Accountable Care, ACO, Affordable Care Act

The Evolution of ACOs

by Gregg A. Masters, MPH


Recently the accountable care industry’s leading ‘skin in the game‘ PPMC 2.0 aka ACOcor equivalent (think PhyCor, MedPartners, FPA Medical, et al) of our time – though Aledade’s model is anything like the pyramid scheme of the PPMC (physician practice management companies) of the 1990s, reviewed the Center for Medicare and Medicaid Services (CMS) recent Notice of Proposed Rule Making (NPRM): CMS Proposes “Pathways to Success,” an Overhaul of Medicare’s ACO Program‘. 

Below are key take-aways from the presentation. The entire webinar is accessible free upon registration here

I will post the Q & A thread that Farzad Mostashari, MD, CEO and Travis Broome, VP, Health Policy, respectively Aledade shared on twitter as well.

Meanwhile, here’s the gist of their analysis and message:

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Accountable Care, ACO, Affordable Care Act

On ACOs and their ‘Stealth’ Upside via @Farzad_MD CEO @AledadeACO

by Gregg A. Masters, MPH

For those of you not on twitter and not following the former National Coordinator for HealthIT and now co-founder and CEO of ACO ‘Management Company’ Aledade, Farzad Mostashari, MD, I’m pasting his rich thread on ACOs and the prospects for its near term future as a tool in the healthcare finance and delivery arsenal. Conventional wisdom is and for the most part remains that ACOs are a ‘mixed bag‘ of predominantly ‘upside only’ (gain sharing), HMO-lite value based healthcare initiatives under the Medicare Shared Savings Program (MSSP) with at best mixed results on projected savings (variably calculated) to the Medicare Trust Fund.

Recently, CMS Administrator Seema Verma upped the value based transitional ante accelerating ACO movement into ‘risk’ issuing the Notice of Proposed Rule Making (NPRM) “Pathways to Success,”  see ‘CMS Proposes “Pathways to Success,” an Overhaul of Medicare’s ACO Program‘.

NOTE: For additional context on the thread offered by Farzad, check out: Founder and CEO of ACO Management Company Weighs in on Regulatory Uncertainty‘.

Posted Thursday, August 30th 2018 by Farzad Mostashari, MD  @Farzad_MD

1/ 2017 #MSSP#ACO Results! ACOs have scaled rapidly across the country! In aggregate, the 472 ACOs were accountable for nearly 9 million Medicare beneficiaries and $95 Billion – that’s a quarter of all fee for service, and almost half of the entire Medicare Advantage market.

2/ If you add up all the actual costs versus benchmarks, these 472 ACOs were collectively $1.1B under their benchmarks (more on whether that’s the right counterfactual later). Medicare shared $780 million in payments with the ACOs, netting the taxpayer $313M.

But wait! There’s lots of evidence that the benchmark underestimates the savings produced. @JMichaelMcW et al have shown convincingly that a true “difference in difference” approach would show substantially higher net impact. The green eyeshades folks at CMS OACT said add 60%.

3/ So that means that the best guess for MSSP savings is actually $1.75B in 2017, with Medicare paying out $780M (45%) – not a bad deal for the taxpayer!!! That does NOT count savings that come from lower costs to the taxpayer from Medicare Advantage rates that are And on quality – the average ACO earned 92% on their quality scores- and the scores improve the longer you are in the program according to the ACO Rule’s Regulatory Impact Assessment. 

4/ Here’s how the CMS actuaries put it:

And on quality- the average ACO earned 92% on their quality scores- and the scores improve the longer you are in the program according to the ACO Rule’s Regulatory Impact Assesment. (The Aledade average quality score applied was over 95%, and as high as 99.8% #GoKANSAS)

farzad aco data quality

6/ Lemme say that again…. ACOs saved Medicare over a Billion dollars in 2017. Cheaper than FFS, cheaper than MA. And they did it without cutting payments to doctors or narrow networks And they did it with higher patient quality. That’s called delivering what was promised.

