Author Archive

Quality in Healthcare

Tuesday, October 23rd, 2012

Magical Thinking in Healthcare

Wednesday, October 3rd, 2012

We all do it. Magical thinking is about engaging in causal fallacies. It is comforting. Otherwise we’d spend our entire lives going: “Say what??!!” But in our national political discourse (and in health care in particular) we have elevated magical thinking to our basic operating model for the future. Bad stuff will happen, then we will do something to [insert simple idea here], then magical thinking happens and the world becomes a better place. Easy.

Magical Thinking in Politics

Both parties have demonstrated an astonishing capacity for magical thinking in the run up to the election. Republicans confidently assert that cutting tax rates for the wealthy will simultaneously grow the economy and not add to the deficit, even though the dismal economic performance from 2000–2007 suggests that precise strategy failed. (It would also be nice if the closed loopholes were specified: namely mortgage deductibility and health insurance deductibility. Instead the loopholes are left to the imagination, and magical thinking, about how the deficit can be reduced by cutting public broadcasting and foreign aid, both minuscule shares of the budget.)

Similarly, Democrats argue that raising taxes on the rich spurs middle class job growth and returns the middle class to prosperity, when in reality the forces of globalization and technology (beyond the control of even presidents) continue to widen gaps between rich and poor.

 

Magical Thinking in Health Care

In health care we have raised magical thinking to an art form. Our legislative process creates incoherent mishmashes of unintended consequences, even when the laws are well intentioned and directionally correct. There are too many examples of magical thinking to cover, but here are a few:

Rich people happily subsidize poor people. For five years I have been arguing that the central question in health reform is “Will rich people write a check to cover poor people?” This whole election was really about that. You will know the answer shortly. But, no matter who wins the election, America must solve the riddle that majorities support government taking action to cover the uninsured but those same majorities are unwilling to pay the taxes to make it happen. This is what scholars call the principle-policy gap.

Budget delusions. The deficit matters; national debt in excess of 100 percent of gross national product matters. We can Krugman in the short run, […to Krugman is a verb I just invented to mean run big government deficits to avoid depression as Nobel Laureate and NY Times columnist advocates) but even Keynes recognized you can’t run these deficits forever. Both sides in the budget debate are delusional. Eventually, we have to cut spending and raise taxes (on everyone), and health care has to be a big part of the new austerity — otherwise the arithmetic doesn’t work (even with magical thinking).

Repeal and replace. It is extremely unlikely that anything would replace Obamacare if it were repealed. And even then the proposed solutions are magical. My personal favorite is buying insurance across state lines. Apparently, my favorite out-of-state health plan, Blue Cross Blue Shield of Tennessee, can have enormous contracting clout with my doctors at the Palo Alto Clinic. I just don’t understand this.

States as laboratories for bad science. As the contrast between Massachusetts and Texas demonstrates, states are very different in their politics and culture. Massachusetts’s health reform took place in a small, affluent, highly educated state with very low numbers of uninsured and relatively generous Medicaid and uncompensated pools. In contrast, Texas has over a quarter of its citizens who are uninsured, and the state seems unlikely to aggressively pursue coverage expansion even if federal money for Medicaid expansion and exchanges are available. Imagining that all states will eventually look like Massachusetts seems like magical thinking, given the Supreme Court’s green light to states’ rights on Medicaid expansion.

Single payer. Another area of magical thinking, common on both the right and left, is the idea that eventually we will have a single payer system because either private based reform fails or Obamacare creeps toward a socialist takeover. A true single payer system requires massive income transfer from rich to poor and a standardized fee schedule delivered in a global budget framework. Put that way, it seems unlikely in the current American political context. Vermont, the only state really considering this, has yet to be specific about how the money would be raised to pay for the single payer plan they propose, but as far as I can tell, it does not involve state-based income tax increases but rather magical thinking about flows of funds from employers and the federal government.

Exchanges. The clock is ticking for the exchanges to get up and running. The vast majority of states will not have a functioning exchange up and running on the due date, even with Obamacare intact. Even the states that are ahead are figuring out quickly that it is tough to design a health plan that can simultaneously fit through the precious metal aperture of affordability specified in the ACA, and be affordable and attractive to the humans who will be mandated to purchase these plans. In my state, California, we are further ahead than almost anyone, yet leaders in the state are ruminating that no HMOs beyond Kaiser can fit through the aperture of affordability and the default plan will be a very-narrow-network, very-high-deductible PPO offering. Folks, we may be headed to that future anyway through the widespread creation of private exchanges which have all the features providers hate about state-based exchanges (narrow networks, low effective provider reimbursement through consolidated purchasing and competitive bidding, and high deductibles and the resulting bad debt problems). It’s Obamacare without the subsidies.

Low-income folk will sign up. Massachusetts had an aggressive social marketing campaign to explain to the uninsured that they should avail themselves of coverage. It worked well. It takes some magical thinking to assume that 15 million-plus newly eligibles will sign up in every state across the country, especially when in many states there is no aggressive outreach, no social stigma to forgoing coverage, and no state leadership behind coverage expansion.

Block grants. When you hear the phrase “block grant,” it is code for “less money.” Few people propose block grants with more money. It defeats the purpose. One battle to watch for after the election is reframing block grant proposals for Medicaid as self-imposed per capita caps on Medicaid spending (states would agree to a cap on federal contribution). This sounds sensible to me, but it may be magical thinking to assume that conservative politicians will take that deal if spending increases as enrollment in Medicaid increases.

Spending the Medicaid managed care dividend before you’ve earned it. Across the country, states are converting their Medicaid programs to managed care. Others, like California, are aggressively pursuing waivers to expand managed care to special needs populations, the disabled and dual-eligibles. While I applaud the move, many states including California seem to be banking the expected savings before they actually earn them. As one CEO of a local Medicaid plan in California told me this week: “I’ll eventually get the 30 percent savings, but it may take three years to get all the care coordination, medical home and population health infrastructure in place for these patients.” Dual-eligibles present a special opportunity (and challenge). Many commercial players (including health plans and at-risk provider groups who thrive on Medicare Advantage) are salivating at the prospect of managing these dual-eligibles. Plans and providers can deliver better care at lower costs and benefit financially in the process. But the magical thinking comes when you have to deal with all the segments of the dual-eligible population. The target population of dual-eligibles for these commercial interests is what one local plan CEO dubbed “the nice old,” namely the little old ladies with chronic conditions that can be managed much better in a coordinated care platform. The commercial players are less interested in the disabled, the institutionalized, the seriously mentally ill and those with serious substance abuse issues, which represent significant sub-segments of the dual-eligibles. The recent transfer of special needs populations into managed care as part of California’s Medicaid waiver provides a small window on this problem nationally. Players in the field estimate that costs for caring for the population were 10 percent to 15 percent higher than anticipated by their actuaries.

The Smith conundrum. My friend Mark Smith, M.D., M.B.A., CEO of the California Healthcare Foundation, has identified a key conundrum in American health policy. The paragons of delivery excellence for value, whether it be Kaiser or at-risk Medical groups, cannot make money on the Medicaid level of reimbursement. So the question becomes, What is the delivery model for the bottom third of the income distribution when Kaiser and other high-value delivery models to which we aspire lose $100 per member per month on these patients, and no one is volunteering to make up the difference in taxes?

Reimbursement reform. Everyone in wonkworld agrees that changing the reimbursement system to align incentives is the key to system transformation. However, Harris Interactive surveys of physicians and hospital leaders consistently show extremely low levels of enthusiasm for new payment models such as bundled payment, global budgets and capitation. Let’s face it. Fee for service is like crack — it’s tough to get off it.

Accountable care organizations. Hospitals and doctors are huddling together for warmth as they face the new future, many under an ACO umbrella. But reality is dawning on these fledgling new organizations, in particular, that structure doesn’t automatically confer performance. Just because you are legally a clinical integration organization doesn’t mean you are integrated clinically. That actually requires hard work…or magical thinking.

Shared savings. Much of the transition from the first curve to the second curve, from volume to value, is enabled through shared savings models. What happens if there are no shared savings, only shared losses? What if a combination of budget cuts at the federal and state levels, organizational intransigence, and poor management fail to yield savings? If that’s the case, where is the fuel for transformation? Right now the principal fuel for much of this is provider-based reimbursement (you pay a cardiologist more in facility fees when the practice is owned by a hospital), which seems to me to be a policy accident waiting to happen.

Patient-centered medical homes. Everyone should have a medical home with a highly integrated team of caring professionals hovering over my medical record, ready to pounce on any deviation from health. Well, that is magical thinking. Even the fathers of the movement concede that really what PCMHs are about is creating the mother of all triage systems, where you identify and concentrate resources on the heavy users to improve care, while automating the primary care and wellness initiatives so that the nagging to maintain health is done by your iPhone, not by the entire cast of Grey’s Anatomy. It’s all about segmentation and focus.

 

Migrating the Business Model

All these examples point to the critical challenge we keep cycling back to in recent columns, and that is migrating the business model. It needs to be done systematically but urgently, with compassion for those we serve, and commitment from those who deliver care. We need to make the system work better and we need to be clear headed about this transformation. And not just succumb to magical thinking.

Ian Morrison, Ph.D., is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Daily and a member of Speakers Express.

 

The Bridge from Volume- to Value-Based Payment

Friday, August 3rd, 2012

Health system leaders now have clarity about the work involved in moving to the new future. It requires clinical integration, deployment of sophisticated health care information technology (IT), clinical performance improvement, financial management to break even on Medicare rates, and intelligent business model migration from the first curve of paying for volume to the second curve of paying for value. (See “Let’s Get to Work!” in the June 2012 issue of H&HN magazine.)

Health system leaders are wrestling most with business model migration. They are uncertain about the pace of change of reimbursement reform, they are fearful of taking population health risk and many have nightmares about a big bad replay of the 1990s when hospitals bought doctors’ practices, health plans or both, and lost their shirts in the process.

This time must be different; we really cannot afford to fail.

