Managing Managed Care

Our inequitable, inefficient, oftentimes uncaring health care "system," revealed. -- Jeffrey G. Kaplan, M.D., M.S.

Med. Newsletter / eBook

Be informed on reform; Newsletter and, if requested, a relevant eBook: "Mgd Care 101 in 2016" (No obligation)

Subscribe to Managing Managed Care newsletter feed

SSL Certificate

Health Insurance Isn't; Nor is It Health Coverage

Does the insurer really know if it was medically necessary? The 'cheapest' plan may not be.  Isn't it frustrating to have to live under employment based health care insurance?  If you lose your job, your employer wants to cut back, or you are a peasant, you're screwed!  Also, as a result of the way we are paid and the insurance model itself, there are "many forces today [that] are propelling us away from the bench or the bedside. No one ever goes into medicine do unnecessary testing, but this sort of behavior is now commonplace. 

Ref.: "10 Things Health Insurers Won't Tell You" [pdf] by Elizabeth O'Brien, WSJ, Oct. 12, 2014 [Saying insurers are focused on "ensuring affordability, stability and accessibility."

  1. They have no idea what to charge you.
  2. If you can figure out the math, you might get a tax break.
  3. Regarding the individual market, shop around.
  4. Out of luck if out of network.
  5. Who's in network, anyway?
  6. Are the really good hospitals, specialists, procedures covered?
  7. The 'cheapest' plan may not be.
  8. 'Where did those charges come from?'
  9. Does the insurer really know if it was medically necessary?
  10. Do the high deductibles make the Affordable Care Act less affordable?

An Insurance King comes out from under a rock and declares:

“We need to move the system from underwriting risk to managing populations," said Aetna CEO, Chairman and President Mark Bertolini. A fortune 100 health care insurer's CEO recognizes the "imminent demise of his venerable, profitable business model.…"  [click for the source of his quote]


A must read satire about the insurance debacle--"How do doctors get paid?"

Feb. 21, 2009


An abridged version of a pertinent blog, rated 'most popular' follows; it predicts change in this rather self-serving "insurance" industry.

 If you don't have the time to read it all, here's my favorite paragraph:

Maria K Todd, MHA, PhD•  JGK, I make a motion we scrap the whole system and you me and Gary go off in a room somewhere (in Colorado, centralized for both of you) and we reinvent healthcare. 

We can improve efficiency and effectiveness through better processes, but dictating how to practice medicine to doctors won't work. Patient satisfaction questionnaires don't improve direct patient care, HEDIS is insufficient as it doesn't measure enough of what's important, Patients aren't engaged, its not our place to judge their lifestyle, (at least not mine). I do blame the doc for the way they are paid, as many sign contracts that they don't understand, and few have the chutzpah to say "no", when "no" is the right answer. 

To keep tweaking things through this Act and that Regulation is a joke. It's tantamount to adding just a teency, weency more sulfuric acid and gunpowder to the mix and turning on the oxygen. 

"When" it blows up, its really gonna stink.

"The demise of the health care insurance industry as we know it" [LinkedIn's MCO Executives Group membership required]

Blog Extract

HL• All lingo. Insurance is about underwriting risk. Managing populations or that risk is the same thing, just a little more proactive. Insurers have a huge challenge managing populations and measuring outcomes. Once you get away from understanding and measuring and pricing for risk, the insurance company will fail. What needs to happen is that core prices of medicine need to drop. Medicine is one of the only businesses that new technology drives up costs, not reduces them. Having said all that, we still have one of the best healthcare systems in the world, even though there are problems. If the Aetna CEO really is going to run his company by not underwriting risk, it is doomed regardless of what else it does.

AS [Senior Director of Marketing]• I completely agree with Bertolini's comment about moving away from underwriting risk and getting much better at managing populations of patients. Harvey, I respectfully disagree with you. Too many health insurance companies focus on understanding and pricing risk, but they don't do enough to act on reducing that risk ... aside from traditional underwriting techniques.

Worse still, the information that health insurance companies accumulate to help price risk is rarely shared with network providers. If it is shared, it's shared in a way that stands little chance of influencing the way that care is delivered to patients. In this new era of accountable health care, the line between health care provider and health care insurer is blurring, with each side expected to do more of what the other side has traditionally "owned".

I'd also argue that we don't have one of the best health care systems in the world. We're a great place to go for what I'll call "rescue medicine" - exactly the country where you want to be if a bus runs you over - but we fall flat on our faces when it comes to managing chronic illness. In many circles of health care - I'd argue in most circles - care coordination does not exist in any meaningful fashion, and our fee for service reimbursement system does nothing to support the proactive management of patient populations.

The audacity is that what I've just shared with respect to managing patient populations and partnering with network providers is supposed to underpin the essence of managed care. Unfortunately, too many insurers have focused on pricing risk and selling new policies as opposed to running a REAL managed care organization. It's time for that to change!

