ACO Principles Worth Fighting For
Much has been and continues to be said about the shortcomings of the CMS regulations/requirements associated with the CMS Accountable CARE Organization initiatives. The WSJ recently posted an article claiming that "the draft rule is so awful that even the models for it say they won't participate."
It's true: many of the regulations proffered to date are cumbersome and disproportionately focused on the financial and compliance aspects of the program. Nonetheless, the philosophical underpinnings of the ACO program, the triple aim of better access, better quality and more cost effective care, are principles worth fighting for when it comes to the delivery of healthcare to our healthcare consumers, Medicare or otherwise.
The deficiencies of the ACO regulations notwithstanding, CMS/CMMI has challenged interested healthcare organizations to propose innovative alternatives to what has been proposed. We at Gorman Health Group embrace that challenge and will continue to participate with CMS and interested healthcare organizations in creating an ACO approach which passes the test of providing the right care, at the right time, in the right setting, and at the right price. We invite you to come join us.
This is what Dumb Looks Like
The poster tells the story behind the photo: "This is a printout of a patient's medical record, sent from one office to another as the patient was changing primary care providers. An EHR was in place in both offices. Additionally, the EHR in both offices was created by the same vendor (a major vendor); each health organization had a customized version. Without base standards the systems are incompatible. Instead, the printouts had to be scanned into the new record, making them less searchable and less useful."
The tech world calls this "digitizing paper processes." The Army calls this FUBAR. Regardless of your preferred observation, it's clear that EMR/EHRs are not yet delivering on their promise. In our Star Ratings practice, we have seen plans and providers struggle with creating Atul Gawande-style checklists that can be tied to a patient record as a paper list might be paper-clipped to a physical record ("Advise on smoking cessation? Check. Flu shot given? Check.). And while we're not going back to paper, the undelivered-promise almost makes one nostalgic for paper itself, one of humankind's top 5* inventions: It's cheap, it doesn't need to be upgraded, it doesn't crash and it best facilitates open, creative thinking by allowing the user to move seamlessly between writing and drawing.
*My other 4 are the wheel, the drum, clean running water and fermented beverages. Fire doesn't count because it was a discovery, as was electricity.
Medical Mythbusters
If John King wanted to confound the GOP candidates for President at last Monday's debate, he might have asked them to comment on this important post by one of our favorite bloggers, Aaron Carroll, over at The Incidental Economist.
If one talks to physicians (and I do!) it's clear that that the spectre of malpractice lawsuits looms large in clinical decision making. Perception or reality? The closer one gets to the actual cost drivers of health care, the more one sees that tort reform is hardly the money pot of savings hoped for by many on the right. Carroll calls this "meme busting" and he has a few other memes in his crosshairs, including the belief that our extra-high spending is driven by an extra-unhealthy population. As it turns out, not so much….
What are some other memes you've confronted in your career that you would like to see examined?
One that occurs to me would be our over-reliance on specialists. Is it a utilization problem… or do we just pay too much?
(Would it surprise you to learn that in Washington we see things a little differently? The much maligned "trial lawyers" at which the GOP loves to take aim also constitute one of the Democrats' largest source of big-money donors. To dramatically limit damages through tort reform would have the effect of shutting this money source off at the tap.)
The New Political Calculus on Health Reform
Fresh off the "shellacking" Republicans dealt to Congressional Democrats in the midterm elections, the GOP made "repeal and replace" of the Accountable Care Act their #1 priority. They had 4 major approaches to accomplishing their goal. None are working out particularly well.
Repeal the ACA: for this to work it would require President Obama's signature, and that was never going to happen to his signature domestic achievement. It passed the House in January and promptly died in the Senate.
Lawsuits against the individual mandate: thus far 26 Republican Attorneys General have filed lawsuits challenging the Constitutionality of the individual mandate. They are winding their way through the courts and inevitably will end up in front of the Supremes in 2012. The conventional wisdom in DC is that there are ample precedents allowing the Feds to tax interstate commerce, even an "inactivity" like not buying health insurance, and that the Court will declare the mandate Constitutional, just in time for the Presidential election. No joy there for Republicans.
Defund the ACA. The deck was always stacked against Republicans here as well, as much of the implementation funding needed for exchanges and the like was pre-funded in the ACA. Very little was left to discretionary appropriations. The GOP walked to the brink of a government shutdown in March but blinked, haunted by the memories of 1994. As a result, they'll only inflict minor damage.