Not the 1990s Anymore

There are five reasons why this time is different:

We have hit the wall on affordability. The average American household cannot afford the average premium, and even though the cost increases have been slowing, there are signs of the cost trend bouncing back.

We have much better quality tools. The tools of quality measurement and improvement are much better than in the 1990s. We have many more measures, more transparency, more quality leaders and, thanks to the American Hospital Association, the Institute for Healthcare Improvement, the National Committee for Quality Assurance and others, we have a whole host of opportunities to learn how to get better.

Care coordination systems have improved. We now have two full decades of innovation in care coordination and care management: from patient-centered medical homes, to readmission management, to large-scale-care coordination by teams of caregivers, to pioneer accountable care organizations (ACOs), to the use of sophisticated software and analytics in predictive modeling.

Physicians are changing. The recent Choosing Wisely campaign initiated by many of the specialty societies in partnership with Consumers Union signals an important step toward a renewed recognition that financial stewardship of clinical resources is an integral part of medical professionalism.

Large-scale sophisticated business systems are emerging. This time we have big players who bring scale, capital and sophistication to clinical integration and health care delivery redesign. Kaiser Permanente alone is a $50 billion enterprise. Many more mega-billion-dollar health systems are being formed in this round of consolidation among existing regional integrated delivery systems and from novel partnership formation — for example, Aetna’s Private Label ACO partnership arrangement with Aurora Health or CIGNA’ s ACO relationship with Tenet, or Optum’s multivariate relationships with delivery systems across the country.

All of this points to the fact that we are getting serious about moving to a new future. But what is the bridge?

 

Building the Bridge

Across the country, health system leaders and their advisors, partners and boards are starting to build the bridge. Harris Interactive surveys document rapid clinical integration across the country with 69 percent of hospitals owning a medical group (the sample was weighted by bed size to reflect the distribution of beds) and a full third of physicians are now in practices owned by hospitals (a number that could exceed 50 percent in the next three to five years if current trends continue).

Similarly, a recently released KPMG/Harris Interactive survey of leaders of the largest health systems, health plans, and pharmaceutical and medical technology companies underscores these trends and shows that larger systems are even further along in their path to clinical integration. (http://www.kpmginstitutes.com/industries/healthcare-and-pharmaceutical.aspx).

The KPMG/Harris Interactive study demonstrates clearly some of the elements of the bridge. A sample of more than 100 C-suite leaders drawn from the top 200 health systems cited the following elements as extremely or very important in building a business model over the next three to five years:

Aligning with physicians to integrate them fully in clinical redesign efforts

98%

Aligning with physicians to preserve and expand market share

94%

Improving quality to take full advantage of pay for performance incentives such as CMS value purchasing

92%

Innovative deployment of health information technology across the continuum of care

92%

Preparing the organization to accept more financial risk in stages

89%

Redesigning clinical care processes using lean, six sigma or other workflow redesign methods

88%

Rationalizing supply chain through standardization of clinical equipment and supplies including orthopedics, cardiovascular and oncology

87%

Focusing on managing readmissions

86%

Partnering with alternate site providers across the continuum of care

77%

Partnering with other organizations such as insurers to help manage risk

76%

Differentiating on quality and service to appeal to affluent, well-insured consumers

60%

Owning and operating alternate site providers such as home health care and skilled nursing facilities

43%

Owning and operating a health plan function

26%

Raising prices on commercial payers

24%

 

It is clear from the survey that integration with physicians is the first priority. It works for two reasons. On the first curve (paying for volume), you cement clinical relationships and volume of existing business. On the second curve (paying for value), you have a platform for migration to more integrated systems of care by redesigning care processes for a world of value-based purchasing. The other wonderful feature in the short run is that provider-based reimbursement allows hospitals to benefit from a change in ownership of clinical practices through higher facilities-based fees. (My good friend and fellow columnist Nathan Kaufman identified this trend in the first column of his series “From the Trenches.”)

The second key observation is that there seems to be less appetite for full risk bearing among health system leaders, with many more leaders preferring to migrate the risk function in stages (89 percent) or partner with health plans (76 percent) rather than outright owning and operating a health plan function (26 percent). This is the core of the bridge dilemma. Many health system leaders anticipate that in the long run, risk and reward will be tied to the triple aim of population health, improved patient experience and lower per capita costs.

Yet, there is no big hurry to jump off the dock. Indeed, in Harris surveys of both hospitals and doctors there is very muted enthusiasm for new payment models such as bundled payment, episode-based payment, global payments or even pay for performance. Private and public purchasers need to send big clear signals to the delivery system that we are moving to a world of accountable care systems delivering coordinated care across the continuum on a triple aim basis; at the same time, the delivery system will need to wean itself from the simple comfort of pay for volume and learn how to build a culture of accountable care.

The final big observation from these data is that none of this can happen without sophisticated health care IT and analytics to support care management, care coordination and population health. Health systems leaders get that and are making rapid progress even though the industry in general is about 20 years behind most other industries in its comfort with and deployment of IT infrastructure.

 

Barriers to Bridge Building

Bridges are hard to build, but done right, they last a millennium or two. There are significant barriers to bridge building. Here are some I have encountered:

Complexity of health systems. Large integrated health systems, particularly those that have academic missions intertwined with massive clinical systems, are extremely complicated enterprises. None more complex, as Jim Collins or other management gurus would agree. But this does not absolve us of the need to build the bridge.

“Best year ever.” I go to a lot of hospital board retreats, and I always ask the CEO: “How’s it going?” The last couple of years, they nearly always whisper quietly: “We had our best year ever.” Enough said. It is hard to change when things are so good. But go ask Jim Collins or Clay Christensen or Kodak, and they will tell you that is precisely when you have to change.

“Nobody told the specialists.” The wisest comment on health reform and the move to accountable care that I have heard was “Nobody told the specialists.” While Choosing Wisely clearly signals an important change in thinking among specialty society leaders, many rank and file physicians (particularly those in lucrative procedure-oriented specialties) are afraid of many of these changes and see them as profoundly harmful. They need to be engaged fully in the redesign discussion, however hard that may be. And they too need to see an economic bridge to the future, one that doesn’t involve either a default to what I have dubbed hamster care: alienated doctors on a treadmill of discounted fee for service, or conversely, everyone trying to do concierge medicine.

Anatomy, not physiology. Another great learning came from a physician leader in a large sophisticated health system that is on the path to true clinical integration. He told me that “we have the anatomy of an accountable care system, but none of the physiology.” True for many successful regional systems that are contemplating the path to accountable care.

The politics of purchasers: two ideologies. As we gear up for a very big election with sharp distinctions between philosophies, we also will face a big ideological choice among our private and public purchasers — illustrated by the recent pair of editorials in The New England Journal of Medicine, where two alternate visions were presented. (See E. Emanuel et al., “A Systemic Approach to Containing Health Care Spending,” and J. Antos et al., “Bending the Cost Curve through Market-Based Incentives,” www.NEJM.org, Aug. 1, 2012.) On one hand, the Journal describes a Berwickian future of accountable care systems pursuing a triple aim of coordinated care. On the other hand, the Journal presents a much more atomistic view in which patient consumers armed only with high deductible health plans use narrow networks and market forces to transform the delivery system. The election will have a major influence on which view prevails, as will intense budget debates to come. Make no mistake: The federal deficit is a health care problem at its core. Greater emphasis on atomistic views may derail some of our best efforts at care coordination and integration.

What happens if the math doesn’t work? The biggest single barrier to bridge building may be that we run out of money for the bridge. The math may not work. The combination of massive Medicare cuts and the sting of skinny networks may close down a lot of bridge projects, and health systems may simply hunker down in the present.

 

Bridge Building Techniques

 

Health system leaders are looking for tools to help them both today and tomorrow, to build solid foundations for the bridge in the present and to build a strong footing for the future. Here are some ideas that may help both today and tomorrow:

Develop continuum of care partners. Some leaders are establishing relationships with retail clinics. They provide a source of referrals today; tomorrow they may be part of a new chronic care delivery system. Similarly, leaders are building closer partnerships with home care, skilled nursing and assisted living facilities that can provide a vehicle for managing readmissions and improving throughput of acute care facilities in a volume-based world. Developing partnerships with alternate sites of care and community-based social services provides an enhanced care coordination platform for a future accountable care system.

Eat your own cooking. Many health systems that are embarking on a journey to accountable care and population health are starting that journey with their own employees. Health systems typically have above average health care users (we know too much and we are not nearly as well-behaved as we should be). By starting population health management pilots on the self-insured health system population, any savings goes straight to the bottom line.

Find some new friends. Bridge building is not an amateur activity. The equivalent of highly specialized civil engineers are required to build business models, to develop shared risk partnerships, to monitor and manage revenue cycle management migration, to develop population health infrastructure. In particular, most systems need adult supervision of spreadsheet migration. By that I mean: What exactly do the sources and uses of funds look like for each of the next five years? How do the spreadsheets synch with the unfolding market reality? And how will those spreadsheets be turned into operational performance?

Leaders and boards are wrestling with design and construction of the bridge. It is empowering to know that bridges can be built, and they can be built to last.

Ian Morrison, Ph.D., is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Daily and a member of Speakers Express.

 


 [ME1]Ian – I don’t get what you mean by the first and second curves of volume.

Consumer Engagement

Monday, July 2nd, 2012

“Consumer engagement is a real problem.” You hear that a lot. Doctors bemoan the fact that patients don’t follow their advice and are not engaged in improving their health. Health plans and employers point to a lack of consumer engagement as a key reason health costs are high and the health status of their workers is not improving. Surveys show that few consumers use cost and quality information to select health plans, providers and treatments.

Yet there is broad agreement that we are going to see a bigger role for consumers in health care in the future, whether it be individuals buying insurance though health insurance exchanges under Obamacare, or seniors buying Medicare plans through an exchange under Ryancare.

If we expect consumers to play a bigger role in health care and make more sensible decisions about their own health and the health care services they consume, then we should take some time to figure out why consumer engagement isn’t working.

You’d Think…..

