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It is doubtful if the ACA will be repealed entirely.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

The Revolution in Magazine Processes "How not to fall behind in an era when everything you think you know might be wrong."

The title could have just as well read

The Revolution 

in 

Health Processes

Conventional print magazines, newspapers have weathered a sea-change in their business model.
And so has medicine and health process.

Health care financing, and administration also are struggling to change even as our current medical system is overwhelmed with increased expenses.  The similarity between magazine process and health process are remarkably alike.

Prominent news publishers, such as the Washington Post, New York Times and many others went out of business at the same time re-inventing their 'product' in a more efficient manner.  In some cases ownership shifted quietly behind the scenes. There were major reductions in staff, overhead and outright elimination of tasks that served no purpose or had been replaced by digitalizing the industry.

Even as this is occurring health organizations are burdened with daily organizations while being mandated by government, CMS, the Affordable Care Act, Insurers, and expansion of new covered benefits such as remote monitoring, telehealth and mobile health care.  The uptick in  expenditures for health IT is overwhelming many, both large and small.  There is no room for error. During the past five years some large institutions spent millions of dollars to purchase EHRs only to find they could not perform as advertised. Providers, and hospitals did not know or have experience in systems that were new and untested in a real world setting.

Health care operated mostly on a cash basis until the birth of managed care, capitation, and other obtuse forms of risk management.  In health affairs risk management used to have to do with risk of disease and/or treatments. Insurance companies were required to have an actuarial basis for setting premium rates against history of their insured disease risks.

Today this risk is carried not just by the insurance company, it has been shifted to hospitals and providers. Other calculations are being considered such as quality of outcomes, measured by re-admission rates to the hospital. The latest in the quirky world of health high finance is the 'accountable care organization. (ACO).

The name was coined by Elliott Fisher as a philosophical term during it's germination period.  Theoretically the organization that saves the most gets a 'kickback' a larger reward incentive than the rest of the providers/hospitals.

The health care company of 2005 is gone. its processes, procedures and priorities would be nearly unrecognizable today. In fact, the medical practice that existed in 2010 is gone too. In a period of accelerated transformation, nothing is more striking than the scope—and pace—of change in the processes through which these companies engage their customers (patients)  The very terms physician and patient devolved into provider and consumer. Physicians are no longer generalists or specialists they are primary care providers. It’s not just peripheral or incremental change, either. What the industry is going through in 2015 is a revolution in processes. In advertising, content creation, marketing, back-office functions and everything in between, what was done just a few years ago has been rendered obsolete, as new ways to interact with and serve stakeholders push the old ways into the trash bin. 

What’s changed is that technology is transforming every single phase of the business. It’s ubiquitous. It’s impacting the business on a wholesale level.”  It’s a new world of “VUCA,” says Lenny Izzo, group president of legal media at ALM. “That’s an acronym for Volatility, Uncertainty, Complexity and Ambiguity. It’s an old military term

Providers and hospitals have become 'punch-drunk' much like boxers and football players suffer from TBD or traumatic brain disorder.

Uncertainty comes in the form of new competitors. It comes with the decline in traditional branding-based display advertising, and the rise of new formats like cost-per-lead sales and programmatic advertising. Complexity comes in the form of tying together new expensive technologies that cross email, web, billing, production, ad-management, and content creation. Ambiguity comes in the form of not having the expertise to evaluate expensive new systems, and sometimes not knowing the right KPIs. Volatility? How about not knowing whether a new software system that cost $1 million will be relevant in 18 months?

This report is an on-the-ground look at process change in magazine media companies and how it’s affecting, well, nearly everything, from organizational structure and staffing needs, to assumptions about efficiency and newly essential skillsets. We’ll look at overall philosophies and approaches, and then explore, mainly through case studies, what publishing companies and executives are actually doing. 

Radical changes in process are driven by several things, of course. But mostly, it’s a function of two things: emerging technologies that enable new methods of serving markets, and a quest within companies for efficiency driven by economic necessity.

The revolution in health is not just in health IT, it includes changes in medical group administration, payment reform, relationships between providers, hospitals and providers, referral patterns and a new dynamic between regulators, licensing boards and providers of health care.

Interestingly, for health provider and magazine publishers, there’s a significant paradox in process change. Because the business model is in a seemingly permanent state of flux, and because technologies become obsolete so quickly, both types of companies find themselves betting huge amounts of money on unproven ideas. “Maybe the paradox of process is that you’re forced to be hyper-efficient in the things you understand, to finance what you hope is our future,” 

Note: Much of this article has been taken word for word from anaticle found on FOLIO  an internet magazine about the publishing business. It was a simple task to substitute health for magazine or publishers.. A true example of 'convergence'

Affordable Care Act.......The Missing Link....It is not Australopithecus

Houston, we  have a problem  "Failure to Launch"

Despite a goal of access to health care for all, however the hinge on the door for acccess is squeaking. News such as this are appearing in medical news.

