Posted in Accountable Care, ACO, Affordable Care Act

The Long and Winding Road to Healthcare Price Transarency

by Gregg A. Masters, MPH

Bitter Pill: Steve BrillWhen Steven Brill published ‘Bitter Pill: Why Medical Bills Are Killing Us‘ in 2013 he brought national attention via a series of personal stories that served to reveal the complex dysfunction inherent in our healthcare delivery and financing system. A veritable ‘conundrum‘ created over the decades of layering managed care complexity (pre-certification, prior authorization, referral management, contract payment adjudication, etc.) on top of the arguably burning ‘fee-for-services’ platform that incentivizes the prevailing ‘do more [units] to earn more [income]’ mentality of hospitals, physicians and allied healthcare practitioners who do not operate in a pre-paid or per member per month capitated environment.

Central to Brill’s narrative was the hospital ‘charge master‘, typically a made up fictional schedule of retail (sticker shock) values with ZERO relationship to the actual cost of services provided nor what would ultimately be paid by the patient or third party on his or her behalf.

Brill admonishes readers to:

Pay no attention to the chargemaster – No hospital’s chargemaster prices are consistent with those of any other hospital, nor do they seem to be based on anything objective — like cost — that any hospital executive I spoke with was able to explain. “They were set in cement a long time ago and just keep going up almost automatically,” says one hospital chief financial officer with a shrug.

Most of us are fortunate enough to have 3rd party coverage via our employer or Government funded programs like Medicare, Medicaid, etc., and benefit from deeply discounted intermediary ‘wholesale rates‘ often beginning at 50% of the published charge master rates.

Ironically, those who of us absent this ‘buffer’ and who could least bear the sticker shock burden associated with arbitrary (no relationship to cost) charge master pricing, i.e., the un and under insured, paid the steepest price, see: ‘Medical Bills Are the Biggest Cause of US Bankruptcies: Study‘.

Consumer Directed Health Plans and the ‘Empowered Patient’ Mandate

Since the launch of the Health 2.0 movement and arguably the ‘digital health‘ innovation industry writ large by co-founders Matthew Holt and Indu Subaiya, MD, some of the start-ups launched addressed the problem of price transparency ‘workarounds’ via back end building of ‘virtual’ contract rate books through platform user submissions of EOBs detailing the charge basis and ultimate contract repricing per the health plan negotiated rate of the services rendered and paid. Some of the companies operating in the space, though not necessarily back-ending virtual rate books, include: Medlio, Change Healthcare, Healthcare Bluebook and Castlight Health, see: ‘8 companies working on healthcare price transparency‘.

Clearly the ‘holy grail‘ here is contract rate-book transparency, but don’t hold your breath. These rates are deemed proprietary and thus closely guarded ‘trade secrets’.

So fast forward to today. It’s 2016 (some 43 years post HMO Act) and healthcare inflation which has shown remarkable restraint principally due to the lingering impact of the great recession of 2008, coupled with the health insurance industry’s new found love affair fueled by the ACA with so called ‘consumer directed health plans‘ (aka code for the ‘cost shifting’ charade). Think of it this way, massive health plans, pooling millions of lives, extracting maximum pricing leverage from providers and exercising varying degrees of medical management oversight have explicitly admitted that as an industry they can NOT manage clinical risk, thus have chosen make provider pricing restraint ‘our’ problem. Afterall, they reasoned the required (mythical absence of?) ‘skin in the game‘ of high deductibles, non-covered services, copayments and co-insurance drives granular price sensitivity since the once 3rd party buffer (if it ever existed) is no longer present to immunize our exposure to the cost of utilizing healthcare services.

Last month The Health Care Incentives Improvement Institute (HCI3 ) and Catalyst for Payment Reform (CPR) issued the fourth installment of the ‘Report Card on State Price Transparency Laws‘. The picture below tells the less than pretty story:

Price Transparency Report Care

 

They open the report noting:

Despite the full integration of price information into almost every other retail experience, it’s typical in American health care for consumers to go into an appointment or procedure knowing nothing about what it will cost until long afterward

And conclude as follows:

Our 2016 Report Card on State Price Transparency Laws shows that price transparency—an obvious expectation integrated into every other consumer experience—is on the minds of state legislators and other health care leaders throughout the U.S. It also highlights why this information is so critical to every health care consumer in every state; prices for routine and very common procedures can vary by more than 50 percent, even in the same geographical area, placing a potentially significant financial burden on individual consumers, a burden that can be avoided with robust health care price transparency. Thus, design and implementation of the legislation matter.