HL• You misunderstood my point. Insurers will never manage care as they would like. What doctor would allow that. I don't mean managing length of stay, etc. Health plan are still insurers at their core and regardless of the latest clichés, have to underwrite risk. Ask the Aetna CEO when he is firing his actuaries. Answer is never. Until competing objectives disappear it is all smoke and mirrors.

JGK• What the insurer CAN do is facilitate (as opposed to obfuscate) needed care. That means allowing a more palatable antibiotic in kids, paying for screening exams like mammography just because the patient is worried that they might have what their mom had, even at age 35, or even pay a fair price for immunization administration, or in office laceration repair, H. Pylori testing and even ordinary labs by Article 28 facilities (now excluded, but not in the private office), sufficient mental health visits and the employment of social workers, etc. It annoys the '_ ell out of me that all those after hours and phone call services are non-reimbursable.

Back to the other side, OTOH, I don't begrudge them for not casting a blind eye to the MRI a screening test for a non-major injury, or common low back pain. What about the ridiculous antibiotic use for nasopharyngits, bronchitis, recurrent H. Pylori, or the worried well? Regardless of the skeptics, not having tort reform is causing be to order more tests and make more referrals than are necessary when confronted with an anxious patient or family. These are, after all, very litigious times when the practitioner has little recourse for being accused, abused and vilified.

I cannot even fathom how an insurer can stop paying for immunosuppression a few years after transplant. Can you? As a pediatrician, can you believe I cannot be reimbursed for an annual physical or shot given one day before its time? It's not like wine, you know!

How I manage diabetics or prevent readmissions of my CHF patients should be rewarded, even approximating the level that specialists get for doing veritably the same thing as I.

Capitation has its evils; fee-for-service its own inefficiencies and causes a surfeit of tests and dumping – perverse incentives they all are. Gatekeeper didn't work. Perhaps what we need is common sense, measuring outcomes and recognizing what it takes to get better results and be an available primary care doc—is that asking too much?

HL• Jeff, I agree with your assessment of the state of the bureaucratic world of health insurers. However, before you place the blame solely on the health insurers, if the group policyholder does not want certain coverage in their contract, the health insurer has to pay according to what the policyholder bought. The ridiculous things like not paying for a physical because it was one day too soon is a foolish practice by insurers. The example you gave are instances that give insurers a bad name, but you do recognize that members of your own profession sometimes do things that help exacerbate a hostile relationship.

The problem is that common sense does not always prevail in our business (health insurance) so we do things that are counterproductive. I have several times recommended that we pay for non-contractual benefits that made sense for the patient in lieu of paying for something that would have been wasteful.

How do we measure outcomes for any particular physician? When we try to do that we get push back that our data is not right, my patients are sicker than the other docs, and on and on. There are clinical software programs that measure physician practice patterns against evidence based medicine criteria, but why should I pay more for having the physician do what he should have done in the first place.

JGK• Clearly, there are many contributors to unwarranted variation - one sentinel of quality, inefficiency and inaccessibility. Suffice it to say, we agree there's much to be done, but it's high time we get going on learning what works, well and where (and the obverse). In my experience, acuity or case-mix adjustment as found within 3M Health Information Systems' CRG is one way to look longitudinally to develop comparative and normative statistics. The time is ripe for a look at episodes of care, aligned incentives and patients having some skin in the game, as well. Thanks for you cogent comments, Harvey and Andrew.

HL• Jeff, you are welcome. Good topic. You are correct. Much to be done, but better by us than government.

JGK: I just have to share this from another LInkedIn group - a parallel discussion called "Healthcare; Managing It Better."

Gene,

From Roger H. Strube, MD: I cover some of this stuff around page 80 of my book, "Discovering the Cause and the Cure for America's Health Care Crisis." By coincidence, it was about 1980. The bottom line is that to manage populations, the physicians (decision makers) must be paid to manage populations and must understand the concept. As long as FFS payment is the norm, docs will have difficulty taking care of their "flock."

JGK: "Anyway, Roger, how would you reorganize health care vertically? Forget the pitfalls of FFS and assume yesterday's MCO is now reincarnated as an Affordable Care Act ACO. Notwithstanding the Achilles' Heel of not having a handle on attribution (who belongs to who, for how long without a mandate, after a specialty consult or hospitalization, after they've lost their job, etc.), how would you give feedback at the point of service to garner better benefit for the consumer and price value for the employer. Certainly not just by squeezing the Doc, would U?

AS• I'd encourage JGK to learn more about Essence Healthcare and how we feed actionable information to doctors at the point of care. And about how we align incentives in ways where doctors earn money by keeping patient populations healthy, or getting them healthy. There is a misnomer that accountable care must take the form of an ACA ACO, or that the key to on trolling costs is to withhold care from patients.

Real innovation is happening in the private sector. Great that the government got everyone excited about shared savings ACOs, and shook up the status quo, but the fact is that some of the most promising models of accountable care are coming from the private sector - CMS' real goal, if you ask me.

