Letter from Washington: Don’t Jump … Yet

Letter from Washington:
Don’t Jump … Yet

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Washington, D.C. hardly seems like a town on suicide watch.

As November turned to December, from the venerable Old Ebbitt Grill near the White House, to Charlie Palmer Steak at 101 Constitution and over to The Capital Grille at 601 Pennsylvania, revelers abounded, in both food and drink.

At the Capitol Hyatt on New Jersey Avenue though, some contrasts were evident. While contestants from the Miss World 2016 pageant moved in and out of the upper lobby to awaiting buses, in the lower-level meeting rooms, also from November 30 to December 2, the mood was hopeful optimism meets whistling past the graveyard.

There the Jefferson College of Population Health summit brought forth Andy Slavitt, Michael Leavitt, Farzad Mostashari, NCQA President Peggy O’Kane, former advisors from the George W. Bush and Obama administrations, officials from Johns Hopkins, the Henry Ford Health System, Brookings, Deloitte, AMA, AHA and the American College of Physicians and many more to dissect MACRA and ponder “population health strategy under the new administration.”

The consensus on where value-based care (VBC) is heading?

Wait and see.

The predictions? The Cadillac tax will go the way of the DeSoto. Medicare Advantage payment models will increase. The overriding attention on ACA insurance will back-burner VBC changes buffered also by MACRA. Track1+ will itself be the savior of MACRA. And looming large is whether Medicare will become a voucher or premium support model.

Voices of hope and optimism, sometimes bordering on defensiveness, could be heard, all as the bipartisan 21st Century Cures bill moved toward law a few blocks away.

Mandatory bundled payments will be killed. Wait a minute; bundled payments have returned nearly 3% to the Medicare Trust Fund, versus .02% by ACOs. Tom Daschle, like Tom Price, was once a shoe-in as secretary of HHS. VBC pilots preceded CMMI. Value preceded ACA. Well, most federal payment models will just be renamed or rebranded, beginning with the term physician.

Former HHS Secretary Michael Leavitt sought calm. “CMMI will be challenged, but the analytics it provides are important to maintain … we need to find the balance between provider readiness and the speed to change between providers and payers … the GOP is not in lockstep … the bottom line is we don’t know.”

As a prelude to his standing ovation, outgoing CMS Administrator Andy Slavitt called for the continuation of lifetime limits, coverage for pre-existing conditions and those up to age 26 be maintained on parental policies.

PTAC to the rescue

Given much attention at the conference was a so-far overlooked element of the MACRA law, the establishment of the Physician-Focused Payment Model Technical Advisory Committee (PTAC).

Amid speculation that the new regime at HHS will, again, decry mandatory bundled payments, shrink MACRA, lay siege to EHRs (which took its lumps from many quarters) and roll back the movement to VBC or quality reporting payment models seen as onerous to physician workflow, PTAC was seen as a potential fresh start.

Its mandate is to assess and put forth new physician-focused payment models, done by a committee of 11 already appointed by the GAO; a committee that includes six MDs. Already nine letter-of-intent proposals have been submitted, and PTAC is to refer winning payment model proposals to, yes, the new secretary of HHS by the spring of 2017.

These new payment models can be APMs, A-APMs, bundled payments; you name it. The criteria for them includes the use of health information technology, risk-level flexibility, value over volume, integrated care coordination and cost-quality metrics.

Physician Heal Thy Future

In the end, Bob Margolis, MD, Duke-Margolis Center for Health Policy, took a more direct position. Physicians should take the debate out of Washington and into their own hands, and realize a future without a government single payer with price controls and salaried doctors.

How? Establish their own care plans around predictive modeling and population analytics. Consider a global capitated population health approach stratifying patients into appropriate treatment plans. Realize that EHRs are not tools for analytics and that BI tools are needed on top. And then, assessing risk-based payment models can be a holistic approach. He reminded the attendees that PCPs and their aligned specialists control 85% of the healthcare spend. In Washington, D.C., that’s called power.

