A Master Class In Health Policy with Kavita Patel

flying cadeuciiThe HxRefactored Conference kicks off April 1st in Boston and we are excited to have Kavita Patel giving a Master Class in U.S. Health Policy.” Kavita is a Managing Director at The Brookings Institution in Washington, DC and has a long history working in health reform for both Ted Kennedy and at the Obama White House.  I interviewed Kavita to talk health care reform impact, insight, technology and and timing.

Matthew Holt: What are the most important changes that you are currently seeing due to Health Care Reform as well as in the health care system as a whole?

Kavita Patel:I would say the most important change is everybody is now intensely focused on transforming every aspect of health care, not only the consumer experience or people who are not already inside the health care system, but also for patients and then for their family members–whether it’s an insurance company that had massive numbers of enrollees, as a result of the Affordable Care Act and the last wave of 11 million people who signed up, or if it’s the one person’s primary care physician who is now looking at whether or not he or she should be part of the patient centered medical home, because he or she is kind of thinking through what the future of medicine will look like, as well as patients and consumers.

Sometimes we hate using those terms.  I personally sometimes hate being referred to as a consumer when that implies like I have some choice.  Now, we’re finally seeing that there are some choices.  It’s not perfect, but it’s something that was a game changer for me in watching of what’s happened since the Affordable Care Act is passed.

MH: This next question is about the pace of transformation.  You’ve mentioned that everyone’s thinking about consumers and there’s also this transformation towards value-based care. How far are we in this transformation that’s going on now? What proportion of health care providers are on board and how many are hanging back and waiting?

KP: I would say that the majority of people are still hanging back and “waiting to see what happens.”  Let me just say that the “wait to see what happens” takes different flavors.  A couple of years ago, it was, “will the Supreme Court turnover the entire Affordable Care Act?” That was one “wait and see what happens.” The next “wait and see what happens” is the King versus Burwell suit around the subsidies and exchanges.  Then the third, active set of “wait and see what happens” are those who believe fee-for-service is never going to die as a payment model because we just don’t know how to do anything better even despite the Obama Administration making some bold announcements recently.

When you asked the question of where are we now, the majority of the country is still in that, “okay, we’re going to see how we do with what the status quo is and just watch to make sure that we don’t jump ahead too quickly.”  I’ve actually had to look at percentages, it’s part of my work at Brookings, and the different sectors of health care.  I would say it’s a pretty safe estimate to say only about 10% of care right now is in that value-based or however you want to describe it.  A lot of that, honestly, Matthew is in your state of California. It’s concentrated geographically.  If you go to my home state of Texas, it’s about one percent.

I think for the people who are technology developers, entrepreneurs in general, it’s smart to keep the business principle of what is currently the majority of the market, which is still fee-for-service.

However, I think successful businesses will understand how to change their own business models to adapt to  what I believe is going to be the majority over the next decade and push us towards more of the premium dollars spent on value-based care rather than payment and fee-for-service silo that we live in right now.

But the question is,f when is that going to happen?  There are some who speculated it will take several decades.  I’m on the shorter end.  I’m a little more optimistic that we’re looking at about 10 to 20 years to see.  For some in the business world, that’s not fast enough, I understand that.  But again, I think you’re looking at pockets of the country that can accelerate faster, but when we talk about the whole country, I think it’s going to take at least the next decade.

MH: There’s a lot of discussion about policy versus technology and implementing EMRs but also in changing the kind of health care organizations using regulation and payment. From the experiences that you have in your own practice, give me a sense about how much change you are seeing?

KP: This is too much jargon, but I am actually a provider that’s in an Accountable Care Organization in Medicare with beneficiaries “assigned” to me in that ACO.  Here’s the bad news. Most of what I do is not dramatically different from what I did before I was a provider in an ACO.  Habits are hard to change.  Honestly, I say this as a doctor with great respect for doctors.  You really have to figure out how to not do this with just a physician.  You’ve got to actually change care from all levels, and places are still struggling with that.

So, while I see bits and pieces, and pockets of real change in other organizations, I’m practicing pretty much how I used to practice two years ago, I would say the differential comes from how people approach truly — a team centered approach.  As a patient, as someone who just delivered a new patient in our health care system (Note, Kavita has a new baby!), I’m part of probably what I would call the traditional fee-for-service majority uncoordinated care.  I’m not saying that with pride, I’m just telling you that that’s still what I do and that’s still what I see despite labels, like accountable care and some of these other things.

Because of my work at Brookings, I’ve gone around the country to other organizations that are “high performing.” I go and dissect what it is that makes them high performing. Yes, they’ve got great doctors and great physician leaders, but more importantly, they really respect how much every member of the team including some of the lowest-waged health care workers, can have an influence on care.  I think that is where we’ve got to shift our mindset in the country.  We’re not going to be able to produce more primary care doctors nor should that be the answer.  It shouldn’t all be about what we do in a hospital or in a clinic.  That’s where developers, technology, entrepreneurs and some really interesting thinking informed by other industries can come to our advantage.

MH: Last question. You’re also on the board of Dignity Health (large provider org), and you’ve been advising HealthLoop and others who are in the technology side of health.   How much do you think that technology can improve that kind of team-based care that you will be talking about?  How much will technology flip the thing without the organization itself demanding it?  How much do we have to wait until somebody at the top says “we’re going to do it differently”?

