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It is doubtful if the ACA will be repealed entirely.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

How Senior Medicare Advantage Plans Game CMS and the System

GAO States CMS Overpaid Medicare Advantage Plans During the Years of 2010 to 1012–Flawed Risk Assessment Calculation Errors 

CMS discovers fraudulent use of algorithm and will sue several plans for $70B

CMS Discovers That Insurers Offering Medicare Advantage “Really Know How To Sharp Shoot A Model With Adjusting Risk For Profit”, A Common Everyday Occurrence in Financial Markets… - Medical Quack

 A report issued this week by the Government Accountability Office reports that the Centers for Medicare & Medicaid Services overpaid the Medicare Advantage program run by private health insurers by between $3.2 billion and $5.1 billion for the years 2010-2012.

The overpayments, according to GAO, were the result of CMS inadequately adjusting based on health status for members enrolled in Medicare Advantage. 

Insurers who run MA plans are paid a set amount per beneficiary, adjusted by a risk score that calculates the expected consumption of health services in the coming year for each beneficiary. 

In practice, the risk scores for beneficiaries with the same health conditions and with the same demographic profile should be the same. However, the GAO discovered in its analysis that coding differences between Medicare Advantage enrollees and those enrolled in the traditional fee-for-service Medicare plan led to “inappropriately high MA risk scores and payments to MA plans.” 

Fraud, What Fraud?

The Medicare Advantage (MA) program was established in 2003 in order to incentivize health plans to provide better care for the elderly and control expenses in doing so. Nearly 16 million seniors are presently enrolled in MA, costing an estimated $150 billion in taxpayer’s money every year. The MA program has grown in popularity with Medicare beneficiaries because it has lower out of pocket expenses than traditional Medicare, offers more benefits, and fills some gaps in coverage.

 Unlike the fee-for-service payment arrangement in traditional Medicare, where each service is billed directly to the government, Medicare Advantage plans receive a monthly, set capitated payment to provide care for their enrolled Medicare beneficiaries. However, health plans do receive a higher monthly capitated payment to care for sicker patients, based on the patient’s “risk score”. The risk score is determined by a variety of factors, but is primarily based on the patient’s Hierarchical Chronic Conditions, or HCC score, which are conditions tied to specific ICD-9 diagnoses.  Risk scores are required to be backed-up by medical record documentation, but the government still has difficulty verifying each diagnosis. (no simple process)

 While the problem of false or improper billing is essentially eliminated in the MA program, fraud remains an issue nonetheless.  Recent investigations by The Center for Public Integrity have highlighted some of the more egregious practices occurring in the Medicare Advantage program related to risk scores, which are not only damaging to the program’s reputation, but have also cost America’s taxpayers an astounding $70 billion since 2008.   However, the most shocking part of their investigation is highlighting how little control the government has in reigning in this problem.

 Research has shown that MA Plans exhibit greater “coding intensity” in documenting disease conditions, so that an MA enrollee’s risk score grows substantially faster than an FFS enrollee’s risk score.  Once Medicare enrollees switch from the traditional Medicare fee-for-service program to a Medicare Advantage plan, their HCC scores increase.  Medicare Advantage plans contend that the higher scores are due to sicker patients, but without intense auditing, it is difficult to support or disprove that logic.

 In addition to the diagnoses obtained from primary physician records, another method gaining ground among Medicare Advantage plans to bolster risk scores is via home health visits. While home health services may legitimately uncover previously unknown medical conditions, more unscrupulous health plans may leverage home health visits as a tool to inflate risk scores, and thus increase their profits from these patients by thousands of dollars each year. Health plans argue that these visits improve patient care, but opponents claim they unnecessarily inflate costs without actually providing more medical services.

Health Care Financing, CMS and HHS have devolved to a dysfunctional chaotic state.  The OIG reports these matters to Congress. So why do your legislators do nothing about it? 

Perhaps it is because they are not smart enough to plan health care while running the rest of the government.