The Affordable Care Act, Accountable Care Organization and the Election

Better Together Health 2016 Event - Better Together     Are we really

The Affordable Care Act has stimulated many changes in health care. What is  considered good or bad depends upon the viewpoint of the provider and/or patient.

We have not yet seen the details of the Republican plan so Health Train Express will not offer our evaluation. Decisions based upon political rhetoric are at the least foolish, and at the worst dangerous.

It is doubtful if the ACA will be repealed entirely. Significant amendments ill be made. Other than some displeasure in the provider and health insurance industry patients who are able to access care are at less risk of not getting urgent care.  Even that presents problems in terms of provider accesss and the high deductible and premium expence for most receiving a partial subsidy. For those who are indigent, they have not expenses.

The progress of the organization being promoted by Medicare and some private insurers is the Accountable Care Organization (ACO).  The progress of developing this organization is fraught with many barriers. The ACO is an HMO on steroids.

Perhaps the closest organization to an ACO is the Kaiser Permanente model. The Counsel of Associated Physicians Group recently held a symposium, Better Together Health 2016 Event - Better Together.

The speakers represent a broad spectrum of the view on Accountable Care Organizations.

ROBERT PEARL, MD   CHAIR, COUNCIL OF ACCOUNTABLE PHYSICIAN PRACTICES
Robert Pearl, MD, is Executive Director and CEO of The Permanente Medical Group and President and CEO of the Mid-Atlantic Permanente Medical Group. Dr. Pearl serves on the faculties of the Stanford University School of Medicine and Graduate School of Business. Dr. Pearl is a frequent lecturer on the opportunities to use 21st century tools and technology to improve both the quality and cost of health care, while simultaneously making care more convenient and personalized.

SENATOR JOHNNY ISAKSON    (R-GA), CO-CHAIR, SENATE FINANCE COMMITTEE CHRONIC CARE WORKING GROUP

Senator John Hardy Isakson (R-GA) is serving his second term in the U.S. Senate, and was recently tapped to lead the Senate Finance Committee’s Chronic Care Solutions working group with Senator Mark Warner (D-VA). The work of the bipartisan committee is to begin exploring solutions that will improve outcomes for Medicare patients requiring chronic care. Isakson is the first Georgian since the 1800s to have served in the state House, state Senate, U.S. House of Representatives and U.S. Senate. He also serves on the Senate HELP Committee, Senate Finance Committee, the Senate Foreign Relations Committee, the Senate Ethics Committee, and the Senate Veterans’ Affairs Committee.

TIM GRONNIGEr    DEPUTY CHIEF OF STAFF, DIRECTOR OF DELIVERY SYSTEM REFORM AT CMS
Tim Gronniger is the deputy chief of staff and director of delivery system reform at CMS. He was formerly a senior adviser for healthcare policy at the White House Domestic Policy Council (DPC), where he was responsible for coordinating administration activities in healthcare delivery system reform. Before joining DPC he was a senior professional staff member for Ranking Member Henry Waxman at the House Committee on Energy and Commerce, responsible for drafting and collaborating to develop elements of the Affordable Care Act. Before joining the Committee staff, Tim spent over four years at the Congressional Budget Office.

CECI CONNOLLY    PRESIDENT AND CEO, ALLIANCE OF COMMUNITY HEALTH PLANS

Ceci Connolly became president and CEO of the Alliance of Community Health Plans in January 2016. In her role, she works with some of the most innovative executives in the health sector to provide high-quality, evidence-based, affordable care. Connolly has spent more than a decade in health care, first as a national correspondent for The Washington Post and then in thought leadership roles at two international consulting firms. She is a leading thinker in the disruptive forces shaping the health industry and has been a trusted adviser to C-suite executives who share her commitment to equitable, patient-centered care.