In theory, consumer engagement should be improved by having a rich environment of information and incentives. American health care is awash with consumer incentives: We pay more out of pocket for health care than residents of any other country, we have large and growing deductibles and co-payments as well as elaborate cost-sharing arrangements (with more to come) in tiered formularies, skinny networks, reference pricing schemes, and so forth. Similarly, we have an entire industry of stars and bars: vendors who produce ratings and rankings of hospitals and doctors, some based on reported quality metrics and others based on organized slander, rumor and patient venting. Yet despite all the information and incentives we consumers remain disengaged. Here are some reasons:

Complexity. In other industries, consumers are readily engaged by simple, easy-to-use products and services. We are distracted by our iPhones to the point where we bump into each other in the street. The iPhone is a brilliant, complex, almost mystical device that is astoundingly simple and intuitive to use. Health care is the complete reverse of an iPhone: It makes seemingly simple things complex. In particular, health insurance is complex and becoming more so; the user interfaces are impossible to navigate, and the language and terminology impenetrable. Even Medicare (a relatively simple form of health insurance) is virtually impossible to navigate. My wife signed up for Medicare last month; after hours on the phone with Medicare agents, she stopped them at Part D worried that it went all the way to Part Z.

Confusion. Health care is not only complex but confusing and even contradictory. Is a mammogram, a PSA test, high good cholesterol, baby aspirin or a colonoscopy a good thing for me? Are three stents better than two? Does it matter which type of artificial hip I get? These are all simple questions with rapidly changing, equivocal answers depending on age and the vagaries of the latest scientific findings. Similarly, we have too many choices of plan options and insurance schemes which behavioral economists argue lead to sub-optimal choices for individuals and for society.

Gotcha. While there are enormous financial consequences of consumers’ decisions, most of these financial effects are felt as a gigantic “gotcha” after the event. Patients get shockingly high bills long after the costly decisions are made and the service delivered. Just poll your friends and family and they will regale you with stories of mysteriously large bills received long after the care happened, bills that are full of obscure mathematics justifying patient responsibility. Oh, and when providers try to make patients pay up front, they get vilified in the press as was the case with a recent front-page story about Fairview Health System in Minneapolis hiring Accretive Health to manage revenue cycle in their ER. When providers get proactive on collecting up front, they are accused of being overly mercenary.

Exchanges: gotcha on steroids. As readers of this column know, I am generally supportive of health reform, exchanges and the like, but I do have real concerns about the enormous gotcha in the making with health insurance exchanges (if exchanges are still standing by the time you read this). Here’s why. An uninsured family of four at 300 percent of the federal poverty level ($67,000 per year) will have an opportunity (mandate) to purchase a health plan through the exchange. The expected premium for this family for a silver plan (a plan that has an actuarial value of 70 percent, meaning on average patients will be paying for 30 percent of the average costs of care) will be $540 per month after the federal subsidy! As I point out to people, instead, the family could have leased a Cadillac SRX loaded with a premium sound system and leather seats. When these people have a medical event and realize they are going to have to pay a ton of money out of pocket after paying $540 a month, it is the mother of all gotchas: They are going to stiff providers on the bill. Bad debt for providers will soar.

Lack of consequences. There are obvious consequences of bad health habits (you die younger and look awful on the way), and being uninsured can surely lead to bankruptcy, but we don’t have a culture of consequences in American health care. Just today a doctor came up to me and asked “When are patients going to be accountable?” All too often, we patients behave badly (over-consuming food and beverages, under-exercising, and exposing ourselves to way too much stress at work). The American super-sized fast food environment makes it hard to be thin. Sedentary, car-loving and cubicle-based lifestyles aggravate the lack of exercise. And there is no real penalty for lack of engagement and accountability for health. Access to health services is rarely restricted or constrained based on likelihood of compliance. In many countries there is overt or covert clinical triage by age and health status. No, not death panels. But if OR time is scarce, a 50-year-old otherwise healthy male needing a coronary bypass is more likely to make it to the front of the queue than an 80-year-old smoker. Similarly, in Holland if you don’t purchase the mandatory private health insurance, you will still get admitted to the hospital, they just won’t discharge you until you pay your back premiums.

Using familiar platforms. The Internet has enabled a transformation in myriad consumer businesses, and smart phones are similarly transforming consumers’ experience on a mobile basis. Consumers are engaged by websites and apps and can deliver spectacular self-service because the platform is familiar, the user experience is intuitive, the metaphors clear. Health is not only behind because of privacy concerns but has failed to leverage existing platforms. My 27-year-old son waited five hours for an urgent care dermatological examination at a prestigious academic medical center. “Why can’t there be something like Open Table?” he asked. “Why not just use Open Table,” I replied. Seriously, why not? And Facebook for follow-up after readmissions, and Google docs for electronic interchange, and Zagat for hospitals and so on. And please don’t roll your eyes and say HIPPA. I am on record for a decade saying: “Ignore HIPPA and do the jail time, it’s easier.”

Getting Consumers Engaged

So maybe we now have some clues on how to engage consumers:

KISS — keep it simple, stupid. This is good advice. Reduce complexity by sloganeering and making things clear: good choice, bad choice. Eat this, not that. There will be a $1,000 impact if you do Plan A, a $100 impact if you do Plan B.

Presume engagement. Increasingly, self-insured employers are turning up the heat on consumer engagement. For example, they offer automatic enrollment in disease management programs if certain clinical thresholds are reached; increased premiums if health behaviors are not improved. A number of employers such as Safeway are experimenting with making health practices such as flu shots mandatory.

Learn from consumer-oriented companies. Consumers are engaged by goods and services that solve their problems: Apple, Starbucks, Expedia, Amazon and Costco can teach us the many ways that consumers can be delighted, remain loyal and stay engaged. Familiar platforms can be applied to problems. If you can use an iPhone, you can use an iPad.

Make the right thing easy. Health care needs to make it easy for consumers to do the right thing. Instead we throw curveballs, we don’t stay open during the hours when consumers want to use our services, then we complain when the patients turn up at the emergency room.

The power of brand. Consumers are influenced powerfully by great brands. We have some great brands in health care — Mayo Clinic and Blue Cross come to mind — but we need more. In many industries brand power is sufficient to engage consumers and move markets. Health care must learn to use the power of brands.

As consumers are asked to make more crucial choices about their health and health care, consumer engagement will become an ever more critical competency for health care providers, payers and suppliers. Get engaged.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Daily.

 

Massively Coordinated Care

Wednesday, May 2nd, 2012

The transformation of American healthcare delivery is on its way, and it is not going back.  Health systems are integrating with their physicians to create new clinical platforms capable of delivering higher value and greater accountability of performance.  More and more leaders are anticipating a future with real incentives to maintain the health of populations rather than just provide services to the very sick.  While we are not in this future quite yet, we are anticipating it and preparing to meet it.

Heavy users, usually those with multiple chronic conditions, are a key target of the healthcare transformation that is underway, because heavy users contribute most to the high cost of healthcare.  I call it the 5/50 Problem:  in any insurance pool the sickest 5% of patients account for 50% of the costs, typically those are patients who have multiple chronic conditions, or have cancer or major trauma.

In terms of identifying and managing these patients, we are beginning to understand about Hot Spots (geographic concentration of heavy users in assisted living facilities and nursing homes, and those residential areas with extreme poverty and multiple social and economic deprivation).  We also have increasing evidence of the effectiveness of medical home models and improved chronic care management techniques targeted at these patients. But we underestimate the degree to which the transformation of care must extend beyond medical care to social services, transportation, self-care and community based support.

At the other extreme of the utilization curve, we are seeing a renewed interest in wellness. prevention, and health promotion.  The aroma of capitation reignites health system leaders appetite for investing in health promotion, wellness and even public health initiatives, but our focus here is on the heavy users.

The field is moving and innovations are on the way to make further gains if health reform goes forward as planned and we stay the course on payment reform and the redesign of the delivery system.  Big data meets new thinking may be the key to unlocking this innovation and creating Massively Coordinated Care.

Big Data

Big Data is a hot new buzzword that refers to the massive datasets that are generated by all the activity in an increasingly digital world.  Facebook’s nearly billion users generate untold terabytes of “Wassups” every single day.  Similarly, in healthcare we are throwing off big data as we increasingly digitize the healthcare system.  One analyst estimated that in 2011 alone, healthcare will generate 150 exabytes of information (by my calculation that is the equivalent to 6 million times all of the published works in the Library of Congress).

Global consulting players and industry gurus such as McKinsey and IBM are talking up Big Data, big time.  McKinsey, for example, estimated that big data could create $300 billion in value by reducing health spending by 8%.  They argued that Big Data adds value to industries in five ways:

  • Makes information transparent and usable faster
  • Enables better performance measurement through digital capture
  • Allows finer grain segmentation
  • Improves business analytics and decision support
  • Enables new products and services

All of these changes are plausible in healthcare and we should welcome them, particularly if they are applied to the challenge of predicting, analyzing, segmenting, treating and coordinating the care of the heavy users of healthcare.

Big Data and the processing power of massive computer’s like IBM’s Watson, can help sort through tough analytical problems and provide guidance and support, maybe even replicating at scale and at speed the really tough knowledge work of clinical-decision making for those patients with multiple chronic conditions.

A good example of how Big data can be put to good use in the service of Accountable Care is the excellent recent piece by fellow columnist John Glaser on the Six  Key Technologies to Support Accountable Care.

(http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=8910003663)

John Glaser describes a set of financial and clinical smartware applied across the continuum of care to improve the targeting, treatment, engagement, coordination, follow-up and payment for a transformed accountable care system.  Such technologies are dependent on Big Data to feed them.

Similarly, large health plans such as Aetna amd Optum (Part of United Healthcare Group) and others are providing analytics and decision support tools to patients, providers and purchasers alike that rely on deep insights that only Big Data can provide.  These tools can help target and coordinate care.

New Thinking Beyond Medical Care

While Big Data can help us focus on the right answer for the right patients and support the institutional transformation to more coordinated and accountable care, perhaps a more important source of innovation will come when we change our mindset on how best to frame the problem of heavy users and the care they need.  Maybe medical care is not the only answer.

