In Pursuit of the Triple Aim: Can Population Health Management Lead the Way?

By Fred Goldstein, MS and Gregg Masters, MPH

Every sector in health care is under pressure to articulate and implement a viable population health initiative that delivers on the triple aim of better health, better quality at a better cost.

Despite a significant investment of resources, we have only achieved ‘mixed results’ to date, and so the industry remains in a continuous learning mode. Although we’ve taken away some insights, we still have a long way to go.

Recently on Pophealth Week, we chatted with the ‘Dean’ of Population Health who spearheaded and continues to steward the nation’s first freestanding College of Population Health at Jefferson University in Philadelphia. David Nash, MD, MBA weighed in on the industry’s evolution — including best practices to emulate —and what near term challenges we are likely to face.

To listen to Dr. Nash’s take, click here, and for additional context checkout ‘The Road From Volume-To-Value: The Pivotal Role of Population Health’.

If you’ve worked in this space – at the strategy or operational level — you know that it can be truly daunting to implement a population health program. This can lead some organizations to shy away from attempting meaningful programs, perhaps even into a copycat ‘me too’ effort. Given the inevitable drive to value-based care, it is a strategic imperative to understand how to build and implement population health initiatives that work.

In its simplest framework, one can think of a population health program in terms of the following components as articulated by the Population Health Alliance Outcomes Guidelines Report Volume 6,  2015.

The steps of the Population Health Framework as shown in the image above include:

  • Identify the population
  • Assess the person for risk(s)
  • Stratify the person into risk levels to target for various interventions
  • Engage the person in a program
  • Intervene with specific services and resources and
  • Measure the process and outcome results

These results are then fed back into the system and the process continued all seeking to improve the overall health of the population.

In Search of Answers

One forum many look to for best practices and key insights is the Population Health Colloquium, now in its 18th year with the Jefferson College of Population Health as academic partner. Scanning this year’s Agenda, one can find presentations in each of the elements above.

Data and Analytics are the essential ingredients of any population health program with intent to identify individuals, assess them for various risks or conditions, stratify them to ensure appropriate levels of intervention and measure a program’s success.

Within the area of assessment, we are moving to an ‘N of 1’ approach given the advances in precision medicine and genomics. This exciting area will be covered at the conference in the mini summit entitled Personalized Medicine, Machine Learning and Genomics: a Clinical Approach to Employer Population Health and Wellbeing.

Payment models and the move to value-based care are among the key levers. Although there have been more than a few stops and starts along the way with the change in administration at the federal level, employers are rapidly embracing these approaches.  There are a number of presentations on this topic, including Journey to Value-Based Care — Experience and Expectations, Accountable Care Atlas: Mapping a Path to Value-Based Care and a Mini Summit ACOs at an Inflection Point: Where the Movement is Headed and Why Some Succeed While Others Don’t.

In the Intervention area, there are presentations covering ‘On the Ground: Population Health initiatives’… and we can’t forget about the patients — they, too, have a strong role to play in these efforts. The Mini Summit, Improving Patient Care and Provider Experience through Population Health Management, is timely and informative.

Community-based programs have become all the rage as we better understand the impact on your health based on where and how you live.  A breakout track entitled Population Health in the Community includes discussions on life expectancy gaps in Chicago; Rural and Urban Issues; and primary care and behavioral health that will address some of the approaches.

The program will feature a session on designing and implementing population health, and of course there will be some incredible keynotes and small panel discussions. The program includes a discussion with two former HHS Secretaries, Tommy Thompson and Michael Leavitt, and baseball great Darryl Strawberry will discuss addiction, a critical issue we are now facing with the opioid crisis.

If you are committed to learning more about Population Health, this meeting is a must. It’s an event where you can learn from experts covering the full breadth of population health services and have an opportunity to network. Whether you choose to travel to Philadelphia or attend via live webinar, please plan to join us and stop by to say hello. We’d love to hear all about what you’re doing in this exciting space.