KAREN CABELL, DO    CHIEF OF QUALITY AND PATIENT SAFETY, BILLINGS CLINIC

Dr. Karen Cabell is the chief of quality and patient safety and a practicing internal medicine physician at Billings Clinic, an integrated medical foundation healthcare organization, located in Billings, Montana. Dr. Cabell has implemented diabetes, heart failure and HTN disease management registries along with point-of-care tools for patients and clinicians to better manage chronic disease. She was involved with Billings’ rollout and adoption of an electronic health record implementation since 2004 including all clinic sites and regional partners to include 15 other hospitals with clinics across a 500-mile radius. Dr. Cabell has been instrumental in gaining alignment between the EHR, quality and patient safety as well as strategic planning to support Billings Clinic’s organizational goals of clinical excellence, operational efficiency, market growth and development, and financial strength.

REGINA HOLLIDAY    PATIENT RIGHTS ACTIVIST, ARTIST, AUTHOR

Artist Regina Holliday is a patient advocate known for her series of murals depicting the need for clarity and transparency in medical records, and for founding the Walking Gallery movement. The Walking Gallery consists of more than 350 volunteer members who make statements about the lapses in health care at public meetings by wearing business suits or blazers painted with patient stories. Holliday’s experiences during her husband’s illness and subsequent death inspired her to use painting as a catalyst for change. Backed by her own patient and caregiving experiences, she travels the globe heralding her message of patient empowerment and inclusion in healthcare decision making. Holliday’s mission is to demand a thoughtful dialog with officials and practitioners on the role patients play in their own healthcare.

MARC KLAU, MD

ASSISTANT REGIONAL MEDICAL DIRECTOR, SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP

Dr. Marc Klau has been with the Southern California Permanente Medical Group for 31 years. He is currently the regional chief of Head and Neck Surgery, providing leadership for 100 surgeons.  He is also the Assistant Regional Medical Director for Education, Learning and Leadership. He now oversees the new KP School of Medicine and all of the Southern California Kaiser Permanente residencies, as well as continuing medical education and leadership.

JANET MARCHIBRODA

Artist Regina Holliday is a patient advocate known for her series of murals depicting the need for clarity and transparency in medical records, and for founding the Walking Gallery movement. The Walking Gallery consists of more than 350 volunteer members who make statements about the lapses in health care at public meetings by wearing business suits or blazers painted with patient stories. Holliday’s experiences during her husband’s illness and subsequent death inspired her to use painting as a catalyst for change. Backed by her own patient and caregiving experiences, she travels the globe heralding her message of patient empowerment and inclusion in healthcare decision making. Holliday’s mission is to demand a thoughtful dialog with officials and practitioners on the role patients play in their own healthcare.

DIRECTOR, HEALTH INNOVATION INITIATIVE, BIPARTISAN POLICY CENTER

Janet Marchibroda is the director of the Bipartisan Policy Center’s Health Innovation Initiative in Washington, DC. She has been recognized as one of the Top 25 Women in Healthcare by Modern Healthcare and is a nationally recognized expert on the use of health IT to improve healthcare quality.

LEANA WEN, MD  HEALTH COMMISSIONER, BALTIMORE CITY

Since taking the reins of America’s oldest health department in Baltimore, Dr. Leana Wen has been reimagining the role of public health including in violence prevention, addiction treatment, and urban revitalization. Under Dr. Wen’s leadership, the Baltimore City Health Department has launched an ambitious overdose prevention program that is training every resident to save lives, as well as a citywide youth health and wellness plan. She is the author of the book, When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests, and is regularly featured on National Public Radio, CNN, New York Times, and Washington Post. Her talk on TED.com on transparency in medicine has been viewed nearly 1.5 million times.

Better Together Health 2016 Event - Better Together

Obamacare, Is the American Public Stupid or were they Deceived....Again

According to government sources, Obamacare is a resounding success. Yet industry experts and pundits examining the implementation say otherwise.

More information is forthcoming about ObamaCare. Jonathon Gruber, Professor of Economics at M.I.T a primary author for the Affordable Care Act was interviewed by

the Daily Motion (video)

He was a key architect of both the 2006 Massachusetts health care reform, sometimes referred to as "Romneycare", and the 2010 Patient Protection and Affordable Care Act, sometimes referred to as "Obamacare".^[1]

Sen. Rand Paul (R-Ky.) made a guest appearance on “Hannity” Monday and said that embattled Obamacare architect Jonathan Gruber should be made to give back the money he received for his work on the health care bill.

