Posts Tagged ‘healthcare reform’

Figure Source: usnews.com

This morning received notice that the Supreme Court will make its final rulings before summer recess on Thursday, June 28th. Among those rulings is the heavily politicized and closely watched decision on the Patient Protection and Affordable Care Act (PPACA), often referred to as Obamacare. In all fairness, Republican nominee Mitt Romney has his fingerprints all over Obamacare as PPACA was modeled after Massachusetts’ own healthcare reform law that was signed into law by then governor Mitt Romney.

Enough history and on to the poll.

With the rule pending, wondering what the readership of this site, which of course are those that seem to eat and breath healthcare in one form or another, believe the Supreme Court will rule. Based on some simple research of our own, we see four possible rulings. Now it is your turn to place your vote as to final outcome.

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Payers, as with the rest of the healthcare industry, have a lot on their plate right now. Healthcare reform, via the Affordable Care Act (ACA) continues its march forward despite legal and political uncertainty. Struggling to define the payer role in Accountable Care Organizations (ACOs), understanding the impact of Health Insurance Exchanges (HIXs) on their business (McKinsey survey results likely have many payers wondering how to market to what may be an enormous uptick in individual purchasers of coverage – something that most are ill-prepared for), and how to better engage consumers/members in proactively managing their health are a few of the top issues that were addressed at the AHIP Institute last week.

But when one sits back and reflects on the AHIP Institute – all of the sessions, all the discussions, the chatter in the halls, underlying messages within the message, the exhibit hall – it boils down to three key themes that this sector of the healthcare industry is grappling with, which much like the three stages of meaningful use, build upon one another:

  • Establishing Trust
  • Engagement
  • Collaboration

Establishing Trust
Health insurers have a major image problem and they know it. Providers don’t trust them, consumers don’t trust them and who knows, maybe even their spouses don’t trust them. Without that trust it is extremely difficult for payers to engage providers and members at a deeper level to improve overall population health and lower their risk exposure (MLR=medical loss ratio).

With the passage of the ACA, payers are now looking at the prospect of at least 30M more members (a significant portion Medicaid) joining their ranks. The 30M estimate could easily be tripled if McKinsey’s research (see above link) is indeed accurate. This creates a two-fold challenge for payers:

  1. How to market to these potential new members through a state-sponsored and run HIX. Payers do not know how to market to a market of one as they are more accustomed to marketing to employers or through brokers to reach that end consumer. Payers need to develop strategies that will assist them in attracting new members through these exchanges and one would imagine that ideally, a payer would prefer to attract the healthiest consumers on the HIX to join their ranks, again to lower MLRs. Successful marketing begins with establishing trust in a given brand and with a consumer trust ranking for payers that is towards the bottom, payers have a long road ahead of them.
  2. How to ensure that these new members receive appropriate care when they need it and not have them turn to the local, and the far more expensive, Emergency Room (ER). Many of these new members are unaccustomed to having a primary care physician and have typically gone to the local clinic or ER for care. Ensuring that these new members receive effective, value-based care will require close collaboration (and education) not only with the new member, but more importantly, the care community in which that new member resides. Payers will need to establish a higher level of trust than they have today with that care community, be they ACOs, Patient Centered Medical Homes (PCMH), clinics, you name it to develop value-based care models. With a gapping shortage in primary care, that will only be exacerbated with ACA, very creative approaches are needed to develop these new care models and trust is often a foundational element to the creative process.

If and when trust is established, the next stage is engagement and for payers it appears that such engagement is sporadic at best. Sure, there are many examples where payers have established partnerships with provider organizations, but it has not been easy. As stated in Part One of this series, Blue Shield of California worked closely with Catholic Healthcare West to establish an ACO model that worked for both parties. This effort took four long years to accomplish which makes one wonder: if Kaiser-Permanente wasn’t beating up both parties in the market, would this ACO even exist?

Payers need this type of deeper engagement with providers to develop new models of care but do they have the time, do they have four years for each significant ACO they wish to establish in a given community/region? With 2014 a short 2.5 years away, one would have to logically conclude: No, there is not enough time. Payers will certainly take lessons learned from initial efforts, but definitely need to accelerate engagement of the provider community. But where is that engagement? While there were representatives of provider groups in attendance at AHIP Institute, AHIP’s failure to put such representatives on the stage to talk of their experiences and what they, the provider community seeks from payers is shocking almost to the point of disbelief.

