Managing Managed Care

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

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The cost of health care is already dear and rising exponentially while its "value" or the return on investment diminishes. What can be done?

We know our health care system is particularly inefficient. As for the quality of care, by any measure it is variable at best.  Why is it so hard to fix our health care system?  For a start, health care coverage should not have anything to do with employment.  For another, practitioners should be paid better when they do better, not when they do 'more.'  In other words, the incentives must be aligned.

Translating Data Into Information

There is need to get out of silo thinking and away from data sequestration.  The simplistic thing to do to effect this transition is to begin capturing and leveraging data that support a wide range of healthcare functions including cost-effective, financially efficient medical decision support, disease tracking (i.e., case management), patient engagement, and most importantly, population health.

  jgk 5/15/17  

Dr. Arnold S. Relman of the New Engand J. of Medicine sums up the main challenge of health care reform, succinctly: "This problem [i.e., the lack of 'practical' suggestions for reform] is a direct result of "the inappropriate organization and perverse economic incentives of a health care delivery system that motivates physicians and medical institutions to maximize their income rather than focus on optimal patient care.”

A health care executive, writes in a LinkedIn blog, June 2013

The three ways to deal with the growing cost of care are: to spend more, than to ration or to innovate; and, the biggest structural innovation+ in health care management would be shifting from transactions and piecework charging to using case-mix-adjusted episodes of care (EOC*) i.e., “designating a single point of financial and clinical accountability over the full longitudinal picture of care. Unfortunately, we're contaminating that innovation with countervailing forces like freedom of choice, privacy and provider competition...good values, all, but distorted under the current non-system and destructive of continuity of care. We've known forever that 5% of patients account for nearly 60% of costs; that duplication and waste reach $800b and beyond; that 40% or more of all true ansactions occur out of even the best of networks and that older patients often see 7 practitioners across 5 discreet practice environments in a single year. The pure concept of a closed system for a captive patient with an active longitudinal record in a care-giving continuum that looks something like a conspiracy to restrain trade accountable care organization. Failing those criteria, watch the retreat to an open, transaction-based system we can't sustain." [Modified for presentation here]

If * Episodes Of Care (EOC) references:

  1. Medicare Payment Advisory Commission (Medpak) “Medicare and the Healthcare Delivery System
  2. Goldfield N, Kelly WP, Patel K. "Potentially Preventable Events: An Actionable Set of Measures for Linking Quality Improvement and Cost Savings." Q Manage Health Care. 2012;21(4):213-219.
  3. "3 barriers keeping data from improving health outcomes." <> [Posted 5/20/2016]
  • ​​​Time and Technology: "“The idea is that we have lots of data—we have to organize it in some digital way. If you would have said that was the problem initially, and the problem is actionable, organized Dr ata at the point of care, easy entry, protecting the interface between patient and physician aund recognizing that … continuity and interoperability are really important, we would have had a digital approach with a very different set of products than we have today.”
  • The wrong incentives: "A nationwide study the AMA conducted with the RAND Corporation found that 'the primary driver of physicians was time face to face with patients,” he said, “and everything that got in the way of that was a disincentive.'”
  • Gaps in education: "One example [of which] is the AMA’s Accelerating Change in Medical Education Consortium [that] consists of 32 medical schools. 'We are now populating the consortium with a learning EHR … which [will] allow students to get the rhythm of what an EHR can do and get them ready for the next generation of EHRs.'”

Regarding Innovation

Before looking further into health care and the managed care method, can we first examine creativity, innovation, stagnation and the status quo by digressing a bit to view "How Google Works" from SlideShare? [Last accessed 10/21/14]

In my opinion, the Top 10 Challenges to Managing Cost, Quality and Access are:

  1. Value: to enhance it, practitioners must be aligned to minimize Cost while maximizing Quality and Access
  2. Pay for what works well. Money's the main stimulus: management suffers from always having inadequate provider incentives
  3. Information technology (IT) limitations—live with it!
  4. Measure andmanage; this requires that data be translated into information (If there's no EHR data, use claims data).  Use it to build—
  5. Episodes of care—a grouper technique that shows all care over time, regardless of setting and it is case-mix or acuity-adjusted.  See 3M's CRGs and the June 2013, Medpac Report to Congress
  6. Outcomes—the key parameter of what we want to reward; clinical results, strangely, are neither tracked nor optimized in most health care practices
  7. Case or disease management
  8. Guidelines/pathways—medical and surgical
  9. Lack of patient loyalty or engagement—it is one of the main stumbling blocks. (A related one is job-lock; move away from 'pre-existing conditions,' waiting periods, heavy co-pays and deductibles, employer-based insurance and state border restrictions)
  10. Defensive medicine is a distraction and it is insidiously costly, despite claims to the contrary

Though we "embrace advances in health care, we must remember that a number of what were thought to be advances turned out to not be beneficial, or even to be harmful." Nevertheless, a recent Institute of Medicine report gives reform its legs by auguring for "a culture that uses rigorous evidence-based standards to help patients feel better and live longer. To that end, the report describes the following areas of research and development, in other words, a "learning system": increasing the usefulness of information technology (i.e., computational power and connectivity), improving organizational capabilities and management science, and increasing focus on enabling patient-centered care."

To briefly elaborate, the "Components of a Learning Health Care System," listed by Smith fall under three broad categories: Foundational Elements--The digital infrastructure and The data utility; Care Improvement Targets--Clinical decision support, Patient-centered care, Community links, Care continuity and Optomized operations; and Supportive Policy Environment--Financial incentives, Performance transparency and Broad leadership.

Smith M, Cassell G, Ferguson B, Jones C, Redberg R. Institute of Medicine of the National Academies.  "Best care at lower cost: the path to continuously learning health care in America" Last accessed September 9, 2012 

Comparative-Effectiveness Research (CER) is that evidence--it is basis by which health care can be not only cost-effective, but also efficacious as applied.  In brief, CER helps us determine what should and what should not be made available, accessible and covered.

Also referred to as "Patient-Centered Outcomes Research Act of 2009," CER makes information available to help "clinicians and patients choose the options that best fit the individual patient's needs and preferences."  The "conduct and synthesis of research comparing the benefits and harms of various interventions and strategies for preventing, diagnosing, treating, and monitoring health conditions in real-world settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision makers about which interventions are most effective for which patients under specific circumstances."

Per the Federal Coordinating Council for Comparative Effectiveness Research, which is established by the Office of the Secretary in the Department of Health and Human Services (DHHS)

CER, broadly, is concerned with the methodology of information technology (I.T.), data infrastructurethe translation of data into information and its promulgation (although they would undoubtedly prefer the word, "dissemination," it being less aggressive).

Conway PH, Clancy C. "Comparative-Effectiveness Research — Implications of the Federal Coordinating Council's ReportPublished at N Engl J Med. June 30, 2009 (10.1056/NEJMp0905631)

The IOM committee also recommended "supporting CER related to patients' decision making, unhealthy behaviors such as smoking, and determining the most effective dissemination methods to ensure translation of CER results into best practices."

Key Priority Areas of Interest

The graph shows 100 primary and 193 secondary research topics by topic with "Health Care Delivery System" being the most prevalent. After that, nearly 1/3 was racial and ethnic disparities, 1/5 was patients' functional limitations and disabilities. Thereafter, in terms of prevalence, were: cardiovascular disease that ranked second as a primary research area [1], geriatrics, psychiatric disorders that ranked third as an area for primary research [2], neurologic disorders [3], pediatrics and cancer [4].

[1] Cardiovascular and peripheral vascular (CV-PVD) diseases were the leading causes of death in the U.S. in 2006. Note: one might consider in this context that heart disease is a co-morbidity where the primary disease or condition is diabetes or obesity, respectively; and both of these are, unfortunately, increasingly more prevalent.

[2] Includes mental health care—venues and locations, provider training, pharmacologic treatments of or for depression and/or suicide consequent to mental disorders.  [Support groups, systems and connectivity, e.g.," font-size:11px">[3] Incorporates diagnostic imaging and interventions for headaches, multiple sclerosis, epilepsy and dementias including Alzheimer's disease.