ObamaCare Architect Thinks You’re Stupid; Pelosi Does Too

Gruber admitted multiple times that Obamacare was written in a non-transparent way intentionally, to exploit the “stupidity” of the American voter.

Real Health Care Reform Should be Affordable

The average Floridian pays way too much for health care. Roughly, 18 percent of your income goes towards your health care, on average. Now research from Harvard shows that health care spending will grow faster than the economy for at least the next 20 years.

The Affordable Care Act was supposed to prevent this, but it cannot. Rather than reform health care, the law merely expanded health insurance, a costly system that leaves patients behind and is largely responsible for spiraling costs.

What Geometry Can Teach Us


 Insurance Plan Reimbursement                                      Patient--Provider Payments    

Think back to your eighth-grade geometry class. You probably learned that the shortest path between two points is a straight line. You can apply this same logic to spending, where the cheapest option involves only two parties. In health care, the two parties that matter are you and your health care provider (your doctor, the pharmacy, etc.). You spend the least money when you pay them directly. onsider how health insurance works. Your money exchanges hands multiple times before it reaches the provider. It first goes to a third party (either the insurance company or the government, such as in Medicare and Medicaid). From there, those entities negotiate compensation schedules with providers and facilities. Both of these steps add bureaucratic and administrative costs to health care’s price tag. And although insurers attempt to lock in reasonable prices on your behalf, they often come up short.Why? Because they’re not spending their money: They’re spending yours. They thus have less of a financial incentive to get the best deal. Businesses and bureaucrats are no different from you and me; if you give them someone else’s money, they’re more likely to spend it foolishly.
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Now consider how health insurance works. Your money exchanges hands multiple times before it reaches the provider. It first goes to a third party (either the insurance company or the government, such as in Medicare and Medicaid). From there, those entities negotiate compensation schedules with providers and facilities. Both of these steps add bureaucratic and administrative costs to health care’s price tag. And although insurers attempt to lock in reasonable prices on your behalf, they often come up short.

Why? Because they’re not spending their money: They’re spending yours. They thus have less of a financial incentive to get the best deal. Businesses and bureaucrats are no different from you and me; if you give them someone else’s money, they’re more likely to spend it foolishly.

The same problem affects you once you have health insurance. After you pay your premiums, insurance gives you the illusion that you’re spending someone else’s money. The health insurance trap thus comes full circle, both insurers and consumers make it more expensive.

This raises the question: If not “Obamacare,” what else? Reformers should start by giving consumers the freedom to make their own health care choices. We need to return health insurance to the role of taking care of unpredictable, catastrophic health care expenses, and leave the great majority of everyday health care decisions in the hands of consumers.

We know this works. In the fields of cosmetic surgery,  lasik eye surgery , alternative medicine, and dentistry, the absence, or minimal presence, of government regulation or health insurance has driven prices down, and quality and service up. This has occured due to these procedures being elective, and requirement for out of pocket payment  by the patient.

Doctors can also refuse to take health insurance. More doctors and hospitals are choosing this path. One of my patients did this and saved $17,000 on a single procedure.

Lawmakers should encourage this kind of patient-focused innovation. Instead, they gave us “Obamacare,” which wraps health care in red tape and forces everyone to purchase health insurance. Real reform shouldn’t leave us with a higher bill.

Dr. Jeffrey Singer practices general surgery in Phoenix and is an adjunct scholar at the Cato Institute.

Physician Abdication of Power

Background:

During the last two decades physicians have abdicated their role to CMS and payers fo policing each other. Resident physicians are closely supervised and gradually given more responsibility for decision making as they proceed from PGY 1-PGY4.  As a chief resident they are responsible for much of the activity of junior residents. Surgical and/or medical residents in certain specialties have their proposed surgical cases reviewed by either a chief resident, or director of the training program prior to scheduling.

During the first year of practice or if the MD change hospitals medical staff regulatons require providers to have a  proctor during a certain number of cases to insure proper judgment and  competence.