==##==

This post is sponsored by the Jefferson College of Population Health

Advertisement

The Road From Volume-To-Value: The Pivotal Role of Population Health

By Fred Goldstein, MS and Gregg Masters, MPH

Two macro trends are converging to further season and ultimately catalyze the transformation of the American healthcare enterprise: the predominant fee-for-service model that fuels the provider ecosystem (hospitals, health systems, medical groups, IPAs, ACOs, or managed physician networks, etc.) and their ‘partner’ financing plans, payors or administrators.

Ecosystem incumbents include national or regional commercial health insurers (payors), third party administrators (TPAs) that enable self-funding options for smaller employers unable to access the administrative services only (ASO) market, and the historically volatile ‘individual’ market.  And, no discussion of markets would be complete without considering the wide range of public sector initiatives including Medicare (Medicare Advantage and Accountable Care Organizations or ACOs) and Medicaid’s outsourcing to contract with managed healthcare organizations.

These two trends, seemingly at odds with one another, are on a collision course… and the health of our nation hangs in the balance. The burning platform regarding fee-for-service is commonly seen as driving a seemingly insatiable appetite for ‘more’, giving rise to widespread conversation and supportive health policy advocating ‘value based’ healthcare with an emphasis on quality, outcomes and affordability.

The roadmap to achieving wholesale transformation of our system to focus on health is perhaps best reflected in the emerging science and practice of population health management.

Population health management depends on  business and service delivery provider/financing sector partnerships to achieve a sustainable healthcare ecosystem that enables the ‘triple aim’. Yet, the results of early population health management initiatives nationally are generally mixed, particularly when they neglect to consider the contextual social determinants specific to the target population and community.

In order to achieve that holy grail of improved health outcomes, we must have a clear understanding of the needs and available resources as well as a coordinated plan that includes all the relevant stakeholders.

To avoid the metaphoric outcome once opined by an Eastern Airlines (RIP) pilot emerging from the cockpit to announce to his passengers:

‘well folks, the good news is we’re making great time, the bad news is we have no idea where we’re going…’

The rest is legion for those who recall the death of legacy carrier Eastern.

Finding A True North – Grounding the Science and Best Practices of Population Health Management

The promise of managing populations efficiently and effectively, leading to a healthier overall America is something that just makes sense, whether the push is from the government, payers or providers. Where can one explore the myriad pieces of the population health puzzle to find out what’s working?  Fortunately, the upcoming Eighteenth Population Health Colloquium, March 19-21 in Philadelphia, Pennsylvania can provide some answers.

This conference, chaired by David Nash, MD, MBA, Founding Dean of the College of Population Health at Jefferson, the first such institution in the country, provides the opportunity to hear from and network with some of the biggest names and companies in the field.

Whatever your area of interest — policy, data and analytics, program design and development, provider-based programs and ACOs, payer-based programs, value-based care and contracting, social determinants of health, technologies or even personalized medicine — .  Dr. Nash and his team are bringing together world class leaders and in a right-sized setting that supports interactions with speakers and networking with other attendees.

If you haven’t been to this conference before, now is the time, as health and healthcare system and communities at large are turning to population health.  Be part of this transformation by attending the Colloquium!

For an invitation to the 18th Population Health Colloquium David Nash, MD, MBA, Dean of the Jefferson College of Population Health provides an overview of what to expect (click image).

For the 3rd year in a row Health Innovation Media will be on the ground interviewing keynote speakers, conference organizers, select sponsors and exhibitors committed to supporting the emerging population health focused economy.

Follow the Colloquium via @pophealthconf. The digital dashboard accessible via #phc18 including newsworthy tweets associated with the Colloquium.

For more information or to register, click here.

==##==

This post is sponsored by the Jefferson College of Population Health

 

 

 

 

 

Center for Medicare and Medicaid Services Releases Accountable Care Organization Performance Results

by Gregg A. Masters, MPH

Friday, October 27th, the Center for Medicare and Medicaid Services (CMS) released details for participating Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP) for the 2016 performance year.  For reporting ACO results view the entire report here.

The National Association of ACOs (NAACOs) weighed in below:

The new results demonstrate the value of a premier Medicare alternative payment model and include a higher rate (56 percent)* of MSSP ACOs generating savings than ever before and an almost equal proportion as last year of ACOs that earned shared savings (31 percent).

This public update follows previously posted results for Pioneer ACOs, the Next Generation ACO cohort and the Comprehensive End Stage Renal Disease ACO (ESRD) care model here.