Not sure if the payers are anymore successful on the member side but with an increasing number of future members being individuals, payers need to seriously rethink their consumer engagement strategies, which today rank dead last of major industries surveyed. Yes, most payers have a PHR offering for their members. Yes, most payers are seeking to engage members via calls to those with a condition. But is any of this gaining traction, engaging consumers/members in a meaningful way to help payers reign  in ever rising healthcare costs? Sure doesn’t look like it and payers will never make it to Stage 3 if they do not get members and providers engaged.

Collaboration is the final Stage 3 for payers. It is the nirvana of deep and meaningful collaboration between all stakeholders to improve healthcare delivery in the US – a new delivery model that reigns in costs, equitably distributes risk, and ensures accountability. This is a very elusive goal that the payer sector, which AHIP represents, is not even close to achieving today.

While a large portion of the “collaboration problem” can be laid at the feet of this industry sector, in all fairness, payers are not completely to blame. Providers, while by and large well meaning, do have some in their ranks that are less so and unnecessarily drive up costs. On the consumer side, for far too long consumers have not been held responsible for taking better care of themselves. There is very little personal, consumer accountability in today’s healthcare system but that is changing, will need to change if we as a nation wish to truly grapple with the extremely serious issue that we can no longer afford the healthcare system (system used loosely as it is hard to call the US healthcare industry a system) that we have today. As one of the keynote presenters, economist Laura Tyson so eloquently put it:

We do not have a debt problem in the US economy, we have a healthcare problem.

Without deep, meaningful collaboration among all stakeholders the debt problem we face today will seem a mere pittance to what we will face in the future. Payers can play an extremely important role in that collaboration but they have some very hard work yet to do to establish trust in the market and then engagement. Based on what we heard and saw at this year’s AHIP Institute, payers are seriously behind in these efforts and at times almost seem oblivious to just how critical these efforts are to their very survival.

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The Health Information Exchange (HIE) market is the Wild West right now.  Vendors are telling us that they are seeing an unprecedented level of activity both for private and public HIEs.  Private HIEs are being set-up by large and small healthcare organizations to more tightly align affiliated physicians to a hospital or IDN to drive referrals and longer term, better manage transitions in care in anticipation of payment reform.  Public HIEs are those state driven initiatives that have blossomed with the $560M+ of federal funding via the HITECH Act.

But this mad rush is creating some problems.

While the private HIEs seem to have their act together in putting together their Request for Proposals (RFPs), such is not the case for the state-driven initiatives.  Rather then formulating a long-term strategy for the HIE by performing a needs assessment for their state, setting priorities and laying out a phased, multi-year strategy to get there, far too many states are trying to “boil the ocean” with RFPs that list every imaginable capability that will all magically go live within a couple of years of contract reward.  Now it is hard to say who is at fault for these RFPs, is it the state or the consultants they have contracted with that formulated these lofty, unreachable goals, but this is a very real problem and unfortunately, the feds are providing extremely little guidance to the states on best practices.

While the above is more of a short-term concern, longer-term we may have a bigger problem on our hands.  The proliferation of private HIEs, coupled with state-driven initiatives with very little in the way of standards for data governance, sharing and use (this includes consent both within a state and across state lines) has the very real potential to create a ungodly, virtually intractable mess that will be impossible to manage.

So maybe it is time to rethink what we are doing before we get to far down this road.

What if we were to say, as a country, that much like Eisenhower did during his presidency to establish the Interstate Highway system, we made the decision that it is the public interest to lay down the network for an “interstate” system for the secure electronic transport of health information?  And rather than be cheap about it as we have done in the past dedicating only modest funding (e.g., NHIN CONNECT), let’s really make the investment necessary to make this work.

Yes, it won’t be cheap, but think of the alternative – 50 states, countless regions all with their own HIE.  Yes, states are required under HITECH to work collaboratively with neighboring states, but this will not lead to enough consistency to create a truly networked nation for the delivery of quality healthcare for all US citizens.

It is indeed time to take a stand for much like Eisenhower’s Interstate system, which I had the pleasure to enjoy as I traveled cross-country this week from Boston to my beloved mountains of Colorado, such an interstate system for the delivery of health information at the point of care will be something all citizens will benefit from. And taking a cue from the image above, rather than a “Symbol of Freedom” it would become a Symbol of Health.