Outside on the newsstands, Washingtonian magazine featured a wistful cover shot of the Obamas for its December issue, headlined “How They Changed Our City.”

Past nightfall, as visitors gathered around one side of the White House to view the Christmas tree, scaffolding was being erected on the other for the upcoming inauguration.

What’s clear throughout the town is that while pockets of the country fume, Washington, D.C. is ready to take change in stride again.

Greg Fulton is industry & public policy lead for Philips Wellcentive

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12 Comments on "Letter from Washington:
Don’t Jump … Yet"


Member
pjnelson
Dec 5, 2016

The root-cause for the Paradigm Paralysis strangling our nation’s healthcare lies in the underlying conflict-of-interest that exists within the decision processes of the institutions distributing the resources that pay for our nation’s healthcare: the institutions that pay for this healthcare also determine the definitions that qualify for this financial disbursement. As a result, we have excessively supported the economic mandate of Complex Healthcare Needs with a minimalist support for the social mandate of Basic Healthcare Needs. Simply stated, Parkinson’s Law applies. There is no reason to trust that a centralized, coercive, and centralized governmental institution will have the governance applicable to our nation’s healthcare, community by community. The Design Principles for managing a Common-Pool Resource, as in our national economy, without exhausting the CPR are already known and well tested (for a long time). Without rationing, there really is no current means to reduce the cost of our healthcare as a portion of the national economy without a renewed strategy for the healthcare of each citizen’s Basic Healthcare Needs. Changing the 5:80 group will not occur until we attend to the 50:5 group on the Power Law Distribution curve, left to right. Hint: the financial requirements for Basic Healthcare Needs don’t follow actuarial principles. In short, we need a strongly collaborative strategy to quickly turn Primary Healthcare into a capitated financial reimbursement process, appropriately implemented through local initiative (as required by the Design Principles).
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OK, take a deep breath and read this again. Please don’t take your pulse. OK then, one last time. Of course, there are many issues with this strategy, especially the currently neglected character of our nation’s Primary Healthcare. The uneven capacity of our nation’s Primary Healthcare for responding to the needs of our citizens encumbered with social adversities will be a major task. We cannot wait any longer as our nation’s medicare eligible population rapidly expands. A ten-year “Land on the Moon” plan will be required with two GOALS: 1) to reduce our nation’s annual maternal mortality ratio by 75% and 2) to reduce the cost of our nation’s healthcare, as a portion of our nation’s economy, by 25%. My judgement is that the concern, commitment and knowledge already exists in every community. What we need is a nationally sanctioned investment in our level of Social Capitol, community by community.

Member
William Palmer MD
Dec 6, 2016

Your key sentence begins with “Without rationing….”
“…..each citizen’s Basic Healthcare Needs.” is not intuitive to this reader. I think these needs are all stochastic…..unless you are talking about a few immunizations. There may be a few predictable needs in the very old but I think these are not relevant in your discussion.

I like most of your comments.

Member
pjnelson
Dec 6, 2016

See http://www.nationalhealthusa.net/summary/appendix-i-definitions/

It represents a “Lexicon” for healthcare reform. Limited as it is, there is a definition for Basic Healthcare Needs. More importantly, it has a contemporary definition for “HEALTH” and a “Caring Relationship.” It may represent a bit of cognitive dissonance but give it a try.

Member
William Palmer MD
Dec 6, 2016

Allan, look at this citation and see if you can understand it. My brain is not able to grasp any meaning here. You’ll find Basic Healthcare Needs down on the list.

Member
pjnelson
Dec 7, 2016

“HEALTH CONDITION” is the second definition in the V I S I O N grouping. It is further defined as having either EMERGENT, URGENT or EXPECTANT attributes as a basis for medical TRIAGE.

Member
Allan
Dec 6, 2016

Bill I assume you are talking about Basic healthcare needs that ends with the following sentence.