Following this period they are allowed to operate alone.  Further proctoring is usually not necessary unless there is a complication or a death. Usually this takes place in a departmental meeting for review. This often serves as a learning experience and is not a punitive affair. If the difficulties persist the physician will be required to obtain further training or more supervision until he demonstrates competence.  The entire process is physician led. It is private and confidential and not discoverable by non-physicians.

During the last two decades physicians have been lax in many regards, and have not required chart reviews prior to surgery nor review of treatment protocols unless there is an untoward event resulting in a morbidity or mortality and after the fact.

Current:

The review and authorization procedure now is conducted by insurers for prior authorization by a non-physician or a medical director for a payer.  This occurs away from the clinical setting when the physician submits the case  history, and proposed procedure.  The intensity of the review by CMS and payers is usually determined by the level of cost and number of procedures that are done.  The ultimate goal is not patient safety, nor quality of care. It is to reduce cost.  Their benchmark for what is reviewed is a simple algorithm.   #of cases X cost/case = total cost. Cases that are done in high volume, or high expense will require prior authorization. Such cases or diagnostics include Cataract removal, Hysterectomy, Spine surgery, Interventional cardiology. Many of these are surgical or advanced medical interventions. Many of the reviews are for expensive imaging, such as MRI or CT imaging.

There has been a gradual erosion of self determination and  pre-surgical review by physicians and surgeons, allowing CMS and payers to intrude into physician-patient relationshiphs.

Future:

Physicians will reclaim the role of ascertaining quality control and prevention of abuse and fraud by peer-review of  expensive and high volume procedures prior to procedures, both diagnostic and Invasive.  It will be required that all pre-surgical cases be reviewed by another member of the department prior to scheduling (except for emergent or urgent need.) The insurance company should not have any role in  prior authorization.  That will be the purview of medical staff, much like PQRI was performed in the late 1980s for cataract removal.  

This system will allow peer and case review for the medical staff and immediate feedback for non-compliant providers.

The insurance system will be simplified.   Delays and/or denials could be eliminated for review, authorization and payments.  Administrative expense could be reduced. This will require some additonal time and effort by physicians.  That is the price for professional freedoms.  Freedom takes effort to maintain.

Is this an idealized vision for the future, or will it come to pass?  Only you and I can decide.

The time has come to draw a red line in the sands of health care.

HTE DIGEST Vol 1 No 2

HTE Health Train Express is Celebrating 10 years of publishing on the internet. Throughout this month we will publish articles from the past ten years.

JAMA (Journal of the American Medical Association) study claims low value care cost Medicare $8.5 B

A substantial number of Medicare Beneficiaries receive low value medical care. Several criteria were used to measure low value care. Medicare spent $8.5 billion, or $310 per beneficiary, on services detected by the study's more sensitive measures of low-value care, while spending on low-value services with more specific definitions totaled $1.9 billion, or $71 per beneficiary.

That accounted for 0.6 percent to 2.7 percent of overall spending, depending on the measures' level of sensitivity. While representing "modest proportions" of total Medicare spending, the researchers note the findings suggest widespread overuse of unnecessary treatments. JAMA Study  KHN Study

SPOTLIGHT ON... First 2015 rate filings show premium hikes

Virginia is first state to release rate proposals for 2015. Premium rates will rise 3.3% (KFHP), 8.5% (Wellpoint Anthem). to accomodate poorer health of many new members likely to boost their health care utilization.

Aetna: Bumpy road ahead for ACOs

Webinar events  Mark Your Calendars:  A collection of free webinars of timely subjects

> Next-Generation Subrogation Solutions - Wednesday, June 4, 2014, 12pmET / 11amCT / 9amPT

> Healthcare's new entrants: Who will be healthcare's Amazon.com? - Wednesday, June 3rd, 11am ET / 8am PT

> New Rx Savings Strategies for Payers - SPONSORED BY: Elsevier

> The Growing Challenge of Medical Identity Theft - Thursday, June 5, 2014 | 1pm ET, 11am PT

> The Internet of Things: How connected devices put data in your hands - Thursday, June 12th, 1pm ET / 10am PT

> Developing for the Internet of Things: Challenges and Opportunities - Wednesday, June 18th, 2pm ET