Ensure Obama is a one-termer: if the President loses in 2012, the ACA is stopped in its tracks. But that's not going so well either…the Republican field is muddled, the economy is sluggishly improving, millions of twentysomethings are still able to stay on Mom and Dad's health insurance because of the ACA, and overnight our mild-mannered Commander in Chief became Black Ninja.
Sure, it's still a long way to next November and much can happen. This is where futures markets are often the best predictors of an outcome. My money -- and many others betting real cash (see http://www.intrade.com/v4/home/) -- is on an Obama re-elect and the ACA implemented largely intact in 2014.
The health reform readiness show must go on.
Accountable Care Organizations (ACOs) for Duals
At the June 3 Alliance for Health Reform meeting on Dually Eligible Beneficiaries (i.e. beneficiaries who have Medicare and Medicaid benefits), the discussion focused on how to address the needs of the most complex, costly and frail beneficiaries. Currently only 100,000 of 9 million duals are in integrated systems. The incentives in Medicare and Medicaid clearly reward shifting care and costs to the other program, e.g. if a beneficiary is shifted to a hospital from nursing home, Medicare will pick up the cost or if a beneficiary is shifted to a nursing home from a community setting, Medicaid will pick up the costs.
While the integrated Medicare and Medicaid funding and benefits in the PACE program is a gold standard for the dual population, this program remains small and is currently serving only 22,000 beneficiaries. Multi-payer ACOs offer an alternative that could better serve a broader segment of the dual population. ACOs are patient centered and offer a structure to coordinate Medicare and Medicaid benefits and funding streams. By focusing on shared savings from better care and integrated care, dual ACOs could avoid the cost shifting incentives in the current programs. Partial or full capitation from Medicare and Medicaid would facilitate the ability of ACOs to make the best use of federal and state funds in the most appropriate setting. Minnesota is embarking on an ACO model for its Medicaid program and a number of the Integrated Delivery Systems in Minnesota are pursuing a Medicare Pioneer ACO demonstration. While the Minnesota ACOs will not be specialized dual ACOs, they will have duals assigned to their providers and there will be an opportunity to see how flexible the ACO model can be in serving this vulnerable population. CMS has funded 15 states to develop fully integrated dual programs and states should consider the ACO model as part of their designs.
Medicare Advantage is Alive and Well
It wasn't long ago that many in the industry thought Medicare Advantage (MA) was on life support, a casualty of health reform. Today it's viewed as a strategic imperative for publicly-traded companies, enrollment continues to exceed expectations, and we're seeing unprecedented valuations for Medicare plans.
Last week WellPoint announced it was acquiring CareMore, a provider-owned MA plan in CA with about 55,000 members -- for $800M. That's about $15,000/member. For perspective, our good friend Carl McDonald at CitiGroup points out that in 2010 for $545M, HealthSpring was able to buy Bravo, a plan with almost twice as many MA members, plus 400,000 Medicare PDP lives. Further, HealthSpring is trading at only $3,500/MA member, while Universal American and WellCare are each under $5,000/MA member.
CareMore is more profitable than most given its clinic operations, and to some extent this was WellPoint's response to United's stealth campaign of buying up CA medical groups. But still. This deal alone will drive valuations skyward, and as a result, more plans will be looking for the exits.
And they'll find buyers. HealthSpring has made no secret of its empire-building inclinations. Aetna and WellPoint have each said they desire more acquisitions to further expand their Medicare footprint. And Medicare revenue comprises on average about 25% of the public companies' earnings. Consolidation will continue in Medicare. And it's clear MA is alive and very well.
Member Evaluations Don't Replace the PCP
For obvious (and very good) reasons, Medicare Advantage plans want to maximize the unique opportunity afforded by in home evaluations of their members. There is no question that these evaluations can yield diagnostic information that is essential to risk adjustment revenue management. The opportunity to collect clinical information and merge it with data from claims and Medicare return files makes it possible for MA plans to positively influence care in a way that fee for service Medicare cannot. Direct member evaluations also provide a way to quantify and improve measurable standards of care such as those included in HEDIS, ADA standards of care for diabetics, ACC standards of care for cardiovascular disease, and Star ratings.
One question that comes up repeatedly in our conversations with plans is whether we can collect even more data during these encounters. Specifically, plans are interested in having our physician evaluators collect specimens for laboratory studies that factor into HEDIS and Stars measures. On the face of it, this seems like a natural extension of the service, but there are a couple of not so obvious drawbacks.
First, we are very hesitant to do anything that might be seen as coming between a member and his or her treating physician. That is a unique and valuable relationship and we want to make sure that what we do only enhances it.