In table form, the results are summarized below:

All in, participating ACOs generated $843 million in gross program savings with a modest net savings of $78.6 million for Medicare in 2016, in addition to material gains in quality scores for aligned ACO Medicare beneficiaries.

While Clif Gaus, NAACOS CEO notes:

These results show the growing success of ACOs, which is a positive trend that should not be ignored. A lot has been accomplished in a relatively short amount of time, and ACOs are on the front line of redesigning healthcare delivery. This is a moment to celebrate them and their hard work.

The ACO ‘Jury’ Is Still Is Out

Given the range of models, risk assumed or gain sharing distributed operating results in a program that some still see as fundamentally ill equipped in a predominant fee-for-services market to materially change physician and beneficiary behavior – and thus enable the elusive ‘triple aim‘ – many in the health policy area including select ACO operators remain convinced to maximize impact the ACO model will ultimately morph into the more robust Medicare Advantage operating platform.

Perhaps the ‘stealth play’ in the mix is the potential upside of Next Generation ACOs to fully leverage their competitive advantages (3 day SNF waiver, telehealth visits, relaxed supervision requirements for post hospital discharge visits and the move to all inclusive population based payments) can up-level both their game AND improve outcomes at lower per capita costs?

On the next episode of This Week in Accountable Care, our very special guest is former Acting Administrator of CMS Andy Slavitt, now Senior Advisor to the Bipartisan Policy Center. Andy was initially part of the ‘fix it dream team‘ that righted the failed launch of Healthcare.Gov, and then presided over the administration of the Affordable Care Act.

Andy is rather familiar with the original intent of the ACA, its many ‘working parts’ and the bumps in the road to perfect the law via provider input, updated rule making and policy refinements.

We’ll get Andy’s take on a range of issues from the political environment to conflicting health policy guidance including broad brush advice to ACO operators.

Join National ACO co-founders Andre Berger, MD and Alex Foxman, MD as we engage this visionary and accomplished entrepreneur turned public service official in critical dialogue impacting the transformation of our industry from its fee-for-services roots to a new model based on a value and patient centricity.

 

Leavitt Partners Weigh in on Medicare, APMs and Provider Readiness for Pivot

by Gregg A. Masters, MPH

It’s been busy since our re-launch at This Week in Accountable Care primarily due to the heavy lifting support from National ACO co-founders, Andre Berger MD, CEO, and Alex Foxman, MD, President and Chief Medical Officer, respectively.

While I moderate the series, Drs. Berger and Foxman serve as co-hosts and subject matter experts as we engage thought leaders and best-in-class ACO operators in focused conversation around local or regional market challenges including headwinds, tailwinds, lessons learned and emerging best practices.

Recently we’ve chatted with top national talent including: Don Crane, CEO, of CAPG, Hal Sadowy, the IPA Association of America, Jay Parkinson, MD, Founder and CEO of Sherpaa Health and author, consultant and futurist Ian Morrison.

Our all-star line-up continues in October with David Muhlestein, PhD, JD, Chief Research Officer, Leavitt Partners on Tuesday October 3rd, Farzad Mostashari, MD, Founder & CEO of Aledade on October 17th, and the rock-star advocate to fix the Affordable Care Act and former Acting Administrator of the Centers for Medicare and Medicaid Administration (CMS), Andy Slavitt on October 31st.

For our chat with David Muhlestein, PhD, JD, Leavitt Partners, Chief Research Officer you may want to read: Medicare Alternative Payment Models: Not Every Provider Has a Path Forward.

An informative Whitepaper that lays out the range of challenges most health systems, IDNs, physicians whether in groups or not face in the pivot to a value based (alternative payment models – APMs).

From the Whitepaper:

The Centers for Medicare and Medicaid Services (CMS) has shown significant support for the development of Alternative Payment Models (APMs).

CMS’ development and testing of 45 payment models has led to the adoption of similar models by other payers. Initial reports indicate that APMs could be key to producing the health care delivery reform necessary to decrease health care costs and increase delivery quality.

