By GREGG MASTERS

As we trudge forward into various iterations of what and how ‘accountable care’ strategies can be sensibly configured and locally seeded for Medicare, Medicaid as well as commercial markets, attention is often focused on the ‘necessary’ but ‘not sufficient’ contribution(s) from health information technology (HIT). It is rare that a conversation centered on accountable care or ACOs in particular doesn’t shift to HIT, where EHRs, HIE’s (heath information exchanges) or other data banking or connectivity solutions aren’t a material part of the dialogue. Often posited as the central spine enabling the required coordination and integration essential to accountable care, the technology side of the challenge frequently preempts other issues including physician culture, clinical and financial risk management tolerance and sophistication, or the history of successful physician/hospital joint ventures, in the local market.

Yet in the paradigm shift from volume to value via accountability many are focused on the presumptive return expected from consumer empowerment and electronic health information connectivity. Whether couched as informed choice via up-leveled health literacy, e-patient activism, ‘data liquidity’ or the litany of supportive ‘apps’ including mhealth, wireless or other prevention and wellness oriented platforms, the consumer empowerment movement incentivized by HITECH and further challenged via the triple aim quest are energizing many entrepreneurs, healthcare providers and even regulators.

Continue reading “June: A Big Month For ACO Watchers”

By Joe Flower

I’ve been saying it for years (and in 3D and Technicolor in my new book Healthcare Beyond Reform): The Standard Model of Healthcare (the traditional unmodified fee-for-service, commodified, defined-benefit payment system) is broken and doomed. It’s fascinating to hear that even the CEO of Aetna, Mark Bertolini, said exactly that recently at a major healthcare technology conference — and that Forbes, a bastion of business and the private approach to everything, would publish an article on his remarks.

At Health 2.0 last fall, Bertolini said that he no longer thinks of Aetna as an insurance company, but primarily as an information company. This time, he made these main points:

Continue reading “Even Aetna CEO Admits: We’re Toast”

By Vince Kuraitis

Over the past decade, I’ve seen a number of studies asking people whom they trust among various health care stakeholders. Nurses, pharmacists, and doctors always come out at the top.  Beyond that:

·Trust of hospitals tends to be high (60–80%)
·Trust of health plans is at the bottom of the heap (10–20%)

Is this written in stone for the future? I don’t think so…and the dynamics for change are in motion.  Please read on.

Here’s the emerging picture I’m seeing:

·Hospitals are dragging their feet in connecting you with your electronic health information.
·Health plans are highly motivated to connect you with your health information.

Hospitals Keeping You from Your Health Records

Yesterday the American Hospital Association released a 68 page letter commenting on proposed regs for Meaningful Use Stage 2. Putting aside my usual analytic tendencies, I’ll simply describe the letter as whiny, snivelly, “can’t do”, mean, and thick-headed.

Continue reading “Hospitals or Health Plans: Who Do You Trust to “Connect” You with Your Health Records?”

By Robert Laszweski

Today’s headline was “Millions Expected To Receive Insurance Rebates Totaling $1.3 Billion.”

The Kaiser Family Foundation estimates that 3.4 million people in the individual market will receive $426 million in consumer rebates because of the Affordable Care Act’s new MLR rules. In the small group market 4.9 million enrollees will see $377 million in rebates, and 7.5 million people will get $540 million in the large group market.

Wow!

But take a closer look at the report. Only 19% of those in the large group market will be getting a rebate and that rebate will average $72.31 per person. In the small group market 28% of those enrolled in these plans will get a rebate averaging $76.37. And, in the individual market 31% of consumers who have these plans will get a rebate averaging $126.81.

The Wall Street Journal, citing a Goldman analysis, is reporting that Aetna will be paying out $177 million in rebates. But Aetna has $11 billion in premium so that’s only a 1.6% rebate. UnitedHealth will be paying out $307 billion but that is only 1% of its $28.8 billion in premium. Wellpoint will pay out $94 million in rebates but that is only .28% of its premium for the year.

The average cost of employer-provided family health insurance is now about $13,000 per year. A family rebate of perhaps $200 will amount to only about 1.5% of premium for the relatively few people who will even get one.

Continue reading “The Medical Loss Report: Fiddling while Rome Burns”

By Joshua Archambault

The Massachusetts Taxpayers Foundation (MTF) put out a report late last week on the cost of Massachusetts health reform. The number from the report that has gotten the most media attention has been– $91 million.

Over the five full fiscal years since the law was implemented, the incremental additional state cost per year has averaged $91 million…

This is a very strange way to interpret the cost data. Here is the breakdown from the report:

The better number to highlight would be the incremental increase each year over the 2006 baseline.

If you add this up and divide by 5, you come up with an average over the 2006 baseline of $738 million, and a state share of $369 million per year. That is a much different story than the $91 million being widely reported.

Continue reading “Is Romneycare A Budget Buster?”

By Vince Kuraitis

I’m surprised and intrigued by Medicare’s announcement of 27 new Shared Savings model ACOs.

Surprised

I had been anticipating this announcement as a defining moment for Medicare’s thrust into accountable care. My expectations had been that we would see either:

Boom — a big splash of new Medicare shared savings ACOs announced, including big name hospitals and medical groups that were starting large scale ACOs, perhaps with hundreds of thousands of patients.

Bust — no one showed up at the party. Providers would have concluded that Medicare ACOs were too risky, bureaucratic, and high effort.

Intrigued

What we got is something in the middle:

• Very small ACOs. Many only meet Medicare’s minimum of 5K patients; most are in the 8 to 25K range; and the largest ACO anticipates 70K patients. Collectively these 27 ACOs plan to serve 375K patients, less than 1% of the entire Medicare population.
• 13 are smaller, physician led
• Only 10 hospitals are involved across the 27 ACOs
• Very few household names

Continue reading “Medicare Announces 27 ACOs. A New Species?”

