Empowering seniors to take control of their own health spending and rewarding the doctors who coordinate patients’ care, as well as the providers that reduce patients’ costs and improve the quality of their treatment, could vastly improve the health of seniors on Medicare, nach a new report by National Center for Policy Analysis Senior Fellow Devon Herrick. Medicare reform requires empowering seniors to manage more of their own health care spending using Medicare Health Savings Accounts (HSAs) coupled with high-deductible Medicare plans. A criticism of HSAs is that hospitalized patients have long since exceeded their deductibles.

In the report Herrick outlines three areas effective Medicare reforms must address:

1)Rising Medicare Spending

Medicare spending per beneficiary has risen from $385 a year in 1970 to a staggering $12,430 today.

Solution: Carefully manage care for the sickest seniors. About 5 percent of patients consume nearly half of all health care dollars, while the sickest 1 percent consume nearly one-quarter of health care expenditures. Used correctly, case management is a way to bring together all members of the medical team to discuss specific care plans and treatment goals for each patient. According to Herrick, “efforts to slow the growth in Medicare spending will have to focus on reducing hospital spending on the sickest beneficiaries by better managing their chronic conditions.”

2) The different levels on which health care occurs.

Care provided in the wrong setting wastes the patient’s – and the health system’s – money.

Solution: Employ the tools used by private health plans. Medicare should use medical homes, Pflege Koordination, and utilization management that reward plans for boosting quality and lowering costs, especially among chronically-ill beneficiaries.

“Doctors are necessary partners to improving health and reducing spending,” says Herrick. “A well-managed physician network is the key to coordinating care, increasing quality and controlling costs.”

3) Mismanaged care that lands seniors back in the hospital.

One-in-five seniors who are discharged from a hospital are readmitted within 30 Tage. More than one-third of Medicare hospital discharges are readmitted within 90 days.

Solution: Improve quality care transitions. A care coordinator at a patient-centered Medical Home could steer seniors to lower-cost health care settings, evaluate the need for home care and ensure seniors receive post-hospital follow up care and comply with drug therapy instructions.

“Poorly managed care transitions – when a patients’ care shifts from one setting to the next – are very costly for the health care system,” explained Herrick. “And it’s a serious problem!"

Zusätzlich, Medicare reforms should look to empower seniors to manage more of their own health care spending using Medicare Health Savings Accounts (HSAs) coupled with high-deductible Medicare plans, said Herrick.

1 out of every 6 patients in the U.S. received care in a hospital rated 1-star[1], according to new research released by Health, the leading online resource for comprehensive information about physicians and hospitals. Had those patients researched local doctors and hospitals to identify and select a physician practicing in a 5-star hospital for their specific procedure or condition, they would have faced a 71 percent lower risk of dying or a 65 percent lower risk of experiencing complications during their hospital stay. If all hospitals performed similarly to hospitals receiving 5-stars, 222,392 lives would have potentially been saved.[2]

Health 2016 Report to the Nation, which compares the patient outcomes resulting from care in hospitals rated 1-star (those with the higher risk adjusted complication rates and mortality rates) against 3-and 5-star hospitals in regions throughout the country, concludes that significant variation in health outcomes exists between hospitals throughout the U.S.

Many Patients Aren’t Receiving the Best Possible Care

As consumers take on greater responsibility for their medical costs due to rising premiums and the increase in high-deductible plans, it is increasingly important that they do their homework and select the right doctor and hospital for their specific needs. Healthgrades provides transparent access to accurate, objective data so that consumers and physicians can make more informed decisions when it comes to finding and connecting with the right physician.

According to Healthgrades, when presented with objective information – including physician experience, patient satisfaction and hospital outcomes – 85 Prozent[3] of patients would select a different physician than they did before doing their homework. Doing research to find the right physician, including understanding the quality of the hospitals where physicians practice, is essential to getting the right care.

“Because narrow networks are limiting many patients’ access to certain physicians and hospitals, it is more important than ever that consumers recognize the symbiotic relationship between doctor and hospital, and do their research to make what may be a lifesaving decision about the care they receive,” said Evan Marks, Chief Strategy Officer at Healthgrades. “Consumers need to trust that the information they’re using to inform their decisions is comprehensive, accurate and – most importantly – transparent. Transparency is crucial to fostering accountability at all levels of the healthcare industry, ultimately empowering consumers to use data to improve their chances of experiencing the best outcomes possible.”

Significant Quality Differences Exist at the Local Level

Healthgrades’ findings also reflect startling disparities at the local level. According to the report, hospitals within close proximity from each other can have significant differences in complication and mortality rates for the same condition or procedure. Zum Beispiel, in Denver, CO, when comparing patient clinical outcomes among hospitals for hip replacement surgery, complication rates varied significantly across facilities, von 3.9 Prozent 13.6 Prozent.

Zusätzlich, few hospitals can claim superior performance across all conditions and procedures; While hospitals may receive a 5-star rating for one condition or procedure, they may not demonstrate superior performance across all areas evaluated. In the Chicago region, von 14 hospitals that received a 5-star rating for treating heart attacks, eight received a 1-star rating when evaluated for total knee replacement surgeries.

Significant Disparities Exist within Markets – Good News/Bad News

The quantity of hospitals in a region also does not directly correlate with the quality of care available to consumers. While most major metro areas may be home to more than 30 Krankenhäuser, only a small percentage may provide better than expected outcomes for the specific procedure a patient needs. Zum Beispiel:

• In Chicago, von 46 hospitals that perform coronary artery bypass graft (CABG) Surgery, only two have a 5-star rating for this procedure.
• In Houston, von 38 hospitals that treat chronic obstructive pulmonary disease (COPD), or emphysema, only one has a 5-star rating for this condition.
• In the greater Los Angeles area, von 41 hospitals that perform coronary artery bypass graft (CABG) surgery, only six have 5-star rating for this procedure.
• In Philadelphia, von 34 hospitals that treat heart attack, only four have a 5-star rating for this condition.
• In the greater New York area (including northern New Jersey), von 102 hospitals that perform colorectal surgeries, only two have a 5-star rating for these procedures.

“The hospital a patient selects for his or her care can significantly impact the chances of experiencing complications, or even mortality, for certain conditions or procedures,” said Archelle Georgiou, M.D., Strategic Advisor, Health. “With quality of life on the line, consumers must be proactive in researching their options and leveraging all the data at their fingertips to make the best decision possible.”

Health 2016 Report to the Nation not only includes more specific comparative data about hospitals throughout the U.S., but also provides consumers with guidance on ways to make the best choices to mitigate the risks of having negative outcomes. Außerdem, Healthgrades has created regional pocket guides – for 50 key markets in the U.S. – highlighting the top performing hospitals for specific conditions and procedures. These pocket guides complement the in-depth information available at Healthgrades.com and provide consumers with an easy to access resource to choose the right hospital for the right care.

Healthgrades is the only site that provides consumers with information on more than 12,000 diseases, conditions and procedures and 1,100 specialties, based on data from more than 90% of inpatient hospital admissions. Access to this data empowers consumers to make informed healthcare decisions and select the right doctor and right hospital for their personal and specific care needs.

Report Background/Methodology

Unlike other organizations evaluating hospital quality, Healthgrades provides objective measures rooted solely in the domains of clinical science and statistical analysis, leaving perception and reputation out of the equation. Every year, Healthgrades analyzes three years Medicare Provider Analysis and Review (MedPAR) data to produce a detailed report on complication and mortality rates in America’s hospitals. Healthgrades findings empower consumers to evaluate and compare hospital performance.

For the 2016 sich melden, Healthgrades analyzed approximately 45 million Medicare patient records for nearly 4,500 short-term, acute care hospitals nationwide, assessing hospital performance relative to common in-hospital conditions and procedures for the Medicare population from 2012 through 2014 and one condition based on All-payer state data from 2011 through 2013.

Healthgrades models adjust for risk factors that influence patient outcomes. These factors may include age, gender, specific procedure performed, and co-morbid conditions, such as high blood pressure and diabetes. The outcomes reflect clinically-based measures, including in-hospital complications or in-hospital and 30-day post-admission mortality.

The 50-year old Medicare program is not aging well; and that’s not good news for seniors, nach a new report von National Center for Policy Analysis Senior Fellow Devon Herrick. When President Johnson signed the Medicare program into law on July 30, 1965, no one anticipated the program to grow at the rate it has. In 2014, the Medicare program spent over $613B to cover healthcare for 54 Millionen Empfänger. The law states that seniors do not qualify for Medicare until age 65, when a larger portion of the country did not live past that age. At its inception, life expectancy for men and women born in 1900 was under 50 years of age. Medicare only expected cover beneficiaries for another few years based on the lower life expectancy rates at that time.

The report identifies three major trends driving Medicare towards bankruptcy:

1. Lengthening Life Expectancies.

Americans born in 1900 and earlier were eligible for Medicare at its inception in 1965, but life expectancy for men and women born in 1900 was under 50 years of age. Heute, seniors can expect to live another 17 bis zur 20 years after reaching Medicare eligibility, and some scientists believe life expectancies could expand by decades before the dawn of the next century.

2. Higher Spending per Capita.

In 1970, only a few years after Medicare was established, annual per capita Medicare spending was only $385. Today it is more than $12,000 and will hit $19,000 in a decade. As a percentage of GDP, the portion of Medicare that taxpayers have to bear will double in two decades – and then double again in the 50 years after that.

3. Rising Drug Prices.

In 2014, Medicare spending on drugs was 0.48 percent of GDP. This proportion will surge as specialty drugs displace spending on cheap generics. Specialty drugs accounted for one-third of drug spending in 2014 despite comprising only 1 percent of drugs prescribed. By the end of the decade, half of drug spending will be on specialty drugs.

Don’t count on the Trust Fund to keep Medicare solvent either. “The Trust Fund itself is little more than a filing cabinet of IOUs that are claims on future taxpayers,” warns Herrick. “There really is no Trust Fund in the traditional sense of one that represents assets that can be sold to alleviate the burden on taxpayers.”

Ausgewähltes Bild Kredit: Flickr über cc

In comments submitted to the Centers for Medicare & Medicaid Services (CMS), the nation’s leading data scientists in healthcare urged federal officials to use new payment policies to reassess how providers are required to use informatics tools, and rethink how quality is measured in a digital world. Officials from the American Medical Informatics Association (AMIA) said new and novel ways to deliver care will rely on dynamic uses of information technology (IT) and other informatics tools, so government policies dictating the use of IT should be flexible and evolve as more experience is gained with new care models.

CMS issued a request for information (RFI) in October asking for stakeholder input on how best to implement a range of policies required by the Medicare Access and CHIP Reauthorization Act (MACRA) von 2015 (PL 114-10). The Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) established by MACRA will replace the current Fee-For-Service payment model for Medicare by 2017 und 2019, beziehungsweise. This system of reimbursement will rely heavily on electronically-specified clinical quality measures (eCQMs) to pay physicians based on how well their patients recover, rather than the number of services delivered. In comments, AMIA said it supported this move to value-based reimbursement, but voiced concern with the industry’s ability to generate accurate and complete eCQMs, and urged more focus on outcomes-oriented quality measurement.

“AMIA supports the overall direction of moving to an outcomes-based payment system, predicated on demonstrating value for payment,” the organization said in comments. “As we transition away from fee-for-service payment, so too must we move away from the quality measurement paradigm underlying that system. Despite earnest efforts, quality measurement has not become ‘a by-product of care delivered,’ as envisioned, and we are concerned the current mode is insufficient to enable this.”

To improve the current approach, AMIA urged officials to devote more resources to testing both the accuracy of the measure calculation, as well as the feasibility of the data collection requirements, and pilot all new eCQMs before their release for use. CMS should also establish a regular cadence of updates/revisions to eCQMs, ensuring adequate time is allowed for implementation of revisions by both the vendor and provider. Further, AMIA suggested these policies create new opportunities to develop better outcome measures, rather than relying on current process measures.

