted the survey.  First of all, the universe of doctors they reached out to were doctors insured by The Doctors Company.  That means large self-insured medical groups, such as those affiliated with Kaiser Permanente, were not included.  Nor were doctors whose insurance was provided by their employers or doctors using other insurance carriers.  This matters because if the TDC insured physicians are not representative of doctors as a whole, the results of this survey would not necessarily reflect the attitudes of all doctors.

TDC provides insurance to 71,000 of the country’s ~700,000 physicians, or about 10%.  According to Dave Troxel, MD, TDC’s Chief Medical Officer, the survey was initially sent to ~36,000  practices that had 15 doctors or less – so doctors choosing to practice in larger groups were not included.  A second mailing went out to the initial group plus ~14,000 additional larger practices (>15 doctors in the group).

More than 5,000 of these doctors filled out and returned the survey.  80% of the respondents of the respondents were male.  This is somewhat higher than the percent of males found in a 2008 study of physicians conducted by the AAMC (72% male vs. 28% female).  And, it is substantially different from the characteristics of the youngest doctors (residents and fellows) who are 55% male and 45% female.  77% of the TDC respondents were 51 or older.  The AAMC survey found 37% of doctors were 55 or older.  So keeping in mind that the TDC respondents are little grayer and more male than the population of US physicians in general, let’s take a look at what the survey showed.

 The times they are a changin’

As health reform begins to roll out, you would think change would be the name of the game.  There are new practice models and payment mechanisms being proposed, such as accountable care organizations and bundled payments, that will be different from the traditional fee-for-service, volume-driven practice of medicine.  However, only 14% of the surveyed doctors reported they were planning to shift their practice model.  Fifty-six percent said they do not plan to change models in the next 5 years.

For all those folks (like me) out there hoping to help practices transform to accountable care in the next few years the implications are obvious.  In fact, only 14% of survey respondents had plans to participate in an ACO.  Comments in this section were interesting, one North Carolina PCP said “ACOs will destroy private practices and raise the cost of health care without improving health.” A surgeon in Michigan opined that “ACOs are nothing but a marketing gimmick” and another in Virginia said “Binding care to hospital in ‘ACO’ is the most expensive way to give care.”  It was a relief, to me anyway, to see that 57% of doctors are either undecided or need more information regarding ACO participation.  One docs summed it up by saying, “What IS an ACO?” Have you ever seen one?” [Does that mean there is hope for ACOs yet?]

Planned participation in patient-centered medical homes was also low.  Only 10% said they planned to embrace this model and 51% were either undecided or needed more information.   39% said they do not plan to participate.  One California PCP stated bluntly that “medical home will not lower the cost of health care” and a Montana-based specialist offered, “Insurance companies must spend a higher percentage of revenue on medical care.  Rather than pay doctors more, they are building patient centered medical homes.”

Physicians do think there will be a shift from smaller groups (solos or two- to three person practices) to larger groups.  This should not be a surprise as, according to Dr. Troxel, small group practices have been disappearing at a rate of about 3% per year for a number of years.  The biggest change reported in the TDC survey was from solo to a larger type of practice (56%) with 30% being from solo to small group and 10% being from solo to hospital practice.

Other interesting findings in this survey are as follows:

  • 44% either have an EHR or are planning to implement on in the next three years (thank you Meaningful Use).
  • 17% have no plans to use an EHR – per Dr. Troxel, one-half of these doctors plan to retire in the next five years.
  • Doctors are still focused on defensive medicine; 65% of those who responded to the survey said that they do not think health care reform will reduce defensive medicine. [This part of the survey contained an interesting comment from a nonsurgical specialist in New Mexico:  “We all practice very expensive defensive medicine.  I realize I order between 5-15 unnecessary MRIs, maybe 2-3 specialist consults, maybe some unnecessary lab test weekly to prevent lawsuits.”]
  • Fully 60% of respondents believe that health care reform will negatively affect patient care.  Comments included “too much interference with patient care”, “without private practice, quality of patient care or choices for patients goes away,” and “physicians have no input/control in providing care.”
  • 22% of respondents, however, were optimistic about health care reform.  Their comments were much more egalitarian, including “far better, more patients can have health care,” “patients are no longer being denied insurance for pre-existing condition” and “better availability and awareness of preventive care measures.”  One doc noted that it “allowed my children to continue to have insurance as college students.”
  • More than half of doctors surveyed believe that increased bureaucracy is reducing the personal interaction with patient essential for building a close relationship and understanding the nature of patient health.
  • But the question that really got these doctors on the same page was this:  How will health care reform impact your earnings over the next five years?  Almost 80% said ‘negatively’ or ‘strongly negatively.’  A PCP from Ohio commented “dropping reimbursements and increasing ‘mandates’ will drive physicians out-of-practice…and quality of care will drop.  There will be no one I trust to take care of me.”
  • So what to do?  Well 43% of respondents said they would retire over the next five years.  Of course, the docs most likely to retire were the older ones who may have retired within 5 years anyway, however, it is of note that 63% of those in the 51-60 age range indicated they were looking to retire in that time frame as well.
  • And most damning of all was the answer to the final question:  Would you recommend health care as a profession?  Nine out of ten responding physicians said no.  One commenting, “I am a third generation physician and have actively discouraged my son from pursuing a career in medicine…” another putting forth that he “would not recommend becoming an MD to anyone.”

As health care undergoes what feels to me like the most rapid change at any time in the last 20-30 years, it should not be a surprise that some physicians – those who entered medicine with the dream of being their own boss of a small independent business – may not want to practice in the brave new world of accountable care organizations, integrated delivery systems, and hospital-owned practices.  It has to be particularly hard if you are just trying to hang in there until you can sell your practice and retire.  This type of change has happened in other professions as well, leaving people bitter and disillusioned at how things played out for them.  Unfortunately, timing is everything

On the bright side of life

We will get through this period of transition and, I believe, emerge with new practice models that are better for patients, better for society, and, in the end, better for the physicians who choose to enter this brave new world of medicine.  So I will close this post by sharing the comments from a handful of the only eleven percent of doctors who responded to the survey by saying that they were likely to recommend the medical profession to their children or other family members in spite of health are reform:

“It is a blessing and privilege to be a doctor.  I am a third generation MD (Surgeon, Pennsylvania)

“It will be a different business model from what we are used to, but I still want to be a physician.” (Surgeon, Tennessee).

And my favorite, from a surgeon in California:

Despite all the bumps in health care, [I] still believe the practice of medicine is a great and rewarding life work!!

To that, I can only add…”me too.”

AMGA 2012: The complete ‘digital footprint’

By Gregg A. Masters, MPH

The synopsis tweeted is pasted below:

Final ‘digital footprint’ for #AMGA12: Reached 66,842 peeps via 273 tweets & an exposure of 638,735 impressions

The trade group arguably representing a majority of forward thinking and innovation oriented, in terms of the active exploration of what and how accountable care business models can be articulated, the AMGA held their annual conference in San Diego from March 7th, – 10th, 2012.

Courtesy of @ePatientDave who was tagged to deliver the closing keynote on Saturday, I had the good fortune to both ‘crash’ the preso, as well as monitor, tweet and re-tweet the action [there are many excellent preso’s which I will bring forward via future posts]. Editors Note: Compared to most other healthcare conferences I attend, the twitter volume was rather thin – much to my surprise, considering the relationship between technology, healthIT and social media.

None-the-less, a ‘digital footprint’ as we say emerged from the event via both the ‘happy fingers’ in the room as well as tweeps out of the room who collectively engaged in the AMGA’s conference proceedings.

For the complete ‘digital footprint’ report, click here.

AMGA12: The ‘half life’ of a conference hashtag

By Gregg A. Masters, MPH

Thanks to fellow healthtweep @PhilBaumann, I learned of another cool ‘infographic’ app to track and display select hashtag metrics posted to Twitter. Below is the infographic created with Visual.ly for the AMGA 2012 Annual Conference tagged #AMGA12:


infographic created with visual.ly