Accountable Care, population health

Accountable Care, Population Health and the Social Determinants of Health

by Fred Goldstein, M.S.

Recently I took part in the Florida Trail Association (FTA) Annual Conference. The FTA develops, maintains, protects, and promotes a network of hiking trails throughout the state, including the unique Florida National Scenic Trail (FNST). This event celebrated the 50th Anniversary of FTA founding.

A Brief History

The National Scenic Trails were authorized under the National Trails System Act of 1968 that began with the naming of the Appalachian Trail (AT) and Pacific Crest Trail (PCT) as the first National Scenic Trails. The AT was originally founded by Benton MacKaye and completed in 1937. It’s over 2,000 miles long. Earl Shaffer was the first person to do a complete single thru-hike of the AT  in 1948. Earl was a soldier returning from World War II who said he was going to “walk off the war”.  More on this and its relevance to current day later.

Jim and Fred at the unveiling of the sign

The Florida National Scenic Trail another of the eleven National Scenic Trails is about 1,300 miles long and has its own originator, Jim Kern. The weekend was a well-earned celebration of Jim’s vision to establish the Florida Trail 50 years ago.  Jim is also a co-founder of the American Hiking Society, and founder of Big City Mountaineers which takes under-served urban youth through wilderness mentoring expeditions.

Jim has become a friend and I am now assisting him as a Board Member of  yet another organization he founded, Friends of the Florida Trail. Most people are not aware that the only National Scenic Trail that is complete from end to end is the Appalachian Trail.  All of the other trails have hundreds of miles of gaps which require hikers to walk along roads and highways, limits access to sections, has access that can be withdrawn at any time and trail routes are constantly changing as a result. Friends of the Florida Trail is working to find a way to complete the Florida Trail.

Hiking and Population Health

Fran Mainella while working at the NPS

So how does my interest in the Florida Trail and getting outdoors relate to my work in Population Health? Well its really quite simple and in fact the guest speaker, Fran Mainella addressed it in her presentation.  Fran was the 16th Director of the National Parks Service under President George W. Bush and before that she was director of the award-winning Florida State Parks for 11 years.

As she said said and I am paraphrasing:

“At the same time that outdoor places and trails seem see to be becoming less relevant to our youth with the advent of new technologies, the internet, online gaming, Facebook, Snapchat and messaging, we have become more aware that getting outdoors, walking and hiking have incredible health benefits.”

We have both seen the link that needs to be created between the healthcare system and these outdoor locations and activities to improve the health of our country. The healthcare system and the trail associations can come together in a mutually beneficial way. It’s a golden opportunity for health plans, hospitals and other providers to promote and create health in their populations while supporting a great cause, the awareness, use and protection of these outdoor assets.

img_6072Our long distance trails provide  even more reason to be supported and this was clearly expressed in what I felt was the best presentation of the entire event. The presentation was given by two recent veterans who discussed Warrior Expeditions and Warrior Hike. As mentioned above, Earl Shaffer thru-hiked the AT after WW II to “walk off the war”. Many of the men and women returning from Afghanistan, Iraq and other places, come back suffering from PTSD and other stress related issues. Warrior Hike, working with Georgia Southern University and other sponsors provides these returning veterans with the opportunity to thru-hike many of the National Scenic Trails to “decompress from their military service and come to terms with their wartime experiences”  or as one speaker said “deal with these demons.”

This year, six veterans began a thru-hike of the the Florida Trail and five completed it. The veterans told incredible stories of their journeys on the Florida Trail and how these long distance hikes positively changed their lives’, providing them with some healing from the trauma they faced.

All of the National Scenic Trails are amazing places, not just because of their beauty, but because of their ability to impact our health, both physical and mental; they are more than just a “walk in the woods” they are about Well-being for us and future generations. We should do all we can to protect and complete them.

A Few More Conference Highlights

There are two other things I’ll mention about the conference.

Ben Montgomery author of  Grandma Gatewood’s Walk gave an engaging presentation. This book, a Pulitzer Prize Finalist is worth a buy. It’s a great story about an amazing woman Grandma Gatewood, who was the first woman and just the 6th person overall to thru-hike the AT in 1955 at 67 years of age. How she did it was unbelievable and why she did it was something we as a society must work to eradicate. Having just completed the book, there’s much more to this story, but I won’t spill the beans.

Kara Montgomery Store Manager of the Jacksonville, FL REI with their award.

In addition to the great presentations, in attendance was  REI and Kara Montgomery.  When REI came to Florida, they located their first store in Jacksonville. Since then I have been able to meet Kara and the excellent staff, purchase many items and introduce them to the FTA. REI has become a strong supporter of the Florida Trail including providing grants in 2014 and 2015.  At this years annual conference they had a booth, provided classes on map and compass and received the Florida National Scenic Trail Volunteer Partner Group of the Year award. Congratulations to REI and Kara and thanks for all of the support you provide to the FTA and other organizations around the country.


Post originally published at Accountable Health, LLC.