7/ the Track 1 ACOs more than held their own here Best guess is that Track 2/3 generated 190M in savings (w 60% spillover) and received $95M (50%) Track 1: $1.5B in savings, $685M in payments (44%) (I’m still a believer in moving to 2-sided risk to help weed out ACO squatting).

8/ You know what was a great investment? Giving small and rural physician-led ACOs an advance payment to help them invest in infrastructure and setup costs. It was critical to the success of several of our @AledadeACO. More commercial payors should do this!

farzad aco data49/ But what this initial release does not help us do is see which type of ACOs are creating the most value. My guess is that it’s not much different from what the CMS actuaries found for PY 2016 – ACOs that include hospitals and directly control more of the cost of care do worse.

farzad aco data510/ The “low revenue” ACOs (in the OACT analysis – less than 10% of total cost of care came to them) were only a third of the lives in the program, but generated roughly 98% of the savings. THAT is why in the ACO Rule CMS proposed letting them stay in low risk models longer.

farzad aco data611/ That was the entire thesis behind “the paradox of primary care leadership” that informed the founding of @AledadeACO That is also why @AledadeACO partners with independent physician practices, not hospitals like others do. jamanetwork.com/journals/jama/…

12/ A quick analysis by the amazing @Travis_Broome divides these 2017 results by whether the ACOs included a “facility/CCN” (CAH, RHC, FQHC don’t count for this purpose) – Same pattern- 95% of the savings are coming from the ACOs that don’t include hospitals.

farzad aco data7

13/ Only 3.5M of the 9M ACO – attributed benecificries were cared for by the smaller ACOs that didn’t include a hospital facility- and they generated 95% of the savings. If you’re an independent practice seeing these results and the policy direction, why would you join a hospital ACO?

So how did @AledadeACO do? We are always very transparent with our results- even when things didn’t go our way- to look for ways to be better, and to make policies better that are holding back broader success. This article 2 years ago was full of pain. ajmc.com/journals/issue…

15/ This was a good year for @AledadeACO. Only 1/7 freshmen ACOs made savings – but we have learned to set expectations – it’s a long game. But 5/8 ACOs that were sophomores or older will get checks. And 2/3 that didn’t get MSSP crushed it in commercial contracts.

16/ But I’m more proud that EVERY ONE of our @AledadeACO have measurably improved health for the patients we are accountable for. We have increased wellness visits, transitional care, and chronic care management- and that’s translated into lower ED visits and readmissions.

farzad aco data8

17/ So where do we go from here? The #MSSP#ACO program has been a hugely successful motivator of nationwide transformation, but it can be reformed, and I believe @SeemaCMS is on the right track. Here’s what I would expect might change between the NPRM and the final ACO rule:

18/ The GlidePath to risk reduces ACO squatting, and brings revenue-based downside risk to MSSP, but the lowered gainshare in 1st 2 years (25%) is not enough to get new entrants and ACO investments. (as suggested) “low revenue” ACOs should get higher gain-share and lower MSR.

farzad aco data9

19/ The refined benchmarking method gives greater predictability by allowing risk adjustment and regional trending-which is great! But the cap on risk adj (3% over 5 years?!) don’t control for rising risk and introduces gaming on falling risk Instead of a cap, do renormalization.

20/ Concern about “windfall profits” led to an ill-advised proposal to cap regional efficiency at 5% – In Medicare Advantage if you are efficient, you get to keep the difference, which has spurred huge innovation in the space. why blunt improvement? 100% tax brackets are not good.

21/ Credit to CMS for trying to fix the unintended “regional comparator” problem – where rural ACO savings are reduced in direct proportion to market share. But the “national trend blend” proposal makes NO SENSE. Let’s just take ACO beneficiaries out of the regional comparison please!

22/ But the biggest impact of these results on the proposed rule should be on the idea that the way to benefit the Trust Fund is to protect it from ACO earnings. These caps, etc reduce ACO earnings – and ACO motivation/participation- and therefore reduced benefit to Medicare.