Family Planning Clinics In Calif. Squeezed By Health Law KQED - February 10, 2014 Millions Trapped in Health-Law Coverage Gap Wall Street Journal - February 9, 2014 They quit their jobs, thanks to health-care law Washington Post - February 9, 2014 Enrolling in Covered California is not for the weak of heart, or spirit.  For those who were previously uninsured for a variety of reasons the affordable care act raise spirits with the elimination of the fear of not being able to pay for health care. The current system was not sustainable financially, however health care is available taking away the financial morass of insurance companies, bureaucracy and government.  Neither government, nor insurance companies provide health care. Physiciains, nurses, hospitals and many other providers care for patients. A consequence of the change will be the marked reduction in 'free care'. The old model of those fortunate enough to pay for their own care, and providers and hospitals having deep pockets to finance care for the less priveleged of our society. In order to assure health care and security for all the down side is forfeiting freedom. The tyranny of absolute security is freedom. Some of  us understand the concept and the reason for opposition to the affordable care act.  Others see it as an opportunity   for free health care.   Those whol will receive this generosity are often not only uninsured, but also un-empowered, and have little impact, are passive and do not have resources, nor influence to make changes. The U.S. Constitution (    )  guarrantees the pursuit of life, liberty and the pursuit of happiness.  That statement places us in a conundrum.  Does that mean care to avoid illness, or treatment to keep one alive? This is not some ephemeral abstract thought embodied in our founding document. Other constitutional guarrantees in the past have been manipulated to make change The Affordable Care Act in Californa is known as  'Covered California'.  Patients who sign up are screened for eligibilty based on income and household size. Those who's income is greater than........are required to purchase a subsidized health insurance policy or face a fine.  Some of these policies look nice, offered by stable companies, such as Blue Shield, Healthnet, Anthem and their providers are listed under providers for Covered California.  However with a more in depth search you will find they did not receive contracts and are not providers.  (small details).....this will reduce access to providers (and some hospitals). None of this has been adequatly explained  Some who look forward to using Covered California should call their chosen provider and ask if they are a provider for Covered California.   Many of them are not, and some may not even know if they are signed up for it.

Feeling the Pain ? ACO ACA HIX HIE HHS CMS ICD10

We physicians have some difficulty objectively measuring pain.  Even subjectively it becomes a challenge when your patient asks for pain medications.

The standard of medical practice now is to ask, "What is your pain level from 1-10 if 10 would be the worst pain  you have ever felt, and 0 is no pain whatsoeverl.  Even this scale is very subjective and is based upon what that patient considers his worst pain.  That depends on many factors. Patients who have never had any pain would not know what the worst pain would be.  Pain thresholds differ greatly from one patient to ano ther.  Comparing one patient to another with  this metric is meaningless.  Perhaps we should set a standard as labor pains. This standard however would only apply to women.

All of the above acronyms are a feature of health reform, which is not painless. The medical lexicon includes countless three letter or four letter acronyms, which are too lengthy to describe here.

ACO, ICD-10, MU, PCMH, and PQRS are more than just an acronym soup. 

Karen DeSalvo now the head of ONC and a former primary care physician from Louisana is the lady for the job of reducing our pain. (perhaps hypnosis, denial, or retirment would be better than the narcotic of acceptance and/or major revision of how government interacts with healthcare.

Diana Manos of Health IT News describes DeSalvo's background: 

To advance America’s triple aim of improving the experience of care, improving the health of populations, and reducing per capita costs of healthcare, DeSalvo outlined five key goals, which ONC will be focused on over this, the second decade of its work.

They are:

1. Increase end user adoption of health IT
2. Establish standards so the various technologies can speak to each other
3. Provide the right incentives for the market to drive this advancement
4. Make sure personal health information remains private and secure
5. Provide governance and structure for health IT

DeSalvo believes interoperability remains the most important issue as a framework for Health Reform.

Despite more than half a decade of progress, Interoperability appears to have stalled.

Michael Schatzlein MD 

of Asencio Health describes the current status of interoperabillity and it's future in the world of the internet.  It's greatest hope is the present generation of internet enabled patients who will demand interoperability, perhaps at the ballot box if bureaucrats cannot accomplish the goal..  The federal government has already invested billions of dollars of your tax money toward this goal.

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.