Accountable Care, health innovation challenges, HealthIT, population health

On the ‘N of 1’ As a Standard for ‘Accountable Care’

by Gregg A. Masters, MPH

When I penned the post, ‘CTE on the Accountable Care Agenda? Junior Seau it’s latest victim?‘ in 2012 my intention was to draw a circle around seemingly unrelated events now finding increasing conversational gravity in the emerging ‘population health‘ zeitgeist where social determinants of health are valued as strategic grist for the mill of health systems and especially their ‘integrated‘ bretheren’s leadership.

It was also my hope that the commentary might generate some sober conversation in the healthcare social media, healthtech and healthIT social media communities. Much to my dismay, there was none.

The causes of this silo-ed, episodic, ‘we’re not concerned with life or health related events that occur beyond the walls of our cathedrals of medicine‘ sick care focus are well known and documented. Though mitigated somewhat by select provisions in the Affordable Care Act with emphasis on transitions of care, avoidance of 30 day re-admissions and continuum of care coordination particularly in the long term, post acute care (LTPAC) space, it’s mostly ‘modified” business as usual in U.S. Healthcare operations.

Oft referred to as the ‘burning [fee for services] platform‘ now clearly in the crosshairs of regulators, health industry leadership, payors, employers and even patients as the source of the problem, everyone is now focused on ‘value based healthcare‘ as the ecosystem’s likely successor footprint.

Yet, we do have a long way to go.

Case in Point

As someone who’s been in the belly of the beast of the ‘healthcare borg’ dating back to the mid 70s, I have witnessed and been to more or less degrees both a strategist (‘disruptor’) and implementation principal to successor waves of ‘innovation’ – ALL intended to tame the rapacious appetite of our ‘do more to earn more‘ healthcare financing and delivery ecosystem.

Decades later the bottomline is we’ve failed, writ large and collectively as an industry. The healthcare spend run rate as a percentage of GDP (then 8%) is now approaching 18-20%., where one out of every five dollars spent in the U.S. finds its way into the coffers of the silo-ed sick-care system we’ve collectively co-created. And while the change or re-engineering imperative was then limited and contained behind mostly closed door board rooms of health systems, health plans and large self funded employers or multiple employer trusts, today that ‘conversation’ is top of mind for our nation. Then, only corporation’s and government’s financial stability were ‘at risk’, today it’s entire nation states at peril.

So clearly something must be done. It must be bold (all inclusive), truly innovative and impactful. No mere tweaks at the margin will do and this may be the last hurrah for a public/private partnership to succeed before the Government has to intervene and solve the problem from the ‘top down’.

Enter the Triple Aim, Value Based Healthcare and the Population Health Mandate

There is non-stop discussion at meetings, conferences, webinars and expositions on the subject of a structural and scaleable pivot of ‘U.S. Healthcare Inc.’, from it’s Fee For Services (FFS) roots and incentives to a successor, sustainable version. Perhaps best framed by Don Berwick and the Institute Healthcare Improvement (IHI) as the ‘triple aim’, the charge to healthcare industry leadership is for a better experience of care, with better outcomes at lower per capita costs.

This ambitious tasking rightly shifts the focus of health system leadership from that which is customarily provided within the walls of the acute – and now subacute – delivery system operating units, to the ‘upstream‘ arguably ‘roots’ of the social determinants of health as discerned by proactive risk stratification coupled with outreach to defined populations.

Technology As Enabler?

Concurrent with the pre-occupation on value based healthcare and emerging focus on population health management, we’ve been discussing and evidencing the value of ‘mhealth’ or ‘digital health‘ apps, platforms and technologies to nest inside current clinical workflows (and beyond?) and fuel delivery of the triple aim. Yet, closing in on a decade later (the iPhone launched in 2007) there is sparse and limited evidence of the salutary benefit of digital health apps to make a dent in the aggregate quality, cost and access challenges we face as an industry.

Whether we’re in collective denial, have all drunk the ‘kool-aid’ thinking this time will be different or simply point to some evidence based believe or faith that technology can serve the greater good of the triple aim’s goals, the expectations and stakes are high – very high in fact. Much talk about contributions from AI, Big Data, Gamification, VR, the Internet of Things and even the Internet of Medical Things, all get woven into often lofty forward looking tech-speak and even policy solutions of how we’re going to make this happen. Yet is this warranted?

A Long Way to Go

A recent experience of mine suggests much work remains ahead. As indicated in the Junior Seau (RIP) post there is a grand canyon divide between the ad copy and rhetoric of population health initiatives and current healthcare operations and financing.

In November I moved to South Lake Tahoe for the ski season. I am 65, in general good health and reasonably active (I surf in San Diego) and recently qualified for Medicare and chose to enroll (i.e., assign my benefits) to a private sector alternative operating under Part C as the ‘Medicare Advantage’ (NOTE: which is a misnomer, since it isn’t Medicare but rather a private and in some markets ‘enhanced version’ when when the health plan is profitable) program organized by Kaiser Permanente in San Diego California. Kaiser Permanente (KP) is a trophy IDS (integrated delivery system) and is often and rightfully acknowledged as ‘best in class‘ in their approach to the organization, delivery and financing of healthcare services. I agree, and thus elected to enroll via their ‘Senior Health Plan‘.