23/ The NPRM RIA estimates through 2024 these caps push $390M in lower ACO earnings, but lower ACO participation under these policies will INCREASE claims costs by $60M- and would prevent beneficiaries from receiving the benefits of the program. That’s not the right balance.

farzad aco data10

24/ The magic of accountable care is when physicians & Medicare partner together to sustainably align financial incentives, help beneficiaries and the Trust Fund. Medicare hasn’t behaved like some commercial payers who are still seeing zero sum. Let’s hold onto that partnership.

POSTSCRIPT:

As someone who’s been at the strategy table for hospitals, parent health systems, IDNs, or managed care joint ventures of all stripes AND an early adopter of this medium (I signed on to my twitter account in August 2008) believing the technology has the potential to ‘democratize healthcare’ from it’s provider centric DNA and fee-for-services fueled addiction to build ‘Cathedrals of Medicine’ separated by moats and silos from the very constituency they ostensibly ‘serve’, I’ve alternated from optimism to pessimism.

While we’ve seen some progress to date with a fair amount of co-opting, compromise and commercial exploitation along the way, I remain committed to the medium and those I follow who offer me both insights, and the connectivity to continue to refine my thought process and leadership contributions whether it be on twitter, our podcast series at This Week in Health Innovation, Health Innovation Media‘s video library,  PopHealth Week or ACO Watch blog posts. If you are NOT following @Farzad_MD or @AledadeACO, and are in the value based healthcare or accountable care space, I strongly recommend you do!

Accountable Care, ACO, Affordable Care Act

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.

 

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?

 

 

 

Accountable Care, ACO, Affordable Care Act

The NextGen ACO: Another Round Opens

by Gregg A. Masters, MPH

The Centers for Medicare and Medicaid Innovation has announced the results of its ‘continuous learning‘ commitment model wherein ‘field reports‘ including provider comments and open door inputs are materially incorporated into tweaks of the Medicare Shared Savings Program (MSSP) as risk is progressively adopted by participating ACOs. This ‘new round’ iteration no doubt includes ‘lessons learned‘ from the Pioneer ACO Program including the many ‘exits’ and risk downgrades opted to date.

In summary, this round is:

‘..one that sets predictable financial targets, enables providers and beneficiaries greater opportunities to coordinate care, and aims to attain the highest quality standards of care.’

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For complete information, see: ‘Next Generation ACO Model | Center for Medicare & Medicaid Innovation‘.

 

 

Accountable Care, ACO, Affordable Care Act, TrumpCare

TrumpCare: As the Puzzle Emerges…

by Gregg A. Masters, MPH

As the Trump administration takes form via the nomination of Rep. Tom Price to ‘steward’ (or decimate) the massive bureaucracy of the Department of Health and Human Services (HHS) with Seema Verma nominated as Administrator of the Centers for Medicare and Medicaid Administration (CMS) the structural touch-points to manifest the ‘repeal and replace‘ agenda of the Affordable Care Act (ACA) may be materializing before our eyes.

medscape_physician_survey2016Dr. Tom Price a Board Certified Orthopedic Surgeon (Editor’s note: the highest paid specialty per Medpage 2016 physician compensation survey and according the the Georgia Combined Board of Medical Examiners a ‘non participant’ in Georgia’s Medicaid program, with zero reported hospital appointments, publications or settled professional liability claims) and a vocal opponent of the ACA with several bills sponsored to enable ACA’s repeal and replacement is no friend of Medicare, Medicaid nor the broader ecosystem enabling the fulfillment obligations of the U.S. healthcare ‘[non]system‘.

Much of this likely health policy directional pivot can be reasonably visioned though the lens of what’s emerging as indicia of ‘TrumpCare‘ – the probable repeal and replacement option for ‘ObamaCare‘ aka the ACA.

In order to drill into what we can expect from President-elect Trump and the leadership team he’s proposed to assemble in order to drive his presumptive health reform vision we need focus on Rep. Tom Price’s historical positions and statements as potential replacement options.

The umbrella policy framework for for what may emerge as ‘Trumpcare’ begins at ‘Great Again‘ the .gov website dedicated to the President-elect’s agenda, and informed viaA Better Way (aka RyanCare) the Republican version to substitute ‘Government controlled‘ healthcare with so-called ‘free market‘ alternatives.