In fact, the potential for transparency to empower consumers, shift costs down, and raise quality rests entirely on the strength and comprehensiveness of each state law’s implementation. This is a perspective that is often lost in some of the research on the effectiveness of price transparency, even though no one should be surprised that weak resources yield poor results. Importantly, a very strong and thorough body of research demonstrates that consumers will seek lower-priced, high-quality providers when given the right information in the right format.

Many states may see low grades for themselves. However, in this report card, they also have a roadmap for improvement. It’s up to states to apply that roadmap to benefit from the desired and proven positive effects of price and quality transparency. 

I am not as optimistic as the authors that price transparency solutions coupled with a growing army of ‘empowered patients‘ are sufficient to tame the rapacious appetite of a predominantly volume incentivized delivery system. Clearly this is a slog unlike any other industry re-tooling, re-invention or re-engineering challenge we’ve EVER faced in the United States. More will be revealed as we move from niche solutions (concierge medicine, direct practice, non-risk bearing ACOs or IDNs, or HMO-lite solutions, etc.) tweaking at the margins of the ecosystem dysfunction but delivering little by way of sustainable contribution.

As I was recently reminded by Dan Munro of a quote often mis-attributed to Winston Churchill:

The question is whether there is any reason to believe that such a new era [think value based healthcare driven by ’empowered patients’] may yet come to pass. If I am sanguine on this point, it is because of a conviction that men and nations do behave wisely once they have exhausted all other alternatives. Surely the other alternatives of war and belligerency [avoiding the inevitable path of risk assumption/integration] have now been exhausted.  Abba Eban,  June 1967 

Bottom-line?

I see HMO’s 2.0 (global risk) in our future. There just isn’t anyway around it, though we’re trying our best to avoid the inevitable.

Your thoughts?

 

Posted in Accountable Care, ACO, Affordable Care Act

Day One: You’re Covered!

by Gregg A. Masters, MPH

August 1st, 2016 marked the first day that I’ve been covered by health insurance since leaving the W2 workforce in 2000 as Vice President of Payor and Provider Contracting at Wellspan Health Network a ‘Super PHO’ launched by Texas Health Resources, post combination of Presbyterian Healthcare System, Harris Methodist Health Services and Arlington Memorial Hospital.IMAG2725

Granted the choice to ‘go bare‘ (i.e., self funding my acute, elective or urgent healthcare needs and exposure for accident or injury risk) and incur the tax (shared responsibility) penalty associated with the post ACA era was a conscious choice. The calculus was derived via a cost/benefit analysis of sorts taking into consideration premium costs, plus deductibles, co-pays and co-insurance of principally the ‘silver metal‘ plans offered via Covered California – the State health insurance exchange operating in California.

Going Bare

My decision to remain bare was in part supported by my history as a low utilizer of physician and hospital services, i.e, as a healthcare insider who rarely used his health plan coverage while insured, and saw the consequences and risks of medical errors and hospitalization ‘up close and personal‘, I reasoned though older and therefore at greater relative risk than when I was in my 40s and 50s, if I continued to eat well, stay physically active (running, cycling and surfing) and refrain from avoidable risks (smoking, drinking alcohol to excess, etc.), the decision to self fund the exposure was somewhat of a ‘reasonable’ if not calculated gamble.

But make no mistake, the decision to bear the tax penalty and retain the health risk was principally a matter of economics. As a self-employed small business operator (I am the founder of Health Innovation Media, a boutique digital media agency) with the typical unpredictable start-up income stream and thus low earnings visibility, I chose to preserve cash and remain uninsured. Unfortunately, the ‘affordable nature’ of ACA related health insurance offerings in the exchange marketplace were neither affordable nor of sufficient value for me to dig into my pocket and pull the trigger on coverage.