Accountable Care, ACO, Affordable Care Act, digital health

Mark (I’m Not a Doctor but So What) Cuban’s Bold Vision or Big Ego?

By Gregg A. Masters, MPH

Mark Cuban CigarLast week witnessed a rather spirited discussion stimulated by a series of tweets from Billionaire owner of the Dallas Mavericks (and anointed judge of entrepreneurial insight on CNBC’s ‘Shark Tank‘) Mark Cuban.

What’s perhaps most poignant in this energetic public exchange is it comes at a time when ‘health’, ‘healthcare’ [and the emerging promise of ‘precision medicine’] including it’s increasing share of GDP (albeit at a decelerating rate of increase) are top of mind for many.

Considering the long, labored and ‘the jury is still out’ nature of whether the Affordable Care Act is necessary and sufficient to cure the ills of volume incentivized but silo-ed U.S. healthcare Mark Cuban aka @mcuban tweeted:

‘If you can afford to have your blood tested for everything available, do it quarterly so you have a baseline of your own personal health’ 

Followed by:

‘create your own personal health profile and history. It will help you and create a base of knowledge for your children,their children, etc.’

‘A big failing of medicine = we wait till we are sick to have our blood tested and compare the results to “comparable demographics”..’

To wit the veteran and respected investigative healthcare journalist and @ProPubica reporter Charles Ornstein aka @charlesornstein replied:

Please don’t listen to @mcuban for medical advice. Paging all doctors.

If you’re tempted to listen to @mcuban, read/listen to this: Is Preventive Medicine Actually Overtreatment?

Then many health-wonks, clinicians, patient advocates and those aligned with responsible healthcare social media stewardship chimed in with their ‘take’ on this exchange including yours truly:

Gregg Masters @2healthguru Timely and good read! via @ddiamond @mcuban Doesn’t Understand Health Care’ c @charlesornstein

Dr. Florence Comite @ComiteMD @mcuban Comparing results to so-called normal range is not ideal. Preferable to use own data. @JCVenter @2healthguru #PrecisionMedicine

Ryan Lucas @dz45tr I’d just assumed he had invested in @theranos. lol. @2healthguru @ddiamond @mcuban @charlesornstein

Michael Tomasson @MTomasson @fqure @2healthguru @mcuban @ethanjweiss @johnpharmd My take:

Gary Wolf @agaricus @2healthguru @lsmarr @mcuban @charlesornstein Don’t think of these tests as entries in a lookup table, but as a basis for learning.

Perhaps the tweet that best framed and unfortunately may prevail in the ‘take-away’ narrative associated with Mark Cuban’s foray into health, healthcare and unwittingly so health-economics was posted by patient advocate and e-health expert Sherry Reynolds aka @cascadia:

Disconnect in medical testing thread @charlesornstein + et al are giving facts @mcuban is building a brand – guess who will win?

While I completely disagree with Mark Cuban and attribute his presumptive perhaps ‘intuitive ‘insights’ to the privileged perch he occupies (I doubt he concerns himself with the cost, systemic impact or health consequences of his recommendations, let alone co-payments, deductibles or co-insurance of his health plan), his argument may align with the broader movement into ‘digital health’ and patient empowerment as most recently expressed by Eric Topol, MD‘s new book ‘The Patient Will See You Now’ which aligns with the likely future of medicine or ‘Medicine 2.0’ – if you will. In this vision clinical medicine is ‘informed by’ genomics and manifests the promise of ‘precision medicine’ to better understand and thus target the fundamental mechanisms of underlying disease pathology and thus prevention.

My net take away from this exchange is reflected below:

Gregg Masters @2healthguru Well if nothing else @mcuban has sure stimulated debate on the value prop of ‘medicine 2.0’. This one via @RogueRad

Meanwhile at The Healthcare Blog Radiologist Saurabh Jha MD further opines in ‘Radiologists vs. Mark Cuban on Don’t Ask / Don’t Tell’ an itemized series of responses to additional queries posed by Mark Cuban.

So back to the ‘bold vision’ or BIG ego’ question: some of this ‘brashness’ may be attributed to what I’ll call the ‘Dallas Effect’ where everything is BIG especially mega-churches, football stadiums, ‘non-profit hospital systems’ and heck even the egos’ of their principal cheerleaders?

Only time will tell who’s on the right side of this narrative. Meanwhile, Mark thank you for your willingness to engage in an important conversation via this democratized medium known as twitter!



Accountable Care, population health, public health

Ebola: What’s Accountable Care Got To Do With It?

by Gregg A. Masters, MPH

I proudly display the ‘MPH” (master of public health) tag awarded by the School of Public Health from UCLA (a long time ago) and have both tweeted and blogged about the ‘we need more MPH’s and less MBA’s’ to solve America’s pressing healthcare challenges (access, affordability and quality imperative or ‘triple aim’) to which we now need to apparently add more robust ‘communicable disease control’ to the ‘value prop’ calculus.

Earlier today I tweeted:

Rick Santelli et al

I meant it…. minimally it’s about your lens, but more importantly ‘values’ in this scramble for purposeful behavior.