I have been particularly impressed by the CareMore story.  A little medical group in California that focused on multiply co-morbid elderly patients enrolled in a Medicare Advantage model.  CareMore does what the name suggest:  they do indeed care more intensively for the patients they consider at risk, and they have very sophisticated and systematic practices for anticipating the needs and problems of these vulnerable patients and intervene medically with MORE CARE before the seriously expensive acute care episodes ever happen.  But CareMore’s reputation and performance was not just built on execution of this medical care strategy, but their willingness to open their thinking to include transportation, fitness classes, concierge services and building the trust and customer intimacy that is more the hallmark of an exclusive retail business than a healthcare provider.

Many of the great innovations in managing heavy users will come from coordinated strategies involving community and social service resources.  (We should not be surprised by this, after all this is what Dr. Ed Wagner’s Chronic Care Model, arguably the fountainhead of coordinated care and medical homes, called for in the first place).

Here is one example of what I mean.  On a recent visit to a community in the Central Valley of California, my wife and I happened to be on a tour of medical Hot Spots that had been identified by an earnest young assistant city manager, after he was exposed to and inspired by, a TV documentary of Atul Gwande’s descriptions of Hot Spots in Camden New Jersey.

The City manager (armed only with little data on 911 medical calls to the Fire Department) had identified about a dozen Hot Spots in his city that accounted for a significant part of the 8,000 Fire Department Emergency call outs at a cost of $4,000 each.  One major Hot Spot was an assisted living facility whose idea of assisted living seemed to be to call the fire department for assistance when patients had any sign of trouble.  Similarly, we toured Hot Spots where fire trucks became taxis, where asthma outbreaks were in apartments that violated building codes, and so on.  When my wife, (an ex ER nurse and systems analyst) asked the question:  “The fire department went out on 8,000 medical emergencies, how many fires did you have?”  The answer came back, “10”.

One valiant assistant city manager, has begun to identify how simple, non-medical, non-healthcare interventions like seniors transportation services, cooperation with and support of landlords on mold remediation, on job counseling and social service support programs, could save millions of firefighting resources.  He doesn’t have access to the records of Medcaid, Medicare, and the City’s hospitals and clinics who incurred the costs and had the unpaid or underpaid bills that resulted from the ER visits, many of which were true emergencies I am sure, but many of which were not.

If we meet people in their lives, not just in our facilities. If we focus particularly on poor people, sick people, the disabled, the mentally ill and the economically vulnerable.  If we meet them then and there with what they need, maybe we can avoid massive, redundant, medical costs born of systems failure.

If we can apply sophisticated analytics and Big Data to this cause, then maybe we can have Massively Coordinated Care, that is better for the heavy users, more effective, more humane and much, much less expensive, as Care More has shown.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Daily and a member of Speakers Express.

 

The Half Life of Healthcare: Understanding the Velocity of Change

Friday, March 2nd, 2012

The key drivers of healthcare have different rates of change.  Coverage expansion is on a two to three year timeline.  Reimbursement reform is on a ten year timeline.  Cultural transformation of institutions is on a thirty year timeline.  Yet there are many areas of healthcare on a short fuse.  Budget cuts at the federal level can happen almost immediately.  Network changes or contracts can change in a year.  Some new technologies can have immediate impacts, others take decades to reach full deployment.  Understanding the different half lives of healthcare is crucial to preparing for the future.  Too many actors conflate these forces into a blur of change moving at the same speed.  That can cause big strategic problems.

Understanding the Velocity of Change

Half Life is a term from radioactive physics referring to the time it takes for a substance to decay by half, it is the rate of change in radioactive decay.  Similarly in healthcare, different dimensions of the future move at different rates.  We may understand this intellectually, but as actors in an unfolding game, we have difficulty in judging the pace of change. My old mentor, Roy Amara who headed the Institute for the Future for twenty years taught us a basic principle about the future that we codified as Amara’s Law:  “There is a natural human tendency to overestimate the impact of phenomena in the sort run, and underestimate it, in the long run.”

Another eminent IFTF colleague, Paul Saffo, had a brilliant insight about the pace of the unfolding future:  “Never confuse a clear view with a short distance.”  A phenomenon I dubbed “premature extrapolation”.

We imagine many important changes are close, even though logic suggests that they might move slower than you think.   For example, the aging of the baby boom as a driver of healthcare utilization has been hyped for as long as I have been in the futures business, which is over thirty years.  And yet the very first baby boomers, those born in 1947, only became eligible for Medicare this year!  We have been so eager to anticipate their arrival in Medicare, this particular major demographic trend is old news.

We are eager to see positive changes happen fast and celebrate their progress even though it may be imperceptibly slow.  One of my basic principles in analyzing future trends is that if something is going to be a big deal in the future, it has to start sometime.  And show meaningful progress year over year.

While we have a tendency to overestimate in the short run and underestimate in the long run, that is not the whole story.  Some things can move faster than you think.  Look at the sting of the recession, and its impact on credit availability for hospitals, and on slowing demand for elective healthcare services; or a change in the law that allowed coverage of 26 year olds.  And there may be more rude short term shocks in our future, that we will highlight in a moment.

So it is important to sort out the rate of change for each of the factors that are causing changes in healthcare and weave them into a plausible unfolding reality.

 

Short Half Life

Some drivers of change can happen pretty quickly (in the next 1-2 years):

  • Budget Cuts.  Perhaps the fastest change that could happen in healthcare is for significant cuts in public programs, particularly Medicare and Medicaid, within the next 12-24 months.  The deficits at both federal and state levels (even though states cannot really run them) may force significant action, much in the way that austerity measures have swept the European economies.  Piled on top of the existing reimbursement cuts in PPACA means this sting could hit the field before the benefits of expanded coverage take hold.
  • Cost Shifting.  A related impact is the immediate potential for providers to cost shift:  make up for the shortfall in public payment by increasing prices to commercial payers.  In turn, employers can simply cost shift (or as they call it cost share) with their employees.  This has been the game for the last decade and has meant that the typical American household is in a PPO with a $1,000 family deductible.
  • Lansky’s Short Fuse.  My friend Dr. David Lansky who leads the Pacific Business Group on Health, gave me the basic idea for this column when he told me that he believes that employers now have a short fuse.  I took this to mean that employers’ patience with inexorably rising costs and cost shifting is wearing pretty thin.  It also explains the speculation that employers may prefer a future where they are off the hook for healthcare, and send their employees to the new health insurance exchanges.  (I would argue that employer exit on a massive scale has a longer half life, maybe in 2018 when exchanges are up and running and the Cadillac Tax kicks in, because by then everyone will be driving Cadillacs).
  • Network Contract Changes.  Large employers can make big changes in their employee benefits plans two years out.  Small employers can switch insurers each year.  Providers can find themselves cut out in a skinny network in a year or two.  I have run into a significant number of hospitals, large and small, caught flat-footed by a sudden change in their preferred provider status as payers (plans and large employers in concert) move to skinny networks.
  • Mergers and Acquisitions.  Hospital leaders can merge institutions on short notice, and buy medical groups even faster.  Witness the rapid contractual integration of hospitals and physicians taking place across the country.  (I say contractual integration because that has a short half life, in contrast to true clinical integration and the related cultural shift toward accountability and quality which may take decades to fully accomplish).
  • Supreme Court Decisions.  The Supreme Court will rule in the summer whether PPACA is constitutional and no matter what the ruling it will have a big and immediate impact.  At the extremes, if PPACA is overturned anticipate less coverage expansion in the future (although the delivery system changes underway will likely continue), at the other extreme if the law is upheld, states like Florida will have to scramble to set up a health insurance exchange in six months, (that will be fun to watch).

 

Medium Half Life

Some aspects of change have a half life that is two to five years out:

  • Coverage Expansion. The major provisions for coverage expansion happen in 2014, a deadline that may drag out if states are unprepared to operate health insurance exchanges or rapidly expand Medicaid coverage.
  • Meaningful Use.  Meaningful use of computers got a major stimulus (pardon the pun) and relatively rapid progress is being made in deploying electronic health records.  The vision of interoperability enabled through robust Health Information Exchanges may take a lot longer.
  • Value Based Purchasing.  AHA Analysts estimate that approximately 9 percent of Medicare reimbursement to hospitals will be at risk based on quality by 2015, based on the value purchasing and readmission reimbursement provisions on the books.
  • Large Group Practice Formation.  Large multi-specialty group practices will be formed through a variety of models over the next five years.  But, we should learn from all the high functioning medical groups that have taken 30 years to become an overnight success.  Culture takes time.

Long Half Life

Some changes take a very long time, perhaps a decade or more:

  • Reimbursement reform.  Some reimbursement reforms like DRGs can be implemented to make significant short term changes in incentives that have a major impact.  The proposed reimbursement reforms in both public and private sectors are moving slowly (but inexorably) toward a new future.  Pilots must take take off and become mainstream.  That usually takes time.
  • Cultural transformation.  Some organizations like Virginia-Mason in Seattle have shown that leadership and commitment can change the culture, but these are exceptions.  Most high-performing cultures take a long time to build.  Patience, persistence and passion are needed to overcome the cultural inertia in most organizations.
  • Medical Education Reform.  Medical education needs to change to reinforce the broader transformation agenda, but it takes a very long time to affect the stock and flow of doctors and other advanced practitioners.  Most of the people practicing 10 years from now are practicing today (do the math).  And academic medicine is not often described as nimble, market sensitive, and change oriented.  There are notable exceptions such as UCLA who are pursuing a rapid and aggressive innovation agenda, but in the main it is hard to turn the academic medicine battleship.