JGK• I want to learn more of your efforts (i.e. going beyond the impressive sales pitch on your public site). First, please fill in some of the blanks - doc panel/patient population stability, in and out of network care, longitudinal view of care, the translation of data into information that is telling of what works and what does not, resolving turf issues,- hospitals to front line care; PCPs to specialists, guidelines, protocols, case management, proactivity, preexisting conditions, mental health, carve outs, and so forth.

Insurers must move from underwriting risk to managing populations and facilitating care. Pie in the sku? Let me ask about the current "system," or "non-system."

* Anyone having trouble with referrals, bureaucracies, co-pays, health plan infidelity (i.e., doctor shopping), job lock, adverse lifestyle choices, poorly coordinated care despite the best intentions, over-testing, red herrings of medicine? For example, Dr. L (an O.D. who does vision therapy) wants zinc and copper levels, cherries and pineapple food allergy testing. Should I comply? Maybe I shouldn't as it reflects poorly on my profile!  

Called "blind alleys," "red herrings," "doctor-induced demand,  inappropriate or over-utilization and fishing expeditions, etc. See:  "Before you get another medical test, figure out whether you really need it." [By Consumer Reports June 24, 2016 from the Washingtonpost.com/]

* How are we handling the worried well, the over-indulgent, the ER abuser, the insurer who won't pay for anti-rejection meds 3 years after a transplant?

* What's working? What's not? - Is mental health in the latter basket?

* How's Access - Are we creating the "Haves" and the "Have Nots?" (IOW is health care a right or a privilege?)

* What's the longevity of a plan member and if they switch (or go visit the specialist) are their tests redone? Just today a psychiatrist sent a young, obese adult with depression and ADD for me to perform the same $ million work-up I did in November!!!

Perhaps that comment was too 'show me.' As we move to greater accountability in healthcare with vertically-oriented health plans, not allowing barriers for prevention, the win-win of adherence/compliance programs and gaining bulk discounts from 'Big Pharma," acuity-adjusted, comparative outcome and process performance statistics, point of contact feedback (and real-time guideline-based advisories), can we expect the health care insurance industry to help? On a mundane, practical level, if they are not underwriting, how will they profit?

Specifically, what can they be expected to do regarding:

  1. Attribution -- identifying patients and Medical Homes (Lock-in never worked)
  2. Developing and making available a longitudinal view of patient care, e.g., case-mix adjusted episodes of care
  3. Prevention including preventing readmission
  4. Compliance / Adherence
  5. Keeping patients out of the hospital
  6. Care facilitation (formerly called "case management")
  7.  
  8.  
  9.  
  10.  

AS• Well, I don't have the time to put all of the answers here, but I can share a 40 page paper that essentially outlines our model of health insurance, which we call the Collaborative Payer Model. Just give me your email address if you actually want to learn more about the model.

A big part of this model is aligned incentives, and the empowerment of primary care physicians - though the model is evolving to give greater consideration to all the unique roles that hospitals can play in managing care. We consider ourselves a full service ally of our accountable providers of care, giving them the information they need to better coordinate patient care. Most of our contracts involve some amount of risk sharing. We have a particularly narrow network but have grown into one of St. Louis' largest MA plans. Many of our individual accountable care providers have panel sizes in the 500 - 700 member range, and some have more than that. Our clinical guidelines are shared along with what I'll call various care considerations, via an accountable care technology platform named Maestro. See Lumeris.com for more details on all of this technology and information sharing, including some acknowledgement about how that information passes through th physician's EMR.

Our approach, which I've admittedly explained at a very high level, is how we've become a 4.5 star Medicare Advantage plan that pays its primary care doctors much more than the national average, with particularly low member cost sharing and very high member/provider satisfaction, as measured by CMS and our plan.

I hope this gives you a little better sense of what we're doing at Essence. We've been working to build a high-performance virtual accountable delivery system for several years, long before people started buzzing about ACOs and the like.

JGK• WAIT A MINUTE OR THREE!

Here's a quick reminder of the topic here---“We need to move the system from underwriting risk to managing populations." With all due respect, being popular in the salad days of integrated health care is not what we should be discussing!

* What's working? What's not? - Is mental health in the latter basket?

* How's Access - Are we creating the "Haves" and the "Have Nots?" (IOW is health care a right or a privilege?)

* What's the longevity of a plan member and if they switch (or go visit the specialist) are their tests redone? Just today a psychiatrist sent a young, obese adult with depression and ADD for me to perform the same $ million work-up I did in November!!!

* Anyone having trouble with referrals, bureaucracies, co-pays, health plan infidelity (i.e., doctor shopping), job lock, adverse lifestyle choices, poorly coordinated care despite the best intentions, over-testing, red herrings of medicine? For example, Dr. L (an O.D. who does vision therapy) wants zinc and copper levels, cherries and pineapple food allergy testing. Should I comply? Maybe I shouldn't as it reflects poorly on my profile!