That I was three years away from Medicare eligibility was also another consideration in my decision to remain bare. Fortunately that chapter in my life ended today. And other than the tax penalties paid, I have remained in relatively good health while still a card carrying member of ‘the worried well‘ club, i.e., I typically though temporarily obsess over this pain, or that bump or lump as signs of my impending demise. For example, though approaching 65 this month, I have NOT had that colonoscopy recommended for men starting in their 50s. So since I don’t know what’s going on down there, I often wonder about the potential for colorectal disease though I have no classical symptoms per se.

Choosing a Health PlanIMAG2724

As one of the estimated 10,000 baby boomers per day turning 65 and thus qualifying for a ‘public option’ aka ‘Medicare’ one of the first decisions to make is the selection of health plan coverage options via Medicare. There are basically four key considerations:

  • Stay in the traditional Medicare program (Parts A and B); and
  • Optionally purchase a ‘Medicare Supplement‘ plan; or
  • Elect a Medicare Advantage participating health plan (Part C)
  • If principally staying in traditional Medicare, add an optional Prescription Drug Plan (Part D)

Medicare Part A covers ‘hospital services’, while Part B which is optional and requires the payment of a monthly premium covers ‘physician services’. Medicare Supplement insurance typically covers the co-payments and co-insurance present in traditional fee-for-services Medicare. While Medicare Advantage is a private health insurance option that contracts with the Centers for Medicare and Medicaid Services and offers typically HMO plan options to Medicare beneficiaries often with little to no premium payment required, and some plans even add drug benefits without having to elect a Part D Prescription Drug plan. Part D is typically purchased when electing to stay in the traditional Medicare program and layer into your benefits prescription drug coverage.

As you approach your 65th birthday be prepared for the tsunami of marketing materials you will receive from health insurance companies, their participating broker/agents and Medicare Advantage plans participating in your service area.

The Choice

Having made my decision, I can see why the typical senior who is not a ‘insider’ in the ways of healthcare operations and finance might need help working through all the plan options presented. This is a potentially confusing experience with a series of questions and plan options to sort through. Yet, for me the choice was relatively easy. I know the pros and cons of Medicare Advantage, the limits of traditional Medicare (with or without a Supplement) and have written about the limits of the Prescription Drug Program off and on over the years. Further, I am almost within walking distance to a Kaiser Permanente Ambulatory Care Center and Kaiser San Diego offers in my service area a no premium Medicare Advantage program that provides additional benefits including drug coverage and health club participation via the Silver Sneakers program.

When I added the maturity of KP San Diego as a quality operator in the integrated delivery space with a reasonably extensive and accessible ambulatory and inpatient facilities network vs. other options that relied upon ‘IDNINOs’ (integrated delivery networks in name only) commonly associated with name plate hospital/health system operators in San Diego (Scripps Health, UC San Diego Health System, Sharp Healthcare) county in partnership with the likes of Humana, Anthem or United Healthcare, the decision was a relatively easy one.

I reasoned if I get seriously sick, I will be cared for by a coordinated team of health professionals who’s incentives are to keep me healthy and out of the inpatient theater (a literal fail moment). Further, as a real IDN, KP San Diego is more likely to operate in a seamless care coordination manner vs. many of the aforementioned players who have to more or less degrees grafted an IDN culture on top of a traditional, silo-ed fee-for-services network of providers.

Finally, I have watched my mother spend hours on the phone dealing with toxic and dated (in excess of a year) billing matters from UC San Diego associated with her membership in Humana’s Medicare Advantage program. Try as they might, the non KP players in this market have yet to achieve the level of IDN operational excellence demonstrated by KP San Diego (and its sister regions in both Southern and Northern California) from point of care services to any billing and collections infrastructure associated with ‘revenue cycle management’ (RCM) purposes.

So a new chapter has begun. We shall see if I reasoned correctly, and KP San Diego is what I assume it to be. More to be revealed!

