Last week, I was riveted to the deliberations on the Senate floor, as the fate of the Medicare Access and CHIP Reauthorization Act (MACRA – so far, more commonly called the “SGR fix”) was decided. One amendment after another failed to pass; the legislation ultimately passed by a vote of 92-8, and was signed into law shortly thereafter.
To date, much of the coverage of MACRA has focused on how it has fixed the “doc pay” problems of the last 18 years – rescuing us from a yearly round of negotiations about how to temporary avoid painful cuts in Medicare’s physician reimbursement rates.
It’s true that MACRA wiped out (and only partially paid for) the accumulated burden of postponed pay cuts. But it also took a huge step in ending the volume-based “fee-for service” payment system that the pay cuts were trying to restrain in the first place. In a volume-based health care world, the only way for the government and other payers to control runaway medical inflation is to make it harder for doctors to get paid (through rejected claims, paperwork, and prior authorizations), and to reduce the price they pay for each office visit, test, or medical procedure. Providers, paid less and less for each visit and service, can try to maintain their income by further increasing volume — seeing more and more patients in less and less time — or routing patients through increasingly questionable services, tests, and procedures. That is the dysfunctional state of US health care today, with patients caught in the middle of the arms race between those who pay the bills, and those who bill them– collateral damage. Continue reading “SGR Appeal: Fixing the Present, Setting a Foundation for the Future”
Filed Under: THCB
Tagged: Accountable Care Organization, ACO, MACRA, SGR Fix
Apr 22, 2015
In recent weeks, the market has reacted to a few noteworthy headlines, all involved with or touching upon value-based discretionary actions, and many with the not-so-hidden question: What’s In It for Me or WIIFM?
- CMS announced that by 2016 30% of fees in health care should be paid for through a value-based system, moving away from fee-for-service.
- ACO results have shown ambivalent outcomes.
- Outcomes-based contracts have permeated the Hepatitis C cost-nado (that’s a cost sharknado, the kind that fiercely defies cost controls and takes over all noise about payment reform and patient preferences).
- Reference-based pricing is a good/bad troublemaker in the middle of the value-based travails.
The latest rampages have appeared on two national and highly-regarded blogs: The Health Care Blog [Value-Based Reform] and The Health Affairs Blog [Go Slow on Reference Pricing].
As one of the loudest proponents on value-based designs, I lift the curtain again to show the thinking behind the movement from fee for service to value-based designs. All of these items above discuss the message of payment reform, or system alignment, but they are intensely linked to the patient-consumer ability to make the right choices, choose the right sites for care, and pay the right amount for services rendered to achieve health security.
This last—health security—should be at the heart of the US health system.
▪ It’s the place where patient competency is built and tested over time, as the patient becomes aware of health risks and chooses to modify behaviors to lower the risk.
▪ It’s the place where, when there are acute or emergent symptoms, there is no question but that the patient will be able to access the appropriate and affordable care in the safest possible setting, hopefully receiving care that delivers the patient back to functional health.
▪ It’s the place where caregivers and administrators are paid a competitive wage for serving the needs of the patient and getting the patient back to the best health possible.
Continue reading “Value-Based Health”
Filed Under: THCB, The Business of Health Care
Tagged: ACO, Health Value Continuum, Incentives, Outcomes, Value-based health reform, Value-based healthcare
Mar 11, 2015
Earlier today, Health and Human Services (HHS) Secretary Sylvia Mathews Burwell announced that HHS is doubling down on the historic shift taking place across the health care industry towards value-based care, and is setting a target of having 50 percent of Medicare payments under value-based care arrangements by 2018.
This would mean that in less than three years, around a quarter of a trillion dollars of health care spending would be made to providers who are being compensated not for ordering more tests and more procedures, but for delivering better outcomes – keeping patients healthier, keeping them out of the hospital, and keeping their chronic conditions in check.
This shift will address a central problem of the US health care system, one that lawmakers and policy experts on all sides of the issue agree is a key contributor to runaway medical inflation.