Additional questions posed by the RFI sought input on how officials should implement policies that require the use of certified EHR technology, and whether new certification criteria are needed to help providers succeed within new payment models. AMIA recommended federal officials avoid overly prescriptive requirements to determine how providers use informatics tools within APMs, but rather focus on the outcomes sought by the use of such tools.

“Ours is a dynamic environment of innovation and invention,” said Blackford Middleton, MD, MPH, MSc, FACMI and current AMIA Board Chair. “AMIA sees policy development for MIPS and APMs as not just an opportunity to change our payment system, but as an opportunity to revisit policies meant to spur adoption and guide use of health IT.”

AMIA President and CEO Douglas Fridsma, MD, PhD, BMZ, FACMI continued, “In much the same way that fee-for-service era policies skewed incentives and provider behavior, overly prescriptive documentation and ‘use’ requirements of the same era have influenced how health IT is developed, implemented and leveraged to improve care. We must evolve both sets of policies if we are going to succeed in this new paradigm.”

As healthcare moves from a fee-for-service model to a value-based care (VBC) Modell, many providers are having to reengineer aspects of their business. “Value-Based Care. Making the Shift: Who Can Help?” is the first report published about this market segment by KLAS. The report found that Advisory Board, Conifer and Evolent scored high with providers in giving them confidence to deal with evolving alternative payment models and preparing for future risk.

Top Firms for VBC Consulting/Management Services

While some providers may have the ability to make the transition to VBC on their own, the vast majority are turning to firms who provide VBC consulting services and VBC managed services. When evaluating providers’ confidence levels and progress toward a successful VBC model, KLAS found that 100% of Advisory Board clients report the firm has a high impact in meeting their triple aim objectives.

For VBC consulting services, Premier and Advisory Board led with the highest scores, while Valence and Lumeris were the most highly rated for VBC managed services. Lumeris clients also gave high marks, citing the company’s ability to help providers reimagine patient care and build a more complete patient profile.

“In order to survive in this new world of value-based care, providers need firms who can help them feel confident in their progress towards Triple Aim objectives, meaning can they impact patient access and satisfaction levels, help improve patient outcomes and reduce healthcare costs,” said Whitford. “Providers can also evaluate firms based on their ability to help them prepare for alternative payment models that are a result of the VBC model.”

Report Background/Methodology

Für den Bericht, KLAS interviewed more than 100 c-suite executives, most of whom have extensive experience in VBC. The interviews identified 33 key functions providers must do differently to make the transition to VBC. All of these critical functions fall into three core pillars: organizational alignment, care management and reimbursement management. The report examines the impact and performance of both VBC consulting and managed care firms and their ability to help providers make the transition.

“A provider’s first step in choosing the right firm is to weigh their needs versus a firm’s capabilities,” said Warren Whitford, research director. “Although the firms we evaluated are trying their best to bring a consistent set of methodologies and processes to an inconsistent market, each provider is on a different trajectory and the market is continuously evolving.”

Bruce Johnson, GHX President and CEO

For the past several years, spurred by regulatory healthcare reform and the overarching need to make the industry more sustainable, the healthcare supply chain has evolved from simply a transaction-driven process into a strategic, data-driven operation.

Infolge, the healthcare supply chain acts as a backbone for the industry’s drive to reduce costs while simultaneously improving patient care. With the last few years defined by supply chain innovation and exploration in healthcare, Global Healthcare Exchange-, LLC (GHX) sieht 2016 marking the acceleration of healthcare supply chain maturation.

“The healthcare supply chain is inherently different than other industries because, at the end of the day, it deals with people vs. ‘things.’ But it’s that very reason – the drive to provide better patient care – why its transformation has been so impactful,", Sagte Bruce Johnson, president and CEO at supply chain provider GHX. “For the last several years, healthcare providers and suppliers have incorporated automation, standardization and data-driven technologies and processes to increasingly leverage the supply chain as a strategic resource. From our vantage point, we see 2016 as the year that healthcare supply chain technology advances to a level of sophistication that will bring it closer to – or even surpass – the supply chain technologies of other industries,” Johnson adds.

GHX has outlined the following 5 Gesundheitsversorgungskette trends to watch in 2016:

1. Operational Experimentation: Now that most hospitals have identified the supply chain as an area not only for cost savings, but also as a resource for significantly improving patient outcomes, 2016 will mark the start of major operational experimentation. Backed by sophisticated, enabling supply chain technology, hospitals will embrace process and product flexibility to find the right formula for both patient- and business-focused success.

2. Preparing for Personalized Medicine: Healthcare leaders will work in lockstep with their supply chain professionals to anticipate yet another wave of industry change. Today’s increasingly informed and connected healthcare consumers, combined with new, game-changing technologies like 3D printers, will challenge the healthcare supply chain to adapt to more personalized medicine in 2016 und darüber hinaus. In many ways, the healthcare supply chain will act as the backbone to support this evolution.

3. Sophisticated Data Management: The healthcare supply chain has been tapped as a goldmine for data, and the past few years have seen providers and suppliers mine that data to do extraordinary things for patient care. Dieses Jahr, with the supply chain on the road to accelerated maturity, organizations will look for even more sophisticated ways to control and manage data that will allow them to fulfill both the regulatory and commercial demands of their businesses.

4. The Year of Credentialing: Die U.S.-. Department of Health & Human Services’ Office for Civil Rights (OCR), which is responsible for enforcing the HIPAA Privacy and Security Rules, has announced it will begin its Phase 2 audits in early 2016. Providers risk stiff financial penalties and reputation damage for non-compliance.For the healthcare supply chain, this will put a sharp focus on credentialing. The rise in credentialing requirements will be one of the patient privacy and safety-related trends in healthcare supply chains this year with particular focus on helping to ensure that the people within the hospital doors are the people who should be.

5. Industry-Wide Best Practices: The acceptance of industry-spanning metrics and measurement best practices will emerge in 2016, led by supplier and provider innovators who have been leveraging their supply chain for many years.

Die Centers for Medicare und Medicaid Services (CMS) is working hard to transition physicians’ payments from volume to value of services. The current Acting Administrator at CMS is a former top executive at United Healthcare, a commercial health insurance corporation. The previous Administrator at CMS is currently the president and CEO of America’s Health Insurance Plans (AHIP), which is the dominant health insurance lobbying group. It may therefore behoove us to rephrase the opening sentence: The corporate-government health care conglomerate is working hard to transition physicians’ payments from volume to value of services.

In response, health care delivery corporations, which are employing large numbers of physicians, are joining their forces through mergers, acquisitions and other arrangements to better manage the transition of physician payments from volume based to value based models. When you ask the architects of this supposedly tectonic shift from volume to value to explain their enterprise, you get back lengthy dissertations about better service at lower cost due to computerization, analytics and standardization of an industry long overdue for modernization. The basic argument is that health care in the U.S. sucks on many levels, and proper management that employs the latest technologies and business methodologies will fix everything that needs fixing.

But what does it mean to pay doctors for value instead of volume? Does it mean that we don’t pay physicians unless we get better? Does it mean we don’t pay for health care unless we are “kept” healthy by our doctors? Does it mean that we don’t pay a red cent for advice or procedures that we judge worthless? How long do we have, post service, to decide if what the physician did was valuable? Thirty days? Five years or 50,000 miles whichever comes first? A lifetime? The answer emerging from opinion pieces published by members of the corporate-government conglomerate, which are intended to soften the ground before official rules and regulations are promulgated, is much simpler and should be much more familiar to any small business owner, or anyone who visited a restaurant or a hotel.

So here is how this is envisioned to work. Physicians will still get paid a base amount per service provided. If the corporate-government conglomerate judges the work of the doctor to be beneficial, they will throw in a 5% gratuity bonus. In Zukunft, if physicians can reduce the overall COGS (cost of goods sold) for the corporate-government conglomerate, they will get a moderate percentage of net profit. Als Letztes, if doctors are willing to take full P&L (profit and loss) responsibility for health care services, they can get a slightly bigger piece of the profit to offset the risk of massive loss. Essentially, if you are a physician, and if you agree to do what the corporate-government conglomerate wants you to do, and if you are really good at it, and if you are willing to put your money where your mouth is, you should expect nothing but financial prosperity in the era of value based care.

The things you would have to do to enjoy the value based financial bounty are not very difficult, particularly when compared to the practice of medicine. The goal is to keep the corporate-government conglomerate happy without distinguishing yourself from the generic woodwork of the new system. There is safety in the herd, and you should aim to be somewhere close to the middle of the herd. Stragglers, and those who venture too far out in front, are usually eaten. Below are a few strategies to help you position yourself for long and uneventful survival.

Percentage Medicine

If you dabbled in the game of tennis, whether as a player or an avid spectator, you are probably familiar with the term “percentage tennis”. Playing percentage tennis means staying away from corners and lines and spectacular shots. It means playing it safe, taking little if any risk, getting the ball over the net without fanfare, and absolutely no aces on serve. Percentage tennis is how middling players, who lack exceptional talent or physique, are advised to play the game. Serena Williams is not playing percentage tennis. Great champions never do.

If you like to think that you are a great doctor, brilliant diagnostician, or anything else preceded by some sort of superlative, tone it down. This is not about excellence. It’s about percentages. Wasting your precious time on the quickly fading Miss Henrietta Wilkins, who spent the Great War welding big chunks of metal in the shipyard, and a variety of other losers, who will never bring their biometric indicators up to corporate-government conglomerate standards, is not considered good percentage medicine. Ideally, you could ship these folks to the nearest community center, but if you can’t, see if you can reassign them to your NP/PA, or some outsourced care management service, and stay away from direct contact. If you want to personally help people, you should consider volunteering in a soup kitchen on Wednesday afternoons.

Generally speaking, seeing patients one-on-one is not a good use of your time. Your initial efforts should be directed to shaping a robust patient panel that can be managed by your care team working at the top of their license. Later on you should switch to maintenance mode and work the analytic dashboards, Excel sheets, pie charts, bar charts, and all the reports and data provided to you by the corporate-government conglomerate. These things are usually marked with red-yellow-green risk indicators, so it’s not that difficult to get started. Watch your reds. If they’re amenable to change, have your staff change them. Otherwise find a way to quickly remove them from your panel. Don’t neglect the yellows either, because if you’re not careful, they have a tendency to turn red without much advance notice.

This is how percentage medicine is played. This is population management and this is also precision medicine because some of those colored risk scores are accurate to the second, or even third, decimal point which is something your over educated human brain could never calculate on its own. As long as your panel looks green, but not too green, because that may be indicative of gaming, you should be safe. If you feel a sudden urge to jump back in and play doctor, maybe with an ominously red marked patient, resist it. Go take a brisk walk around the block or listen to a motivational TED talk. Try making a nifty Power Point presentation for the next leadership meeting (Power Point art can be very relaxing) or book some travel to a health innovation conference.

Fake it ‘till you make it

When you see patients, and you will have to for a while longer, you will need to present a caring and expert, yet humble, persona that reflects well in satisfaction surveys. You will have to be persuasive, without coming across as overbearing, when you steer clients towards product lines that are most beneficial to the corporate-government conglomerate, which is either your one true customer, or your direct employer. You will have to cultivate an engaging and compassionate image to elicit the trust of your clients. You will need to be friendly, but not too familiar, to maintain a certain aura of non-threatening expertise. You will need to say please and thank you, and you will need to display properly calibrated humility when apologizing for the shortcomings of the new and improved system, without throwing your superiors under the buss.