By JONATHAN HALVORSON

Of all the provisions of the ACA, probably none has received greater attention from health insurers than the exchanges. Though the exchanges are expected to be the conduit for just a small fraction of all the insured at their start in 2014, they will be where most of the growth in health insurance lies. Given the rule that the individual exchanges must be integrated with Medicaid, their role will be critical for any insurer that wants to compete and grow in the individual or Medicaid markets. The dominance of the exchanges for growth in the small group and even the Medicare markets may not be not far behind. It should be no surprise if, eventually, all fully-insured business goes through the exchanges, leaving only self-insured plans outside.

So getting it right matters. Now is the time to think hard about getting it right, before the exchanges are created and inertia sets in. And, as some have argued, getting it right means that we think about the exchanges as places for people to choose their health care, not just their health insurance. So how should we do that?

Here is what we should not do: make it easy to choose care without considering both the quality and the cost of care delivered by the care system. It would be an enormous lost opportunity to improve consumer attitudes towards health care if we built the exchanges to make it easy for people to reason: “I like doctor A. Doctor A accepts insurance products X, Y and Z. Of these three, insurance product X seems to have the lowest cost, so I’ll choose product X.”

Continue reading “Another Look at Health Insurance Exchanges”

By Michael Turpin

As the Supreme Court debates the boundaries of government’s role in mandating the purchase of insurance, the discussion continues on whether the public or private sector is best positioned to drive market reforms necessary to meet our goals of lower costs and higher quality. As the son of a Phi Beta Kappa neo con who believes government should be the size of a sand gnat and as the husband to a British citizen who loves national healthcare and was born through a midwife, I often find myself lost in a political no man’s land with volleys being exchanged from the right and left.  To complicate Thanksgiving dinner further, thirty years of healthcare consulting, including a three-year stint in Europe, hospitalization for pneumonia in the NHS and a tour of duty as a senior executive for a national insurer has left me with my own conflicted convictions about  how we might fix our broken system.

On the eve of the Supreme Court determining the fate of PPACA, strong opinions are in full bloom like cherry blossoms along the Mall.  In his particularly sharp remarks to government attorneys, Justice Kennedy, considered a swing vote by many, cautioned that Congressional intervention to mandate citizens the “duty ( to buy coverage) to act “ was a slippery slope that sets dangerous precedent and impinges on individual rights. Justice Roberts added, “And here the government is saying that the Federal Government has a duty to tell the individual citizen that it must act … That changes the relationship of the Federal Government to the individual in the very fundamental way.”

Justice Scalia was quick to wade in after Justice Roberts questioning, ” what would be next in the role of the government dictating to its citizens ( if the mandate were to be upheld). “I will tell you the next something else (we will next tell Americans to do) is exercise, because we know that lack exercise contributes to illness.” It seems that this debate is indeed creating odd bedfellows as civil liberties advocates are joining conservatives in warning that the next thing the government will be telling people is that they cannot drink sugary soft drinks or that they have to eat broccoli.  It is hard to find a time when a conservative Justice and the ACLU share a common opinion about anything.

Continue reading “Much Ado About Broccoli”

By David Shaywitz, MD

Durably improving health is really, really hard.

I’ve discussed this in the context of drug discovery, which must contend with the ever-more-apparent reality that biology is incredibly complex, and science remarkably fragile.  I’ve discussed this in the context of patient behavior, focusing on the need to address what Sarah Cairns-Smith and I have termed the “behavior gap.”

Here, I’d like to focus on a third challenge: measuring and improving the quality of patient care.

I’ve previously highlighted the challenges faced by Peter Pronovost of Johns Hopkins in getting physicians to adhere to basic checklists, or to regularly do something as simple and as useful as washing hands, topics that have been discussed extensively and in a compelling fashion by Atul Gawande and others.

Several recent reports further highlight just how difficult it can be not only to improve quality but also to measure it.

Consider the recent JAMA article (abstract only) by Lindenauer et al. analyzing why the mortality rate of pneumonia seems to have dropped so dramatically from 2003-2009.  Originally, this had been attributed to a combination of quality initiatives (including a focus on processes of care) and clinical advances.  The new research, however, suggests a much more prosaic explanation: a change in the way hospitals assign diagnostic codes to patients; thus, while rates for hospitalization due to a primary diagnosis of pneumonia decreased by 27%, the rates for hospitalization for sepsis with a secondary diagnosis of pneumonia increased by 178%, as Sarrazin and Rosenthal highlight in an accompanying editorial (public access not available).

Continue reading “Why the Fragility of Health Outcomes Research May Be a Good Outcome for Health”

By Brian England

Last week, the U.S. Supreme Court heard six hours of oral arguments for and against the constitutionality of the new health care law. As a small business owner, I am not a constitutional scholar, but I can definitively say this: the Affordable Care Act is cutting my health care costs and helping my business.

My wife and I run an auto repair shop in Columbia, MD. We started as a small, family-business in 1978. Now, we’re a well-respected business with 19 employees, a long string of awards and a reputation for service.

One of the biggest barriers to growing a successful business has been the rising cost of health insurance. We’re committed to offering insurance coverage, but over the past 10 years it has become a real struggle to keep up with the costs.

We’ve become accustomed to rates going up 10 percent to 20 percent each year (sometimes even more), and we’ve had to look at many different ways to deal with the extra expense. We’ve got a great agent who does a lot of research and works hard to find the best options for us. But in the end, we’re the ones who have to decide what to do — and foot the bill.

Continue reading “Health Care Reform: Good for Business”