 

Posted in Accountable Care, Affordable Care Act, health reform

The 2016 Medicare Trustees Report: One year closer to IPAB cuts?

by Gregg A. Masters, MPH

From the relentless drone of ‘where are the jobs, Mr. President?’ to the misguided fear mongering of ‘death panels for Grandma’ administered by un-elected, faceless bureaucrats to the de facto death of American Democracy itself the attacks on the Affordable Care Act (ACA), flawed indeed as it is, is starting to log results, some of them are quite impressive as noted by a recent piece at Morning Consult titled: ‘Trustees: Medicare Savings Recommendations Forestalled’.

View more details on Brookings.edu
View more details on Brookings.edu

This morning Brookings in association with the American Enterprise Institute and the Schaeffer Initiative for Innovation in Health Policy at the University of Southern California hosted ‘The 2016 Medicare Trustees Report: One year closer to IPAB cuts?‘.

The event is summarized by its organizers as:

For most of the last five decades, the most-discussed finding by the Medicare trustees has been the insolvency date, when Medicare’s trust fund would no longer be able to pay all of the program’s costs. Last year’s report projected that the hospital insurance trust fund would be depleted by 2030 – just 14 years from now. The report also predicted a more immediate and controversial event: the Independent Payment Advisory Board (IPAB), famously nicknamed “death panels,” would be required to submit proposals to reduce Medicare spending in 2018, with the reductions taking place in 2019. Do we remain on this path to automatic Medicare cuts next year?

The American Enterprise Institute and the Schaeffer Initiative for Innovation in Health Policy, a collaboration between the USC Leonard D. Schaeffer Center for Health Policy & Economics and the Brookings Institution, hosted a discussion of the new 2016 trustees report on June 23. Medicare’s Chief Actuary Paul Spitalnic summarized the key findings followed by a panel of experts who discussed the potential consequences of the report for policy actions that might be taken to improve the program’s fiscal condition. You can join the conversation at #MedicareReport.

In the tsunami of misrepresentation and outright deception of the many moving parts of the ACA the ultimate barometer of success – at least from the health policy perspective – is the forecasted effect the law was to have on the U.S. Treasury, i.e., it will bankrupt the country and undermine the roots of our pluralistic healthcare ecosystem, replacing it with a ‘top down’ Government run Federal quagmire.

EDITOR’s NOTE: for the Acting CMS Administrator’s take on the Federally Faciliated and State Run ‘Marketplace’, check out Andy Slavitt’s recap via ‘Marketplace Year 3: Issuer Insights and Innovation (Part 3).

Well the ACA results are in and the truth be told, while not a sealed trend (there are both headwinds and macroeconomic wildcards in the mix), the data is ‘encouraging‘.

Enjoy the audio!

 

Posted in Accountable Care, Affordable Care Act, Triple Aim

Hey, Remember IPAs, PPOs and TPAs?

by Gregg A. Masters, MPHAAPAN 2016 Forum

In a last man standing of sorts in what some may call the legacy and aging infrastructure of the ‘vote with your feet‘ PPO industry including it’s allies in the TPA (Third Party Administrator) space, the American Association of Payors, Administrators and Networks (AAPAN) is holding its 2016 Annual Forum in my former hometown of Dana Point, California at the Ritz Carlton, Laguna Nigel.

The mission of American Association of Payors, Administrators and Networks (AAPAN) notes it provides:

….the platform for the unification of payers, administrators and networks and the ability for a stronger collective public policy voice to enhance the position of each stakeholder as essential to the future of affordable healthcare delivery options centered on patient choice.

According to its subsidiary the American Association of Preferred Provider Organizations (AAPPO) the ‘PPO chassis’ accounts for:

An estimated 200 million Americans, or about 81 percent of all Americans with health care coverage (excluding those receiving military health care), receive their health care services through a PPO delivery system.

A history of managed care As a ‘collaborative association’ on behalf of the PPO industry initially positioned as a complementary (if not an HMO-lite) alternative to the more aggressive gatekeeper HMO option (see history of managed care era in graphic), AAPAN has a track record of success from advocacy, to thought leadership and operating best practices and solutions.

The Association aligns two potentially silo-ed (though synergistic) interests: the American Association of PPOs (AAPPO), the Third Party Administrators Association of America (TPAAA). For an issue brief on valued based healthcare and the need for network standards, see: The Need to Standardize Network Value-Based Purchasing Requirements.