“iii. the periodic reassessment of a person’s HEALTH as a basis for determining the person’s priorities for defining a comprehensive care plan to achieve optimal HEALTH for that person.”

I am not getting much of anything from this section. The entire section sounds like an open definition where one could lay claim to basic healthcare for almost anything. What is a HEALTH CONDITION? That undefined phrase seems to remain undefined while everything follows and that is the most important definition , but is used to create definitions.

Member
pjnelson
Dec 7, 2016

Any discussion of HEALTH probably benefits with its agreed-upon definition. It seems that the recent references to a possible definition use the term “human capabilities.” No one has attempted an effort to define it. So, my list of Definitions begins with a contemporary view of HEALTH (FOUNDATION section) and includes of definition for HUMAN CAPABILITIES in the final OTHER section. All of this is augmented by a list of CAUSES OF UNSTABLE health in the APPENDIX Page of the Blog.

To be accurate, there is a low level discussion of HUMAN CAPABILITIES in the Pediatric literature. It is mostly tied to the temperament attributes identifiable soon after birth among all newborns.

Member
Allan
Dec 7, 2016

“Any discussion of HEALTH probably benefits with its agreed-upon definition.”

I appreciate anyone brave enough today to try and establish a definition of healthcare, health condition or health. I find it an impossible task, at least for me, because it doesn’t seem possible to satisfy everyone’s vision of what health is, and what health is becomes further distorted by politics and economics.

At the site you provided above I looked up health condition:

“HEALTH CONDITION may be defined as a change in a citizen’s HEALTH… ”

But, I was stuck on the word Health so I went further all the way to the WHO.

“WHO definition of Health

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

I realized at that point the only time I reach that WHO definition is when I am anesthetized or on drugs.

Member
William Palmer MD
Dec 6, 2016

I do agree that in a few dozens or maybe hundreds of years–after we thoroughly understand the genome, the epigenome, and the proteome, etc. and their interaction with the specific environment of a patient–THEN we shall be able to talk about the citizen’s basic healthcare needs and have it mean something.

Member
pjnelson
Dec 7, 2016

I agree.

Member
William Palmer MD
Dec 5, 2016

We keep dancing about health care financing as if we believe that the WAY we pay for a good or service is more important than the supply of the service or its demand or the content of that service. And that the WAY can control the content, the supply, the demand and its quality? It is as if we are fixated on trying to find the golden technique in buying groceries and we miss the examination of the production of the food and all the ways it can be transported and what is the content of the food and its demand by the public.

We appear to neglect the examination of the many other parts of the market and favor a fixation on the way things are paid for.

E.g. what if the content of health care is non-ambulatory hospital care* and we deem it is a public good and we manage it through hospital districts or counties and pay for it by a mix of local and state and federal dollars?

*The demand and content is care for conditions that might kill, disable, or bring bankruptcy upon, a patient as determined by triage on admission.

And there is no billing or finance department in the hospitals and no billing codes and the only records are medical records?

And everyone in paid by salary?

And we forget ambulatory care and allow everyone to do anything they want here. They can pay cash or insure themselves or be on state safety-net programs.

Member
pjnelson
Dec 7, 2016

I don’t agree! There is no widely-recognized tradition in our land for managing a common-pool resource. To be honest, there are isolated exceptions. There is a fresh water aquifer under the city of Los Angeles. Beginning around 1930, the five counties of Los Angeles eventually developed a collaborative agreement with all (except one) of the high water users to limit pumping from the aquifer. These Agreements also provided the financing for bringing in water from outside of Los Angeles. It took thirty years, and there was no involvement by either Sacramento or the Beltway in these agreements. The other, of course, is the agricultural Cooperative Extension Service established with the Smith Lever Act by Congress in 1914. Our nation produces more food with resources applied than any other nation, by a wide margin. The Design Principles for this exist but are very poorly recognized by our centralized governmental institutions. My Blog basically proposes to use these Design Principles to mobilize the reform of our nation’s healthcare industry, community by community.