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Nearly a year after the HIT Policy Committee’s meaningful use recommendations were approved by ONC chief Dr. David Blumenthal, an extensive comment period that solicited some 2,200 comments, the final Stage One meaningful use rules will be released today at 10:00am.  Details for today’s conference call are:

WHAT: CMS and ONC will host a press briefing to announce the final rules on Meaningful Use and Standards and Certification under the HITECH Act’s Electronic Health Records (EHR) incentive program.
WHO: Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services
Donald Berwick, M.D, Administrator, Center for Medicare & Medicaid Services
David Blumenthal, M.D., M.P.P., National Coordinator for Health Information Technology
Regina Benjamin, M.D., M.B.A., Surgeon General
WHEN: Tuesday, July 13, 2010
10:00 a.m. EDT
WHERE: Great Hall, Hubert H. Humphrey Building
200 Independence Avenue, S.W.,
Washington, D.C. 20201
Dial In: Call in: 800-857-6748
Verbal Passcode: HHS

A Couple of Thoughts on the Pending Release
A significant amount of effort by many a talented and dedicated individual has gone into providing the initial policy framework and ultimately the final language for these rules.  Hats-off to them for their service for what they may have done is defined much of the future core elements of healthcare IT systems in the decade to come.  Granted, this is only Stage One rules, we have only an inkling of an idea as to what to expect in Stages 2 & 3, but there is no doubt in our minds that these rules will have an impact on the HIT market, more broader technology adoption and use in healthcare and even more broadly, a fundamental change in healthcare delivery and the role of the citizen/patient.

While these rules will have a noticeable impact, we are less confident that they will have a lasting impact for two primary reasons:

  1. It remains to be seen just how many physicians will take the bait (incentives) to buy a “certified EHR” and jump through all the hoops to demonstrate their meaningful use of said EHR.  Yes, $44k may seem like a lot initially, but when you start digging a little deeper into what the total cost of ownership is for an EHR and the number of hoops you must jump through to get that incentive payment, that attractive $44k starts looking less attractive in a hurry.
  2. Looming on the horizon, just beyond the street noise that is meaningful use and the HITECH Act, is a far larger change agent, the Healthcare Reform Bill that was passed into law earlier this year.  Tucked into that legislation are a number of significant changes, primary among them, payment reform via CMS’s Innovation Center.  Following the old adage, “follow the money,” we at Chilmark foresee a restructuring of the healthcare delivery system that will necessitate the adoption of IT not for the aforementioned “meaningful use” but to more efficiently and effectively run operations.  (Over in the radiology world, an article on Aunt Minnie clearly directs radiologist to start thinking efficiency.) This is what organizations both large and small, and not just radiologists, need to be thinking about as meaningful use, in retrospect, may be seen as more of a distraction than anything else.

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Yesterday, had the privilege to attend and present to a packed audience in New York City for CRG’s conference: IT & the Future of Managed Care: The Next Wave. Unlike most conferences I attend that are predominately focused on either the provider consumer sector of the healthcare market (tomorrow its the local New England HIMSS Chapter’s Annual Event), this event was for payers.  In light of the recent passage of the Healthcare Reform Act, ARRA and the move to digitize providers, they had a lot on their minds, particularly with regards to their future role in the digitization of medical records.

Following is my presentation. Brief as it is (was part of a panel and had about 7 minutes to fly through it), it does have a few nuggets worthy of a looksie.

Key Event Take-Aways:

Payers are struggling to develop new cost control models.  The Patient Centered Medical Home (PCMH) is attracting a lot of attention, lots of pilot studies currently underway or will be launched this year.  Remains to be seen as to true efficacy of this care model.

Telehealth is definitely ramping up, or at least some of the more innovative payers are looking to use telehealth in rural settings. (Of course, we have heard this so many times before and it remains to be seen if this time it is for real, but Cisco among others is making a big push, and with payers behind it, it may actually take hold).

Payers want to introduce best practices (comparative effectiveness) into the clinician’s workflow to insure that clinicians are complying to well-regarded and uniform standards of care.  Again, objective is to lower costs of care and improve outcomes.  Challenge, however is that clinicians are trained to deal with variability, they thrive on it.  Best practices, standards of care, etc., run counter to clinician training/culture.

Providing cost transparency/comparisons to consumers to allow them to consider costs as a variable in their healthcare decision making is difficult in many regions of the country as providers do not wish to be compared on costs and are reluctant to share such information.