So one might say, though a larger share of the employer based insurance market remains in a PPO type (vs. HMO) benefit plan design their role and industry leadership visibility may have been somewhat muted (if not, absent from the health reform narrative) since the rollout of the Affordable Care Act (ACA) and it’s emphasis on Accountable Care Organizations (ACOs) dominated the reform narrative.

AAPAN intends to raise this profile and remind many in the space that PPOs, TPAs and even IPAs (Independent Practice Associations) have a material and meaningful role to play in enabling the triple aim even if their initiatives aren’t tagged ACOs per se.

The 2016 Forum hashtag is #AAPAN16, and the digital dashboard is here. Do follow the tweetstream for thought leadership insights from key industry executives, entrepreneurs and change agents. See keynotes and sessions here, including Health Innovation Media co-host, Douglas Goldstein aka @eFuturist.

The program schedule is here.

 

Posted in Accountable Care, ACO, Affordable Care Act

Must listen JP Morgan Healthcare Conference Webcasts: @Centene

by Gregg A. Masters, MPH

NOTE: This is second in a series of ‘Must listen’ webcasts produced at JP Morgan’s 34th Annual Healthcare Conference. The first focused on telehealth sector market leader Teladoc. For background and details on this august gathering, see ‘If It’s January, It’s JP Morgan Healthcare Conference. Remaining companies to detail as they represent important ‘bell weather’ insights relative to their respective sectors, include: Aetna, AthenaHealth, Centene, Genomic Health, Molina Health,Universal American, Tenet Health, as well as several from the ‘non-profit’ (tax exempt) sector including Baylor Scott and White

Centene’s operations and strategy positioning insights are material on a number of levels including the ‘urge to merge’ in the HMO or managed care space, and the implications such continuing consolidation holds for movement towards clinical and financial integration in the provider space. Additionally as many predict the future viability of the Medicare Trust Fund may rely largely on the efficacy of how Part C stakeholders articulate a sustainable vision of Medicare Advantage program to extend and enhance the life cycle of the Medicare program itself.

For direct link to the JP Morgan Healthcare Conference, click here. For the associated Centene profile, click here, the deck here and webcast, here.

For two related pieces on navigating the ‘white waters’ of the market’s transformation from volume-to-value as well as the recent ‘collateral damage’ (aka data breach) of healthIT as central spine enabling the transformation, check out ‘Centene–Health Net Entity Could Be Medicaid Leader and ‘Centene loses hard drives with health info on 950,000 beneficiaries, launches search‘, respectively.

Meanwhile, here are some slides which paint the picture both company and industry:

Centene overview

Centene growth 2015

Screen Shot 2016-01-27 at 11.41.27 AM

Screen Shot 2016-01-27 at 11.41.42 AM

Screen Shot 2016-01-27 at 11.41.57 AM

Centene

Centene specialty growth

Centene growth strategy

Centene market vy product

Centene pipeline

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Centene:

http://jpmorgan.metameetings.com/confbook/healthcare16/company.php?company=CENTENE+Corporation&p=19768&special_list_title=

http://marketrealist.com/2015/07/centene-health-net-entity-medicaid-leader/

Posted in Accountable Care, Affordable Care Act, health insurance reform

CMS Quality Measure Development Plan: A DRAFT

by Gregg A. Masters, MPH

An inspirational leader and ‘disruptive‘ politician taken down well ahead of his time once opined:

“Ask not what your country can do for you, ask what you can do for your country…” John Fitzgerald Kennedy

Fast forward some 55+ years and season such an invitation with the relentless drone of 24/7/365 faux patriotism, hate mongering, intolerance, and emotive ‘hell no‘ sound-bytes proferred by those who self righteously claim title to the ‘take back our country’ narrative and you may ask yourself how did we get from there (the Peace Corps) to here (carpet bomb em)?

Yet, in our unique strain of American democracy even through studies empirically demonstrate a consistent disconnect between what Americans want and what their representatives codify via policy with a capital ‘P’, the bottom line is look in the mirror ‘we are the government’.