Since value based health care is a team sport, you will need to cultivate a non-disruptive, non-elitist image to present to the team. The team of course includes representatives of the corporate-government conglomerate, some of whom you will interact with in person, and others who will be watching you through rolled up dashboards and reports. Read a couple of value based policy papers or newspaper articles (they’re about the same as far as depth and substance are concerned), and memorize a few key words and phrases, such as “transformation”, “lifestyle and behavioral modifications”, “less is more”, “consumers want to be kept healthy”, “patient activation”, “triple aim”, “quadruple aim” (there is no quintuple aim yet, but watch for it soon), “our health care system is broken”, “$3 trillion”, “medicine has always been about information processing”, “the single most important thing to have is good data”. Stuff like that. When in doubt, just prepend “patient-centered” to whatever you plan to say next.

After a while, all of this will become second nature. If you get really good at it, you may want to go for a leadership role within the corporate-government conglomerate. It pays much better, and there are decent opportunities for advancement. Another option is to drop out of whatever is left of patient care and join the entrepreneurial side of the house. You can join a startup, or make your own. You need not be a techie or understand technology in any way. Startups are hungry for MDs, so they can advertise products “built by doctors”. Investors love that type of stuff and potential customers still have some residual respect for physicians. It won’t last long, so do it now or you may miss the boat.

One thing is certain though. A passive-aggressive attitude, or its burned-out martyrdom cousin, won’t do you any good. If you really and truly can’t get on board with the destructive recreation of your profession, you’d better quit. Get out and open a boutique cash-only practice or subcontract with one of those hit and run value based telemedicine services for the healthy or just find something else to do. Write a book, buy a little farm and make organic goat cheese, dabble in politics, start a movement. Have some fun. Life is short.

Margalit Gur-Arie ist der Gründer, BizMed. She schreibt regelmäßig um den Schnittpunkt der Gesundheitsversorgung & Technologie auf ihrer Seite: On Health Care Technology. Folgen ihr auf Twitter an @margalitgurarie

Opinions expressed by HIT Consultant Contributors are their own.

Republican committee leaders in the Senate and House today asked the administration for information about the 316 security breaches on HealthCare.gov catalogued in a new sich melden released by the nonpartisan government watchdog, the Government Accountability Office (GAO). Between October 2013 bis März 2015, HealthCare.gov had 316 security incidents, einschließlich 41 which involved personally identifiable information.

The GAO reported that HHS does not have complete records of how many people these incidents impacted and whether impacted individuals were notified. The letter sent to HHS Secretary Sylvia Burwell and Centers for Medicare & Medicaid Services Acting Administrator Andy Slavitt is seeking information specifically about the report findings that between October 2013 bis März 2015, HealthCare.gov had 316 security incidents, einschließlich 41 which involved personally identifiable information.

The letter was sent by Senate Health, Bildung, Labor and Pensions Committee Chairman Lamar Alexander (R-Tenn.), Senate Finance Committee Chairman Orrin Hatch (R-Utah), House Energy and Commerce Committee Chairman Fred Upton (R-Mich.), House Ways and Means Committee Chairman Kevin Brady (R-Texas), House Oversight and Government Reform Committee Chairman Jason Chaffetz (R-Utah), Senate Judiciary Committee Chairman Chuck Grassley (R-Iowa), Senate Commerce Committee Chairman John Thune (R-S.D.) and Senate Committee on Homeland Security and Governmental Affairs, Permanent Subcommittee on Investigation Chairman Rob Portman (R-Ohio).

In the letter Republican committee leaders in the Senate and House wrote: “In order to assist us in fulfilling our oversight responsibilities, ‎please send us a list and description of every security incident involving HealthCare.gov since October 2013, including how many individuals’ records were compromised, whether the incident involved personally identifiable information, and whether the affected individuals were notified. Please also send the HHS Breach Response Team’s charter and Standard Operating Procedures, its annual reports since 2013, the CMS breach response plan, and the after-action reports for each security incident.

“If HHS did not inform affected individuals, we urge you to change that policy immediately.”

The leaders, who had previously requested information from the administration about the website’s security, told Secretary Burwell they were concerned that they had not earlier been informed of the security breaches.

The leaders have requested a reply by April 6, 2016.

With growing efforts to provide people with information about health care prices, some health care experts have expressed concern that patients may avoid low-price care if they associate price with low quality. Jedoch, most Americans do not associate the price of care with the quality healthcare, nach einem analysis of survey data published in the April issue of Health Affairs.

While health care prices vary widely throughout the country, there is no evidence that higher prices are associated with higher quality or better health outcomes.

In the analysis, researchers found that a majority of Americans (ranging from 58-71 percent depending on how the questions were framed) do not think health care cost and quality are associated. Fewer than one-quarter (21-24 Prozent) perceive an association, während 8-16 percent are unsure. The analysis was conducted by David Schleifer and Carolin Hagelskamp of Public Agenda, along with Kathryn Phillips of the University of California, San Francisco, and is based on a nationally representative survey von 2,010 adults conducted by Public Agenda and funded by the Robert Wood Johnson Foundation.

“Most people do not believe they have to pay more money to get better quality health care” said Schleifer. “Jedoch, a small portion of Americans do think better care costs more or are unsure, which underscores the need to publicly report information about both quality and price.”

Individuals who say they have shopped around for health care, comparing the prices of one provider or service against another, are more likely to perceive that price and quality are associated than individuals who have not compared prices. Researchers do not know whether there is a causal relationship between comparing health care prices and associating price and quality.

“It may be that people who already think better care costs more money are more likely to be comparing prices. But if comparing prices somehow causes people to think that better care costs more, then the governments, insurers and other companies who are developing transparency tools need to figure out how to address those perceptions,” said Schleifer.

The researchers also found that African-Americans, Hispanics and those under age 30 are somewhat more likely than others to believe cost and quality are associated.

Results also depended on whether people were asked about high price/high quality care or low price/low quality care. People were less likely to believe price and quality were associated if they were asked about high price/high quality care.

“We know from other studies that people perceive information differently depending on how it is framed. Zum Beispiel, they are more likely to buy ground beef that is labeled 75 percent lean versus labeled 25 percent fat,” said Phillips. “Ähnlich, we found people perceive price and quality differently when described as high price/high quality versus low price/low quality. We need to consider how people actually perceive price and quality information so we can design the right tools and policies.”

Am Montag, die Centers for Medicare & Medicaid Services (CMS) announced its largest-ever initiative to transform and improve how primary care is delivered and paid. The initiative called the Comprehensive Primary Care Plus (CPC ) Modell will be implemented in up to 20 regions and can accommodate up to 5,000 practices, which would encompass more than 20,000 doctors and clinicians and the 25 million people they serve.

The initiative builds on the Comprehensive Primary Care initiative launched in late 2012 and is designed to provide doctors the freedom to care for their patients the way they think will deliver the best outcomes and to pay them for achieving results and improving care.

“Strengthening primary care is critical to an effective health care system,", Sagte Dr.. Patrick Conway, CMS deputy administrator and chief medical officer. “By supporting primary care doctors and clinicians to spend time with patients, serve patients’ needs outside of the office visit, and better coordinate care with specialists we can continue to build a health care system that results in healthier people and smarter spending of our health care dollars. The Comprehensive Primary Care Plus model represents the future of health care that we’re striving towards.”

Comprehensive Primary Care Plus (CPC ) Model Overview

The five-year CPC model will benefit patients by helping primary care practices:

– Support patients with serious or chronic diseases to achieve their health goals
– Give patients 24-hour access to care and health information
– Deliver preventive care
– Engage patients and their families in their own care
– Work together with hospitals and other clinicians, including specialists, to provide better coordinated care

Primary care practices will participate in one of two tracks. Both tracks will require practices to perform the functions and meet the criteria listed above, but practices in Track 2 will also provide more comprehensive services for patients with complex medical and behavioral health needs, einschließlich, as appropriate, a systematic assessment of their psychosocial needs and an inventory of resources and supports to meet those needs.

CPC Model Track Overview

In Track 1, CMS will pay practices a monthly care management fee in addition to the fee-for-service payments under the Medicare Physician Fee Schedule for activities.

In Track 2, practices will also receive a monthly care management fee and, instead of full Medicare fee-for-service payments for Evaluation and Management services, will receive a hybrid of reduced Medicare fee-for-service payments and up-front comprehensive primary care payments for those services. This hybrid payment design will allow greater flexibility in how practices deliver care outside of the traditional face-to-face encounter.

To promote high-quality and high-value care, practices in both tracks will receive up-front incentive payments that they will either keep or repay based on their performance on quality and utilization metrics. The payments under this model encourage doctors to focus on health outcomes rather than the volume of visits or tests.

Practices in both tracks also will receive data on cost and utilization. Optimal use of Health IT and a robust learning system will support them in making the necessary care delivery changes and using the data to improve their care of patients. Track 2 practices’ vendors will sign a Memorandum of Understanding (MOU) with CMS that outlines their commitment to supporting practices’ enhancement of health IT capabilities.

These partnerships will be vital to practices’ success in the care delivery work and align with the Office of the National Coordinator for Health IT priority to ensure electronic health information is available when and where it matters to consumers and clinicians.

Under the CPC model, Medicare will partner with commercial and state health insurance plans to support primary care practices in delivering advanced primary care. Advanced primary care is a model of care with five key components:

– Services are accessible, responsive to an individual’s preference, and patients can take advantage of enhanced in-person hours and 24/7 telephone or electronic access.

– Patients at highest risk receive proactive, relationship-based care management services to improve outcomes.

– Care is comprehensive and practices can meet the majority of each individual’s physical and mental health care needs, including prevention.

– Care is also coordinated across the health care system, including specialty care and community services, and patients receive timely follow-up after emergency room or hospital visits.

– It is patient-centered, recognizing that patients and family members are core members of the care team, and actively engages patients to design care that best meets their needs.

– Quality and utilization of services are measured, and data is analyzed to identify opportunities for improvements in care and to develop new capabilities.

CMS will select regions for CPC where there is sufficient interest from multiple payers to support practices’ participation in the initiative. CMS will enter into a Memorandum of Understanding (MOU) with selected payer partners to document a shared commitment to align on payment, data sharing, and quality metrics in CPC+.

CMS will accept payer proposals to partner in CPC from April 15 through June 1, 2016. CMS will accept practice applications in the determined regions from July 15 through September 1, 2016.

Die Merriam-Webster dictionary has many definitions for the term system, but the most straightforward, and arguably the most applicable to our health care conversation is “a regularly interacting or interdependent group of items forming a unified whole”. The common wisdom is that our health care system is broken and hence our government is vigorously attempting to fix it for us through legislation, reformation and transformation. We usually work ourselves into a frenzy arguing how the government should go about fixing the system, but I would like to take a step back and question the assumption that health care is, or should be, a system. This is not about splitting the hairs of semantics. This is about proper definition of the problem we wish to solve.

You could argue that we use the term system loosely to refer to everything and there are no nefarious implications to calling health care a system. We have a transportation system, an education system, a legal system, a financial system, a water system, a political system and so forth. Note however that we rarely talk about our food system or auto system, fashion system, hospitality system, etc. We call those industries. Starting to see a difference here? Good. Our government obviously regulates both systems and industries, but it regulates them differently. And systems have distinct characteristics that industries seldom have, such as built-in (systemic) mechanisms for discrimination, and institutionalized (yep, systemic) corruption aplenty.

When we begin by assuming that health care is a system, we assume that health care should possess those same characteristics. We assume that health care in Beverly Hills will be, by design, different than health care in Flint, Michigan. We assume that health care delivered in private settings will be different than health care accessed in public settings. We assume that some areas will have sprawling, on demand health care hubs, while others will have none. We assume that public engagement in health care is for show only, while the billionaire class and its carefully constructed echo chamber get to make all our health care decisions. We assume that health care is, and always will be, rigged. And based on these assumptions, we proceed to fix our health care “system”.

You may be tempted to dismiss these thoughts as specious demagoguery, strawmen, soapbox arguments or just plain exaggerations. Schließlich, health care system fixing includes such socially beneficent endeavors as expanding “coverage” for the poor (Medicaid expansion), subsidizing insurance for the less poor (Obamacare exchanges), granting insurance to the sick (preexisting conditions), and a steady drumbeat of accountability, measurement and reduction in “disparities” for “vulnerable populations”. To that I would respond by pointing you to several recent utterings from public figures empowered to effect health care reforms.