However, these models are only available to select provider types, and some providers, such as emergency physicians and audiologists, have no Medicare APMs in which they can participate. To realize the full benefits of APMs, additional collaboration between CMS leadership and providers is needed to develop new models for providers who do not currently have access to them.

Be sure to join us October 3rd at 5PM Pacific/8PM Eastern for a conversation with David Muhlestein on This Week in Accountable Care with Andre Berger, MD and Alex Foxman, MD. co-founders of National ACO.

ACOs Fudging the Numbers?

by Gregg A. Masters, MPH

I came across this piece on the Healthcare Blog penned by Kip Sullivan, Esq, critiquing this article posted in Health Affairs last May ‘Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO‘. Sullivan raises valid points as the the legitimacy of claiming or inferring statistically insignificant results as a meaningful contribution of the subject ACO (a Partners Health sponsored venture) to ‘bending the cost curve’.

Sullivan un-bundles his argument effectively and raises issues for the industry writ large – including participating ACOs, their sponsors, the regulatory crew at both CMS and CMMI – and even the health policy press covering the sector.

I post the first few paragraphs of the piece below, for full reference the entire article on the Healthcare Blog is accessible via ‘On the Ethics of Accountable Care Research‘.

  • Is it ethical for health policy researchers to claim that a Medicare ACO reduced “spending” by 2 percent if the reduction was not statistically significant?
  • Is it ethical for them to do so if they made no effort to measure the cost to the ACO of generating the alleged 2 percent savings nor the cost to Medicare of giving half the savings to the ACO?
  • Does it matter that the researchers work for the flagship hospital within the ACO that was the subject of their study?
  • Does it matter that the ACO and the flagship hospital are part of a huge hospital-clinic chain that claims its numerous acquisitions over the last quarter-century constitute not mere empire-building but rather “clinical integration” that will lower costs, and the paper lends credence to that argument? 
  • Is it ethical for editors to publish such a paper? Is it ethical to do so with a title on the cover that shouts, “How one ACO bent the cost curve”?

These questions were raised by the publication of a paper  by John Hsu et al. about the Pioneer ACO run by Partners HealthCare System, a large Boston hospital-clinic chain, in the May 2017 edition of Health Affairs. Of the eight authors of the paper, all but two teach at Harvard Medical School and all but two are employed by Massachusetts General Hospital (MGH), Partners’ flagship hospital and Harvard’s largest teaching hospital. [1]

Partners has been on a buying and ….

Comment

As someone who’s been in this dance since the mid 70s (PSROs, HSAs, HMOs, IPAs, PPOs, EPOs & all derivative plays) launched into Medicare risk via TEFRA (the Tax Equity and Fiscal Accountability Act) which introduced us to ‘Medicare Choice’ the for-runner of Medicare Advantage, I can say Sullivan’s critique of fully ‘burdening‘ ALL transformational efforts is rarely – if ever – factored into the volume to value pivot ‘investment calculus‘ of the effects of the intervention (in this case a Pioneer ACO) on the national spend.

It should be noted, the entire managed care industry can be assessed a gigantic collective FAIL for that matter as well. Since managed care penetrated ‘mainstream medicine‘ principally via extension of the HMO model typically on an IPA (independent practice association) chassis (vs. group or staff models) with the exception of a brief period in the 90s premiums continue their relentless upward march; while most payors continue to write commercial business only via an enterprise and industry wide cost shifting (risk transfer) charade. The tacit admission that there is no there there in the prevailing health insurance industry zeitgeist. They’ve proven they can NOT manage clinical risk, period.

So Kip, you might want to go a little lighter on those on the front lines trying to tame the ‘rapacious appetite’ of our ‘healthcare borg‘!

 

 

Tufts Health Plan Forms MassHealth Accountable Care Organization Partnership with Four Provider Organizations

Press Release | Watertown, MA | August 18, 2017 

The Massachusetts Executive Office of Health and Human Services (EOHHS) recently announced that Tufts Health Plan has signed contracts to form Medicaid (MassHealth) Accountable Care Organization (ACO) partnerships with four provider organizations:  Atrius Health, Beth Israel Deaconess Care Organization, Cambridge Health Alliance, and Boston Children’s Accountable Care Organization.