Half Life in Action

Here are some key examples of the half life phenomenon to watch for:

  • Medicare.  The future of Medicare will be an enormous issue in an election year.  Medicare must be changed, but how much, how fast, and for whom?  Proposals to shift Medicare to a voucher plan for those who are 55 or younger today, is a long half life proposal.  (It won’t save in the short run but will have big impacts in the long run). Cutting the Medicare budget in 2013, has a short half life.  Bending the trend through reimbursement and delivery reform could take a very long time, maybe forever.
  • ACOs.  Accountable care is a megatrend, not necessarily the formal CMS pilot programs, but the general idea that integrated systems of care are being formed to provide accountable care to the population they serve.  You can buy the doctors tomorrow, but managing the half-life of payment reform, and business model migration is tricky stuff.
  • Health Information Technology Infrastructure.  We are seeing relatively rapid deployment of HIT and real progress towards meaningful use.  But we must keep the pressure on to build an infrastructure to support the vision of a high performing health system.  Finding faster pathways to interoperability will be required.

My advice to leaders is to discipline yourself to parse the future and use the half life concept to understand the pace of each of the individual elements of change.  If you conflate the future and see all the big changes as clear and close, you may have trouble in developing a sensible strategy, sequenced to meet the unfolding future.   Conversely, try to find ways to shorten the half life of change for elements such as clinical redesign and cultural transformation that are key to meaningful change.  I am very encouraged, because on my travels, I see front line providers stepping up to change clinical processes to make them better, safer, and high performing and they are doing this rapidly.  The best way to have a better future is speed up the good parts.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Daily and a member of Speakers Express.

 

Reinventing Rural Health

Monday, January 2nd, 2012

America is a big country. Every summer vacation with my family, I drive exactly 1,000 miles each way from San Francisco to Northern Idaho; I don’t go through another city. If you take a 1,000-mile drive across Europe, you not only have crossed 10 countries, you are now in Asia.

So, as a geography major who has been to just about every state (and a majority of them in the last year alone), I understand that America is one big piece of real estate, and a lot of people, almost 20 percent, live in rural areas. But, even in states like Indiana, Nebraska, Kansas, Oklahoma or Texas, most people live within 90 miles of a pretty fancy hospital, and even more live within 20 miles of a Walmart (which, we are told, may well be a key health care provider in the future).

Critical Access

Part of the reason so many rural communities are relatively accessible to major hospitals is that we built the hospitals before we built the freeways.

However, according to Census classifications, a full 60 percent of rural residents live in rural areas that are adjacent to urban areas, while only 10 percent of rural residents (some 2 percent of the total population) live in remote areas with small populations.

Rural hospitals account for about a third of the nation’s hospitals but only about 12 percent of national hospital spending.

At the core of our national policy toward rural health is financial support for critical access hospitals (CAH). There are 1,327 CAHs across the country, and they must meet three core criteria (among many other complex regulatory provisions), according to the Department of Health and Human Services:

  • They must have an acute care average length of stay of 96 hours or less.
  • They must have 25 acute care beds or less.
  • They must be 35 miles or more from another hospital (or 15 miles from another hospital in mountainous terrains or on secondary roads).

This latter distance provision was debated during super committee deliberations when proposals were floated to change the distance criteria, potentially reducing the number of CAHs. In a lot of states like Kansas, Indiana and Nebraska, that change would dramatically reduce the numbers of hospitals designated as critical access. When I spoke to hospital associations in those states in the last few months and asked whether a 20-mile change in the distance provisions would affect their designation, a significant minority of the audience raised their hands. (By the way, when I asked, “How many of you are within 25 miles of a Walmart?” almost everyone raised a hand.)

In addition, because of the previous provisions in some states that governors were able to designate critical access facilities using an “any necessary provider rule,” you ended up with CAHs that are quite close together. In counties in rural heartland states such as Iowa and Indiana (with not many mountains), you can find two, three or even four CAHS in the same relatively small county or within a stone’s throw of the county line.

The number of counties per 1,000 square miles and per 100,000 population also increases the number of CAHs that are geographically proximal, because so many hospitals built in the Hill-Burton era were county based. To give perspective on this phenomenon, take three large states with large populations and large land area: California, New York and Florida. California has 58 counties, New York has 57 counties while Florida has 67. Compare that with Texas (254), Georgia (159), Kentucky (120), Missouri (115), Kansas (105) and Illinois (102).

There are other relatively small population states such as Iowa, Indiana and Nebraska that have more than 90 counties each. I understand that these county lines were derived by natural boundaries based on how far you could ride a horse in a day in the 18th century. But they create a density of local government and health care infrastructure that varies enormously across the country, and it may be fuel for unneeded duplication of facilities and services.

But the really critical thing to understand about critical access hospitals is that they operate under a cost-based system of reimbursement. This seems to be a model that is inconsistent with the trends of the time. As Todd Linden, CEO of Grinnell Regional Medical Center in Iowa and a national thought leader in rural health care, told me in an interview: “Being a cost-based component of a health system that is moving overall to value-based reimbursement is going to be like trying to put a square peg in a round hole.” He’s concerned that CAHs might get left out of accountable health development plans or shared savings models because cost-based payment doesn’t necessarily lead to quality or efficiency.

Grinnell’s hospital is a tweener at around 50 beds, so it is too big to be a critical access hospital with cost-based reimbursement, but it has all the challenges of any rural health facility, such as heavy Medicare and Medicaid dependency.

Critical Community Resource

While many rural health facilities may be sustained economically by cost-based reimbursement, they are in turn a major economic engine, if not the economic engine of rural America. Hospitals are the largest employer (generally after local government) in most small towns. By the way, the same is true in very big cities, but at least in many large cities there are some other employers of scale. In smaller communities, hospitals may be the sole economic engine, and both a platform for and symbol of continued community cohesion. They are important not only for the health care services they deliver, but for maintaining the overall economic vitality and viability of the communities they serve.

Rural Health Challenges

Rural health is tough to manage, from both a policy and practical point of view, for many reasons. UnitedHealth Group (in conjunction with new survey research from my colleagues at Harris Interactive) recently produced a fantastic fact-based review of rural health, which I urge you all to read as a deep dive into rural health. (See “Modernizing Rural Health Care” [Working Paper 6], published in July 2011 by the UnitedHealth Center for Health Reform & Modernization.) Drawing on that paper and other resources, such as the Institute of Medicine’s 2005 report on the issue and the ongoing great work of the Rural Policy Research Institute, the picture is pretty clear, and the challenges for rural health are great:

Dominated by public coverage. Rural health is more dependent on Medicare and Medicaid coverage and has lower levels of commercial insurance and a resultant higher level of uninsured.

Higher health needs. Rural populations tend to be older and in poorer health, with higher rates of obesity and poor health habits, such as smoking. In addition, they have a surprisingly high set of needs in terms of drug abuse, according to the United report. (This squares with my anecdotal evidence: I can’t tell you the number of relatively rural states I have visited that claim to be the crystal meth capital of America. I Googled this question and apparently there is no clear winner: It depends on which denominator you use. Suffice it to say that crystal meth is a big problem everywhere, including the rural heartland.)

Difficulty attracting providers, particularly specialists. A full 12 million Americans live in areas designated as primary care shortage areas (defined as having less than 33 primary care physicians per 100,000 population). Of that 12 million, 5 million are living in rural areas. (Presumably, the residual is found in underserved urban areas.)

It is difficult to recruit new physicians to rural areas. Most new doctors want to be close to big cities with Starbucks and symphonies. They want to eat tofu and drink soy macchiatos, not watch soy grow. Even premium pay for rural service won’t overcome the tendency of young physicians to pick urban areas and employed practice environments. The big question is who will replace the current generation of rural primary care physicians and good all-round generalists in the surgical and medical specialties. As Grinnell’s Todd Linden told me: “I am trying to hire a good generalist orthopedics specialist who can handle a wide variety of cases; they don’t exist anymore.”

Sub-optimal in scale, both clinically and financially. While cost-based reimbursement can cover a multitude of operational sins and inefficiencies, it is pretty clear that rural health violates the basic economic principles of economies of scale and scope. It also violates the well-established health services research linking volume to outcome.

Similarly, there are basic operations research principles that show that the smaller the institution, the lower the occupancy rate. (A CEO of a large Midwestern health system that I visited last week had just toured a critical access hospital in his system that had a census of zero all that week; now that’s low occupancy.) Conversely, cost-based reimbursement can lead to overbuilding and to small institutions acquiring technologies (such as robotic surgery equipment or advanced imaging) that are arguably too advanced for the setting.

Quality of care differentials. The UnitedHealth working paper using published scientific evidence, Harris Interactive surveys of doctors and patients, and claims data analysis paints an overall picture of health care quality (both perceived and measured) to be slightly lower in rural areas compared with urban areas overall.

For example, the analysis of quality performance for the 256 hospital referral regions (HRRs) for which there were sufficient data found that 75 percent of HRRs had rural quality lower than urban quality, 20 percent had the same quality, and only 5 percent of HRRs had rural quality that was higher than urban quality. This last group of relatively high-performing rural HRRs tends to be in regions where larger integrated systems of care have been developed, such as in the Upper Midwest.

Aging plant and equipment. Half of CAHs are more than 40 years old. The aging physical plant of these Hill-Burton institutions means that renovation, rebuilding or repurposing is high on the strategic agenda of hundreds, if not thousands, of facilities. (Hill-Burton was a 1946 act that provided funding and support for the upgrading of hospitals, particularly in rural areas.)

Measuring quality with small numbers. Quality measurement and reporting is challenging in rural health because of the small number problem, where it is difficult to have statistically reliable measures of performance because the number of events is low. This is a problem generally in health care as we drive to finer granularity of measurement to the individual provider level. The issue is even more challenging in the case of rural health because of low volumes and dispersed populations.

The Helping Hand of Health Reform

The Patient Protection and Affordable Care Act provides assistance to rural health care in a number of ways, including coverage expansion through exchanges to an estimated 5 million additional rural residents, expansion of Medicaid, increases in rural health funding for rural health clinics, support for telehealth and meaningful use of electronic health records, training grants for rural providers, and differential payments for primary care.

Rural health policy experts seem to advocate a mini version of national health care delivery reform (with the addition of telehealth initiatives). This version would encourage a team-based primary care focus through patient-centered medical homes. (To an outsider such as me, however, it seems like that is what country doctors have been doing for the last 100 years.

Reinvention Options

As we redesign the overall health care delivery system from volume to value, we raise the question of what happens to rural health care. While the challenges described here are real, in my travels I detect a growing openness to reinvention of rural health among community leaders and hospital CEOs across the country.