It use to be career minded and service oriented professionals where drawn into clinical medicine, the allied health professions (collectively ‘the helping professions’) and healthcare administrative services (their enablers) out of a sense of mission and giving back. So when I enrolled at UCLA in the School of Public Health the ‘route’ into hospital or health services administration was principally via the ‘MHA’ (Master of Health Administration), the ‘MPH’ (Master of Public Health) or even ‘MPA’ (Master of Public Administration) graduate degree programs.

The ‘MBA psychology’ had yet to infect the career progression glidepath, albeit that fire was in part stoked by the emergence of the proprietary hospital management industry (where I spent a fair amount of my time) intent on driving both revenue and share gains, but principally by deploying ‘secret sauce’ (superior management chops) operating efficiencies in exchange for quarterly earnings growth. Yet, since those early days the MBA strain seems to have dominated the current cultural pool of professionals entering the ‘admin’ or professional manager theater. Unfortunately, and while I generalize, most MBA students/graduates are really good at the profitability thing (sometimes squeezing out the last bit of profit from failing business models or burning platforms) and usually from an investor exit frame of reference. Rarely do we see a ‘community benefit’ or ‘sustainability of the healthcare delivery ecosystem’ sit on top of the MBA cultural indoctrination.

So as we watch the systemic exposure of the operational and worse yet horrific cultural gaps on display between the acute care health system and the ‘clean up crew’ as represented by ‘public health types’ i.e., both state departments of health or public health and their federal overlords at CDC, one must wonder about the viability of these apparently ‘parallel worlds’ with different incentives, values and cheerleaders.

Perhaps via this historically rationalized ‘financial class’ disconnect we’ve reached a teachable moment? Might we actually think about how public health and acute care medicine can work together for the greater good?

I think so! Will you join me?

Originally posted at PublicHealthHQ




AHIP: It’s Not Cost Shifting, We’re ‘Unleashing Patients’

By Gregg A. Masters, MPH

Seriously folks, you’ve got to hand it to the PR firm supplying the American Health Insurance Plans (AHIP) with the brilliant, timely and thematically near argument resistant messaging copy just revealed via a .PPT preso titled ‘Health Care Innovation in the Context of Rising Health Care Costs‘ and delivered by Karen Ignani, aka to some as ‘Darth Vader’.

Perhaps brilliant does not capture the pure genius of the campaign, but lets pull back the cover a bit. Stay with me as I walk you through some thought process and history.

The practice of cost shifting has been a fact of life in American health care since the birth of the Medicare and Medicaid programs. Shortly after passage the ratcheting down of very generous third party reimbursement programs built on cost plus, and ‘you tell us what’s a reasonable charge’ for this procedure systems, the prospective payment system was introduced and the Government started to clamp down on their payment liability, thereby pushing onto the private payor market (mostly an indemnity, charge based liability system). Seeing the obvious writing on the wall, and enabled by both state and federal legislation payers re-branded themselves as ‘managed care plans’ and began to ‘cap’ the full burden of this cost shifting via selective contracting (both HMO and PPO), deploying a series of professional and institutional pricing tactics including case rates, per diems (both tiered and global), conversion factors, resource based relative value system (RBRVS), prepayment, capitation, percent of premium and other forms of limiting payments to providers, globally speaking.

The net effect of this ‘dance’ though modulated by a series of disabling public backlashes to the premise of the success in the managed care formula, essentially watered down the primary model that seemed to produce results for a brief period of time in the mid 90s, i.e., medical cost inflation dipped to zero and below.

Fast forward two decades, and the pace of healthcare consumption of GDP has more than resumed it’s upward march, and the rapacious appetite of the health care borg remains as unquenched as ever.

Yet this time, we’re entering an era with a mantra of ‘patient empowerment’ aided via the exploding and enabling series of platforms, devices, sensors, applications and mega availability of connectivity to the cloud as a service provider to perhaps once and for all enable informed choice, and thereby modulate the healthcare borg’s appetite.

The timing could not be more exquisite. The move by health plans on their own right into the high deductible (or consumer directed) health plan market has been received by a large ‘yawn’ for the most part. The scant research available to suggest that HDHP’s do not compromise access and quality and thereby contribute to poorer overall population health status are mostly sponsored by the industry and questioned by some as to their credibility.

But add to that the appeal of the mhealth, quantified self, personal responsibility for one’s health ethic, etc., and throw in the wellness and prevention agenda sensibilities, and voila, you have a compelling formula to appeal to a growing subset of the health care consumer and provider marketplace (from @Qliance to @CarePractice).

Brilliant? You betcha! Will it work, well that jury is still out. To get some context on the question, check out a recent webinar titled: ‘How Social Media is Revolutionizing the Healthcare Industry‘. You might want to pay particular attention to the exchange between Adam Bosworth, aka @adambosworth, of Keas and James Kean, aka @JamesRKean of @wellnessFX.

What’s this got to do with ACOs you say? More on that one in the next post.