The new ACOs feature a value‐based payment structure for providers who had largely been paid fee for service for MassHealth members in the past.  For members, this means the opportunity to receive medical, behavioral, dental and long-term support services in an integrated model of care.  This will improve quality of care, the member experience, and potentially help stabilize Medicaid costs in Massachusetts.

“We support the Commonwealth’s goal of providing integrated health care to MassHealth members that is more efficient and improves their overall health,” said Tom Croswell, president and CEO of Tufts Health Plan.  “We have partnered with four highly-regarded provider groups, all of whom share our vision of what collaboration and highly coordinated care can look like.”

Continued Croswell:  “Tufts Health Plan has an excellent reputation for our collaborative approaches with providers.  We’ve been working with value-based contracts for more than 20+ years, starting in our Medicare Advantage plans.  We know first-hand that working closely with providers on coordinating care results in healthier members.  We’re excited to broaden our success and bring this approach to our Medicaid members.”

MassHealth ACO transformation is a major component in the state’s five-year innovative 1115 Medicaid waiver from the federal government, which allows Massachusetts to restructure the current health care delivery system for 1.9 million MassHealth members.

Tufts Health Plan’s ACO partners are:

  • Atrius Health, which provides high quality, patient-centered and coordinated care to more than 740,000 adult and pediatric patients in eastern and central Massachusetts.
  • Beth Israel Deaconess Care Organization, a value-based physician and hospital network that partners with providers to improve quality of care while effectively managing medical expenses.
  • Boston Children’s Accountable Care Organization is an ACO comprising Boston Children’s Hospital and its affiliated primary and specialty care physicians. Boston Children’s Hospital is the No. 1 ranked Children’s Hospital in the nationand is a 415-bed comprehensive center for pediatric and adolescent health care.
  • Cambridge Health Alliance, an academic community health system committed to providing high quality care in Cambridge, Somerville and Boston’s metro-north communities. CHA has expertise in primary care, specialty care and mental health/substance use services, as well as caring for diverse and complex populations.

 

Editor’s Note: We are in the process in scheduling a Tufts Health Plan executive on an episode of This Week in Accountable Care with Andre Berger, MD and Alex Foxman, CEO and President/CMO of National ACO. Once confirmed we’ll post the details here with a profile of Tufts Health.

==##==

Florida Association of ACOs Partners with Caredove

Sponsored Post:

22 Aug 2017 7:00 AM | Jacksonville, FL

Partnership Broadens Florida Based Organization

The Florida Association of ACOs (FLAACOs), the premier professional organization for Accountable Care Organizations (ACOs) and value based healthcare leaders throughout Florida, announced today a strategic partnership with Caredove, Inc. to provide its Statewide ACO membership with access to Caredove’s advanced, online e-referral platform which focuses on making it easy to transition patient care into home care and community services.  Under the agreement, Caredove will work with FLAACOs and its ACO members to establish and build out trusted networks between its ACO members and the organizations and agencies providing home care and community support services in the communities they serve.

Nicole Bradberry, CEO of FLAACOs, states:

“Our partnership with Caredove shows our continued commitment to bring additional value to our members and to take a leadership role in helping to address those aspects of care needs to help our member’s patients stay healthier in their homes and communities and to avoid costly readmission into the Acute care system”.

 It is anticipated that over 1000 home care and community agencies will be implemented on the platform, serving some 40+ ACOs across the state.  Caredove’s CEO, Jeff Doleweerd, said

“We spent thousands of hours examining how patients access service to different home care and community services. We saw the same problems over and over. Clinicians couldn’t locate helpful services, patients didn’t know what would happen next, intake staff were overwhelmed while triaging referrals, voicemails would pile up, and patients wouldn’t get connected with the care they needed. We created Caredove to solve these problems”. 

The development of the initial e-Referral networks in Florida under this agreement will pave the way for additional parties to join the platform.  We’re happy to be working with FLAACOs to bring Caredove to benefit the patients of their ACO members.”

Richard Lucibella, CEO of Accountable Care Options (Boynton Beach Florida) and FLAACOs Board member, is an early adopter on the Caredove platform. 