[Editor’s Note: At the bottom of this post we list a series of recent links associated with relevant health reform conversations].

Perhaps the most useful insights as to what is likely to survive the political consideration process is sourced from the collection of Republican authored repeal and replace proposals sourced from the historical work of Representative Tom Price.

At a June symposium organized by the American Enterprise Institute (AEI), Rep. Price, who serves as Chair of the House Budget Committee previewed his vision of healthcare reform with the following summary statements:

‘the ACA violates all of the principles that all of us hold dear…. accessible, affordable, a system of the highest quality and a system that provides choices for the American people – for patients.’

‘What we have put together is a patient centered plan that respects those principles. That allows everybody to have access to the coverage that they want not what the government forces them to buy.’

‘To solve the insurance challenges of portability and pre-existing and to save hundreds of billions of dollars.’

‘A few specific examples I’d like to share with you…

‘the individual and small group market – those of you who recognize or are in that area [Editor’s Note: code-speak for special interest groups including brokers, agents, MGAs and underwriters] you appreciate that its been ‘destroyed’ [Editor’s Note via essential health benefits, no preexisting conditions, mandatory MLR ceilings, removal of lifetime caps and the individual mandate] and so we want to re-constitute that market and make it responsive to patients and allow them to purchase the kind of coverage that they want [Editor’s Note: via a return to ‘junk insurance’ and ‘mini-med’ policies] not what the government forces them to buy [Editor’s Note: on the exchanges or via ACA sanctioned group health policies].’

‘Second we waste hundreds of billions of dollars [Editor’s note: estimated at a $55.6 Billion Price Tag Large, But Not a Key Driver of Total Health Care Spending] …due to lawsuit abuse in this country, the practice of defensive medicine and instead of just putting a band-aid on it, we propose a bold and robust solution that would allow physicians through practice guidelines [Editor’s note: Evidence Based Medicine, or so-called “cookbook medicine” by the AMA] to basically have a “safe harbor” [Editor’s note legal CYA] if your doctor does the right thing for a given diagnosis or given set of symptoms then they ought to be able to use that as an affirmative defense in a court of law – that’s the kind of proposal that we put forward.’

‘And third in addition the healthcare system that works for patients is one the must respect the physician patient relationship [Editor’s note: typically third party disintermediated practice, i.e. direct practice, concierge medicine, retainer or membership models] and so what we do is incentivize the highest quality of care without bureaucratic intervention. This better way, this plan right here that puts forward positive commonsense solutions for Medicare, Medicaid and for the larger healthcare arena so that we respect the principles of accessibility, of affordability of quality and of choices…’

There is so much fluff here we decided to do a deep dive on ‘PopHealth Week‘ with healthcare thought leaders and former health system and JV enterprise operators Fred Goldstein, Douglas Goldstein and Gregg Masters. We weighed in on some of the provisions of Representative Price’s tantalizing offers to the American people to deliver a viable alternative to the ACA that:

‘allows everybody to have access to the coverage that they want not what the government forces them to buy;

solves the insurance challenges of portability and pre-existing; and

saves hundreds of billions of dollars.’

You be the judge! Or as some may be recently awakening to: ‘Republicans suddenly discover that Obamacare repeal might not be so awesome, after all‘ or ‘Senate GOP Tips Its Hand: An Obamacare Replacement Could Be A Long Way Off‘.

If like me you are interested in how this unfolds I encourage you to follow the conversation on twitter via #PriceWatch and #TrumpCare hashtags.

More will no doubt be revealed! Some earlier context here and here.

Let’s drain the swamp, after all we now what works!