CMS_quality_development_planWhether it’s the creation and passage of what merged into the ‘Affordable Care Act‘ (ACA) or how the ‘public’ participates in both the legislative process and its implementation via the rule making process initiated aka the ‘notice of proposed rule making’ (NPRM), we are presented with both the opportunity and as it turns out obligation to engage in and thus granularly shape (via a dialectical bottoms up vs. top down exchange) the ground rules which in turn govern our economy and the conduct of its constituent industry stakeholders.

In the quest to advance the efficacy of quality initiatives (garbage in garbage out) one recent effort is the DRAFT release of the ‘CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models‘.  

As an industry we are process oriented sometimes to a fault. Moreover the ‘check the box’ or drop down nature of many of these measures lends itself to the argument that the state of the industry to actually measure, document and report healthcare quality is at best a crude representation of what is actually going on. Clearly there is more work to be done if this industry is to matter.

To help readers of this blog, the introduction of the executive summary is pasted below:

I. Executive Summary

Background

A transformation of the U.S. healthcare delivery system gained momentum in 2010 with the passage of the Patient Protection and Affordable Care Act (Affordable Care Act).1

The law established the Health Insurance Marketplace to extend consumer access to affordable care through private payers and provided strong incentives in publicly financed healthcare programs to connect provider payment to quality of care and efficiency. 

Building on the principles and foundation of the Affordable Care Act, the Administration announced a clear timeline for targeting 30 percent of Medicare payments tied to quality or value through alternative payment models by the end of 2016 and 50 percent by the end of 2018.
These are measurable goals to move the Medicare program and our healthcare system at large toward paying providers based on quality, rather than quantity, of care.2

The passage of the Medicare Access and Children’s Health Insurance Program (CHIP)
Reauthorization Act of 2015 (MACRA)3 supports the ongoing transformation of healthcare delivery by furthering the development of new Medicare payment and delivery models for physicians and other clinicians. Section 102 of MACRA4,i requires that the Secretary of Health and Human Services develop and post on the CMS.gov website “a draft plan for the development of quality measures” by January 1, 2016, for application under certain applicable provisions related to the new Medicare Merit-based Incentive Payment System (MIPS) and to certain Medicare alternative payment models (APMs).

The law provides both a mandate and an opportunity for the Centers for Medicare & Medicaid Services (CMS) to leverage quality measure development as a key driver to further the aims of the CMS Quality Strategy:

• Better Care,
• Smarter Spending, and
• Healthier People. 5

Measure Development Plan Purpose
The purpose of the CMS Quality Measure Development Plan (MDP) is to meet the requirements of the statute and serve as a strategic framework for the future of clinician quality measure development to support MIPS and APMs. CMS welcomes comments on this draft plan from the public, including healthcare providers, payers, consumers, and other stakeholders, through March 1, 2016.ii The final MDP, taking into account public comments on this draft plan, will be posted on the CMS.gov website by May 1, 2016, followed by updates annually or as otherwise appropriate.i

So here it is… have at it. Perhaps your input will in fact shape the substance and steward the glide-path of how the transformation from volume to value can be realized. Certainly it’s worth your consideration. Afterall, another attributed Kennedy quote with biblical DNA may apply here:

“We are not here to curse the darkness, but to light a candle that can guide us through the darkness to a safe and sure future. For the world is changing. The old era is ending. The old ways will not do.

The problems are not all solved and the battles are not all won and we stand today on the edge of a New Frontier – a frontier of unknown opportunities and perils, a frontier of unfulfilled hopes and threats.

It has been a long road to this crowded convention city. Now begins another long journey, taking me into your cities and towns and homes all over America.

Give me your help. Give me your hand, your voice and your vote.”

John Fitzgerald Kennedy

Posted in Accountable Care, Affordable Care Act, health insurance reform

12 Steps to the Triple Aim or Value Based Healthcare

by Gregg A. Masters, MPH

It has been challenging at times being in the ‘innovation conversation’ dating back to the 70s (who remembers ‘WIN’ [whip inflation now], PSROs or even HSAs (no, not the WIN \ Whip Inflation Nowprivatization funding mechanism, but the CON overlords) watching what get’s reported by industry press or online media as ‘innovation‘ or ‘bold new thinking‘ amidst a ‘cottage industry’s’ 3x trillion spend rate – including it’s culpable supply chain and many vendors (some may even say ‘pigs’) at the trough.