“As we’ve extended our Chronic Care Management efforts, we’ve gained a better understanding of the extent to which behavioral health and community social services can impact out patients’ health status. We’ve all known this to be an issue, particularly in the Medicare population.  Our CCM teams at Accountable Care Options continue our leadership position here on behalf of our patients, and are excited about the very real promise of the Caredove platform to support and potentially multiply our current efforts.”

“Overall, we’re seeing great interest and excitement about the platform in Florida and elsewhere”, says Jim Atkinson (Chief Growth Officer at Caredove), “and, we are working to expand the network through Community & Public Health groups as well as to bring Payers and Health Systems into the trusted exchange.”

ABOUT FLAACOs                                                                                                 

FLAACOs, also known as the Florida Association of Accountable Care Organization, mission is to provide members a vehicle to collaborate, ensuring that each healthcare organization grows and thrives. The Florida-based association aligns goals to help member ACOs shift physician incentives and improve health-care outcomes across the state. FLAACOs provides a voice for the accountable care marketplace and its participating providers, payers, and individual physicians. The goal of FLAACOs is to provide advocacy and support to all Florida accountable care organizations so that together they can become the health-care models of the future. To learn more click here.

ABOUT CAREDOVE                                 

Caredove is a healthcare solutions company providing its online platform to make it easy for patients to gain access to home care and community services.  Providers and care coordinators, as well as patients and family caregivers, can Search for geo-available home care and community services, Book appointments and e-referrals directly into those services, and Connect through secure data communication and organization-specific referral and intake workflows.  Caredove is a true healthcare platform that builds trusted webs between Referrers (Providers/Care Coordinators), Service Providers and their mutual patients.   Caredove currently covers over 80 categories of Home Care and Community Services.  On the platform referrals are always free and it’s easy to invite referrers and service providers to the network so there is no impediment to its growth in serving each local community. For more information, click here.

 

The ‘Value Pivot’: The CAPG Story

by Gregg A. Masters, MPH

While HMOs have been around since President Richard Nixon – yes a Republican who embraced the vision of ‘universal coverage‘ for Americans via the HMO Act of 1973 – healthcare stakeholders in the volume fueled fee-for-services (FFS) ecosystem have been mostly change resistant with some exceptions.

Nixon’s sanguine call for a National Health Strategy in 1971 will put today’s health policy and serial frustrations around building common ground on health reform in an important historical context and frankly serve as a wakeup call to all the late comers in this conversation who are just discovering that ‘health care is complex‘.

Nixon noted:

The toughest question we face then [post passage of Medicare and Medicaid] is not how much we should spend but how we should spend it. It must be our goal not merely to finance a more expensive medical system but to organize a more efficient one. – President Richard M. Nixon 1971

He further opines a theme we’re rather familiar with today whether it by the increasing popularity of direct or retainer based medical practice or the resurgence of the HMO model particularly the growth of Medicare Advantage plans:

Emphasizing Health Maintenance. In most cases our present medical system operates episodically–people come to it in moments of distress–when they require its most expensive services. Yet both the system, and those it serves would be better off if less expensive services could be delivered on a more regular basis.

If more of our resources were invested in preventing sickness and accidents, fewer would have to be spent on costly cures. If we gave more attention to treating illness in its early stages, then we would be less troubled by acute disease. In short, we should build a true “health” system-and not a “sickness” system alone. We should work to maintain health and not merely to restore it.

ACA Repeal, Replace or Fix?

Some 36 years later we can still relate to Nixon’s goals for a National Health Strategy and are far from it’s fulfillment in terms of migrating from a ‘sick-care’ to a preventive or wellness based system. All of the talk about population based payments or value based healthcare notwithstanding, our system of financing and delivery remains a fee-for-services, do more to earn more web of financial incentives. This is changing though very slowly.

As has been noted elsewhere:

‘The future is already here – it’s just not evenly distributed’. – William Gibson, The Economist December 4, 2003

Given the variable and regional distribution of ‘innovation‘ in business or service delivery models supporting alternatives to traditional fee-for-services medicine, we in the healthcare sector can certainly attest to Gibson’s observation. While contextual to the tech sector it is wholly applicable to transformation efforts in healthcare.