The logic is straightforward: by simply paying for the volume of services delivered, every provider has a strong incentive to do more — more tests, more procedures, more surgeries. And under this system, there is no financial incentive to maintain a comprehensive overview of patient care – to succeed by keeping the patient healthy, and health care costs down.
In making this announcement, Secretary Burwell took a step that many within HHS had been advocating quietly for years, and which many outside it have advocated more loudly.
Skeptics may ask: what does this accomplish? And why announce it now, when health care costs are already rising at the slowest rate in decades?
Continue reading “A Courageous First Step”
Filed Under: THCB
Tagged: ACO, Bob Kocher, Farzad Mostashari, HHS, Value-Based Medicine
Jan 26, 2015
Mohammad Al-Ubaydli: Let’s just start from the beginning. Tom, can you please give us an introduction about yourself and your background?
Thomas Tsang: I’m a general internist by training. I practiced internal medicine in New York City, first at a small community hospital where I predominantly worked with residents and medical students and mostly taught principles of outpatient medicine, ambulatory care and interviewing techniques.
Then I was recruited by the Charles B. Wang Community Health Center. That’s when I got to use some of the public health knowledge that I had acquired: I worked on various public health initiatives for the community in New York City. The health center itself served a predominantly Asian population. It had four sites and one of the things that I did in the beginning was implement an electronic health record. That work led to my involvement with the Board of Health of New York City, which, in turn led to my work in Congress.
I was then selected for the Robert Wood Johnson Foundation/IOM Health Policy Fellowship on the Committee on Ways and Means-Subcommittee on Health and worked on some of the policies that led to the creation of ACO’s, i.e., Value-Based Purchasing, Pay for Performance and so on. I was fortunate enough to actually help implement some of the policies that I worked on! It’s a long answer to your question, but that’s the route I took.
Mohammad: It’s perfect. It’s really interesting to learn. Among the many things under your belt, it sounds like you have a successful electronic health record deployment, which is good–so well done! Tell me and our readers a bit about Accountable Care Organizations. What is an ACO and what is the point of it?
Thomas: The ACO is not a very new concept. It was a term that was coined by Elliott Fisher from Dartmouth Medical School, who is the director of Center for Health Policy and Clinical Practice. I hate to use the word HMO, but in a way, it’s almost like an HMO. It’s not really an HMO because it is actually a provider-led organization, not an insurance-led one.
Continue reading “Why ACOs Are not HMOs and Other Important Questions”
Filed Under: THCB, The Business of Health Care
Tagged: ACO, EHR, HMO, holistic care, Interoperability, Mohammad Al-Ubaydli, Quality, Thomas Tsang
Jan 16, 2013
In 2013, I’m focused on five major work streams:
· Meaningful Use Stage 2, including Electronic Medication Administration Records
· ICD10, including clinical documentation improvement and computer assisted coding
· Replacement of all Laboratory Information Systems
· Compliance/Regulatory priorities, including security program maturity
·Supporting the IT needs of our evolving Accountable Care Organization including analytics for care management
I’ve written about some of these themes in previous posts and each has their uncharted territory.
One component that crosses several of my goals is how electronic documentation should support structured data capture for ICD10 and ACO quality metrics.
How are most inpatient progress notes documented in hospitals today? The intern writes a note that is often copied by the resident which is often copied by the attending which informs the consultants who may not agree with content. The chart is a largely unreadable and sometimes questionably useful document created via individual contributions and not by the consensus of the care team. The content is sometimes typed, sometimes dictated, sometimes templated, and sometimes cut/pasted. There must be a better way.
Continue reading “Brainstorming About the Future of Clinical Documentation”
Filed Under: Uncategorized
Tagged: ACO, Clinical Documentation, CMS, Geisinger, ICD-10, John Halamka, Kaiser, Mayo, Meaningful Use Stage 2, Physicians, quality metrics, SNOMED-CT
Dec 18, 2012