As indicia of the impending collapse of our aging house of cards healthcare delivery and financing industry (continued burnout rates driving physician exits to direct practice or concierge medicine, un-ending and nauseating opposition to the ACA, mega and no so mega hospital mergers, associated practice acquisitions and health plan consolidation, not to mention the codification of the cost shift charade via the lower metals designations of the ACA and including armies of dissatisfied patients suffering in a provider centric culture) continues to accumulate, it affirms what Esther Dyson once presciently characterized as the ‘calcified hairball‘ given it’s ‘resistance is futile’ [to change] nature.

Healthcare Inflation

Recent healthcare inflation moderation trends notwithstanding (see: ‘2014 National Health Spending; The Great Moderation Likely Not Over‘ by healthcare futurist Jeff Goldsmith) whether a function of ACA implementation in part of as a whole, the industry has essentially and collectively failed to deliver on the principles of the triple aim – which existed in spirit considerably before it’s labeling by the Institute for Healthcare Improvement (IHI). Providers continue to maximize their profits or ‘excess revenues over expenses’ for the ‘non-profit’ [aka tax exempt’ sector] often at the expense of community benefit.

Perhaps no other chart series in line item detail captures and evidences this slow burn of fail as the progressive and relentless growth of one man’s healthcare premiums in California. Take note of the persistent [cost] shift from the payer (health plan) to the patient or beneficiary.  If this is the best we can do via ‘wholesale purchasers’ (market savvy health plans) leveraging millions of members and ‘medical management’ and network contracting infrastructure, how can an army of independent and often clueless if not dis-empowered agents (patients, members sometimes at the point of service) do better?

[Editor’s note: one reason for an earlier post on the need for a ‘new IPA’ i.e., independent patient association]

This testimony was provided by Josh Libresco to the Department of Managed Care in California during their consideration of rate hikes by health plans.

Testimony1

Testimony2

 

 

 

Time for a New Manifesto?

With this history as both context and some may say ‘institutional memory’, I thought I might make sense to take heed of what’s become rather well known in the 12 step recovery community (from AA to Al-anon and many derivatives) which is to admit our ‘addiction’ to the arguably ‘easier softer path’, i.e., fee for services medicine.

Perhaps this can be a manifesto of sorts to embrace as we embark upon this journey for volume to value based healthcare?

Adapted from the 12 Steps of Alcoholics Anonymous

1. We admitted we were powerless over our addiction to fee for services medicine – that our healthcare delivery and financing model had become unmanageable.

2. We came to believe that power greater than ‘do more to earn more’ incentives (global capitation) could restore us to sanity and deliver on the triple aim.

3. Recognizing the finite nature of healthcare resources we made a decision to dedicate our will and our professional lives to the pursuit of the triple aim and the associated sustainable healthcare economy.

4. We made a searching and fearless moral inventory of our contributions to a seemingly ‘resistance is futile’ healthcare borg.

5. We admitted in our silo-ed huddles and to one another the aggregate nature of our collective wrongs.

6. We were entirely ready to have a calling to the ‘greater good’ transform a profit maximization – at any expense- operating culture.

7. We humbly asked our ‘higher power’ for faith in value based healthcare and for support to let go of the fee for services addiction.

8. We made a list of all patients, payers, or employers we had harmed, and became willing to make amends to them all.

9. We made direct amends to such stakeholders wherever possible, except when to do so would injure them, others or our ability to facilitate the journey from volume to value.

10. We continued to take personal inventory and when we felt the temptation to default to legacy inertia promptly admitted it.

11. We sought through mindfulness, meditation and collaboration to improve our vision and practice of value based healthcare, sharing openly for the knowledge, capacity and willingness to deliver this historically elusive goal.

12. Having had a professional if not spiritual awakening as the result of these steps, we tried to carry this message to one another and practice these principles in all our affairs.