Medicaid for America

Let’s begin with the all-powerful Acting Administrator at the Centers for Medicare and Medicaid, Herr. Andrew Slavitt. The “acting” prefix is there, because for some reason, Herr. Slavitt is running the largest (taxpayer financed) health care insurance entity in the country without proper Congress confirmation. In a recent string of Tweets, Herr. Slavitt refers to our “beloved modern Medicaid program” as “America’s healthplan”, proudly reminding us that Medicaid is 72 million strong (“Working people, families, majority white…") and growing. I think it’s safe to assume that Mr. Slavitt himself is not receiving his medical care through “America’s healthplan”, and neither does anybody he associates with. It is also safe to assume that an accomplished executive like Herr. Slavitt, who is Harvard and Wharton educated, understands all too well that the size of Medicaid is inversely proportional to the prosperity of the American people. If the sheer notion of a senior political appointee in the Obama administration being ostentatiously proud to see working families forced to beg for public charity is not triggering a fire alarm in your head, then I don’t know what will.

One could argue that since Obamacare expanded Medicaid to people above official poverty levels, perhaps a bigger Medicaid does not necessarily imply more poor people, but a more generous society. One could make such argument, if federal poverty levels were a realistic measure of poverty, or if we didn’t have other sources of information. The grim reality is that even middle class Americans are now lacking the ability to purchase decent medical care, or insurance instruments for the same, and hence the Obamacare exchange subsidies for cheap insurance, which is marginally better than Medicaid in some ways, and substantially worse in other ways.

In another insightful tweet, Herr. Slavitt observes that “In exchanges, consumers vote with their feet and with their feet they say unaffordable care is a deal breaker”. Note how elegantly, inability to pay for nice things due to being destitute in general, is now framed as a preference, something you vote for with your feet. This is precisely how establishment henchmen convinced us that we vote with our feet when we shop at Walmart while decently paying jobs are being vacuumed from underneath our very same feet. Being poor and unable to afford eclectic amenities prized by the elites is a consumer preference, one very short step away from arguing that being on food stamps or sleeping under a bridge are merely choices some consumers make.

Health care in America is expensive. Expensive, obwohl, is a relative term, and if America’s working class didn’t see its income consistently go down the 1% drain, perhaps health care would seem more affordable. But American health care is also expensive in absolute terms. Mostly it is expensive because each service and each item is priced higher than anywhere else in the world. Tackling the pricing problem is guaranteed to upset the masters of establishment henchmen, so they worked hard and found a couple of other alternatives to generate cheapness, just in case the voting with feet thingy blows up in their face (as it seems to be the case right now). The trick is to deflect scrutiny from real issues, and assign responsibility (blame) to doctors and the people in general.

The Return of the Broccoli

I’ve written compulsively about the apparent war on doctors in the past, and I am certain I will be writing more, but the war on people is a much more intricate subject. It’s relatively easy to separate a quarter of one percent of people from the herd, paint them as for-profit mass murderers and sic the hungry mobs on them. But then how do you subdue the mobs? For that, my friend, we have government. We have behavioral economics. We have the experts and pundits in that echo chamber. And we have the righteous souls who innocently light the fuse of every calamity.

I’m old enough to remember the debates preceding the Obamacare litigation in front of the Supreme Court, culminating with both Justice Scalia and Chief Justice Roberts pondering whether the government has it within its enumerated powers to make you buy broccoli. Before the broccoli debacle, the same libertarian lunatic fringe wondered if government can order Americans to lose weight, or if the government can mandate that we buy certain products from certain manufacturers. Of course Obamacare and its mandate to buy health insurance or be penalized by the IRS survived these outlandish challenges, and the IRS is doing its best to rake in those penalties. It must be doing a great job too, because it sounds like IRS services for mankind could be drastically expanded.

Steven Findlay is an expert health care policy journalist, with an illustrious record working for the Consumers Union, and one of the handpicked advisors who shaped the Meaningful Use program. Herr. Findlay recently commented on The Health Care Blog, making the following statement: “Hell, I’d support tax breaks for people who quit smoking and/or can document to the IRS that they exercise 3 times a week for an hour each time!” Hell, tatsächlich! But if the IRS can collect penalties for failure to purchase insurance, and grant tax credits for buying Pella windows, why not offer tax breaks for making your body more productive and more efficient?

Was Mr. Findlay writing in jest? Vielleicht, but note that Obamacare is already empowering health insurers and employers to offer “incentives” and “discounts” for a variety of wellness schemes, which are essentially paycheck penalties on sick and “non-compliant” people. And note also that these types of shell games are only effective if you are poor enough and forced to vote with your feet every time someone reaches for your empty wallet. I wonder if voting with your feet would be an IRS approved form of exercise…

This is the glorious power of systems. This is the power of a “regularly interacting or interdependent group of items forming a unified whole”. This is why health care must become a system where the “items” regularly interact in formulaic pathways. This is why free range actors randomly affecting the system cannot be tolerated by the centrally installed array of levers and signaling networks.

This is why independent medical practice must die, small hospitals must be euthanized, and managed population health must encompass the entire nation (minus the elite caretakers) down to the minutest detail. This is why each one of us must be systematically tagged, numbered and catalogued in the vast repositories of “precision medicine”. And this is precisely why health care must never be allowed to become a system.

Margalit Gur-Arie ist der Gründer, BizMed. She schreibt regelmäßig um den Schnittpunkt der Gesundheitsversorgung & Technologie auf ihrer Seite: On Health Care Technology. Folgen ihr auf Twitter an @margalitgurarie

Opinions expressed by HIT Consultant Contributors are their own.

Ms. Jeannie is a 65 years old woman, slightly overweight with mild hypertension that is perfectly controlled. Ms. Jeannie is the office manager at Dr. Abrams, the pediatrician down the hall, who’s been taking care of your kids since you moved here. Ms. Jeannie called earlier because her allergies are killing her today and she’s out of refills for her blood pressure meds anyway. After an uneventful 15 Minuten, and a brief chat in the hallway, Ms. Jeannie pays her $15 copay and heads back to work. Medicare will pay you another $60 in a few weeks. On to Bob Burns who is here for his DOT physical and his BP is through the roof… again…

Somewhere in our nation’s capital, someone has decided that when you go about your day like this, you’re doing a lousy job, because you provide very little bang for the buck they pay you. Maybe Jeannie could have seen your nurse instead of wasting your time with trivial things. Maybe she could have just stayed at her desk in Dr. Abrams’ office and talked to your nurse over Skype or email. And why is it that you can’t get a grip on Bob’s blood pressure and make him take his meds and understand that driving a truck is not a form of exercise? You need to provide value, instead of just counting volumes and volumes of expensive visits that may or may not work. This is wasteful. You need to learn how to do better with less money.

This is the heart and soul of MACRA. This is what 962 pages of gibberish are trying to elucidate for those who have the time to read 962 pages of government regulations on a Wednesday morning. You can certainly try to set aside time to pore over the intricacies of how Medicare plans to not pay you the $60 it owes you for seeing Jeannie, but if you have twenty to forty hours to read, I’d suggest taking another shot at Ulysses which may be a more rewarding and less frustrating choice. In Medicare’s defense though, it’s not that they don’t want to pay you anything for seeing Jeannie. Unterlassen Sie, that would be dumb. Die 962 pages of labyrinthine regulations are about $3 that Medicare may be withholding from or adding to your $60 remittance for similar visits with Ms. Jeannie in 2019.

There are plenty of good summaries of MACRA out there (hier is a great one), so I’m not going to repeat any of that here, because frankly, it doesn’t really matter. Als Erstes, the SGR formula which MACRA is supposedly replacing was never implemented. Chances are good that the furious mathematics at the fraying edges of medicine described in the latest notice of proposed rulemaking will suffer a similar fate. Second, even if Medicare spends the prerequisite billions of dollars to implement a national mechanism for withholding your $3, booking one more patient per day will completely neutralize any effects on your practice and your personal income. Alternatively, and particularly if you are “of a certain age” this may be a great opportunity to spruce up your golf game, as Dr. Halamka himself is suggesting.

The Doctor Whisperers

Have you ever trained your pooch to walk nicely on a leash, to sit and stay and rollover whenever you tell him to? If so, chances are that you used those little bits of liver treats to reward good behavior. You don’t reward your pup in training with huge T-bones because he will ignore you for the next hour or two as he enjoys his bone. For obedience training, you use cheap, tiny morsels over and over again, along with profuse words of encouragement, until Rover gets the idea, and then you replace the liver bits with a pat on the head, and then you just assume that the dog is conditioned to always do what you want him to do, without rewards. And that’s how Rover becomes a good dog. Die $3 Medicare incentive is your liver bit. Using it repeatedly, every 15 minutes or so, all day every day, is how you will be trained to become a good doctor.

The people who run programs like the MACRA are not stupid. They know, and the math is pretty straightforward, that the $3 training morsels won’t make any difference in Medicare finances, but at the end of the day you will learn to always pay attention to the handlers and respond to nonverbal cues in a reliably consistent manner. Zum Beispiel, many EMRs today have special markings for data fields that must be captured for Meaningful Use or PQRS. Some are color coded, others are marked with little stars and practically all have lists of items that were “satisfied” or not. Those are equivalent to yanking Rover’s choke collar, schnell, gently and ever so slightly. Nobody wants to hurt their “best friend”. We train docs for their own good, because well trained, obedient dogs are happy dogs.

Leider, not all dogs are created equal. Great Pyrenees for example were bred for centuries to work independently, mostly alone, mostly at night, to protect their sheep from big bad wolves. Having shared my home with a few great ones over the years, I can tell you that they find fetching sticks a rather uninteresting proposition. Buried deep in the bowels of the 962 pages is a cute little table forecasting whose chain will be yanked and who will be getting those $3 bits most of the time (page 676). As you would expect, 9 von 10 solo docs and 7 in 10 docs practicing in groups of less than 10 will be penalized, while over 80% of those working in very large systems, or rather their employers, will get rewarded. The heart and soul of MACRA has no room for independent doctors. They either submit themselves to employment in the service of big corporations, or go their separate way.

Other People’s Money

A century ago, under similar circumstances as we are experiencing today, Louis D. Brandeis railed against the “curse of bigness”, and particularly the bigness of bankers who used “other people’s money” to exert undue influence (control) over the nation’s economy solely for their personal benefit and with complete disregard for the welfare of the people. To be sure, Justice Brandeis, as Thomas Jefferson before him, was disgusted with big corporations and big government as much as he was appalled by big banks. Both before and after his Supreme Court appointment, Brandeis experienced significant success in his crusade against bigness, but a century of American politics as usual managed to destroy practically everything he achieved, and to add insult to injury, today it’s not just the big banks that get to play games with other people’s money.

Die 962 pages (with more to come) of MACRA regulations are how big government is creating a set of financial instruments that nobody understands (including the authors) to affect 20% of the American economy, not to mention the lives of 300 Millionen Menschen, using other people’s money to benefit the bottom lines of big corporations and for the personal aggrandizement of political appointees. I may be wrong, but I believe Justice Brandeis would be irate at the mere thought that the Federal government is proposing to award 7.5 cents to medical doctors who are “registered for a minimum of 6 months as a volunteer for domestic or international humanitarian volunteer work”. Thomas Jefferson would probably observe that our tree of liberty is long overdue for some refreshments, but I digress.

From its inception, health care reform has been focused on diverting physicians’ attention from patient care, which comes naturally to most of them, to counting things supposedly representing patient care. First came counting scripts sent electronically to pharmacies, then came counting the number of times the mammogram box was checked, the number of times the Pacific Islander box was ticked, the number of times one glanced at this or that list, culminating with the number of dollars patients are costing the insurance company. The MACRA is just the next step in the succession of incremental steps designed to transition Medicare to a Medicount program. The problem with this strategy is that you are counting other people’s money.

