By LES FUNTLEYDER

We recently participated in a program at Columbia Business School’s Healthcare Program on whether ACOs (Accountable Care Organizations) will fail. For those of you that don’t know, ACOs are one of the structures promulgated by PPACA (aka Obamacare) designed to encourage better cost control and quality improvement in the healthcare system.

The current zeitgeist among the commentariat is that ACOs will fail (examples: here and here). We think the reason for the one-sided nature of the question is that those of us who lived through the healthcare upheaval in the early and mid “90s” saw first hand the failure of PHOs, PPMs and IDNs (and all of the other acronyms now relegated to the dustbin of history). When ACOs are touted as a saving grace for the system, you can almost hear the collective groan of the industry veterans.

Ever the contrarian, however, we took the side of the debate that said ACOs will NOT fail. The premise of our argument was that since we already have a good idea of why the structure will fail, we can, a priori, fix the shortcomings, and though likely, ACO failure is not inevitable.

There is an extensive list of why list of why ACOs will fail. We put them into four general buckets.

Infrastructure: The system has mis-allocated resources so we have too many of some things and not enough of others leading to inefficiencies.

Technological/telecommunication: For a number reasons the healthcare system has not adopted technology as fast as other industries.

Cultural: Providers are habituated to fee-for-service payment mechanisms and patients aren’t likely to change their own healthcare behaviors.

Inertia: The well known system problems (e.g. asymmetry of information, the Pareto nature of patient demand, unexplained variation of care, counterproductive incentives) have been around forever and are difficult to overcome.

Because we spend most of our time identifying private healthcare companies with investment potential, we often get a view into what is happening in the entrepreneurial space under the punditry radar.

Continue reading “The ACO Failure Hypothesis: Likely But Not Inevitable”

By Brian Klepper

What is the path forward for physicians who want to remain in private practice, outside the constraints of health system employment? How will the environment change and what new demands will that place on practices and physicians? What follows are the observations of one industry-watcher who has worked on all sides of health care, but who now spends most his time focused on the interests of those who pay for it. No crystal ball, but several trends are clear.

There are now concrete signs that health care’s purchasers are exhausted and seeking new solutions, that a competitive marketplace is emerging and getting increasing traction. As they abandon ineffective approaches, the paradigm that has dominated the industry for the past 50 years will be upended. The financial pressure felt by buyers will transfer to the supply side health industry that has come to take ever more money for granted.

For decades, fee-for-service payment, inclusive health plan networks, and a lack of quality, safety and cost transparency have been enforced by health industry influence over policy, effectively neutralizing the power of market forces.

Without market pressure, physicians have felt little need to understand their own performance relative to that of their peers. The variation of physician practice patterns within specialties has been high, with some physicians’ “optimizing their revenue opportunities” by veering wildly away from evidence-based practice. Even so, until recently in this dysfunctional environment, it has been nearly impossible to identify high and low performers.

Continue reading “How Physician Practices Can Prepare for a Health Care Marketplace”

By Al Waxman

Now that President Obama has been re-elected and the Supreme Court has upheld the Accountable Care Act, healthcare reform is here to stay. So what does reform mean for healthcare investors? I believe it will usher in a new fertile period for innovative,venture‐backed companies that can navigate the brave new world of healthcare delivery and management.

The Accountable Care Act impact on healthcare IT investing is already being felt.Venture investment in 2013 is showing significant growth from last year. In 2012,according to PWC, a global accounting firm,the life sciences sector which includes healthcare IT accounted for 25 percent of all venture capital dollars invested which totaled nearly $1.2 billion in 163 deals,more than double the $480 million in 49 deals in 2011 and almost six‐times the $211 million in 22 deals in 2010.

Now is the time to make order out of chaos and to set the stage for a next‐generation healthcare system that can effectively service our nation. At Psilos Group, we have just released our fifth Healthcare Economics and Innovation Outlook and identified the following four areas as the most promising opportunities for healthcare investors in 2013 and beyond: Private health exchanges, consumer‐focused insurance programs, 21st century healthcare technologies, and innovations that reduce error and waste.

Investing In Exchanges

The healthcare insurance marketplace—and the way insurance is bought and sold—is facing massive change.Healthcare insurance exchanges, both public and private,promise to create a more organized and competitive market for buying healthcare insurance, which could moderate price increases that are currently spiraling out of control.