* How are we handling the worried well, the over-indulgent, the ER abuser, the insurer who won't pay for anti-rejection meds 3 years after a transplant?

Consider the idea that how you feel may be telling of how you actually are [duh!], but what this is really pointing out is pay more or by the piece makes for red herring diagnoses, false positives and blind allergy medicine.

"The basic strategy behind early diagnosis is to encourage the well to get examined — to determine if they are not, in fact, sick. But is looking hard for things to be wrong a good way to promote health? The truth is, the fastest way to get heart disease, autism, glaucoma, diabetes, vascular problems, osteoporosis or cancer ... is to be screened for it. In other words, the problem is over-diagnosis and over-treatment.

Screening the apparently healthy potentially saves a few lives (although the National Cancer Institute couldn’t find any evidence for this in its recent large studies of prostate and ovarian cancer screening)."

"If You Feel O.K., Maybe You Are O.K." pub. NY Times, Op-Ed: February 27, 2012 by H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice,  author of “Overdiagnosed: Making People Sick in the Pursuit of Health.”

SM commented on "How would you overhaul entitlement programs?" The answers may be just what the reformists need to see, hear, feel.

“ Does a single-payer system remedy this? Not if the provider still has to document what they have done for reimbursement... ”

Regardless, "the major provisions of the ACA represent a tremendous step toward interstate equity."

MCO Execs Group:

DO U HAVE THE COJONES (metaphorically-speaking) TO MEASURE RESULTS?

Bob Goff (2 posts ago) spoke here, on the MCO Executives' forum to the issue of handling (or not) bundled payments. He pointed to how difficult it is to get 'buy in, but do we really need buy in?

With case-mixed adjusted episodes of care, we can and have aligned the incentives and reduced cost while maintaining access and quality. Instead, we settle for process measurements and patient satisfaction surveys. When it comes to the elephant in the room, $Cost$ - those parameters simply don't cut it!. We must measure and compare RESULTS!

The following is from Jeet S. Guram, B.S., and Robert E. Moffit, Ph.D., "The Medicare Advantage Success Story — Looking beyond the Cost Difference" February 22, 2012 (10.1056/NEJM p1114019)

"Since we don't know whether healthier seniors disproportionately select Medicare Advantage or traditional Medicare, and since beneficiaries' health status affects clinical outcomes, Healthcare Effectiveness Data and Information Set (HEDIS) measures focus on care-delivery processes, using medical records to assess the adherence of plans to widely agreed-on clinical practices. [Regarding] performance in 2007, the most recent year for which data are available, on HEDIS measures in Medicare Advantage plans and fee-for-service Medicare, after adjustment for geographic differences. Medicare Advantage plans outscored fee-for-service Medicare on 9 of 11 measures.4 [See the Table in the original article]

The Affordable Care Act lowers benchmarks while continuing to base Medicare Advantage payments on fee-for-service spending levels. A better reform, advocated by Coulam and colleagues, would break that link: traditional Medicare would also submit bids, the government would set payment levels equal to each county's lowest bid, and beneficiaries desiring a more expensive plan would have to pay the difference.5

Under that system, traditional Medicare, no longer the default option, would compete with private plans on a level playing field. Private plans would gain substantial market share by providing Medicare coverage at the lowest cost in a county. As plans experimented with coverage models, attempting to deliver benefits in attractive, inexpensive ways, the most efficient approach in each county would be reached, and the rate of growth of Medicare spending would slow."

The following is based upon or directly referenced from the Naylors' recent JAMA article, "Seven Provocative Principles for Health Care Reform."

A. Legislation and regulation must be simplified. ”[C]hanging too many things at once leads to unintended consequences as well as confusion about causes and effects.

Warning: the “ACA may at once be too big to fail and too big to succeed.”

B. Capping spending and engaging in strategic rationing is inevitable.

“Spending caps do mean that Canada and other nations tend to ration care by availability, with queuing based on first-come-first-served or clinical need. Conversely, the US system essentially rations care by income, education, and insurance.”

C. Fairness in paying for care and accessibility to health care are evergreen objectives of health policy makers. Nevertheless, be careful--fairness is seldom defined. Moreover, “disparities in service utilization and, importantly, in health status stubbornly persist, even in highly egalitarian systems.”

D. Spending more does not equate with achieving a higher quality of care “but may instead lead to diminishing marginal health benefits.” “The law of diminishing marginal returns applies to most areas of human endeavor,”

When resources are constrained “implicit rationing” by clinicians takes place [specific reference: David Mechanic, 5]. This “helps explain why substantial increases in health care spending do so little to improve overall population health statistics and also underscores the importance of defining fairness. At risk of oversimplification, it seems the US definition of health care fairness presumes that wealthier citizens should have an inalienable right to choose to spend more, even if the marginal yields are trivial. The Canadian definition presumes that individual citizens do not have that right, even if the marginal yields are meaningful.”