Every dime the Federal government spends on obedience training (or culling) for doctors, is our money. Every nickel Medicare is spending on managing the largest accounting exercise known to mankind, is our money. Every penny commercial insurers spend on adopting the Medicount method, is our money. We are the true risk bearers for this experimentation, and so far we are seeing nothing but downside. Public health expenditures are going up. Private insurance premiums are going way up. Out of pocket expenses are going up. Our life expectancy is going down. Suicide rates are up. Addiction rates are up. Mental distress levels in general are up. And yet we are all compelled by taxation laws to fund our own demise without honest representation, without informed consent and without any legal recourse.

Maybe not this summer, and maybe not this fall, but what do you think comes next?

Margalit Gur-Arie ist der Gründer, BizMed. She schreibt regelmäßig um den Schnittpunkt der Gesundheitsversorgung & Technologie auf ihrer Seite: On Health Care Technology. Folgen ihr auf Twitter an @margalitgurarie

Opinions expressed by HIT Consultant Contributors are their own.

Anmerkung der Redaktion: Kyle Stapp is the Program Director at Eligibility.com where he oversees the educational center inside Eligibility.com and works daily with program applicants to answer their questions. His programs include Medicare, Unemployment, und mehr. Folgen Sie ihm auf Twitter an @kyle_stapp, or connect with him on LinkedIn.

According to the Center for Medicare and Medicaid Services (CMS), 32% of Medicare beneficiaries are enrolled in a Medicare Advantage plan, amounting to 17.1 Millionen Menschen. This number has been increasing as beneficiaries flock towards the competitive prices. Of these beneficiaries, 9.72 million enrolled in a plan provided by one of four insurers: UnitedHealth, Humana, Kaiser, and Aetna. With Aetna’s recent acquirement Humana, these three remaining companies now control 60% of the market for Medicare Advantage programs.

One thing that these three insurers, und andere, have to look out for is the announced annual changes to the Medicare Advantage and Medicare Part D programs, stated in the 2017 Rate Announcement and Call Letter. The original proposal for these changes was made back in February 2016, and following a public comment period, CMS finalized their updates that will take effect starting next year. The updates include a variety of implications for both insurers and beneficiaries including:

1. Improved accuracy when interpreting plan performance

There was some concern about dually eligible enrollees and/or low income subsidy enrollees affecting the ability of Medicare Advantage plans to achieve high Star Ratings. For 2017, CMS intends to better interpret plan performance among plans with a high percentage of dually eligible or low income beneficiaries, allowing these plans to achieve higher Star Ratings where deserved.

2. Reduction of opioid overuse

CMS aims to continue reducing the number of Medicare Part D beneficiaries who overuse or abuse their opioid prescriptions, an effort that has already demonstrated success through the Part D Overutilization Monitoring System. In accomplishing this, CMS will work to control opioid sales using “point-of-sale edits” or safeguards before opioid prescriptions are given to patients, which is intended to limit the number of false positive results for opioids as well as opioid prescription abuse.

3. Addition of medication-assisted treatment coverage.

Die 2017 Call Letter addresses intentions to improve access for beneficiaries to medication-assisted treatment (MAT). The updates include ensuring that Medicare Advantage plans provide the same MAT coverage and substance use disorder treatment coverage as is provided by Original Medicare. Außerdem, the update requires that Part D plans which cover MAT are to ensure access to this treatment.

4. Improvements in the area of drug utilization among beneficiaries.

With regards to the Medicare Part D program, the updates announced in the 2017 Call Letter plan to address certain drug utilization issues. One of these updates will help eliminate prescription drug waste by limiting prescriptions to one-month supplies. In cases in which patients are given multiple-month prescriptions and do not need to complete all months’ worth of medication, a shorter prescription will reduce the amount of drug waste.

As a part of this update, sponsors will also be required to inform beneficiaries of any new drug coverage that becomes available to them mid-year, giving them access to better quality medication options if needed. CMS also hopes to increase beneficiary awareness of Medicare drug spending with the implementation of this update.

The finalized changes announced in the 2017 Rate Announcement and Call Letter are intended to improve the Medicare Advantage and Part D programs and provide better quality care to beneficiaries, including those from low income households and dually eligible individuals. It is clear how some might benefit from these changes, but many beneficiaries believe they won’t see any of these improvements affect their coverage.

Tatsächlich, some see these changes as more beneficial to the insurers than the beneficiaries. Zum Beispiel, changes in interpreting plan performance will help some companies gain a higher rating, yet won’t affect the beneficiaries. Further, changes in drug utilization may prevent some beneficiaries from paying for more medication than they need, jedoch, it may help the insurers to a larger extent since they often cover a majority of these costs.

5. 2017 Rate Announcement

Natürlich, these improvements come at a cost. The announcement also included the finalized Medicare Advantage rates for 2017. The Advance Notice released in February had estimated a 1.35% increase in Medicare Advantage rates, but the finalized rate increase came in much lower at just 0.85%. Some ways in which these rates will changed are:

– Higher standard initial deductible. The standard initial deductible for 2017 ist $400, nach oben $40 from the 2016 standard initial deductible of $360.

– Higher initial coverage limit. The initial coverage limit for 2017 ist $3,700, nach oben $390 from the 2016 initial coverage limit of $3,310.

– Better Donut Hole discounts for generic and brand-name medications. Those who reach the Donut Hole or Coverage Gap of their Part D coverage will receive a 49% discount on generic prescription drugs, a discount increase of 7% von 2016, and a 60% discount on brand-name medications, nach oben 5% from 2016.

6. What All of This Means for Medicare Advantage Beneficiaries

Sponsors argue that Medicare beneficiaries should see the 0.85% increase as a win opposed to the proposed 1.35% increase, but some still wonder whether these stated improvements are worth the elevated rates. Zusätzlich, some worry that improvements won’t be realized at all, and the only change they will see is higher cost. Schließlich, beneficiaries find frustration in that the rate increase is estimated to elevate revenue by 3.05% for plan sponsors in 2017.

One reason why Medicare enrollees have been migrating towards Medicare Advantage plans is the favorable rates due to a competitive marketplace. Jedoch, this competition seems to be lessening, representing a major cause for concern on behalf of the beneficiaries. The modest rate increase might seem minimal, but some beneficiaries worry that this, complemented by the consolidation of plan providers, might disincentivize some from actually improving quality. Weiter, many of those who believe changes can be made still will not see a significant improvement in their coverage.

Following the 2017 Rate Announcement and Call Letter up until October of this year when the Medicare Advantage enrollment period begins, insurers will be spending their time creating Medicare Advantage plans that align with the updates and changes announced in the Call Letter. Beneficiaries are encouraged to stay updated on any additional information regarding 2017 Medicare Advantage plans that may be released by CMS.

Quellen:

http://www.wsj.com/articles/federal-regulators-propose-increase-to-medicare-advantage-rates-1455924070

http://www.beckershospitalreview.com/finance/cms-finalizes-2017-medicare-advantage-rates-8-things-to-know.html

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-04.html

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-04-04.html

http://www.modernhealthcare.com/article/20160404/NEWS/160409961

https://q1medicare.com/q1group/MedicareAdvantagePartD/Blog.php?blog=A-preview-into-2017–CMS-releases-finalized-standard-2017-Medicare-Part-D-prescription-drug-plan-coverage-parameters&blog_id=556&frompage=18

Anmerkung der Redaktion: Jonathan Rickert is the CEO and Co-founder of Array Health, a provider of private insurance exchange technology that simplifies the process of buying health insurance with e-commerce platform.

Provider-sponsored plans (PSPs) are a disruptive force in today’s evolving healthcare market. By combining healthcare financing and care delivery with strong, familiar brands in the local community, PSPs are able to break the traditional constraints of the fee-for-service model and deliver more efficient care at a lower cost.

These benefits are contributing to the robust growth of PSPs in recent years. Nach dem 2016 AIS Directory of Plans, 26 new PSPs were added and PSP enrollment increased 10 Prozent von 2014 bis zur 2015. Establishing a PSP is one thing; making it financially successful is another.

PSPs need to overcome several obstacles – including acquiring new members, influencing member behavior and tightly integrating with the health system – to ensure success. Health insurance ecommerce platforms – commonly referred to as private exchanges – are particularly well suited to help PSPs address these needs and thrive in this new environment.

Private exchanges can help a PSP achieve its goals by addressing these three core challenges:

#1 – Acquiring Members

For PSPs, attracting new members is critical. Similar to traditional insurers, PSPs must offer both group and individual plans to help them scale. In 2014, 43 percent of PSPs with more than 10,000 members had both group and individual business, according to the latest AIS data, and that grew to 53 percent last year.

To support member acquisition, PSPs need an ecommerce solution that supports both lines of business. Private exchanges offer modern shopping capabilities to support a broad line of health and voluntary insurance products. A private exchange platform makes it easy to add the products consumers want, such as disability, critical illness, health savings accounts and pet insurance. Außerdem, private exchanges enable PSPs to differentiate themselves with a unique ecommerce experience that millennials and baby boomers alike can appreciate. A private exchange enables PSPs to fully control their marketing channels across all lines of business (group, individual, retiree and others). By owning the channel and the data that comes with it, PSPs can easily target and personalize marketing efforts, which is key to acquiring new members.

#2 – Influencing Member Behavior

There has long been a fundamental paradox between the goals of a hospital system and those of a health plan: Providers focus on care delivery, while health insurers’ primary concern is cost. With a PSP, the health system assumes financial responsibility for insured members’ health. Infolge, there’s a financial incentive for a PSP to ensure its members remain healthy. The PSP arrangement makes it easier for hospital systems to provide the best care at the lowest cost.

A private exchange platform offers a key advantage: Employers and insurers can activate wellness and care management programs at the time of enrollment. When implemented correctly, these types of programs are very effective in educating members by providing information about how to stay healthy or proactively manage a chronic health problem. In einer aktuellen AIS webinar, Jim Parker, president and CEO of Indiana University Health Plan, talked about the programs his PSP has in place to help patients manage their care, which have decreased inpatient admissions by up to 10 Prozent.

#3 – Integrating with the Health System

For a PSP to be successful, a member’s experience should be seamless, whether he or she is interacting with the payer or provider side of the house. A private exchange enables the PSP to personalize the shopping experience for each member based on data collected from the health system; this could be as simple as letting members know which of their preferred doctors are within the health system.

When insurance is tailored to each individual’s specific needs, it’s a winning formula for all parties involved: the member, the health system and the insurer. Zum Beispiel, someone with a chronic condition who is the parent of several children will need different insurance coverage than a single, healthy, young adult. This type of personalization – which allows consumers to evaluate plans based on payment preferences, utilization expectations, and provider and formulary preferences – is where ecommerce platforms shine. Private exchanges are designed to offer consumers the choices that make sense for them and help them understand their options.

Integration of healthcare and health insurance organizations results in consumers who are most satisfied with their care and experience. Nach einer aktuellen JD Power Umfrage, integrated plans have an average overall satisfaction score of 746, was 63 points higher than that of non-integrated plans. And since consumers are more likely to trust their medical provider than their health insurer, the strong trust factor can extend to the PSP. This strength of the provider brand was a major reason that Bluegrass Family Health, the insurance arm of Baptist Health system, was rebranded as the Baptist Health Plan letztes jahr.

PSPs have important decisions to make when evaluating what technologies are best to support their needs. Private exchanges enable PSPs to maintain high levels of consumer satisfaction, help keep patients as healthy as possible and cultivate strong member-for-life relationships.