Here are some examples of promising approaches:

Regional integrated systems. Large urban-based health systems in primarily rural states are building significant scale by bringing regional facilities into systems of care through outright ownership of facilities, or through formal and informal regional networks of affiliation. Examples include Avera Health, a network of hospitals, family care practices and specialty clinics located in South Dakota, Minnesota, Iowa and Nebraska that have created sophisticated e-health links to their more remote partners.

Similarly, while Mayo Clinic is a global brand, less well known is the Mayo Clinic Health System, which describes itself as “a family of clinics, hospitals and health care facilities serving 70 communities in Minnesota, Iowa and Wisconsin.” “Mayo Clinic Health System,” it maintains, “links the expertise of Mayo Clinic with health care providers (including 17 owned hospitals) in local communities to offer patients a full spectrum of health care options. Patients receive quality health care at their local clinic or hospital, and, when needed, can receive highly specialized care at Mayo Clinic.” More and more such regional systems like these will emerge, but not all through direct ownership and acquisition.

High-tech rural ambulatory centers. Many of these new regional systems will repurpose individual facilities into regionalized hub-and-spoke sub-networks (analogous to the transformation in the airline business). Many rural hospitals may have a better long-term future for the institution and the community as a high-tech ambulatory care hub with limited short-stay capacity and a heli-pad on the roof or across the street.

Rural community-based continuum of care centers for the chronically ill. To a larger extent, the longstanding, valid and important role that rural hospitals have played is as a center for managing the aging rural population with chronic illness. In many rural communities, aging parents remain down on the farm while their children Skype them from L.A. or New York. Preserving the local capacity to have older patients “age in place” with the appropriate level of support for their chronic care needs seems an incredibly valuable asset, nationally and locally.

On a trip to Ireland last year, I was deeply struck by the potential for aging in place as an economic base for rural communities. We drove through fishing villages that clearly have not many farmers or fishermen left, but have seemingly thriving long-term care and assisted living facilities that, as far as I could determine, were the sole economic base for miles around.

Referral platforms. Many urban-based hospitals, faced with tightening appropriateness of care standards and a tough economy for elective procedures, are looking to expand their regional referral footprint. I joked with a large Midwestern system recently that, if you added all the growth aspirations of every adjacent regional hospital system in the Midwest, you would have to bring in the entire population of China for them all to come true. (It’s a wee bit of an exaggeration but directionally correct.) The result will be that, if rural facilities try to remain independent, they may have their economic base eroded by expanding urban-based regional systems that seek to maintain the economic viability of their own high-tech core operations.

A High-Tech Approach to Rural Health Care

Rural communities have as much right to high quality health care as the rest of us. But the answer can’t simply be providing sufficient cost-based reimbursement to keep all systems doing what they are doing, especially if they are under-scale for true quality care. In my view, the solutions will come through a reinvention of rural health care delivery, including:

  • imaginative use of contemporary information and communications technology;
  • regionalized quality improvement initiatives; and
  • rationalized deployment of clinical technology and human resources.

I am confident that regional health system leaders and their rural partners will figure all this out. While the politics of reinvention are extremely difficult, both nationally and locally, rural health leaders (board members, rural hospital CEOs and the community at large) are passionate and committed to doing whatever it takes to serve their rural communities.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Daily and a member of Speakers Express.

The Spot Market

Wednesday, November 2nd, 2011

We are all very busy building massive accountable care behemoths to compete in the new future. Like medieval fortresses, with lords, knights and serfs aligned under a common flag, these new organizations will dominate the health landscape of the future. Or will they?

A counter trend is one in which payers (employers and health plans) are trying to unlock the value inside these massive fortresses, by identifying a subset of the knights and serfs, who are top quadrant (better and cheaper) than the rest of the organization, and encouraging patients to visit only them. Similarly, new organizations are being formed with health plans in direct partnership with physicians that are prepared to contract for the expensive services of hospitals and specialist providers for (the reduced volume of) specialty services, on an as-needed basis. Welcome to the spot market.

The great Wikipedia, from whence all true knowledge comes, defines a spot market as “a public financial market, in which financial instruments or commodities are traded for immediate delivery.” Willing buyers find willing sellers in real time. If supply exceeds demand, prices go down; if demand exceeds supply, prices go up.

For spot markets to function there must be transparency, real-time information on prices and motivated buyers and sellers who are willing to trade. Doesn’t sound much like health care, does it?

But wait, there are a number of forces that are coming together to create change toward a spot market for hospital and specialty services. These trends may have a big impact on providers and may challenge the movement toward massive accountable care systems.

The Reinvigoration of Skinny Networks

The idea of tiered networks is certainly not new. What is giving the high-performance network new life is the fact that health care costs (premiums and out-of-pocket costs) are now so high that consumers are willing to make real trade-offs between choice and costs.

My colleagues at Harris Interactive recently conducted an elaborate consumer trade-off survey to identify what consumers value most and what they are prepared to trade off to get it. The survey showed that consumers’ highest priorities were (in order): low monthly premiums, high technology such as MRIs (and they see no irony in those two top priorities together), keeping dependents on their plan, maintaining their current physicians, and access to inexpensive generic drugs.

What are consumers prepared to give up? The will give up access to prestigious academic institutions (throwing Cedars, Stanford and the Mass General under the bus in the process) and they will, on balance, give up choice of hospitals and, to a lesser extent, choice of specialists. (The rank order of these preferences did not change across almost all demographic segments including those consumers with chronic illness).

We interpret this survey as showing a greater willingness of consumers (even consumers with high health care needs) to accept skinnier networks than the market is currently delivering. In particular, the current high-performance offerings by health plans have been about only about 3 percent cheaper than the norm. What consumers really want, and what variation research tells us, is that a skinny network with only the high-performing providers could be 30 percent cheaper. Advice to health plans: If you build it, they will come.

Mining Variation

A second major trend favoring the creation of spot markets is the growing interest in variation on an all-payer basis. The Dartmouth Atlas work has shown us for 30 years the unwarranted variation in utilization of services for Medicare patients. Provider density (more specialists means more specialty services per capita) and provider preferences are the key drivers of variation. This rich analysis of service variation is being extended to all payer data sets (including commercial insurance claims data) and exposing similar inexplicable variation. For example, Stanford researchers found that the residents of Clearlake, Calif., have 15 times the rate of coronary angioplasty as those in neighboring Sonoma.

In a wonderful newspaper report on the original Stanford study of this phenomenon, journalist Emily Bazar tracked down some Clearlake patients who had stents inserted and had declined the suggestion from local cardiologists to have repeat procedures, even though they were asymptomatic. The patients told their doctors (in effect): “No thanks, Doc, I’m good, I’ve had enough for now. Two’s my limit…” (See “High Rates of Heart Procedures Seen in Clearlake,” San Francisco Chronicle, Sept. 4, 2011, www.sfgate.com.)

But, even more interesting are the new variation analyses using commercial claims data where price information is included. Commercial insurance prices vary much more dramatically than do Medicare reimbursement rates. As a result, formerly inexpensive geographic areas seen through the eyes of Medicare-only analyses (such as the Dartmouth Atlas) become expensive areas when commercial prices are considered.

So, for example, recent total cost analysis of medical groups in Northern California versus Southern California (conducted by the Integrated Healthcare Association as part of its Pay for Performance Initiatives) shows that Northern California has lower utilization of services but higher prices. Conversely, Southern California has higher utilization of services but lower prices. On balance, Northern California is more expensive: Price trumps quantity. It is the up to 10-fold variation in pricing of specialty services such as imaging, colonoscopies and surgical interventions that is fueling renewed interest in spot market initiatives such as reference pricing.

Reference Pricing Schemes

Reference pricing is a model of reimbursement in which payers pay a fixed price for a service and consumers are at risk for the total costs of care beyond that fixed price. Your choice whether you go to the more expensive provider.

A truly fine health care journalist, Julie Appleby of Kaiser Health News, in collaboration with USA Today, scooped me on reference pricing models in her article of Sept. 22, 2011, titled “Companies Steering Workers to Lower Priced Medical Care.” (Honest, check with my editor; I had this idea in the works for a while for this column.) I will not repeat her great points and the examples she cites, because I agree 100 percent with what she found are the important examples of the phenomenon. Just go read it at www.kaiserhealthnews.org. But, let me just reiterate the key message: Reference pricing can have a powerful effect on providers because it is a purchasing method that engages consumers with meaningful information and incentives at the moment consumers have to choose their location of care decisions.

For example, if you the California Public Employees’ Retirement System member want to pick one of the 45 high-quality hospitals in California that have negotiated a fixed-hospitalization payment of $30,000, there will be no additional costs for your knee replacement. But if you select one of the other 400 odd places in California that do it but do not participate in the plan, you the patient pay the entire difference in cost (maybe $20,000 to 30,000)! That will focus the mind. Lest you say “That’s horrible, patients are being effectively bribed to have hip and knee replacements in some Shell Station in Oakland,” let me tell you that Cedars-Sinai in the south and Stanford in the north are participating hospitals.

Now how many knees do CalPERS members have? Apparently, on average two each, but the annual replacement rates for the entire population is not a huge number. More important than the actual impact on volume is the signal it sends to providers: High price-setter beware. It is but a beginning, a shot over the bow.

Registries

As the idea of reference pricing spreads to other frequent high-cost elective services such as maternity care, orthopedic interventions of all types, colonoscopies and imaging studies, more and more science-based evidence will help patients and providers make better decisions. The creation of registries (large databases that capture information on clinical performance, including patient reported outcome measures) can help identify the high-performing method of care and the providers who deliver it. Cardiology has led the way, but orthopedics, gastroenterology and even oncology will follow.

New evidence will come from the fruits of the research investments being made in comparative effectiveness. While the enabling legislation forbids the use of comparative effectiveness research in making reimbursement decisions in public programs, there is nothing to stop private payers steering patients to high-performing providers, and they would be nuts not to do it.