It’s noteworthy that when Nixon signed the HMO Act into law in 1973 it was to ‘to help demonstrate the feasibility of the HMO concept over the next 5 years‘, see: Statement on Signing the Health Maintenance Organization Act of 1973.

Yet the HMO model had been incubating for a while, i.e., Kaiser Permanente dates back to 1947, as does the Ross-Loos Medical Clinic (1929) and Group Health Association of D.C. (1937). So indeed, innovation uptake in the healthcare sector does have its own unique ‘footprint‘ and experience.

Before pivoting to today’s theme, I want to underscore the glacial pace with which the healthcare delivery and financing sector embraces change. Consider this classic observation to frame both the optimism and nature of the challenge via Charles H. Mayo, MD of Mayo Clinic fame.

Many are called to the healthcare services industry with a range of motivations, some from a sense of mission to serve others, while another cohort focuses on the upside of financial gain resulting from cures to it’s many inefficiencies and inequities.

I suspect some of Dr. Mayo’s optimism envisioned what was to come via the above pioneers in the prepaid world of HMOs that Nixon codified into law in 1973.

Meet Don Crane CEO CAPG

True to form with the uneven distribution of innovation, it’s fact that certain geographic regions have witnessed more or less ‘innovating‘ away from the industry standard FFS platform. California has been in the forefront of provider risk assumption since the mid- 1980s. HMOs in California prior to the expansion into ‘mainstream medicine‘ via the independent practice association (IPA) movement, where of the staff or group model variety. Their market share was relatively low and they remained a ‘niche play‘ of typically labeled ‘second rate‘ medicine by their mainstream ‘bretheren’. However, the handwriting was on the wall as to the directional vectors for both financing and the delivery of care.

Born as the California Association of Physician Groups, CAPG sensing the need to share and migrate both it’s philosophy and core competencies in risk assumption and operational excellence began a national expansion. From a California focused association of risk savvy medical groups, CAPG is now advocating and supporting scheduled and scaled risk assumption by member groups nationwide. It’s mission statement notes:

CAPG is the leading association in the country representing physician organizations practicing capitated, coordinated care. Our membership currently comprises close to 300 multi-specialty medical groups and independent practice associations (IPAs) across 42 states, the District of Columbia, and Puerto Rico.

Tuesday, July 25th at 5PM Pacific/8PM Eastern on This Week in Accountable Care, NACO co-founders Andre Berger, MD and Alex Foxman, MD will engage Don in a broad conversation on value based healthcare economy including alternative payment models (APMs), ACOs, the promise of it’s Next Generation Models and the performance of Medicare Advantage plans.

Join us!

 

 

CBO Weighs in on Trumpcare 3.0

by Gregg A. Masters, MPH

The non-partisan Congressional Office weighed in today on the impact of the Better Care Reconciliation of of 2017 as amended and rebranded as the ‘Obamacare Repeal Reconciliation Act’.

Their summary notes the coverage impact as follows:

  • The number of people who are uninsured would increase by 17 million in 2018, compared with the number under current law. That number would increase to 27 million in 2020, after the elimination of the ACA’s expansion of eligibility for Medicaid and the elimination of subsidies for insurance purchased through the marketplaces established by the ACA, and then to 32 million in 2026.
  • Average premiums in the non-group market (for individual policies purchased through the marketplaces or directly from insurers) would increase by roughly 25 percent—relative to projections under current law—in 2018. The increase would reach about 50 percent in 2020, and premiums would about double by 2026.

On the fiscal impact the graphic lays it out below:  For a complete CBO report, click here. 

Senate GOP Health Reform Fail: Many Knew This Day Was Coming

by Gregg A. Masters, MPH

Unlike many in the conversation on social media including the likes of Twitter, Facebook, LinkedIn and blogs such as ACO Watch, I have been active in the health reform exchange of ideas since registering my twitter handle @2healthguru in August of 2008. My participation has been of the ‘sweat equity’ variety vs. those who are compensated for their content, curation or advocacy.