MACRA seems to be the talk of the town right now. MACRA and MIPS and APM and the dozens of sub-acronyms flying around like so many arrows in this Game of Thrones, Battle of the Bastards. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law over a year ago. That’s right, MACRA is the “law of the land” now, and it became law of the land with overwhelming bipartisan support in Congress and with much lobbying and cheerleading from medical associations. MACRA is not a proposal. It’s not some random regulation. It’s not something that can be stopped or changed without an act of Congress.

And MACRA is very lengthy and very detailed legislation. There is nothing surprising or unexpected in the recent publication of proposed implementation details that was not spelled out in the original MACRA text. It is possible that the degree of specificity in the CMS proposed rules for MACRA implementation finally hit home with the clarity absent from typical legislative language.

It is also possible that an actual implementation date a few months down the road is more threatening than one that is a few years out. Either way, we are now witnessing a flurry of social media chatter lamenting MACRA, asking for changes in MACRA and demanding to stop MACRA altogether. I hate to say it, but all this huffing and puffing is a day late and a dollar short, folks.

Amongst the avalanche of angry articles, militant tweets, desperate conversations, calls for action (commenting on the proposed rules), apologies and condescending propaganda, perhaps the most touching post I’ve seen came from David Introcaso at The Health Care Blog, which shows in great detail how the MACRA is not really measuring “value”.

Dear David, MACRA wasn’t meant to measure anything. It wasn’t meant to improve anything. It was meant solely to aid and abet the McDonaldization of health care. Submitting MACRA comments to the CMS is like bickering over the choice of rope after being sentenced to hang by the neck until you are dead.

Efficient, quantifiable, homogenized, controlled and dehumanized, that’s what health care must become, and when it does, health care will be plentiful, easily accessible and affordable for all poor people everywhere. Like Happy Meals. So how do we fight this? If you’re a physician in a leadership position, you don’t. Why should you?

The more money we can save by cutting down “inappropriate utilization”, and the more money we can save by penalizing working doctors, the more cash will become available for executive bonuses. If you are a physician entrepreneur, you have bigger fish to fry. This is your once in a lifetime opportunity to invent a Zuckerberg platform for health care or a Bezos venue for online health care. If you just see patients from dawn to dusk, well, why are you doing that? There are leadership programs and entrepreneurial classes for doctors sprouting everywhere.

If you’re old fashioned or driven by idealistic notions, get over it. We live in a globalized economy. We don’t live on Planet Earth. We don’t live in a global village, or even a globalized society. We don’t even live in the Matrix. We live in the economy. It’s the economy, stupid. It’s like the Serengeti, dumbass. Migratory herds of wildebeests, Zebras, antelopes, whose sole purpose in life is to be eaten by big cats. Is there a way out?

Can the wildebeests, stop as one, turn around as one, and vanquish the predators? They tried that in Great Britain the other day. They called it Brexit. The globalized economy is still reeling from that blow, and every fat cat, every hyena, every vulture and every maggot, mobilized to define the Brexiters as a bunch of racist, bigoted, ungebildet, mentally challenged, Luddite, toothless old farts, too stupid to appreciate the majestic beauty of the Serengeti.

On my Twitter stream some of the more frustrated physicians suggest that perhaps doctors should take a page from the Brits and stage a Drexit. True, revolution is contagious, but what does the doctor plight have to do with Brexit and globalization?

Post Brexitum Ante Drexitum

On June 23rd the people of Great Britain decided by referendum that European Union technocrats, congregating in Brussels Belgium, shall no longer be empowered to dictate which tea kettle an Englishman can or cannot use. The Brexit was essentially a vote against globalization, against a common regulatory framework and against the free movement of labor to support a common market where the rich get richer, the middle classes gets poorer, and the poor get to work for a bowl of thin gruel. Globalization has been excellent for the elites and not too shabby for a slice of society immediately under the elites, while gutting the vast majority below. And the gutted majority was supposed to meekly accept the inevitability of this new world order. Is this starting to ring your liberty bell?

There are approximately one million medical school graduates in the U.S. Derer, a small number are considered elites. These are the CEOs of big companies, the CMOs and CMIOs, the board members of every kooky startup, those who give keynote addresses at industry shindigs, those who write books, give interviews and do podcasts, those who shape and promote government agendas. Then come the thousands of highly specialized physicians who make money by the boatloads and are shielded from reality (for now). At the lower end are all other working doctors, with primary care bringing up the massive rear. The distribution of riches and pain seems similar to the UK, the US, and frankly, to a host of other third world countries.

Whereas working people are told that they suffer from “anxiety” and various “phobias” (and stupidity), doctors are labeled “burned out” or “suicidal” (or disruptive) when failing to live up to the McDonaldization of life in the global economy. The elites of course are immune to these afflictions due to their superior visionary intellect. The rest of us need to be gently “nudged” to alter our “behavior”. Physicians need to have their “culture” and “readiness to change” evaluated. We all seem to need remedial education for how to “communicate”, how to “transform” or “adopt change”, how to be “sensitive”, and how to be grateful for all the unearned “privileges” we enjoy while billions of others are worse off. My grandma used to make similar arguments for why we should eat her revolting creamed spinach, but let’s go back to globalization.

Globalized Health Care

Remember when we used to say that all health care is local? We don’t say that anymore. Now we have centers of excellence far away from home and small rural hospitals that are all but doomed. Dr. Phil and Sir Richard Branson want me to get medical advice from strangers in other states. My TV frequently advertises state of the art hospitals in Dubai. Transkription Dienstleistungen, claims processing, utilization reviews, and even radiology services have been globalized already. As technology pushes itself into medicine, with apps and artificial intelligence and even those pedestrian EHRs, remember that computers, Tabletten, phones and such, are all made in China’s slave labor camps, software is largely made in India or Pakistan or by imported slave laborers, maintenance and help desks are mostly overseas and some are in private American jails.

The lethal combo of HITECH/ACA/MACRA is essentially a redistribution of payments from local doctors (and the local people they employ) to cheaper semi-skilled and unskilled labor across state lines and across the globe. The benefits accrue to global corporations directly and indirectly, because profits in globalized business models are much larger, and the locus of power is shifted from geographically anchored professional expertise to global technocrats. This is not a disruptive innovation. From the days of Nebuchadnezzar to the East India Company and beyond, those who wished to rule the world understood that commandeering and destroying local infrastructure and uprooting people are the best ways to foster compliance with centralized governments far away.

Hard Drexit vs Soft Drexit

Unlike the Brexiters, physicians have no country of their own, und das Gomer Blognotwithstanding, there is no mechanism for a referendum. There is no Union or Guild or national body that could allow doctors to organize a serious Drexit that will pull all doctors, or at least a critical mass of practitioners, out of the acronym games. But even if a Physician Union existed, it is not clear what doctors would want to exit. Do they opt out of Medicare and Medicaid en masse? Do they opt out of all insurance contracts, because they are essentially the same? Not likely. Perhaps a small number of physicians who provide the least expensive services could survive in cash only practices, but the vast majority could not. And the producers of HITECH/ACA/MACRA know too well that this kind of Drexit is not an option.

But there is a softer type of Drexit. One choice is to pay for protection. This is a time honored method for keeping bad guys from raiding your small business. There are companies, health systems and even insurers that will bundle physicians of all specialties into large organizations to better cope with large regulatory climates designed for the global economy. Theoretically, you can remain independent in such arrangements. Theoretically. The other choice is an equally time honored method for standing your ground. Civil disobedience.

You don’t have to comply. Nobody is going to take your medical license away, and considering the meager ratio of physicians to population, nobody is going to prevent you from seeing patients. They will however pay you a bit less than if you complied with HITECH/ACA/MACRA. Think of it as an independence tax (low single digit percentages) over the next decade or so. If you sit down and calculate the price you’d have to pay for compliance with regulations, including opportunity costs, you will find that civil disobedience puts you slightly ahead or, at the very least, it breaks even with compliance.

Bottom line here is that you need to do your own math. Ignore the rhetoric. Ignore the doomsayers and the saviors of mankind. Every single person who opens their mouth on this subject has a vested interest that may or may not align with your interests, and the interests of your patients. Remember that the technocrats at the CMS are forecasting that you will be taxed no matter what you do, so why spend money and effort on a rigged game?

Stattdessen, turn it around. Refuse to serve in the army of globalization on moral and ethical grounds. Wear it like a badge of honor. Advertise your Drexit. Make a poster for your clinic. Put it on your website. Stand with your patients. Let them know that you put patients first and money a distant second. Be a conscientious objector to a world order where we the people don’t matter anymore.

Margalit Gur-Arie ist der Gründer, BizMed. She writes regularly about the intersection of healthcare & Technologie auf ihrer Seite: On Health Care Technology. Folgen ihr auf Twitter an @margalitgurarie

Opinions expressed by HIT Consultant Contributors are their own.

With growing efforts to provide people with information about health care prices, some health care experts have expressed concern that patients may avoid low-price care if they associate price with low quality. However, most Americans do not associate the price of care with the quality healthcare, according to an analysis of survey data published in the April issue of Health Affairs.

While health care prices vary widely throughout the country, there is no evidence that higher prices are associated with higher quality or better health outcomes.

In the analysis, researchers found that a majority of Americans (ranging from 58-71 percent depending on how the questions were framed) do not think health care cost and quality are associated. Fewer than one-quarter (21-24 percent) perceive an association, while 8-16 percent are unsure. The analysis was conducted by David Schleifer and Carolin Hagelskamp of Public Agenda, along with Kathryn Phillips of the University of California, San Francisco, and is based on a nationally representative survey of 2,010 adults conducted by Public Agenda and funded by the Robert Wood Johnson Foundation. 

“Most people do not believe they have to pay more money to get better quality health care” said Schleifer. “However, a small portion of Americans do think better care costs more or are unsure, which underscores the need to publicly report information about both quality and price.”

Individuals who say they have shopped around for health care, comparing the prices of one provider or service against another, are more likely to perceive that price and quality are associated than individuals who have not compared prices. Researchers do not know whether there is a causal relationship between comparing health care prices and associating price and quality.

“It may be that people who already think better care costs more money are more likely to be comparing prices.  But if comparing prices somehow causes people to think that better care costs more, then the governments, insurers and other companies who are developing transparency tools need to figure out how to address those perceptions,” said Schleifer.

The researchers also found that African-Americans, Hispanics and those under age 30 are somewhat more likely than others to believe cost and quality are associated.

Results also depended on whether people were asked about high price/high quality care or low price/low quality care. People were less likely to believe price and quality were associated if they were asked about high price/high quality care.

“We know from other studies that people perceive information differently depending on how it is framed. For example, they are more likely to buy ground beef that is labeled 75 percent lean versus labeled 25 percent fat,” said Phillips. “Similarly, we found people perceive price and quality differently when described as high price/high quality versus low price/low quality. We need to consider how people actually perceive price and quality information so we can design the right tools and policies.”

On Monday, the Centers for Medicare & Medicaid Services (CMS) announced its largest-ever initiative to transform and improve how primary care is delivered and paid. The initiative called the Comprehensive Primary Care Plus (CPC+) model will be implemented in up to 20 regions and can accommodate up to 5,000 practices, which would encompass more than 20,000 doctors and clinicians and the 25 million people they serve.

The initiative builds on the Comprehensive Primary Care initiative launched in late 2012 and is designed to provide doctors the freedom to care for their patients the way they think will deliver the best outcomes and to pay them for achieving results and improving care.

“Strengthening primary care is critical to an effective health care system,” said Dr. Patrick Conway, CMS deputy administrator and chief medical officer. “By supporting primary care doctors and clinicians to spend time with patients, serve patients’ needs outside of the office visit, and better coordinate care with specialists we can continue to build a health care system that results in healthier people and smarter spending of our health care dollars. The Comprehensive Primary Care Plus model represents the future of health care that we’re striving towards.”