From our perspective, exchanges are an intelligent place to invest. Software and services will power the exchanges. Psilos envisions massive opportunities for technologies that enable operators of both public and private exchanges to build high functioning platforms, including the shopping software and back‐end administrative technology and service products needed to serve tens of millions of people efficiently.

Continue reading “The Affordable Care Act: Like It Or Not, It’s Catalyzing a Golden Age In Health Care Investing”

By Ishani Ganguli, MD

Walgreens, the country’s largest drugstore chain, announced on April 4th that its 330+ Take Care Clinics will be the first retail store clinics to both diagnose and manage chronic conditions like asthma, diabetes, high blood pressure, and high cholesterol. The Nurse Practitioners (NPs) and Physician Assistants (PAs) who staff these clinics will provide an entry point into treatment for some of these conditions, setting Walgreens apart from competitors like Target and CVS whose staff help manage already-established chronic illnesses or are limited to testing for and treating minor, short-lived ailments like strep throat.

A one-stop shop for toothpaste, prescription drugs, and a diabetes diagnosis? The retail clinic phenomenon has its appeal: it allows patients convenience and better access to care through longer hours and more locations than our health care system now provides. Walgreens leaders bill their latest offering as a complementary service to traditional medical care. They envision close collaboration with physicians and even inclusion in Accountable Care Organizations, according to reporting by Forbes’ Bruce Japsen (though it’s not clear how the retailer would share the financial risk or savings in such a model).

By Jaan Sidorov, MD

Writing in the March 20 issue of JAMA, Drs. Douglas Noble and Lawrence Casalino say that supporters of Accountable Care Organizations (ACOs) are all muddled over “population health.”

This correspondent says the article is what is muddled and that the readers of JAMA deserve better.

According to the authors, after the Affordable Care Act launched the Medicare Accountable Care Organizations (ACOs), their stated purpose has morphed from Health-System Ver. 2.0 controlling the chronic care costs of their assigned patients to Health System Ver. 3.0 collaboratively addressing “population health” for an entire geography.

Between the here of “improving chronic care” and the there of “population health,” Drs Noble and Casalino believe ACOs are going to have to confront the additional burdens of preventive care, social services, public health, housing, education, poverty and nutrition. That makes the authors wonder if the term “population health” in the context of ACOs is unclear. If so, that lack of clarity could ultimately lead naive politicians, policymakers, academics and patients to be disappointed when ACOs start reporting outcomes that are limited to chronic conditions.

Continue reading “Accountable Care Organizations Can Change Everything, But Only If We Get the Definition Right”

By Dan Diamond

In November 2008, the New England Journal of Medicine convened a small roundtable to discuss “Redesigning Primary Care.”

U.S. primary care is in crisis, the roundtable’s description reads. As a result … [the] ranks are thinning, with practicing physicians burning out and trainees shunning primary care fields.

Nearly five years out — and dozens of reforms and pilots later — the primary care system’s condition may still be acute. But policymakers, health care leaders and other innovators are more determined than ever: After decades where primary care’s problems were largely ignored, they’re not letting this crisis go to waste.

Ongoing Shortage Forcing Decisions

The NEJM roundtable summarized the primary care problem thusly: Too few primary care doctors are trying to care for too many patients, who have a rising number of chronic conditions, and receive relatively little compensation for their efforts.

Continue reading “The Radical Rethinking of Primary Care Starts Now”

By Rob Lamberts, MD

It’s been a month since I started my new practice. We are up to nearly 150 patients now, and aside from the cost to renovate my building, our revenue has already surpassed our spending. The reason this is possible is that a cash-pay practice in which 100% of income is paid up front has an incredibly low overhead. My admitted ineptitude at financial complexity has forced me to simplify our finances as much as possible. This means that the accounting is “so simple even a doctor can do it,” which means I don’t need any front-office support staff. I don’t send out bills because nobody owes me anything. It’s just me and my nurse, focusing our energy on jury-rigging a computerized record so we can give good care.