KP has made enormous investments in HealthIT having adapted EPIC to serve their regions’ individual operating units. KP has also embraced technology and innovation via their Garfield Innovation Center and present with a well staffed and focused social media enterprise that seems linked to its member services group.

The Event

On Friday, I headed up to the summit at Heavenly Mountain with my girlfriend Lori. Upon exiting the Gondola and traversing up to the Ski lift to the Summit I started to feel light headed, stopped, looked up and collapsed backwards. According to Lori:

‘your eyes rolled up, your face went pale and you looked expressionless. I was alarmed.’

None-the-less, determined to get to the top for the first run of the season I elected to proceed and we entered the lift to the Summit. On the way up, we had cross winds gusting between 20-30 MPH. The temperature hovered in the low 20s to teens and the air was thin and dry.

I was wearing a ski dickey and found it difficult to speak and breath. Clearly this was not normal. Yet, we exited (9500 foot elevation) and began our decent down to Tamarack Lodge. Midway through the run I stopped, began to feel light headed and very dizzy. Gasping for air, I leaned onto my poles and then everything went dark. I collapsed again.

Lori took charge, summoned the ski patrol via a passing skier. Ski Patrol arrived, placed me on oxygen, suggested I was experiencing altitude sickness and STRONGLY recommended immediate descent to the Heavenly Center for hydration and rest (65oo foot elevation).

The Social Stream – More than What I Had for Lunch

Once the fog lifted and I began to feel better, I decided to tweet my experience in the public square and tag my health plan (KP San Diego, the Heavenly Ski Center and my Twitter ‘friends’) to alert them about my experience. For both my twitter colleagues and the Heavenly Center it was an FYI with a Ski Patrol shout out to Nathan (the EMT).

For KP San Diego it was a ‘heads-up’ as in hey, this happened to me today and ‘I think you should know.’ Now I know KP has a patient portal via MyChart and one I’ve been in and out of a few times, in addition to a ‘go to the emergency department‘ when in need advisory. Yet, we’re in the age of population health, risk assessment, prevention and ‘patient generated health data’ (PGHD) including massive investments in ‘listening’ technology for the rich streams of content posted to social networks.

Now add the fact that healthcare is a litigious and thus risk averse environment. Therefore sitting on the sidelines and at best ‘listening’ is probably less risky than realtime or ‘asynchronous’ attempts to ‘intervene’. I’m sure a bevy of corporate lawyers counsel against ill advised engagement outside the normal ‘theater of operations’. Yet, I am old enough to remember when the Darling and Nork cases began to peck away at the immunity from liability traditionally argued by many hospital administrators that ‘we’re just the doctor’s workshop’ and have no control (and by extension no liability) for their actions. Yup, that once was the standard of practice a few decades ago.

The Messaging

Here are the series of tweets posted related to this narrative.

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The Health Plan’s Response

Several days later… and in ‘async’ fashion KP weighed in via Direct Message on Twitter. I previously tweeted about my inability to reschedule a colonoscopy from a San Diego location to the Sacramento area since I am in South Lake Tahoe for the ski season. I learned that I could NOT opt for a local option as the health plan didn’t operate that way [paraphrased]. The tweets below pertain specifically to the incident on the mountain.

9:19am
@KPMemberService
Hi, Gregg. I noticed your recent tweets and wanted to follow back up with you. If you’ve already sent your email, we have not received it. Can you please resend it? Thank you! ^Jamison

9:49am
Gregg Masters MPH @2healthguru

No point in sending log to you. After DM, spoke to my PCP. She advised I can not schedule colonoscopy in NorCal (Sacramento) w/o changing PCPs. Suggested we delay until I return to Oceanside in April. Really bad form for KP. If true, you are NOT an IDN, but a federation of providers under a common marketing banner with discrete regional accounting, but worse clinical operations. I am VERY disappointed, since I am and have been a fan of KP. I am 65. I’ve been self employed since 2000, and un-insured by choice since. My health plan is my health. If KP is committed to my health, then a simple risk profile of these facts would expedite the colonoscopy as a preventive tool. I shouldn’t have to point this out to my health plan. Then add my fainting on mountain at Heavenly (9500 foot elevation) with minimally hypoxia if not cerebral edema, AND ZERO recognition or comment from @KPsandiego who I tagged [in tweet]. I mean seriously, with the investment made in tech, how can you not leverage proactively on behalf of your members? I am shocked. If this is M-F brand listening tool only and not deployed as adjunctive to KPs clinical risk management surveillance program, you are clearly missing the boat of the PGHD wave that is sweeping the ecosystem under the banner of ‘digital health’ tools. Again, I am a KP fan and believe you need be held to a higher standard given all the accolades received via others in the industry. Please pass this concern in its entirety to both Robert Pearl and Bernard Tyson who I personally hold responsible for these systemic (x2) ‘fails’. I am blogging about this experience (including this response) as a N of 1 example of ‘accountable care’ in the new age of population health contextualized via social [i.e, lifestyles of] determinants of health plan members (including their known risk profiles). Thanks for asking. My concerns go considerably beyond the usual scope of member services, and I do hope you pass on my comments in their entirety to senior leadership. My blog comments will be posted to @ACOwatch as my N of 1 version of ‘accountable care’ to this post: acowatch.me/2012/05/02/cte… Thanks Gregg

@KPMemberService
Thank you for your detailed reply, Gregg. I will definitely make sure to pass along your experience and concerns to our senior management staff. ^Jamison

Much To Do About Nothing or Reflexive Provider vs. Patient Centric Response?