Comprehensive Primary Care Plus (CPC+) Model Overview

The five-year CPC+ model will benefit patients by helping primary care practices:

– Support patients with serious or chronic diseases to achieve their health goals
– Give patients 24-hour access to care and health information
– Deliver preventive care
– Engage patients and their families in their own care
– Work together with hospitals and other clinicians, including specialists, to provide better coordinated care

Primary care practices will participate in one of two tracks. Both tracks will require practices to perform the functions and meet the criteria listed above, but practices in Track 2 will also provide more comprehensive services for patients with complex medical and behavioral health needs, including, as appropriate, a systematic assessment of their psychosocial needs and an inventory of resources and supports to meet those needs.

CPC+ Model Track Overview

In Track 1, CMS will pay practices a monthly care management fee in addition to the fee-for-service payments under the Medicare Physician Fee Schedule for activities.

In Track 2, practices will also receive a monthly care management fee and, instead of full Medicare fee-for-service payments for Evaluation and Management services, will receive a hybrid of reduced Medicare fee-for-service payments and up-front comprehensive primary care payments for those services. This hybrid payment design will allow greater flexibility in how practices deliver care outside of the traditional face-to-face encounter.

To promote high-quality and high-value care, practices in both tracks will receive up-front incentive payments that they will either keep or repay based on their performance on quality and utilization metrics. The payments under this model encourage doctors to focus on health outcomes rather than the volume of visits or tests.

Practices in both tracks also will receive data on cost and utilization. Optimal use of Health IT and a robust learning system will support them in making the necessary care delivery changes and using the data to improve their care of patients. Track 2 practices’ vendors will sign a Memorandum of Understanding (MOU) with CMS that outlines their commitment to supporting practices’ enhancement of health IT capabilities.

These partnerships will be vital to practices’ success in the care delivery work and align with the Office of the National Coordinator for Health IT priority to ensure electronic health information is available when and where it matters to consumers and clinicians.

Under the CPC+ model, Medicare will partner with commercial and state health insurance plans to support primary care practices in delivering advanced primary care. Advanced primary care is a model of care with five key components:

– Services are accessible, responsive to an individual’s preference, and patients can take advantage of enhanced in-person hours and 24/7 telephone or electronic access.

– Patients at highest risk receive proactive, relationship-based care management services to improve outcomes.

– Care is comprehensive and practices can meet the majority of each individual’s physical and mental health care needs, including prevention.

– Care is also coordinated across the health care system, including specialty care and community services, and patients receive timely follow-up after emergency room or hospital visits.

– It is patient-centered, recognizing that patients and family members are core members of the care team, and actively engages patients to design care that best meets their needs.

– Quality and utilization of services are measured, and data is analyzed to identify opportunities for improvements in care and to develop new capabilities.

CMS will select regions for CPC+ where there is sufficient interest from multiple payers to support practices’ participation in the initiative. CMS will enter into a Memorandum of Understanding (MOU) with selected payer partners to document a shared commitment to align on payment, data sharing, and quality metrics in CPC+.

CMS will accept payer proposals to partner in CPC+ from April 15 through June 1, 2016. CMS will accept practice applications in the determined regions from July 15 through September 1, 2016.

The Merriam-Webster dictionary has many definitions for the term system, but the most straightforward, and arguably the most applicable to our health care conversation is “a regularly interacting or interdependent group of items forming a unified whole”. The common wisdom is that our health care system is broken and hence our government is vigorously attempting to fix it for us through legislation, reformation and transformation. We usually work ourselves into a frenzy arguing how the government should go about fixing the system, but I would like to take a step back and question the assumption that health care is, or should be, a system. This is not about splitting the hairs of semantics. This is about proper definition of the problem we wish to solve.

You could argue that we use the term system loosely to refer to everything and there are no nefarious implications to calling health care a system. We have a transportation system, an education system, a legal system, a financial system, a water system, a political system and so forth. Note however that we rarely talk about our food system or auto system, fashion system, hospitality system, etc. We call those industries. Starting to see a difference here? Good. Our government obviously regulates both systems and industries, but it regulates them differently. And systems have distinct characteristics that industries seldom have, such as built-in (systemic) mechanisms for discrimination, and institutionalized (yep, systemic) corruption aplenty.

When we begin by assuming that health care is a system, we assume that health care should possess those same characteristics. We assume that health care in Beverly Hills will be, by design, different than health care in Flint, Michigan. We assume that health care delivered in private settings will be different than health care accessed in public settings. We assume that some areas will have sprawling, on demand health care hubs, while others will have none. We assume that public engagement in health care is for show only, while the billionaire class and its carefully constructed echo chamber get to make all our health care decisions. We assume that health care is, and always will be, rigged. And based on these assumptions, we proceed to fix our health care “system”.

You may be tempted to dismiss these thoughts as specious demagoguery, strawmen, soapbox arguments or just plain exaggerations. After all, health care system fixing includes such socially beneficent endeavors as expanding “coverage” for the poor (Medicaid expansion), subsidizing insurance for the less poor (Obamacare exchanges), granting insurance to the sick (preexisting conditions), and a steady drumbeat of accountability, measurement and reduction in “disparities” for “vulnerable populations”. To that I would respond by pointing you to several recent utterings from public figures empowered to effect health care reforms. 

Medicaid for America

Let’s begin with the all-powerful Acting Administrator at the Centers for Medicare and Medicaid, Mr. Andrew Slavitt. The “acting” prefix is there, because for some reason, Mr. Slavitt is running the largest (taxpayer financed) health care insurance entity in the country without proper Congress confirmation. In a recent string of tweets, Mr. Slavitt refers to our “beloved modern Medicaid program” as “America’s healthplan”, proudly reminding us that Medicaid is 72 million strong (“Working people, families, majority white…”) and growing. I think it’s safe to assume that Mr. Slavitt himself is not receiving his medical care through “America’s healthplan”, and neither does anybody he associates with.  It is also safe to assume that an accomplished executive like Mr. Slavitt, who is Harvard and Wharton educated, understands all too well that the size of Medicaid is inversely proportional to the prosperity of the American people. If the sheer notion of a senior political appointee in the Obama administration being ostentatiously proud to see working families forced to beg for public charity is not triggering a fire alarm in your head, then I don’t know what will.

One could argue that since Obamacare expanded Medicaid to people above official poverty levels, perhaps a bigger Medicaid does not necessarily imply more poor people, but a more generous society. One could make such argument, if federal poverty levels were a realistic measure of poverty, or if we didn’t have other sources of information. The grim reality is that even middle class Americans are now lacking the ability to purchase decent medical care, or insurance instruments for the same, and hence the Obamacare exchange subsidies for cheap insurance, which is marginally better than Medicaid in some ways, and substantially worse in other ways.

In another insightful tweet, Mr. Slavitt observes that “In exchanges, consumers vote with their feet and with their feet they say unaffordable care is a deal breaker”. Note how elegantly, inability to pay for nice things due to being destitute in general, is now framed as a preference, something you vote for with your feet. This is precisely how establishment henchmen convinced us that we vote with our feet when we shop at Walmart while decently paying jobs are being vacuumed from underneath our very same feet. Being poor and unable to afford eclectic amenities prized by the elites is a consumer preference, one very short step away from arguing that being on food stamps or sleeping under a bridge are merely choices some consumers make.

Health care in America is expensive. Expensive, though, is a relative term, and if America’s working class didn’t see its income consistently go down the 1% drain, perhaps health care would seem more affordable. But American health care is also expensive in absolute terms. Mostly it is expensive because each service and each item is priced higher than anywhere else in the world. Tackling the pricing problem is guaranteed to upset the masters of establishment henchmen, so they worked hard and found a couple of other alternatives to generate cheapness, just in case the voting with feet thingy blows up in their face (as it seems to be the case right now). The trick is to deflect scrutiny from real issues, and assign responsibility (blame) to doctors and the people in general. 

The Return of the Broccoli

I’ve written compulsively about the apparent war on doctors in the past, and I am certain I will be writing more, but the war on people is a much more intricate subject. It’s relatively easy to separate a quarter of one percent of people from the herd, paint them as for-profit mass murderers and sic the hungry mobs on them. But then how do you subdue the mobs? For that, my friend, we have government. We have behavioral economics. We have the experts and pundits in that echo chamber. And we have the righteous souls who innocently light the fuse of every calamity.

I’m old enough to remember the debates preceding the Obamacare litigation in front of the Supreme Court, culminating with both Justice Scalia and Chief Justice Roberts pondering whether the government has it within its enumerated powers to make you buy broccoli. Before the broccoli debacle, the same libertarian lunatic fringe wondered if government can order Americans to lose weight, or if the government can mandate that we buy certain products from certain manufacturers. Of course Obamacare and its mandate to buy health insurance or be penalized by the IRS survived these outlandish challenges, and the IRS is doing its best to rake in those penalties. It must be doing a great job too, because it sounds like IRS services for mankind could be drastically expanded.

Steven Findlay is an expert health care policy journalist, with an illustrious record working for the Consumers Union, and one of the handpicked advisors who shaped the Meaningful Use program. Mr. Findlay recently commented on The Health Care Blog, making the following statement: “Hell, I’d support tax breaks for people who quit smoking and/or can document to the IRS that they exercise 3 times a week for an hour each time!” Hell, indeed! But if the IRS can collect penalties for failure to purchase insurance, and grant tax credits for buying Pella windows, why not offer tax breaks for making your body more productive and more efficient?

Was Mr. Findlay writing in jest? Perhaps, but note that Obamacare is already empowering health insurers and employers to offer “incentives” and “discounts” for a variety of wellness schemes, which are essentially paycheck penalties on sick and “non-compliant” people. And note also that these types of shell games are only effective if you are poor enough and forced to vote with your feet every time someone reaches for your empty wallet. I wonder if voting with your feet would be an IRS approved form of exercise…

This is the glorious power of systems. This is the power of a “regularly interacting or interdependent group of items forming a unified whole”. This is why health care must become a system where the “items” regularly interact in formulaic pathways. This is why free range actors randomly affecting the system cannot be tolerated by the centrally installed array of levers and signaling networks.

This is why independent medical practice must die, small hospitals must be euthanized, and managed population health must encompass the entire nation (minus the elite caretakers) down to the minutest detail. This is why each one of us must be systematically tagged, numbered and catalogued in the vast repositories of “precision medicine”. And this is precisely why health care must never be allowed to become a system.

Margalit Gur-Arie is the founder, BizMed. She writes regularly about the intersection of healthcare & technology on her site: On Health Care Technology. Follow her on Twitter at @margalitgurarie

Opinions expressed by HIT Consultant Contributors are their own.

Ms. Jeannie is a 65 years old woman, slightly overweight with mild hypertension that is perfectly controlled. Ms. Jeannie is the office manager at Dr. Abrams, the pediatrician down the hall, who’s been taking care of your kids since you moved here. Ms. Jeannie called earlier because her allergies are killing her today and she’s out of refills for her blood pressure meds anyway. After an uneventful 15 minutes, and a brief chat in the hallway, Ms. Jeannie pays her $15 copay and heads back to work. Medicare will pay you another $60 in a few weeks. On to Bob Burns who is here for his DOT physical and his BP is through the roof… again…

Somewhere in our nation’s capital, someone has decided that when you go about your day like this, you’re doing a lousy job, because you provide very little bang for the buck they pay you. Maybe Jeannie could have seen your nurse instead of wasting your time with trivial things. Maybe she could have just stayed at her desk in Dr. Abrams’ office and talked to your nurse over Skype or email. And why is it that you can’t get a grip on Bob’s blood pressure and make him take his meds and understand that driving a truck is not a form of exercise? You need to provide value, instead of just counting volumes and volumes of expensive visits that may or may not work. This is wasteful. You need to learn how to do better with less money.