> Boosting physician adoption of CPOE to maximize its benefits - Wednesday, June 25th, 2pm ET/ 11am PT

Better MLR compliance reduces consumer rebates

Insurers issued about $513 million in rebates for 2012 under the medical-loss ratio requirement, according to a Commonwealth Fund report released Tuesday. That's half of the amount paid in 2011, showing greater compliance by insurers with the Affordable Care Act's MLR rule.  Commonwealth Fund announcement and study (.pdf)

CMS decided to increase the Medicare Advantage payment rate by 0.4 percent after it proposed in February to lower rates for plans,  Despite the reversal, some insurers like Aetna and Humana have still predicted Medicare Advantage payments will drop by as much as 4 percent.

Health IT News:

> Within two decades, Google might dominate the medical technology industry as the company currently spends $8 billion a year on research. Article

Shortage of Health IT Professionals Imperils Health Care Reform…

During the past ten years  adoption of EHR, HDX, and Hospital EHRs created a tsunami of demand for experienced IT professionals.  Despite funding for training of HIT personel via the HITECH ACT ongoing demand has created a shortage, impacting EHR installations, and Health Care Reform.  Much of Health Care Reform requires integration of data silos and data analytics

Is Meaningful Use is On the Ropes?

Controversy and disagreement continues in regard to Federal mandates for inclusion of Meaningful use standards for electronic health records. Meaningful use was designed to guide transition to EHRs that would exchange data, increase patient involvement, and allow data collection for analysis.  Providers are mandated to either modify their present EHR or completely replace their software.  This comes at a time when there are many competing increases in bureaucracy, planned adoption of the ICD-10 diagnosis tables.  Providers have said that the definition of Meaningful Use by HHS is not the same as meaningful use by providers.  EHRs continue to be inconsistent, not user friendly, nor intuitive.

Small Data

Health care and health reform are being influenced by seemingly unrelated spheres of influence. Many industries are effected by these same interactions in banking, transportation, defense, technology, basic science, education and government.

The age in which we live is both exciting and terrifying. Now that I am a septagenerian I see it is both. And somehow we will survive, grow stronger and thrive.

The catalyst is largely information technology and cyber technology, whether it is functions for gathering data, analytics,pseudo artificial intelligence, or robotics.  All of it is shaped by bits and bytes.  Even the basic materials of the integrated circuit and computer microprocessors will undergo basic changes perhaps away from silicon to carbon or even biological compounds such as the building blocks of DNA, nucleic acids.

Rather than having a simple bit or byte, nucleic acids as we know them, offer 4 different subunits that form a lexicon for building proteins from amino acids.

Big Data is often quoted in health care for analytics, for biological and research discoveries.

We in health care are now being continuously bombarded about the essentiality of gathering more and more information. Our government is underwriting some of the costs and also placing a large burden upon not only physicians but all providers, and hospitals to enter health data into the IT infrastrucure for some future use, some of which is still not defined, and some which is truly unproven.  Despite this billions of dollars have been and will be spent on this endeavor.

There have been some precautionary notes offered from other sectors:

Viewpoint: Why your company should NOT use “Big Data”

The latest trend is “Big Data”. The original concept of Big Data was the concept of using all of the information a company collect that was being thrown away due to costs and capacity constraints. With the rapidly declining cost of storage and retrieval, combined with machine learning, we should be able to find insights in all that ‘garbage data’ and use it to make better decisions in the core business. At least that’s the theory. As far as the basic theory goes it’s all true, but it’s not the full story.

Like a lot of trends, the drive to mastering Big Data has gone a little overboard. Google searches for the term “Big Data” has grown from practically nothing in 2010 to almost 200,000 searches a month by the end of 2013

It has become so ingrained in company cultures that to say you don’t want to use Big Data is a bit like saying you are against data-driven decision making. It would be career suicide to say Big Data is a waste of company time and resources.

The graph below depicts the exponential growth of big data over time.