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Trumpcare Resources c/o Fred Goldstein:

https://www.donaldjtrump.com/positions/healthcare-reform

http://www.cbsnews.com/news/what-will-trump-do-about-obamacare/

http://www.politico.com/story/2016/11/obamacare-defenders-vow-total-war-231164

https://www.govtrack.us/congress/bills/114/hr3762/summary

http://healthaffairs.org/blog/2016/11/09/day-one-and-beyond-what-trumps-election-means-for-the-aca/

http://www.commonwealthfund.org/publications/blog/2016/nov/challenges-for-president-elect-trump-and-congress?omnicid=EALERT1125198&mid=fgoldstein@accountablehealthllc.com

https://www.greatagain.gov/policy/healthcare.html

http://www.dailykos.com/story/2016/10/23/1584745/-Paul-Ryan-has-three-great-ideas-to-improve-Obamacare

http://www.theatlantic.com/health/archive/2016/11/our-bodies-our-trump/507131/

https://www.greatagain.gov/policy/healthcare.html

http://www.commonwealthfund.org/publications/blog/2016/nov/challenges-for-president-elect-trump-and-congress?omnicid=EALERT1125198&mid=fgoldstein@accountablehealthllc.com

http://www.dailykos.com/story/2016/10/23/1584745/-Paul-Ryan-has-three-great-ideas-to-improve-Obamacare

https://www.washingtonpost.com/news/wonk/wp/2016/11/12/donald-trump-is-beginning-to-face-a-rude-awakening-over-obamacare/

http://www.nationalreview.com/article/442120/obamacare-repeal-republicans-should-ensure-health-care-reform-bipartisan

http://blogs.wsj.com/briefly/2016/11/10/5-questions-about-affordable-care-act-coverage-after-donald-trumps-election/

http://www.johnsoncitypress.com/News/2016/11/13/What-would-health-care-look-like-under-Trump.html?ci=stream&lp=1&p=1

http://www.wsj.com/articles/donald-trump-willing-to-keep-parts-of-health-law-1478895339

http://www.healthcaredive.com/news/speculations-swirl-around-trump-hhs-leadership-pick/430301/

https://www.sciencebasedmedicine.org/medical-science-policy-in-the-u-s-under-donald-trump/

http://thehealthcareblog.com/blog/2016/11/13/dear-mr-president-elect-about-that-ryan-plan-thing/

http://www.modernhealthcare.com/article/20161111/NEWS/161119989?utm_source=modernhealthcare&utm_medium=email&utm_content=20161111-NEWS-161119989&utm_campaign=mh-alert

http://www.hhnmag.com/articles/7843-health-reform-and-the-trump-white-house-implications-for-key-stakeholders?utm_campaign=111516&utm_medium=email&utm_source=hhndaily&eid=254508792&bid=1588113#.WCsKPQk6jpM.twitter

http://www.politico.com/tipsheets/politico-pulse/2016/11/obama-dares-gop-on-obamacare-do-it-better-than-me-217419

http://www.vox.com/2016/11/17/13626438/obamacare-replacement-plans-comparison

http://www.wnd.com/2016/11/7-keys-to-effective-health-care-overhaul/

http://www.nationalreview.com/article/442529/obamacare-donald-trump-repeal-replace-tax-cuts

 

Accountable Care, Affordable Care Act, health reform

TrumpCare: What We ‘Know’?

by Gregg A. Masters, MPH

You’ve no doubt heard the expression: ‘a picture is worth a thousand words‘.

Well courtesy of Oliver Wyman Health we have an infographic that segments key provisions of ‘TrumpCare’s‘ impact on providers. For original graphic, click here, and timely commentary, see:Special Election Coverage: What Now? The Impact of a Trump Presidency‘ via Partner Sam Glick.
TrumpCare Impact on providers

Oliver Wyman breaks down the identifiable components of TrumpCare’s impact on providers as follows:

TrumpCare screen-shot-2016-11-15-at-10-06-48-am screen-shot-2016-11-15-at-10-07-00-am

 

So much ‘meat’ remains to be put on the bone. Assuming anything whether ‘substantiated’ by previous campaign rhetoric or more recent ‘indicia‘ of what will emerge post ‘repeal and replace‘ or now ‘amend’ intentions relative to the ACA (see: ‘As the TrumpCare Pivots Begins‘) is without a doubt ‘faith based‘ reliance on what remains essentially an aggregate ‘hologram‘ of President-Elect Trump’s health reform agenda.

Stay tuned!