[4] Cancer is second to CV-PVD in U.S. deaths and "one of the most costly diseases to treat. [It] is the focus of six recommended primary CER topics, including screening technologies for colorectal and breast cancers and the [appropriate] use of imaging technologies for diagnosing, staging, and monitoring all cancers.

Iglehart, John K. "Prioritizing Comparative-Effectiveness Research -- IOM Recommendations." N Engl J Med. June 30, 2009; pub. Online: 0: NEJMp0904133

The following are two other, important references

"The Costs of Failure: Economic Consequences of Failure to Enact ... Health Reforms," The Commonwealth Fund Blog.

"A Roadmap to High-value Healthcare Delivery," by Denis A. Cortese, MD and Robert K. Smoldt, MBA where they discuss some of the concepts of and options for improving health care delivery; the authors "zero in on the need to change existing healthcare provider financial incentives toward ‘pay for value’* as a key stepping stone toward high-value healthcare delivery."

* Cortese and Smoldt define "value" as "patient outcomes divided by total cost per patient over time."

Incidentally, CMS is seeking input on how to advance value-driven care

"The Centers for Medicare & Medicaid Services (CMS) wants comments on proposed innovations in advanced primary care, including ways to encourage more comprehensiveness in primary care delivery and moving reimbursement from encounter-based towards value-driven, population-based care." They will entertain reasonable and appropriate input from "consumers and consumer organizations, healthcare providers, associations, purchasers and health plans, Medicaid agencies and other state offices, quality review organizations, social service providers, HIT vendors, and other stakeholders. [jgk:​ link failed 9/6/15]

General topics of interest include:

  • increased comprehensiveness of, and patient continuity with, primary care (i.e., care provided with greater depth and breadth and through longitudinal relationships between patients and primary care providers),
  • care of patients with complex needs,
  • moving from encounter-based payment or encounter-based payment with care management fees towards population-based payments to support the infrastructure needed for advanced primary care and to promote accountability for costs and quality of care,
  • mechanisms to support small primary care practices in the transformation to advanced primary care,
  • advanced primary care within accountable care organizations,
  • multi-payer participation,
  • performance measurement that is meaningful to beneficiaries and clinicians, and
  • use of health information technology, including electronic health records, data analytics, and population health tools, to support advanced primary care."

Submissions must be supplied using the form found at Comments must be received on or before 11:59 pm EDT, March 16, 2015.

For questions regarding RFI submission contact

"6 simple questions great leaders ask" by Molly Gamble [(Twitter | Google+); September 09, 2014], asking about performance–the audience (e.g., employee); the leader; testing assumptions; long view and how one can be helpful

Source: Eric McNulty for stategy+business, director of research at the National Preparedness Leadership Initiative as referenced in Becker's Hospital Review. [Email Ii you have questions about copyright or linking.


The U.S. healthcare system is broken, The 'fix,' however, is at hand--turn up the competition by empowering consumers with data, translated into cogent information; data that are available at the point of contact with the patient and whenever it is needed for informed decision-making and choosing among healthcare options.

"The end result of this fundamental shift to this new model of healthcare delivery would be achievement of the 'triple aim' of better clinical care, improved population health and lower costs. Essentially, I suggest we give the people informed choice, then stand aside and let free market principles do the rest."

Larry A. Cesare, Psy.D. "A Proposed Consumer-Driven Alternative to the Affordable Care Act." LinkedIn.  Jan. 19, 2017



watch: how big data and automation are disrupting healthcare

"Technology and automation are facilitating healthcare reform under the rubrick of value-based care.  We see in that payers and providers beginning to leverage big data, which is also empowering healthcare consumers. Verscend’s President and CEO, Dr. Emad Rizk discussed this 'metamorphosis' at the 2017 Health Care Forecast Conference held at the Paul Merage School of Business at the University of California, Irvine." [This excellent interiew is published, online by, March 10, 2017]



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