Second, we are concerned about the chain of responsibility in collecting that information. First, a physician or other licensed provider has to order the test in question. Our physicians can certainly do that, but then someone has to take the responsibility of checking the result and providing appropriate care based on the results. That our doctors cannot do since that would require establishing an ongoing clinical involvement that would directly conflict with our determination not to interfere with the member's relationship with their treating physician. An alternative would be for the plan medical director to accept responsibility for ordering and following up on the lab studies, but most plan CMOs are not willing to do that.
For those reasons, we have been hesitant to collect lab specimens as part of our evaluations, although we willing to discuss alternatives with our clients who need that service.
Exchange Will Do You Good
Two interesting items have been posted in recent weeks that perfectly capture the contrary motion of health reform implementation. The first, found in the Washington Post, addresses the laggard's pace many states are keeping in implementing provisions of health reform--- in particular the health insurance exchanges that subsidize the purchase of private insurance by low and middle income citizens. The controversial second, which appears this month in a McKinsey newsletter describes the incredible market pressures to do just that.
For years, Washington wonks and informed political spectators have marveled at the left's inability to tie the issue of health care coverage to the interests of small businesses, which politicians of both persuasions never miss an opportunity to refer to as "the engine of the American economy." Money that goes to high employee premiums does not go to creating jobs--- at least, not for the small business in question. The McKinsey article projects that 30% of employers will "definitely or probably" stop offering health insurance to employees after 2014 (the schedule date of exchange implementation) and that more than 50% of companies with a high awareness of the health care law will simply stop offering insurance and send employees to Exchanges. Wowza.
There are a number of interesting things about this extraordinary (if it turns out to be true) change in coverage: first, the tremendous churn of beneficiary eligibility across subsidy levels just got more interesting, as a new class of pseudo employer-sponsored beneficiaries floods the market. Second, the risk pool changes. Lastly, if you make your living selling small group business policies, it may be time to open that Ebay store because your job is a whole heck of a lot less secure beginning in 2014. You'll be in good company. Many state Governors may find themselves in the same boat if they do not implement the exchanges in a timely manner, thereby depriving small businesses of the ability to make coverage the Government's problem and find more productive uses of capital. To do so gives the opposition party a golden talking point going into the 2012 elections.
Risk Adjustment: This isn't Dodgeball, People
Let's have a quick check in about risk adjustment and the multi-disciplinary team that should be pushing it to success.
Remember the days of dodgeball? ...picking teams and getting smacked by the red rubber ball? In risk adjustment, you must ensure your team has the right members, or you're gonna be left with more than just a ball-shaped bruise on your thigh. Here are the teams, and some of the members you must ensure are on your committees:
- Risk Adjustment Strategy: Risk Adjustment, Finance, Network Management, IT, Compliance and Medical Management, plus an Executive Sponsor
- Risk Adjustment and STARS Synergy: Risk Adjustment, Finance, IT, Medical Management, Quality/STARS, Network Management, and Member Services
- Risk Adjustment & EDPS: Risk Adjustment, IT, Claims, and Vendor (if you have one selected)
Make certain your team members:
- Understand the basic rules of risk adjustment
- Clearly recognize the importance of risk adjustment success
And don't forget:
- You MUST have an executive sponsor for those inevitable bumps in the road
- There MUST be alignment between the departments on priorities and strategies so that there is a clear path to your objectives.
This isn't dodgeball. Risk Adjustment is more like Capture the Flag. There will be winners; there will be losers. NO TROPHIES for participation. Pick your team well and keep them focused.
June is GO Time for Risk Adjustment: Your Program Check List
It's June! And most people are thinking about summer vacation... unless, that is, you work in risk adjustment.
This is Go Time.
Those living in the risk adjustment world should have their programs designed and launched by now. Are you on target? Here's your checklist:
- Chart Review: List Developed, Outreach Done, Collection and Coding Started
- Goal: 20-30% by the end of June
- Hospital Data Collection: You've contacted your high admission hospital and you are on schedule for receiving tons of hospital data electronically by August 15th to insert into your September Sweeps.
- Goal: All 2010-2011 through QTR 2 in by August 15th
- Prospective Evaluation: List developed, outreach done, evaluation scheduling started
- Goal: You should be sitting at about 20-20% completed
After doing this for the year, we realize that from Thanksgiving to the New Year the physician offices, hospitals, and members are much harder to reach. Retrieval and closure rates fall significantly.
Save your vacation requests for a winter getaway ... It is Go Time Now