The details can be found at the original article on ViewPoint

Repeal the President’s Health Care Law

I wrote in several posts why Obama Care will be de-constructed by the American Culture for many reasons.  Eventually it will be re-constructed in a manner consistent with the American Cultual beliefs,  which will avoid intruding on basic Constitutionally guaranteed freedoms. (regardless of what the Supreme Court has ruled.

All early signs point to erosion of ObamaCare

    All Signs Lead to the Destruction of ObamaCare
    Vital Signs Diminishing for Obamacare Is Life Support Imminent?
    The Fears About IPABs in the Affordable Care Act
    Death Spiral ? Is this the Black Hole for the Affordable Care Act?
    Will the Affordable Care Act Overwhelm the Health System?

    ACO Expectations May be Unrealistic
   

Senator Orin Hatch has initiated a Legislative proposal has connected changes leading to a uniform health insurance system:


Title 1: Repeal the President’s Health Care Law
        Section 101: Repeal Obamacare
Title 2: Replace Obamacare With Sustainable, Patient-Centered Reforms
        Section 202: Create a New Protection To Help Americans With Pre-Existing Conditions
Section 203: Empowering Small Business and Individuals with Purchasing Power
Section 204: Empowering States With More Tools to Help Provide Coverage While Reducing Costs
Section 204: Expand and Strengthen Consumer Directed Health Care
Title 3: Modernize Medicaid to Provide Better Coverage and Care to Patients
        Section 301: Transition to Capped Allotment to Provide States with Predictable Funding and Flexibility
        Section 302: Reauthorize Health Opportunity Accounts To Empower Medicaid Patients
Title 4: Reducing Defensive Medicine Practices And Getting Rid of Junk Lawsuits
        Section 401: Medical Malpractice
Title 5: Increasing Price Transparency to Empower Consumers and Patients
        Section 501: Requiring Basic Health Care Transparency to Inform And Empower Patients
Title 6: Reducing A Distortion in the Tax Code That Increases Health Costs
        Section 601: Capping the Exclusion of An Employee’s Employer-Provided Health Coverage

There is no reason why employer group coverage cannot be continued with the caveat that it must conform to not banning pre-existing issues, and eliminating any cap on benefits.
Tax code issues regarding health benefits should not have a limit, nor require a threshold of income under which deductions can be claimed.
The IRS should be prevented from administering penalties, nor punish using a penalty and/or fine mechanism.

Taken together the aforementioned ideas will lead to an end result. Each section must be evaluated against a background of common sense without regard to self-interest in any part of the health system.

If we want a re-birth of our system we cannot drag along the dysfunctions present in our present system.
I would add the aspect of improving the health of our citizens.  This may not be properly measured by outcome studies based on reducing costs. The metrics need to be re-evaluated for that component of reform.

The underlying and most important goal is to improve access and quality of care. While Obamacare addresses costs, it does little if nothing to improve access. This challenge requires more funding for primary care physicians education and reassess certain specialties now included in primary care listings. Many internist are not primary care oriented, although considered PCP, nor are obstetricians/gynecologists.

Meet the Press with Mayo Clinic and Cleveland Clinic

Visit NBCNews.com for breaking news, world news, and news about the economy

Dr. John Noseworthy, President and CEO at Mayo Clinic, appeared on Meet the Press with David Gregory alongside with Dr. Toby Cosgrove, CEO of Cleveland Clinic, this past Sunday to discuss the impact of the Affordable Care Act and the future of health care in America.

issues covered by Dr. Noseworthy included:

1. The need to modernize the health care delivery system to drive quality at lower cost.
2. Dealing with the sustainability of Medicare in the long term.
3. Using available technology such as telemedicine to improve patient care and deliver knowledge.
4. Funding research through the National Institutes of Health.

Dr. Noseworthy emphasized the Mayo Clinic has remained outside the political arena. 

Mayo Clinic and Cleveland Clinic represent the best of IDNs (Integrated Delivery Systems). Most healthcare in the U.S. is delivered by much smaller organizations. MC and CC easily are converted to a formal Accountable Care Organization and are being promoted as ideal models for quality of care, and reduced costs.  Not all organizations have these  full potentials.  The expense and investment for smaller institutions may not have a return on investment nor demonstrate cost savings.