E. Transactional micromanagement of health care is suboptimal, whether publicly or privately administered. Administrative costs of health care in the United States are far higher than in Canada, a difference only partly attributable to the plethora of payers in the United States. Whereas many nations, including Canada, give clinicians substantial autonomy to allocate constrained resources, the United States has built a massive industry based on micromanaging clinical care to contain costs. [6]” Clearly, budgeting is essential and in particular, prepayment mechanisms must be established to make spending more predictable, both in public and private plans.

REFERENCES

Naylor CD, Treumicht Naylor K. "Seven Provocative Principles for Health Care Reform." JAMA. 2012;307(9):919-920. doi: 10.1001/jama.2012.252

5. Mechanic D Approaches to controlling the costs of medical care: short-range and long-range alternatives. N Engl J Med. 1978;298(5):249–254.

6. Grumbach K,, Bodenheimer T Reins or fences: a physician's view of cost containment. Health Aff (Millwood). 1990;9(4):120–126.

MKT• I don't wish to take a stand for or against a man (Obama), but as for ACOs:

First: IT AIN"T AN ACO UNLESS CMS/MEDICARE BAPTIZES IT AS SUCH! That three letter acronym should be reserved exclusively for a reference to an entity formed for a specific purpose as described in PPACA regulation. PERIOD. To do otherwise really confuses what the thing is, its objective, corporate form, operation, and funding.

Second: As for the commercial payer "thingy" that needs to have a different infrastructure and corporate form and operation than an ACO purpose built for CMS and in order to comport with PPACA regulation.

I am starting to show signs of 564.1 and according to recent literature, it is of neurogenic etiology, as I contemplate and forecast what will happen with contracting, integration and alignment in the face of commercial payer contracting entities and their inability to produce deliverable to the extent that they will be paid for that which they contracted.

Rather than be redundant, ditto your first post from "Goff". What he said is spot on, point by point. But again I will be called a heretic and a naysayer.... for holding an opinion at odds with what is generally accepted and not being the rah rah girl. But hey, the last time the medical community called me that, in the end, I was correct then too. So what!

The majority of American hospitals and physicians are like lemmings. Here's why I say that: Lemmings don't commit mass suicide when they migrate, but instead the "result" of their migratory behavior. Driven by strong biological urges, some species of lemmings migrate in large groups when population density becomes too great. (See the analogy here?) Lemmings can swim and may choose to cross a body of water in search of a new habitat, but many may drown if the body of water is so wide as to stretch their physical capability to the limit.

I'd sooner dig a hole and scream into it and vent my frustration with what is happening here, for all the good it would do.

$1.4 million is just the start. It is understated, because for starters, any entity that needs that much capital, needs to develop a Private Placement Memorandum and file with the SEC because most of the doctors are not "sophisticated investors" with net worth over $1M. That alone adds cost, but not quality or patient benefit.

The compensation of a managed care analyst if you hire them as a W-2 is nationally estimated at $94 per hour (mode). EACH of these commercial payer agreements will cost at least 100 hours in combined analysis, revision, and negotiation time with the payer, PLUS another 200 hours of messenger time if the group has about 30 physicians, and about $15,000 in financial modeling fees, and another $25 K for the actuarial analysis of the capitation or bundled fees risk. Add more docs? ...Add 3H for additional messenger time, per doc.

And don't kid yourself, you won't want to be on only one contract per "thingie" So multiply this by the number of contracts. Even if you contract this out to someone like me, who knows how and what to do, the time factor may be trimmed significantly, but it won't be "cheap". Try to do it yourself? Ha! Go get a mirror, wash your hands, hold the D-I-Y Surgery book in one hand and operate on yourself with the other. Good luck with that! Don't forget to position the lights so that the book doesn't cast a shadow on the operating field or you won't be able to see what you're doing.

Jeffrey, why did you bring me in here? Can you write a scrip for LEVSIN? I'm gonna need it today on account of revisiting this topic.

JGK• Maria, your irritable bowel syndrome notwithstanding, you suggest that an ACO is narrowly defined by a reg. Give it time, but as we await it's evolution (as managed care, next generation) we need to talk about panels, attribution, patient loyalty, case mix adjustments, tracking medical processes and outcomes. The end game is a successful balance of cost, quality and access. How do u see that all being managed? (When the balloon gets squeezed it pops out somewhere else)? How r u going to align the incentives? Neither fee-for-service nor prospective or bundled payments do that? Tell us how to do all this.

AS• Why don't you think bundled payments align incentives? Surely you'd agree bundles are better than straight FFS?

JGK• Clearly bundling, prospective payment by episodes of care (with acuity adjustment) and other ways to compare processes of health care to attributable outcomes, help align incentives, however, applying groupers to poor data, even EHRs, monitoring performance over time, taking into account job lock (and loss), not having universal health care, etc. really mess things up, royally. The question is what to do about these problems, confounds and missed opportunities?