Leveraged Group Practice

New multispecialty group models may provide a further boost to these spot market trends. For example, Kaiser’s Mid-Atlantic Permanente Medical Group under the leadership of Dr. Bernadette Loftus, has recently rocketed to the top of the charts in National Committee on Quality Assurance ratings. Unlike the mother ship of Permanente in California, Kaiser Mid-Atlantic does not have its own hospitals. Instead, it contracts with willing provider partners for those services.

Kaiser Mid-Atlantic is embarking on a new strategy of medical center hubs that combine sophisticated diagnostic and outpatient surgical services with the capacity to have up to 23-hour lengths of stay. These models could enable Kaiser to internalize an increasing amount of specialty care and may provide them (and others) with a replicable business model in hospital-dominant regions such as the Northeast.

Similarly, Optum Health (the artist formerly known as Ingenix, part of United Health Group) has set the provider world atwitter with its recent purchase of Monarch Health, a very large 2,300-physician IPA in Southern California. The smart people at Optum, in combination with the smart people at Monarch, may very well develop reproducible business models that improve the health of the populations they serve by streamlining care coordination, reducing use of specialty services and hospitalization, and applying business discipline across the revenue cycle. In addition, boutique firms such as Accretive Health are fast-rising stars that bring together HIT, business process and re-engineering assets that can enable provider groups to take risk and produce high clinical and financial performance.

Physician-led accountable care organizations may also provide a new force to reduce demand for hospitalization and specialty services in the Medicare population. While enthusiasm for CMS’s original Shared Savings Program has been underwhelming, we may still see some new entrants who find a way to make a good living by doing less, not more, for fee-for-service Medicare patients. And don’t forget about Medicare Advantage plans that have an even greater impact on demand and that I discussed in a previous column, “Medicare Disadvantage”).

All of these emerging models are not hospital centric, and they could put downward pressure on the overall demand for specialty and hospital services.

Over Capacity

But the greatest potential driver of the spot market may be the emerging overcapacity in health care. It’s true that expanded health care coverage will expand demand for services. And true that we have an aging population, and a seemingly endless appetite for new medical interventions. But Harris surveys of hospital executives reveal an astonishingly high proportion of hospitals planning for expansion (for example 72 percent of hospitals with new construction or renovation plans, 65 percent planning on expanding satellite facilities, and 48 percent adding new surgical or operating facilities). It reminds me of commercial real estate: Every developer thinks his or her office building will sell because tenants will come from the other guy. They can’t all win; it is a zero-sum game.

Many strategy consultants point to the ambitious expansion plans that neighboring competitors have in most markets across the country. The capacity being planned may create over-supply—powerful fuel for a spot market.

Watch This Space

My advice is to watch this trend toward spot markets very closely. A newly released AHA report “Hospitals and Care Systems of the Future” (which flatteringly draws on my Second Curve concept) provides an excellent road map of migrating hospital and health systems from volume to value. But migration toward value, not volume, may also create a perfect environment for spot markets to flourish.

The bottom line: Be high-performing and competitive on costs and quality at the procedure level, the service line level, the enterprise level and the population level, and you will have nothing to worry about.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Daily and a member of Speakers Express.

The Primary Care Problem

Friday, September 2nd, 2011

Every month we edge closer to the future. One of these scenarios will play out: We are getting closer to full-blown implementation of Obamacare by a battered re-elected president and a divided Congress, or we will have Obamacare repealed by Mitt Romney (ironic), or we will be starting over with a clean sheet of paper, step by step, with authentic American solutions (What are these exactly?), perhaps Texas-style. It is going to be fun to watch, regardless.

Meanwhile, hospitals and doctors (particularly primary care and cardiologists) are running toward each other at an astonishing rate, preparing to huddle together for warmth in whatever future we end up in.

As a result, the price of primary care practices is rising rapidly with bidding wars for sophisticated groups leading to valuations approaching 10 times EBITDA (earning before interest and taxes, depreciation and amortization). Bidders include large hospital systems, large health plans and other large medical groups in many markets across the country.

The economic premium currently being enjoyed by primary care practices (larger groups in particular) is well deserved but a relatively recent phenomenon.

It is clear that in the last two decades we did not honor our primary care physicians. This was brought home to me personally in March, when I conducted a strategic retreat for all the CEOs of the provincial medical associations from all the Canadian provinces. (Like most Canadian professional meetings held in March, the meeting was not held in Canada, but in Palm Springs.) I was astonished to learn that primary care doctors in most Canadian provinces earn 50 percent to 100 percent more in net income before taxes than their American counterparts. The same is true in the United Kingdom.

Health Reform and the Surge

Most people believe that whatever happens with the crazy people in Washington, the health care system of the future will have to place a greater emphasis on primary care. Primary care will be even more crucially important if coverage is expanded as PPACA requires.

If health reform and the massive expansion in coverage go ahead as planned we now have some inkling of the challenge. A recent study of the Oregon Medicaid lottery provided a researcher’s dream: a double-blind randomized trial where half of the people in the trial eligible for the expansion in adult Medicaid won the lottery and got the Medicaid card and the other half did not. An exquisite, careful study of the impact of this lottery, conducted by Oregon, MIT and Harvard researchers, showed that insurance coverage indeed matters: Patients with coverage access care more frequently (including preventive care), their financial burden drops and their health status improves. In particular:

“Using a randomized controlled design, the study finds that for uninsured low-income adults, enrollment in Medicaid has the following effects in increasing access to and use of health care after about one year:

  • Insurance increases the likelihood of using outpatient care by 35 percent, using prescription drugs by 15 percent and being admitted to a hospital by 30 percent, but does not seem to have an effect on use of emergency departments.
  • Insurance increases the use of recommended preventive care such as mammograms by 60 percent and cholesterol monitoring by 20 percent.
  • Insurance increases the probability [that] individuals [report having] a regular office or clinic for their primary care by 70 percent and the likelihood that they report having a particular doctor that they usually see by 55 percent.
  • Overall the increased health care use from enrollment in Medicaid [leads to] about a 25 percent increase in annual health care expenditures.”

Similarly, the experience of Massachusetts health reform has been analyzed carefully in the last year and shows strong and continued public support for the program, improved access to care (albeit with some waits for appointments), increased utilization of primary care, and rising total costs that are more attributable to the rising costs of the delivery system than to solely the expansion of coverage.

In California, a recent survey of Californians earning below 200 percent of the federal poverty level conducted by the Blue Shield of California Foundation documented the care experience and expectations of those most affected by proposed health care coverage expansion. In particular, more than half of those low-income Californians were less than “well satisfied” with their current care arrangements, most wanted their own primary caregiver, a majority were expecting improvement from reform and 58 percent were “very or somewhat interested” in changing providers. Now, whether the providers that these lower income folks were planning to go visit will actually take them is a whole other issue. Nevertheless, this was an important research contribution that highlights the potential impact health care reform will have on increasing demand and changing the location of care in the primary care marketplace.

Solving the Primary Care Problem

So where are we with solving the primary care problem? First, we need to define what the problem is. There are three main views of the problem.

The primary care shortage view: There is a mainstream view that we will be short some 40,000 to 60,000 primary care doctors over the next decade, a deficit that could be even higher under health reform. Folks worry that as all the aging internists and PCPs retire in the next decade, we will be unable to reverse the lack of interest in new medical graduates becoming primary care doctors. (If you have the marks, why not go for the big bucks as a specialist?) Suggested remedies include providing subsidies for training; encouraging primary care physicians to stay in rural areas, or treat Medicaid patients, through differential payment; increasing primary care payment rates more broadly; expanding community clinics (such as Federally Qualified Health Centers); providing safe harbors for malpractice; and so forth. I am down with all of this, but the remedies miss the point that even if you do all this you really don’t dramatically alter the total number of physicians in the time frame of health care reform and you do nothing about the productivity of each physician. As an old physician colleague of mine once said to me: “There is only so much doctoring you can do in a day.”

The scope of practice/substitution view: A common view is that the primary care problem can be solved by changes in scope of practice, and the creation of a whole new cadre of nurse practitioners and physician’s assistants. These new professionals take over the bread and butter tasks of primary care physicians, get paid well, and go home at 5:00 p.m. Many organizations, including the integrated system giants like Kaiser, are realizing that simple substitution by physician’s assistants or nurse practitioners is not really that much more cost-effective from a total wage and productivity point of view. And the big issue is that organized medicine ferociously defends against scope-of-practice creep. Awkward! Again, scope of practice changes, and substitution of other professionals is not a quick fix, or a cheap one.

The primary care redesign view: The third view held dear by true believers in delivery system reform (myself included) is that we have to change the way we do what we do if we are going to improve throughput and performance. There are two flavors of this view: 1) the patient-centered medical home (PCMH) and 2) rapid and continuous delivery system innovation. The PCMH folks have their believers, their conferences, their champions and their stars. It is all good stuff and clearly directionally correct. The PCMH believers argue that everyone should have a PCMH and be treated the same way. I don’t think that is feasible or even desirable. We must focus the model on the sub-populations that need the PCMH such as routine diabetic patients, and develop other more appropriate models for other segments such as the ambulatory ICU that was developed for the multiply co-morbid population with high risk of readmission.

As a consequence, I am more persuaded by the writings and teachings of primary care redesign gurus such as Dr. Tom Bodenheimer and colleagues at the University of California San Francisco, Dr. Richard Boemer and colleagues at Harvard Business School, and Dr. Arnie Milstein and colleagues at Stanford University (the creator of the ambulatory ICU concept). They argue for more comprehensive and deep-rooted managerial, systems engineering, reimbursement and policy innovation that will get doctors engaged in developing skills and capacities to manage ever large panels of patients, through multi-disciplinary teams of IT-enabled caregivers (with great system skills and a passion for continuous performance improvement). Big sentence, big task, big work.

This rapid and continuous innovation needs to be encouraged wherever we find it, from integrated care nonprofits to for-profit chains of retail clinics and care centers. We should be agnostic about model designs; instead, we should focus on results in terms of quality and outcomes, costs and patient experience.

What’s a Health System to Do?