KP: You know, this comes up a lot. My husband’s actually a technology guy and he always reminds me, technology should not replace any of these attributes–the coordination, the hands-on touch, a doctor and patients seeing each other in some fashion, or people talking to each other.  Technology should enable that.

I think the issue for the companies that I’ve been advising, and even when I’ve seen Dignity get involved in the innovation space with companies, has been more about where we can identify gaps–not just technology as an enabler.  Even in institutions that don’t necessarily have the culture just right or all those dynamics figured out, where can technology actually help improve the work flows, the data exchange?

So that doesn’t necessarily take wholesale clinical or patient-centered leadership.  It just takes in each organization from where they are right now and understanding how the product you’re developing can take them forward in their trajectory.  If you’re an organization like Dignity that’s a little more advanced, it’s going to be a different trajectory, and it’s going to be a different technology.  Where I practiced primary care, for example, it might be much more basic, but it could still be a really valuable asset for the doctor, the patient, the institution or on the flip-side, for the entrepreneur.

I’ll just say this, I know you’re not asking this but I find myself sometimes doing a lot of head tilting when I meet entrepreneurs who are extremely gifted and have an amazing depth and skill set for niche area of analytics, developments, technology platforms, cloud based solutions. I try to have them understand how complex the health care process is.  Technology has a huge a role in simplifying it but at the same time the developer or the entrepreneur needs to understand the non-technology part of this and how they should understand all that exist. When a patient is scared, for example, how can technology bolster and support that interaction?

That’s something that’s really hard to do.  That’s not something I find myself having a solution to.  But Matthew, your organization has been, in my mind, one of the higher functioning organizations that help people push their limits of thinking.  This is exactly where we need to go.  I’m a big believer of user-driven design.  I think that’s a component that really is missing from some of our solutions today.

Join Kavita Patel (The Brookings Institute), Matthew Holt (Health 2.0), and Deven McGraw during her Master Class in U.S. Health Care Policy Workshop. You can register on the website here.

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3 replies »

  1. As for computerization and documentation requirements, I hear too many complaints, especially from primary care doctors, that it takes too much time away from being able to meet with and talk to patients. If they can’t see as many patients per day as they did before and adequately address their issues and complaints, they have to raise their charges significantly to cover their overhead and earn a respectable living. It looks like the technology is causing more problems than it solves to me.

  2. I don’t really see anything wrong with pursuing value / bundling where it makes sense and not pursuing it where it doesn’t make sense.

    A concept like capitation may work for Kaiser which has 8-9 million members and also has an insurer as a key part of its organization. It doesn’t work so well for an ACO with a few hundred or a few thousand assigned members who, if on Medicare at least, are allowed to see providers outside of the ACO. A very small number of very expensive outlier cases can easily blow up the economics of the payment model.

    As for computerization and documentation requirements, I hear too many complaints, especially from primary care doctors, that it takes too much time away from being able to meet with and talk to patients. If they can’t see as many patients per day as they did before and adequately address their issues and complaints, they have to raise their charges significantly to cover their overhead and earn a respectable living. It looks like the technology is causing more problems than it solves to me.

    I wish there were an easy and comprehensive way to inform doctors, especially in hospital emergency rooms, about the following information for each patient: medications, allergies, if any, the names of doctors treating the patient, any significant diseases or conditions the patient has and whether or not there is a DNR, living will or advance directive. The patient’s insurer could presumably provide at least some of this information if the patient or a family member can’t.

  3. I understand why everyone wants us to get paid by some unit of value. My problem is that I find it is difficult to group services that could be valued in a standardized scheme that would be useful. A few things do fit: fix an arthritic knee or hip; treat an aspiration pneumonia; maybe CHF-uncomplicated; hernia; appendicitis; almost fractured bone except some in the feet that never heal; psoriasis; most skin tumors. Colds. UTIs. You get it. We can all intuit these.

    It is easier to find illness that would never fit into groupings (that would have some standardized value): all mental disease. All drug re-hab problems. Almost all sepsis. Most pulmonary interstitial fibrosis. Most lung masses; Most rheumatoid and auto-immune disorders. Most renal disease. All neurodegenerative diseases, et al infinitum. Essentially these are the illnesses that have a large coefficient of variation in their LOSs in the hospital or in their episodes- of-care -times as outpatients. In fact, this might be a way to identify unbundleable services.

    How else can we bundle? or get services into value-able groups? Well, we could take a case with complicated co-morbidities and promise to do the intervention needed for just one component of the illness. Like we will manage the acute pulmonary embolism for one month for this amount of dough. But we will not guarantee any costs if there is found to be chronic thromboembolic pulmonary hypertension. Or, we will treat this aortic aneurysm surgically, but not promise to try to keep him going medically for months and months. In other words, we bundle for value where we can and bill FFS where we can’t.

    This seems shabby and slipshod to me.

    Another way we might go is to give bids on micro-capitation intervals. By this I mean that we try to guarantee our prices for a short term interval of say a week. Say we are in the middle of a complex case of endo-carditis and COPD and CHF….we could give a value bid for the next week of total care, including both hospital and physician care.

    But doesn’t this leave the payer without any comparisons? He can never relate our bids to those of other groups because the permutations are almost infinite. Scratch this.

    One soon comes to the conclusion that the value idea is OK, but that it is very difficult to implement in the trenches. But maybe there are additional approaches?