What's the best way align incentives and get the costs down without hurting quality?

Without incentive alignment, health care reform is merely a shell game - apply pressure in one place and like a balloon, it pops out somewhere else.

But bundling, paying prospectively by episodes of care (with acuity adjustment) and comparing the processes with the outcomes of health care can help align incentives. We have demonstrated the effectiveness of these types of payment strategies. Nevertheless, applying groupers to poor data, even data from EHRs, monitoring performance for too short a period of time, allowing patients to doctor shop to the point of not having any continuity or follow-through - that fails every time. And, don't forget employment-based insurance. I really hate job lock (and job loss), not having universal health care, etc. These kind of things really mess up the best laid plans.....

The question is what to do about these obstacles and missed opportunities?

MKT• Bundling payments isn’t as simple as most think it to be. One simply cannot use a snowplow method and shove it all in a pile and not have a division of the pot strategy memorialized into a participating provider agreement.

This is tedious and requires actuarial assistance in a capitated or sub-capitated environment. I am not trying to say "pay me for the answer as a consultant", here. By no means. But it is Sunday and my mother in law is visiting for a day from out of state, so I have to be a good wife... or else my integration and alignment here at home will be in trouble.

Please, if you don't mind, I wanted to acknowledge your comment JGK, but I can't do it today. I do have some ideas, but this is not the forum for such a lengthy treatise, hence the new book that is currently with the publisher for copyediting...

Physician Alignment and Integration: IPAs, PHOs, MSOs ACOs...and Beyond.

By the way, I am going to need a few docs, administrators and others to take a sneak peak at some of the chapters for the publisher's peer review and endorsements process. These get placed on the back cover of the book and on Amazon.com - so anyone out there, please let me know if you are interested. Doing this gets you a complimentary copy of the book direct from the publisher when it comes out. (About a $90 cover price)

I will come back tomorrow and answer in greater detail, at least the cliff notes version.

JGK• I'd love to take a 'sneak peak at "Physician Alignment and Integration: IPAs, PHOs, MSOs ACOs...and Beyond."

Back on point, however, in today's paper is the announcement of health care insurance market "Exchanges" State (or if not, it defaults to the Fed at a price) insurance vehicles that satisfy the mandate for insurance and allow for competitive pricing and benefit plans. O.K. so you get insured, how to we make health care spending more rational and how do we pay more for better results (and the obverse--how do we justify paying less well for poorer performance)?

Maria K Todd MHA PhD• JGK, you are talking heady holy grail stuff here (referring to previous posts). Us mere mortals are likely incapable of coming up with the solution alone. Too bad they don't ask those of us with insight to come together in a roundtable discussion with the politicians in the gallery to simply listen in. I'd cover my own expenses to participate in something like that. 

I also have a non profit through which it could be organized, but the nonprofit is only a week old and has no members on the books yet. The Healthcare Business Institute could issue a position paper on this as a think tank/roundtable where there are no sacred cows. 

Your thoughts?

To your post from about 12 days ago, 
"What the insurer CAN do is facilitate (as opposed to obfuscate) needed care. " Jeff, you are sounding like a "doctor" who has mistaken the identity if an insurer, one who accepts and manages "indemnification" the financial risk associated with making one whole for the cost of healthcare expenses, in accordance with the policy limits of a contract. 

Step back for a moment and humor me for a moment, I am not trying to get all snarky here. Let me try to refocus this without writing another book. 

In my professional opinion, (humble ... or not) the way I see it is that physicians should be managing my care. That's my job description for my doctor. I have no misinterpretation of what role goes with which entity. I don't want an insurer managing my healthcare, a church dictating what goes on in my bedroom, or a politician designing my health benefits. 

For example, my sister, who is recovering from breast CA only cares about the affordability of her copay, what pain meds she got to have something to chat about at the country club, and what her new boobs will look like at 49, now that the cancer is eradicated. She places value on that 7 minute intrusion in her busy day that it is only seven and not eight. I find the 7 minute visit insufficient to manage my care, helping me manage my decisions by providing education, answering my questions, weighing options, comparing effectiveness, clinical and cost of care outcomes, current literature, etc. But....I am an educated patient and I give a s@$t. 

Our doctors cannot manage our care (mine or my sister's) alone. They require integration of the care team so that each renders the best he or she has to offer, without trying to do too much in areas where they are not best qualified. They require alignment of the channel partners (hospital, ancillary, insurer, self-funded employer, actuary, MBA, bankers, computer geeks, programmers, technology partners, etc., AND THE ENGAGED PATIENT ) to make up an integrated health delivery system that is purpose built to automate that which can be automated, fund its development and design, and build within it a series of meaningful checks and balances to create a sort of "balanced scorecard" of health delivery effectiveness, patient satisfaction, functional restoration, elimination or mitigation of disease progression, and so forth. 