Payers, as they have been for a number of years, are promoting collaborative care but are still running into significant challenges in making this happen.  The usual obstacles stand in their way, primary among them is data ownership and trust.  Payers are hopeful that HIE initiatives via ARRA and in the future CMS penalties will finally break this log-jam.

Significant interest in what Google Health and HealthVault are doing and where are they headed.  Few that I talked to are ready to commit (allow their members to export their claims data) to either platform, but they are having some pretty serious discussions internally as to what they should do. Surprisingly, (then again maybe not) no one at his event ever mentioned Dossia.

This was a well-run event with some excellent presentations.  Certainly plenty of hand-wringing in the audience as this sector grapples with both healthcare reform and the digitization of the provider sector.  What role payers will play in the future is fairly well-spelled out in the Healthcare Reform Act. Lesser known is what role payers will play within the context of healthcare IT.  Payers believe that they can play an important role in facilitating care (via telehealth, care coordination or clinical decision support tools) but as I told the audience in one of my closing comments:

Clinicians do respect the role that payers can play to a point, but there is still a level of distrust and do not expect a clinician to allow you to enter the exam room.  Keeping that in mind and respecting it will instill a level of good will that can lead to more fruitful interactions/collaborations in the future.

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Not one to comment on broader political issues but just can’t help myself today after awakening to the news that Kennedy’s Senate seat has gone to the Republican upstart Scott Brown.  Whatever happened to carrying on Kennedy’s legacy for healthcare reform, something Martha Coakley vowed to support and Brown vowed to defeat? Has Massachusetts really gone Red (or just a lighter shade of Blue)?

Reflecting on my own thoughts and vote for Martha, have come up with the following missteps of Martha’s that ultimately led to her losing what was considered a sure thing, Kennedy’s seat in Congress.

1) Assuming the cat is in the bag. Skating to an overwhelming victory in the Democratic primary, Martha naturally assumed that Kennedy’s seat was her’s for the taking.  Sure, the Republicans would put someone on their ticket, a sacrificial lamb, but a serious contender, no.  Surprise, surprise.  Yes, the Republicans put forward a relatively unknown State Senator from a small community, but this unknown Scott Brown proved to be an extremely engaging and aggressive politician.  By the time Martha’s political machine realized that they had a serious challenger on their hands, it was too late, his momentum too great.

2) Forgetting Tip O’Neill’s most famous quote, “all politics are local”: Martha’s stump speeches spoke often of carrying on the agenda for change that brought Obama to office.  That resonated well with the Democratic faithful (and Democratic leadership) but like the rest of the nation, Massachusetts voters are increasingly independent, siding with neither party, instead looking for a candidate that will be their voice in Washington fighting for their specific needs and concerns.  Martha’s “voice” was not her own, was not that of the Massachusetts electorate, but that of a political machine which is increasingly being viewed as detached from the current reality of most citizens in the nation, Massachusetts included.

3) Failure to engage and capture the imagination: What can I say, listening to Martha speak was about as exciting as watching spring thaw of a frozen New England pond.  As much as I can not stand the majority of Brown’s positions (against healthcare reform, still thinks climate change is not anthropomorphically induced, likes to use the terrorism scare tactics of the Bush era, etc.) I have to admit, he was an engaging and dynamic speaker.

This vote is not necessarily a vote against Obama and his policies, despite such pronunciations in numerous right of center publications.  No, this was a local election about local issues.  The candidate that won was the one who was most successful in taking the pulse of the local electorate, empathize with their concerns and reflect back to them that he understands and will do something about it.

Now it is Washington’s turn to get out of their stretch limos and connect to the local populace and begin addressing some of the very real issues and needs of the body politic or risk losing more than the passage of a Bill before Congress.

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healthreformAs just about everyone knows, Obama is hosting a huge Healthcare Summit today in DC bringing together stakeholders to have an open discussion on how we, as a nation, can reform healthcare.

To tune into the discussions in real-time you have two choices.  First is the new government website, HealthReform.gov which has live video streaming happening right now from any of the five breakout sessions.  Unfortunately, hard to tell what is the focus of each of the five sessions or who is present.  Having listened to some of these videos, find much of it just common positioning statements.

An alternative is to the straight videos is something called a “twitterfall”  which is a waterfall of comments (actually tweets), by those who use twitter. This particular twitterfall has streaming comments/tweets by those listening to the various summit discussions and providing their own input.

One thing I am struck by is the approach that this administration is taking. Clearly they have learned from their predecessors and are practicing full transparency, involving the public in this discussion to move the conversation forward.

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