One can argue,  hey dude work within the system, i.e., call/alert KP via member services, enter a note to your PCP in the MyChart portal or head to an Urgent/Emergent Care Center – quit whining.

Yet, am I wrong to think that in an era of ubiquitous, real time and ‘asynchronous’ tech stacks afforded by major social networks where participants are ‘tagged’ as in a ‘headsUP’ fashion, need be viewed solely as a forum for posted images of cats or what’s on the menu today?

When and where do we walk the talk of the upside of digital health tools, the value of patient generated data and the big data and massive analytics engines that routinely data-mine these streams for population health insights and actionable ‘intelligence’?

So maybe this is just too much to expect even from best in class performers – the likes of KP. Maybe the residual ‘resistance ifs futile’ legacy inertia is just too powerful to overcome systemically and we’ll just have to be happy with at best tweaks at the margins.

I for one think we need to up the ante and hold both the providers and financiers accountable to this dysfunctional ecosystem we’re so often powerless to influence or change.

I am committed to make a difference. Where are  you?

 

 

 

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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!

 

Accountable Care, health reform, JP Morgan Healthcare Conference, Medicare

Must listen JP Morgan Healthcare Conference Webcasts: @MolinaHealth

by Gregg A. Masters, MPH

NOTE: This is the third 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, the second on Centene. For background and details on this august annual 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, Genomic Health,Universal American, Tenet Health, as well as several from the ‘non-profit’ (tax exempt) sector including Baylor Scott and White

Molina Healthcare’s operations and strategy positioning insights are similar to Centene and in many ways constitute bell weather operators in the same space. Market and performance comparisons 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 Molina Healthcare profile, click here, the deck here and webcast, here.

Meanwhile, below are some slides which outline the company’s performance and market sector overall:

JPM_MolinaHealthcareJPM_MolinaHealthcare_revenueJPM_MolinaHealthcare_membership

 

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JPM_MolinaHealthcare_medicaid
JPM_MolinaHealthcare_medicaid_growth JPM_MolinaHealthcare_medicaid_spend

JPM_MolinaHealthcare_acquisition JPM_MolinaHealthcare_year_ahead

 

 

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

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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/

Accountable Care, ACO, Affordable Care Act

Tom Scully Tutorial & Diagnosis of Medicare Program

By Gregg A. Masters, MPH

washington journal scully on medicareAn excellent ‘tutorial’ of sorts on the Medicare program is provided by Tom Scully, former Bush era (2001-2004) administrator of the Centers for Medicare and Medicaid Services, who opines on the Medicare and Medicaid Acts of 1965.

He discusses President Lyndon Bain Johnson’s vision of the bill and looks at the present state of the program including his preference for ‘means testing’, the role of Medicare Advantage and issues associated with the expansion of Medicaid via the Affordable Care Act.

Scully also fires a shot over the bow of the The National Committee to Preserve Social Security and Medicare claim via ‘Top 10 Reasons Americans Love Medicare‘ questioning the relative ‘efficiency’ of the program compared to it’s commercial equivalents or fee-for-service (‘traditional’) Medicare.

7.  Medicare is efficient. Only 1% of traditional Medicare’s spending is overhead compared to 9% for private insurance and 6% for privatized Medicare (aka Medicare Advantage plans).

Scully notes:

Yeah, I think that’s completely and totally wrong… I’m trying not to be partisan and be objective on this. But look  Medicare is a wonderful program. It’s incredibly efficient….but basically what Medicare is it’s a single payer system where the Government pays every doctor in Toledo and every hospital the same thing. So the problem is as you have in any system – in the history of any economy in the world – when you fix prices, is volume…. so what you get is competition over volume….which is what they are incentivized to do…  

Regarding CMS, on the ‘efficiency’ claim Scully notes, perhaps in a moment of hyperbole:

I love CMS. The employees are great. They have no clue what’s going on in the healthcare system…it’s just by design that they don’t.

The video segment is courtesy of Washington Journal with original source link here. For a chronology of Medicare see: ‘Medicare Turns 48‘ courtesy of AARP.

For additional Scully insights see: ‘Care Innovation Summit: A Very Sober Assessment!

NOTE: If only Scully type rationality were native to the ‘don’t confuse me with facts’ oppositional Republican mindset of some these days, we’d be more about fixing problems than blame – just saying.