My advice for all of you out there running large, ever-growing health systems (especially those systems that are rapidly integrating with their doctors), is as follows:

  • Do the math. You better figure out the latent primary care demand that will be released in the surge of 2014 in your local market. As the Oregon trial shows, when people have a card, they turn up. When they have a new shiny card, provided by Medicaid or the exchanges, and they can now come to you rather than the lower-end guys down the street, they just may.
  • Owning doctors doesn’t make them more productive. Just because you now own the primary care doctors doesn’t increase the number of them in total, and employment doesn’t automatically imply massive improvements in productivity—maybe the reverse.
  • Watch ER utilization closely. In Oregon, the lottery expansion of Medicaid did not seem to change ER utilization either positively or negatively. That was a better than expected outcome from my perspective. I worry a lot that this experience will not be replicated in states like California, Texas or Florida where I would expect massive numbers seeking primary care at your ER because they have nowhere else to go; because mainstream primary care providers just won’t take the patients’ insurance card; and because of the high deductibles, the pathetic reimbursement, or both.
  • Build primary care capacity with a purpose. In this feeding frenzy of primary care integration, especially the integration of primary care physicians with hospitals, you really have to ask yourself the tough questions: Why am I doing this? Do I know how to manage this? And what is the end game here? If the answers to these three questions are, respectively, “So the other guys don’t do it first,” “I have no clue” and “Beats the hell out of me,” you have a wee bit of a strategic problem in the making.
  • Learn from the PCMH movement but don’t become a stuck zealot. I would encourage all capable delivery systems to experiment and learn from the PCMH movement, but I worry that this is a new inflexible dogma in the making. Get up to speed and move on, ever faster.
  • Get smart on the primary care redesign research. There is a growing body of ideas, research, pilots and experts focusing on the redesign research field. I urge you to get up to speed and incorporate the insights into your planning.
  • Create continuous innovation capacity. The key resource for the future will be the ability to adapt and innovate for higher performance no matter what the environment. The future could go many different ways: regulated pricing, capitation, brutal public sector reimbursement cuts, very skinny commercial networks. Or all of the above, simultaneously. You need to build the capacity to innovate around any obstacle.
  • Make, buy or ally. The innovation capacity may not all be in-house; you may have to buy it or partner with it. A good example is Froedtert Healthcare’s initiatives to build shared services partnerships with like-minded systems to fulfill a wide range of shared service goals including delivery system innovation.
  • Trust but verify. Don’t believe everything you see on PowerPoint. Just because it made it onto the slide doesn’t mean it works. Measure and manage actual results and innovate accordingly.

I believe that we have to redesign primary care, no matter what happens in Washington. The need is urgent. Let’s get going here—the clock is ticking.

Medicare Disadvantage

Saturday, July 2nd, 2011

Everyone agrees that Medicare is a cause of projected federal budget deficits. But it is also a key symbol of what’s wrong with America according to the political right (a generous federal government entitlement program) and what’s right with America according to the political left (a tax-based, universal health insurance program for the elderly).

In politics, it’s game on for 2012 and beyond, as the candidates start campaigning in earnest (provided they still have a campaign staff, after they come back from summer vacation). Medicare will loom large in the political debate over the next two years, because it is at the core of the discussion on values, priorities and national economics. It also is the key battleground for the broader health care problem: how to develop a viable, affordable health care delivery system for an aging and economically diverse society.

The Basic Politics

Seniors go to the doctors and vote. That’s their major sources of recreation. Seniors hated Obamacare; indeed according to a Harris Poll, a substantial majority of those over 60 favor repeal of the health care bill. (Seniors could not figure out how cutting $500 billion from Medicare was not going to hurt them, even though it all came out of the hides of providers and other health care actors). Seniors’ deep dislike of Obamacare partly explains why 58 percent of voters over 60 voted Republican in the 2010 Congressional election (compared with the low 40 percents in the Reagan or Bush the Elder years).

Then came the Arab Spring and the Ryan Spring. The Arab Spring raised hopes of democracy in the Mideast, and raised gas prices in the Midwest, putting even more pressure on economically vulnerable aging baby boomers. The Ryan Spring brought forward concrete proposals from Republican leaders to turn Medicare into a voucher program where the value of the voucher rises only at CPI plus 1 percent, exposing seniors to cost escalation above that rate. Arithmetically it would pauperize lower-income seniors in short order, but it would contain the rate of growth in federal expenditures. The argument is that elderly consumers would put pressure on private insurers to find a better deal for them. Really?

The public reaction to the Ryan proposal has been mostly negative. A June Harris/Health Day poll showed that majorities of seniors over 65 (64 percent) and those between 50 and 64 years of age (56 percent) prefer to keep Medicare as it is now. Looking at the population as a whole, the Harris Interactive/Health Day poll shows a small plurality of the public is opposed to the voucher idea (28 percent oppose, 27 percent favor and 45 percent are not sure). However, opposition rises when the plan is described as a Republican plan. For example, an ABC News/Washington Post poll from June in which the plan was characterized as a Republican plan had 49 percent opposing, 32 percent supporting and 19 percent not sure.

Democrats, emboldened by a special election victory in a normally Republican congressional district in Upstate New York, are salivating at the opportunity of defending a popular, traditional Medicare program in the next round of elections. But simply defending traditional Medicare is not the same as fixing Medicare.

The Harris Poll found that 81 percent of the public believes that at least “some changes are needed to make Medicare affordable for the average American.” And the public has a clear preference for what that means: significant majorities or pluralities favor cuts in fees paid to doctors, hospitals and especially drug companies. They also favor having higher income people pay more for their Medicare benefits. They are much less interested in raising taxes to pay for Medicare, increasing out-of-pocket contributions for all or raising the age of eligibility.

While provider fee cuts seem to be a very likely outcome in a new era of austerity, they have their own risks in terms of political backlash from the special interests on one hand, and significant cost shift to private payers on the other.

The real key to fixing Medicare is to change the reimbursement and delivery system for seniors so that it is affordable as a universal tax-financed vehicle. (You may also argue that this is the central problem for all of health care, but let’s limit our discussion to Medicare for now.)

So how could that be done, in a way that might garner more than ideologically polarized support?

Here are some ideas to think about.

Patient Protection and Affordable Care Act Tools: A Long Time to Payoff

Embedded in the health reform bill are a series of tools to advance improvement in the long run performance of the Medicare program, in particular:

• accountable care organizations (ACOs);
• patient-centered medical homes;
• the CMS Innovation Center; and
• the Independent Payment Advisory Board (IPAB).

Most of these initiatives will have no measurable impact on Medicare finances in the short run, although a lot of hope was placed on ACOs.

ACO: DOA

Well, well, well, did the ACO thing ever fizzle on entry. Basically, the initial regulations said to participating providers that if you clear enormously high quality hurdles while substantially cutting your revenue for patients, then CMS will let you keep some of the revenue that you just cut. You are kidding, right?

(I hate to gloat, but the failure of the ACO regulations is that they violated a lot of Morrison’s 10 Laws of ACOs identified in a previous column: Chasing Unicorns: The Future of ACOs). [Haydn, please embed link to Ian’s previous column by this title.]

The ACO concept was supposed to stimulate the formation of more organizations like Mayo Clinic. Yet, Mayo Clinic and their kin have announced they will not participate. The broader enthusiasm in health care is equally curbed. The bar is set too high, the rewards are too low and it is all too much like hard work.

However, despite the lack of enthusiasm for the Medicare ACO Shared Savings Program, all across the country, hospitals are integrating with physicians to pursue accountable care aims. They just want someone in the payer community to give them some real incentives to keep going.

CMS has reached out in search of pioneers: these are Ninja-level provider groups who are battle-hardened to accept much greater risk and accountability (do not try this at home) on terms that are yet to be determined. It remains to be seen whether CMS finds some willing pioneers.

Perversely, those pioneers may end up joining a program right under CMS’s nose: Medicare Advantage.

The Ironic Rediscovery of Medicare Advantage

Smart hospitals are starting to evaluate whether Medicare Advantage might be a better vehicle for their efforts to integrate for accountability for Medicare patients. Those health care systems with a captive or friendly health plan might find it administratively simpler, less onerous in terms of quality and transparency, and more profitable to expand into the Medicare Advantage business.

After all, if you are going to all that trouble to meet the triple aim of better care for patients, higher performance for the population and cheaper per capita costs, wouldn’t you want to get the lion’s share of the premium saved by doing that hard work? Watch out for more to follow the early pioneers in the area, especially those providers who know they can beat quality and performance standards to earn back the Medicare Advantage bonuses for quality.

Health Plans also see opportunities to engage with the emerging ACO-ready provider systems in commercial contracts. There are numerous experiments from California to Minnesota where commercial payers (both Blues and others) are building ACO relationships with providers. It is but a small next step to integrate a shared saving Medicare Advantage deal with those contracts, which may be more appealing for hospital leaders than being in a direct relationship with CMS, under the intense scrutiny of the federal government.

Medicare Advantage plans are a hot property right now. Recent transactions have been at record high valuations, most recently Wellpoint’s acquisition (for $800 million) of CareMore, a niche Medicare Advantage plan based in California that focuses on the heavy user sub-population of Medicare recipients.

The CareMore valuation teaches us two key things. First, that in a world of risk-adjusted capitation, Medicare Advantage plans have an enormous incentive to seek out heavy users of care, if they know the secret sauce of managing those patients. Second, the secret sauce of managing heavy users looks a lot more like “social work and transportation services meets compassionate heavy duty case management” than it does the siloed, high-tech disjointedness that today characterizes care for most of the multiply co-morbid elderly.

We can solve our short-term Medicare budget crisis by slashing provider payment levels, but in the long run that will condemn us to a health care system of hamster care, where providers are on a treadmill of discounted fee for service.

Rather, we should build organizations and partnerships that embrace risk for the care of the elderly population. These sophisticated service businesses must combine cutting-edge information technologies, evidence-based medicine, and patient- and family-centered support systems to keep costs low and to keep us patients functioning, at the highest possible level, into our dotage. At least that is what I am hoping for: You had all better come through.