Again... in my opinion, to ask an insurer to step out of their indemnification role is to ask them to move the wheel weight to a place in the circle where it does not belong. The wheel will wobble or even start bouncing at higher road speeds, not just roll down the road smoothly. When that happens, the vibration creates additional problems which beget more and more cumulative problems. 

Now, let's relate it to the original article, as I think this discussion has gone down a few too many paths. Insurance out, managed care in? If we look at the purpose of having insurance as the indemnification coverage, and managed care done by aligned and integrated clinicians and care team providers, why should either be in or out? 

If I refocus momentarily to what is happening in the "insurance" world, there are 395 or so NCQA accredited insurance and managed care plans out there, and 210,000 self-funded employer health benefit plans, union benefit plans, HSA and HRAs. The market is moving towards groups of 50 or fewer opting to self-fund through a trust account, general assets of the corporation, some insurance products, and more cost shifting to employees. The common denominator here that is the weakest link in the integrated and aligned care team, and the thing that can do the most to rectify the imbalance of that wheel - is an engaged patient. Those with the take a pill, and "hey check out my new boobs at the age of 49", instead of "holy crap, how did I get cancer? and what can I change so I don't get it again or get more of it?" attitude is the holy grail. 



more to come

Capitated withholds didn't change physician behavior. With more than 30% of people now having qualified HDHPs packaged with "insurance" policies, and no managed care, we will learn that similarly, this won't really change employee behavior.

That old adage of the effort is only as strong as the weakest link in the chain. It's not the insurer, its not the employer, its not the doctor. We have to somehow motivate the critical mass of patients into the aligned and integrated care team, or realize that we are attempting to teach a pig to sing.

Otherwise, the only other thing to do is figure out how to do an end run on the patient that doesn't give a s#%t that will make a difference in outcomes of care quality. The last time I checked, to do that without consent is called "battery". What's wrong with the system as we know it, is not fixable at this level.

Capitated withholds didn't change physician behavior. With more than 30% of people now having qualified HDHPs packaged with "insurance" policies, and no managed care, we will learn that similarly, this won't really change employee behavior.

That old adage of the effort is only as strong as the weakest link in the chain. It's not the insurer, its not the employer, its not the doctor. We have to somehow motivate the critical mass of patients into the aligned and integrated care team, or realize that we are attempting to teach a pig to sing.

Otherwise, the only other thing to do is figure out how to do an end run on the patient that doesn't give a s#%t that will make a difference in outcomes of care quality. The last time I checked, to do that without consent is called "battery". What's wrong with the system as we know it, is not fixable at this level.

GS• A great discussion. When I was director of managed care for Colorado Medicaid, I had several contractors from United to Kaiser to local grown safety net plans. But the one that I always said was the only true managed care plan was the little PACE organization called Total Longterm Care. Nowadays I am with my second PACE organization. I started a rural pilot in Colorado and now am with a 20 year old PACE in Oakland, California. 

PACE, being 100% at risk, fully capitated and also the provider aligns every incentive. The biggest struggle is to bring on new providers and other disciplines and undoing their FFS mindset. But it really works. The rub - the feds won't let us scale it. In the entire US, PACE serves less than 30,000 frail seniors. 

The ACA and consequent dual pilots coming out of CMS are attempts to have large scalable organizations develop a PACE like view and it will be interesting to see what happens.

JGK Just curious - why would anyone impede this kind of progress -- realigning 
the incentives? Please speculate (so I can hate the politicians, lobbyists 
and anti-competition blokes, even more).

MKT JGK, I make a motion we scrap the whole system and you me and Gary go off in a room somewhere (in Colorado, centralized for both of you) and we reinvent healthcare. 

We can improve efficiency and effectiveness through better processes, but dictating how to practice medicine to doctors won't work. Patient satisfaction questionnaires don't improve direct patient care, HEDIS is insufficient as it doesn't measure enough of what's important, Patients aren't engaged, its not our place to judge their lifestyle, (at least not mine). I do blame the doc for the way they are paid, as many sign contracts that they don't understand, and few have the chutzpah to say "no", when "no" is the right answer. 

To keep tweaking things through this Act and that Regulation is a joke. It's tantamount to adding just a teency, weency more sulfuric acid and gunpowder to the mix and turning on the oxygen. 

"When" it blows up, its really gonna stink.

JGK Waste Less; Add Value 
To make health care reasonably profitable for private payers and more affordable for patients, those who manage health care must focus on reducing cost, which is far easier than increasing the health benefit or medical loss ratio. Unfortunately, as Berwick and Hackbarth point out, "programs to contain costs use cuts, such as reductions in payment levels, benefit structures, and eligibility. A less harmful strategy would reduce waste, not value-added care." The authors are adamant that the opportunity is huge and far greater than one could possibly achieve from "more direct and blunter cuts in care and coverage."

Reducing the cost of doing business is usually preferable to spending tons to generate new business or spending with reckless abandon--over testing, for instance, what some call 'shotgun medicine.' Waste management, by definition improves efficiency and cost-effectiveness; once that is a core competency, it is easier to strategically invest scarce resources in making marginal if not major improvements in access and quality.