Our attention to care has not gone unnoticed. Yesterday I got a call from a local TV news reporter who wanted to do a story on what I am doing. Apparently she heard rumor “from someone who was in the hospital.” I was the talk of the newsroom, yet I’ve hardly done any marketing; in fact, I am trying to limit the rate of our growth so I can focus on building a system that won’t collapse under a higher patient volume. I explained this to the disappointed reporter why I was not interested in the interview by telling her that I left my old practice because I needed to get off of the hamster wheel of healthcare; the last thing I want to do now is to build my own hamster wheel.

Continue reading “Trickle Up Economics”

By MIKE MIESEN

“Will Accountable Care Organizations (ACOs) work?”

That question has been thrown around for years, serving as fodder for Twitter-fights, myriad health care blog posts, and hours of beer-soaked barroom debates (if you’re shameless as I am). Adding to the discussion are Clayton Christensen, Jeffrey Flier, and Vineeta Vijayaraghavan (or CFV, as I’ll refer to them), of Harvard Business School, Harvard Medical School, and Innosight fame, respectively.

In a recent Wall Street Journal article, they answer the question with a resounding “No.” But, in doing so, they treat ACOs and other health care delivery mechanisms – part of what I’ll call the “New New Thing in Health Care” – as mutually exclusive. Contra CFV, ACOs may help spur the exact disruptive innovation in health care that Christensen is known for discussing.

Continue reading “Really Big New Thing”

By Bob Wachter, MD

These should be the best of times for the patient safety movement. After all, it was concerns over medical mistakes that launched the transformation of our delivery and payment models, from one focused on volume to one that rewards performance. The new system (currently a work-in-progress) promises to put skin in the patient safety game as never before.

Yet I’ve never been more worried about the safety movement than I am today. My fear is that we will look back on the years between 2000 and 2012 as the Golden Era of Patient Safety, which would be okay if we’d fixed all the problems. But we have not.

A little history will help illuminate my concerns. The modern patient safety movement began with the December 1999 publication of the IOM report on medical errors, which famously documented 44,000-98,000 deaths per year in the U.S. from medical mistakes, the equivalent of a large airplane crash each day. (To illustrate the contrast, we just passed the four-year mark since the last death in a U.S. commercial airline accident.) The IOM report sparked dozens of initiatives designed to improve safety: changes in accreditation standards, new educational requirements, public reporting, promotion of healthcare information technology, and more. It also spawned parallel movements focused on improving quality and patient experience.

As I walk around UCSF Medical Center today, I see an organization transformed by this new focus on improvement. In the patient safety arena, we deeply dissect 2-3 cases per month using a technique called Root Cause Analysis that I first heard about in 1999. The results of these analyses fuel “system changes” – also a foreign concept to clinicians until recently. We document and deliver care via a state-of-the-art computerized system. Our students and residents learn about QI and safety, and most complete a meaningful improvement project during their training. We no longer receive two years’ notice of a Joint Commission accreditation visit; we receive 20 minutes’ notice. While the national evidence of improvement is mixed, our experience at UCSF reassures me: we’ve seen lower infection rates, fewer falls, fewer medication errors, fewer readmissions, better-trained clinicians, and better systems. In short, we have an organization that is much better at getting better than it was a decade ago. Continue reading “Is the Patient Safety Movement in Critical Condition?”

By JOE FLOWER

Rapid change is engulfing health care across the United States, but the strategic responses of organizations to these changes are sharply divided. In the shift that has been broadly shorthanded “from volume to value,” many organizations across the country are deeply engaged in moving toward “value” by building new partnerships, affiliations, capacities and economic structures, striving to bring better health and health care to more people for less money.

At the same time, some organizations are using the chaos and fluidity of the moment to double down on the old way, aggressively seeking greater volume reimbursed at higher rates. For now, within their regions, some of these organizations appear to be “winning” at the game, building greater market share and margin and increasing their budgets. But is this in fact the wisest strategy to follow in the long run, not only for their institutions but for the good of their missions and the people they serve?

Moving toward Value

Virtually all serious attempts to answer the question, “Why do we pay so much more for health care in the United States?” have pointed to the competition for reimbursements under a commodified, insurance-supported fee-for-service system. If what you pay for is items off of a list, what you will get is lots of items, especially the more profitable ones. That’s how we end up with a system in which waste (stuff we could simply do without) is pegged by repeated studies at one-third or higher.

Continue reading “Divided Health Care Nation”