Many of us in the healthcare space (both clinical and administrative) are addicted to the industry and find it difficult if not impossible to exit whether physically or emotionally. Some commit out of a sense of mission, giving back or being of service, while others for the economic upside this vast ecosystem (which I have labeled the healthcare borg resisting any attempt to materially restrain its appetite) affords to exploit low hanging fruit from a fragmented, inefficient and unwieldy financing and delivery system. Many have personally enriched themselves via the frequent churn of asset ownership (hospitals, nursing homes, imaging centers, ambulatory surgery centers, etc.) or via niche solutions with little to no sustainable value followed by quick exits and generous investor returns.

This timing of my entry into social media was co-incident with the deliberative process that ultimately rendered unto the American public what was merged as the Affordable Care Act (ACA),

In the early days of twitter those of us active in the community spoke of the ‘addictive’ nature of twitter engagement, some even referred to this virtual community as ‘the matrix’. Bonds were formed, some of which remain intact to this day.

The ‘Fictional’ Obamacare ‘Disaster’

This morning Donald J, Trump aka the POTUS weighed in on the failed efforts of Senate GOP leadership to advance the Better Care Reconciliation Act of 2017 as amended by Senator Ted Cruz to the Senate floor. He said:

By the way Obamacare isn’t failing, it’s failed…

That this man continues to minimally misrepresent and worse intentionally lie to the American public is beyond the capacity for many to comprehend. From the American Academy of Actuaries to the Non-partisan Congressional Budget Office and multiple authorities in the underwriting to delivery space including risk bearing provider organizations and integrated delivery systems the narrative is quite to the contrary.

And where there is evidence of market instability or ‘failure‘ there is explanation including serial GOP initiatives to undermine the Affordable Care Act specifically with respect to ‘qualified health plans‘ (QHPs) listed on State run or Federally Facilitated Marketplaces (FFM) aka ‘Exchanges.’

The ‘death spiral‘ or ‘disaster‘ narrative is principally vested in the following argument:

  • Major health plans and regional players who initially developed individual market product(s), i.e., benefit plans, and associated provider networks including premiums) for these exchanges are withdrawing participation from select markets.
  • Premiums for some QHPs have increased by 100% or more on select exchanges; and
  • In some states and select counties there are no participating health plans with QHPs offered

On the face of this narrative, yes it makes sense. This market instability is unacceptable. No one can celebrate a law who’s principal intent is to expand coverage can applaud the absence of health plan participation at the state or county level.

But let’s peel back the curtain and look at the reasons for this ‘instability‘ claim. From day one of the Obama Administration, the GOP agenda was to make him a ‘one term President‘.

On the ACA given it’s passage was a straight line party vote with no support from GOP even though the health reform consideration process was an open and lengthy affair, Senator McConnell et al’s agenda was to remain the ‘party of no‘ and criticize the very model of health reform they had not long ago proffered as a public/private solution,  See: ‘GOP ACA Myths‘ where I’ve posted links to credible voices and JD Kleinke’s classic: ‘Why There Is No Obamacare Replacement — In One Picture‘. 

The bottomline is any ‘fails’ or under performance of the ACA whether enrollment projections, premium sticker shock, exchange exits or regulatory burdens have been engineered by a relentless series of sabotage efforts from defunding risk corridors, to current (see: This Blame Game Driving Up Health Insurance Costs) threats to not fund the subsidies that make QHP listed plans ‘affordable‘. And let’s not forget the big SCOTUS decision on Medicaid expansion which gave Red State Governors the ‘option’ whether to expand coverage for their citizens.

Karma?

So the ‘who knew healthcare was so complex’ remark offered by POTUS earlier this year was pure BS. I buy his ignorance of health policy and the complexity inherent in a cottage industry with a $3+ trillion spend, but what about those GOP ‘health wonks’ engaged in this process – from the ‘Senate Quackers’ (my term), i.e., Tom Coburn and John Barrasso – both politicians playing the doc card during ACA markup in 2009, or even worse one half of the GOP ‘young guns’ now Speaker Ryan who’s a budget [and by declaration health] wonk. What’s their excuse for this ‘surprisingly epic fail’?

This is a HUGE squander of the public trust!  And contrary to POTUS assertions, the GOP now has complete ownership of the chaos they’ve stoked from the beginning to this gross mis-management of the legislative process. It’s laughable that GOP are trying to pin this one on the Democratic party.

My god, wake up GOP. You ‘own’ healthcare. Fix the ACA.