"In just 6 categories of waste—overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse—the sum of the lowest available estimates exceeds 20% of total health care expenditures."

Caveat: "The potential economic dislocations, however, are severe and require mitigation through careful transition strategies."

Donald Berwick, MD, MPP and Andrew Hackbarth, MPhil in "Eliminating Waste in US Health Care" Published online in JAMA, March 14, 2012.

 [Free full text]

JGK Unfortunately, private conversations are just that, but let me make some observations: 
Health care's like the three-legged stool; its legs are Quality, Cost and Access. Shear off some of one leg and you'll have imbalance, instability - always. Another analogy--squeeze a balloon and it surely pops out somewhere. What I am getting at with these analogies is the NATURAL CONSEQUENCES of partial system manipulation. We all know the disturbance created by under funding primary care, paying FFS, prospective payment, referrals when a doc is not at risk for it, shot-gun medicine for fear of forgetting something (our litigious society just waiting to blame someone), etc.



So let's say you pay an incentive for immunizations - a win-win so long as the risk-benefit ratio is O.K. How about PSA's, every 5-year colonoscopies, yearly PAPs or mammograms in the young (without risk factors), tympanostomy tubes, even T&A's, coronary artery stents without lifestyle control? It is now clear that many of these lead to unnecessary anxiety, further testing. Moreover, much of this diagnostic intervention has virtually no effect on survival or quality of life. The problem, of course, is knowing who to test, but the biggest problem in health system reform is not knowing what works and paying, and paying, and paying for what does not. Not having universal coverage, trying to get by with smoke and mirrors, not having, for instance, systematic measurement and management of processes and outcomes, and suffering from discontinuity of care (i.e., lack of follow through / follow-up) makes everything worse.



And then there's the matter of failure to case-mix adjust so outcome "apples" are compared to "oranges," resulting in wrong health planning from misleading statistics - example, the best hospital gets a bad rap because they take on the riskier cases. Additionally, there's the unbelievable, increasing to epidemic proportions adverse lifestyle choices. Also, health care may be impeded financial barriers to access (i.e., from cost-sharing) or bureaucratic hurdles, neither of which is reflected in the outcomes statistics. Not finally, consider what happens when one hires the fox (the specialist) to guard the hen house (the specialist doesn't get paid much for NOT doing). With a surfeit of specialists and a dearth of PCPs it's no wonder we see a growth of procedures, access problems and the dissolution of the 'Medical Home' concept

2/28/2012 |The New Face of Medicaid | Linda Hamacher CEO Genesse Health

Listen to the recording (below) of this informative discussion with Linda Hamacher about the changing face of Medicaid. Ms. Hamacher plans on sharing highlights of a recent presentation made at the Medicaid Innovations Forum.

Genesee Health Plan (GHP) is a community-based non-profit that provides primary care & other basic services to 27,000 low-income, uninsured adults in Genesee County, Michigan, one of the most economically depressed areas of the U.S. The Genesee Health Plan is the only local one in Michigan that is funded directly by the community through a special millage. The plan reduced its enrollees’ use of emergency department services by 51% and hospital admissions by 15% between 2006-2007. The success of the Genesee Health Plan has demonstrated that any community–even one with scare resources–can provide basic, affordable health services to uninsured adults.  Yadon, Richard. "Medicaid Matters" Feb. 28, 2012  Streamed Talk Show


When evidence says don't pay for the test (treatment or procedure)

The American College of Gastroenterology speaks to non-endoscopic, serologic testing to confirm or refute H. pylori eradication.[1]  However, because of its "lower specificity, serologic testing leads to more treatment of patients without active infection, more antibiotic resistance, and wasting of resources.[2]  [Furthermore,] unnecessary eradication therapy in incorrectly diagnosed patients accounts for nearly 40% of the overall cost of serologic testing.[2] 

< [See medicaleconomics.com/ to learn more about why some insurance companies are deciding not to cover serologic testing.

References

1. Chey WD, Wong BCY; Practice Parameters Committee of the American College of Gastroenterology. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. 2007;102(8):1808-1825.

2. Vakil N, Fendrick AM. How to test for Helicobacter pylori in 2005. Cleve Clin J Med. 2005;72 (suppl 2):S8-S13.

"Why are some insurance companies deciding not to cover serology for H. pylori testing?"   See medicaleconomics.com/", Dec.11, 2015

 


Physician Dissatisfaction

"I believe most doctors continue to want to be like the physician knights of the golden age of medicine. Most of us went into medicine to help people. We want to practice medicine the right way, but too many forces today are propelling us away from the bench or the bedside. No one ever goes into medicine to do unnecessary testing, but this sort of behavior is rampant. The American system too often seems to promote knavery over knighthood."  Dr. Sandeep Jauhar "Why Doctors Are Sick of Their Profession." WSJ.com 8/29/2014