This is the heart and soul of MACRA. This is what 962 pages of gibberish are trying to elucidate for those who have the time to read 962 pages of government regulations on a Wednesday morning. You can certainly try to set aside time to pore over the intricacies of how Medicare plans to not pay you the $60 it owes you for seeing Jeannie, but if you have twenty to forty hours to read, I’d suggest taking another shot at Ulysses which may be a more rewarding and less frustrating choice. In Medicare’s defense though, it’s not that they don’t want to pay you anything for seeing Jeannie. No, that would be dumb. The 962 pages of labyrinthine regulations are about $3 that Medicare may be withholding from or adding to your $60 remittance for similar visits with Ms. Jeannie in 2019.

There are plenty of good summaries of MACRA out there (here is a great one), so I’m not going to repeat any of that here, because frankly, it doesn’t really matter. First, the SGR formula which MACRA is supposedly replacing was never implemented. Chances are good that the furious mathematics at the fraying edges of medicine described in the latest notice of proposed rulemaking will suffer a similar fate. Second, even if Medicare spends the prerequisite billions of dollars to implement a national mechanism for withholding your $3, booking one more patient per day will completely neutralize any effects on your practice and your personal income. Alternatively, and particularly if you are “of a certain age” this may be a great opportunity to spruce up your golf game, as Dr. Halamka himself is suggesting.

The Doctor Whisperers

Have you ever trained your pooch to walk nicely on a leash, to sit and stay and rollover whenever you tell him to? If so, chances are that you used those little bits of liver treats to reward good behavior. You don’t reward your pup in training with huge T-bones because he will ignore you for the next hour or two as he enjoys his bone. For obedience training, you use cheap, tiny morsels over and over again, along with profuse words of encouragement, until Rover gets the idea, and then you replace the liver bits with a pat on the head, and then you just assume that the dog is conditioned to always do what you want him to do, without rewards. And that’s how Rover becomes a good dog. The $3 Medicare incentive is your liver bit. Using it repeatedly, every 15 minutes or so, all day every day, is how you will be trained to become a good doctor.

The people who run programs like the MACRA are not stupid. They know, and the math is pretty straightforward, that the $3 training morsels won’t make any difference in Medicare finances, but at the end of the day you will learn to always pay attention to the handlers and respond to nonverbal cues in a reliably consistent manner. For example, many EMRs today have special markings for data fields that must be captured for Meaningful Use or PQRS. Some are color coded, others are marked with little stars and practically all have lists of items that were “satisfied” or not. Those are equivalent to yanking Rover’s choke collar, quickly, gently and ever so slightly. Nobody wants to hurt their “best friend”. We train docs for their own good, because well trained, obedient dogs are happy dogs.

Unfortunately, not all dogs are created equal. Great Pyrenees for example were bred for centuries to work independently, mostly alone, mostly at night, to protect their sheep from big bad wolves. Having shared my home with a few great ones over the years, I can tell you that they find fetching sticks a rather uninteresting proposition. Buried deep in the bowels of the 962 pages is a cute little table forecasting whose chain will be yanked and who will be getting those $3 bits most of the time (page 676). As you would expect, 9 out of 10 solo docs and 7 in 10 docs practicing in groups of less than 10 will be penalized, while over 80% of those working in very large systems, or rather their employers, will get rewarded. The heart and soul of MACRA has no room for independent doctors. They either submit themselves to employment in the service of big corporations, or go their separate way.

Other People’s Money

A century ago, under similar circumstances as we are experiencing today, Louis D. Brandeis railed against the “curse of bigness”, and particularly the bigness of bankers who used “other people’s money” to exert undue influence (control) over the nation’s economy solely for their personal benefit and with complete disregard for the welfare of the people. To be sure, Justice Brandeis, as Thomas Jefferson before him, was disgusted with big corporations and big government as much as he was appalled by big banks. Both before and after his Supreme Court appointment, Brandeis experienced significant success in his crusade against bigness, but a century of American politics as usual managed to destroy practically everything he achieved, and to add insult to injury, today it’s not just the big banks that get to play games with other people’s money.

The 962 pages (with more to come) of MACRA regulations are how big government is creating a set of financial instruments that nobody understands (including the authors) to affect 20% of the American economy, not to mention the lives of 300 million people, using other people’s money to benefit the bottom lines of big corporations and for the personal aggrandizement of political appointees. I may be wrong, but I believe Justice Brandeis would be irate at the mere thought that the Federal government is proposing to award 7.5 cents to medical doctors who are “registered for a minimum of 6 months as a volunteer for domestic or international humanitarian volunteer work”. Thomas Jefferson would probably observe that our tree of liberty is long overdue for some refreshments, but I digress.

From its inception, health care reform has been focused on diverting physicians’ attention from patient care, which comes naturally to most of them, to counting things supposedly representing patient care. First came counting scripts sent electronically to pharmacies, then came counting the number of times the mammogram box was checked, the number of times the Pacific Islander box was ticked, the number of times one glanced at this or that list, culminating with the number of dollars patients are costing the insurance company. The MACRA is just the next step in the succession of incremental steps designed to transition Medicare to a Medicount program.  The problem with this strategy is that you are counting other people’s money.

Every dime the Federal government spends on obedience training (or culling) for doctors, is our money. Every nickel Medicare is spending on managing the largest accounting exercise known to mankind, is our money. Every penny commercial insurers spend on adopting the Medicount method, is our money. We are the true risk bearers for this experimentation, and so far we are seeing nothing but downside. Public health expenditures are going up. Private insurance premiums are going way up. Out of pocket expenses are going up. Our life expectancy is going down. Suicide rates are up. Addiction rates are up. Mental distress levels in general are up. And yet we are all compelled by taxation laws to fund our own demise without honest representation, without informed consent and without any legal recourse.

Maybe not this summer, and maybe not this fall, but what do you think comes next?

Margalit Gur-Arie is the founder, BizMed. She writes regularly about the intersection of healthcare & technology on her site: On Health Care Technology. Follow her on Twitter at @margalitgurarie

Opinions expressed by HIT Consultant Contributors are their own.

Editor’s Note: Kyle Stapp is the Program Director at Eligibility.com where he oversees the educational center inside Eligibility.com and works daily with program applicants to answer their questions. His programs include Medicare, Unemployment and more. Follow him on Twitter at @kyle_stapp or connect with him on LinkedIn.

According to the Center for Medicare and Medicaid Services (CMS), 32% of Medicare beneficiaries are enrolled in a Medicare Advantage plan, amounting to 17.1 million people. This number has been increasing as beneficiaries flock towards the competitive prices. Of these beneficiaries, 9.72 million enrolled in a plan provided by one of four insurers: UnitedHealth, Humana, Kaiser, and Aetna. With Aetna’s recent acquirement Humana, these three remaining companies now control 60% of the market for Medicare Advantage programs.

One thing that these three insurers, and others, have to look out for is the announced annual changes to the Medicare Advantage and Medicare Part D programs, stated in the 2017 Rate Announcement and Call Letter. The original proposal for these changes was made back in February 2016, and following a public comment period, CMS finalized their updates that will take effect starting next year. The updates include a variety of implications for both insurers and beneficiaries including:

1. Improved accuracy when interpreting plan performance

There was some concern about dually eligible enrollees and/or low income subsidy enrollees affecting the ability of Medicare Advantage plans to achieve high Star Ratings. For 2017, CMS intends to better interpret plan performance among plans with a high percentage of dually eligible or low income beneficiaries, allowing these plans to achieve higher Star Ratings where deserved.

2. Reduction of opioid overuse

CMS aims to continue reducing the number of Medicare Part D beneficiaries who overuse or abuse their opioid prescriptions, an effort that has already demonstrated success through the Part D Overutilization Monitoring System. In accomplishing this, CMS will work to control opioid sales using “point-of-sale edits” or safeguards before opioid prescriptions are given to patients, which is intended to limit the number of false positive results for opioids as well as opioid prescription abuse.

3. Addition of medication-assisted treatment coverage.

The 2017 Call Letter addresses intentions to improve access for beneficiaries to medication-assisted treatment (MAT). The updates include ensuring that Medicare Advantage plans provide the same MAT coverage and substance use disorder treatment coverage as is provided by Original Medicare. In addition, the update requires that Part D plans which cover MAT are to ensure access to this treatment.

4. Improvements in the area of drug utilization among beneficiaries.

With regards to the Medicare Part D program, the updates announced in the 2017 Call Letter plan to address certain drug utilization issues. One of these updates will help eliminate prescription drug waste by limiting prescriptions to one-month supplies. In cases in which patients are given multiple-month prescriptions and do not need to complete all months’ worth of medication, a shorter prescription will reduce the amount of drug waste.

As a part of this update, sponsors will also be required to inform beneficiaries of any new drug coverage that becomes available to them mid-year, giving them access to better quality medication options if needed. CMS also hopes to increase beneficiary awareness of Medicare drug spending with the implementation of this update.

The finalized changes announced in the 2017 Rate Announcement and Call Letter are intended to improve the Medicare Advantage and Part D programs and provide better quality care to beneficiaries, including those from low income households and dually eligible individuals. It is clear how some might benefit from these changes, but many beneficiaries believe they won’t see any of these improvements affect their coverage.

In fact, some see these changes as more beneficial to the insurers than the beneficiaries. For example, changes in interpreting plan performance will help some companies gain a higher rating, yet won’t affect the beneficiaries. Further, changes in drug utilization may prevent some beneficiaries from paying for more medication than they need, however, it may help the insurers to a larger extent since they often cover a majority of these costs.

5. 2017 Rate Announcement

Of course, these improvements come at a cost. The announcement also included the finalized Medicare Advantage rates for 2017. The Advance Notice released in February had estimated a 1.35% increase in Medicare Advantage rates, but the finalized rate increase came in much lower at just 0.85%. Some ways in which these rates will changed are:

– Higher standard initial deductible. The standard initial deductible for 2017 is $400, up $40 from the 2016 standard initial deductible of $360.

– Higher initial coverage limit. The initial coverage limit for 2017 is $3,700, up $390 from the 2016 initial coverage limit of $3,310.

– Better Donut Hole discounts for generic and brand-name medications. Those who reach the Donut Hole or Coverage Gap of their Part D coverage will receive a 49% discount on generic prescription drugs, a discount increase of 7% from 2016, and a 60% discount on brand-name medications, up 5% from 2016.

6. What All of This Means for Medicare Advantage Beneficiaries

Sponsors argue that Medicare beneficiaries should see the 0.85% increase as a win opposed to the proposed 1.35% increase, but some still wonder whether these stated improvements are worth the elevated rates. Additionally, some worry that improvements won’t be realized at all, and the only change they will see is higher cost. Lastly, beneficiaries find frustration in that the rate increase is estimated to elevate revenue by 3.05% for plan sponsors in 2017. 

One reason why Medicare enrollees have been migrating towards Medicare Advantage plans is the favorable rates due to a competitive marketplace. However, this competition seems to be lessening, representing a major cause for concern on behalf of the beneficiaries. The modest rate increase might seem minimal, but some beneficiaries worry that this, complemented by the consolidation of plan providers, might disincentivize some from actually improving quality. Furthermore, many of those who believe changes can be made still will not see a significant improvement in their coverage.

Following the 2017 Rate Announcement and Call Letter up until October of this year when the Medicare Advantage enrollment period begins, insurers will be spending their time creating Medicare Advantage plans that align with the updates and changes announced in the Call Letter. Beneficiaries are encouraged to stay updated on any additional information regarding 2017 Medicare Advantage plans that may be released by CMS.

Sources:

http://www.wsj.com/articles/federal-regulators-propose-increase-to-medicare-advantage-rates-1455924070

http://www.beckershospitalreview.com/finance/cms-finalizes-2017-medicare-advantage-rates-8-things-to-know.html

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-04.html

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-04-04.html

http://www.modernhealthcare.com/article/20160404/NEWS/160409961

https://q1medicare.com/q1group/MedicareAdvantagePartD/Blog.php?blog=A-preview-into-2017–CMS-releases-finalized-standard-2017-Medicare-Part-D-prescription-drug-plan-coverage-parameters&blog_id=556&frompage=18