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Simon Nath

CMS Approval Another National Nod to the Power of Telehealth

Screen Shot 2016-03-11 at 3.43.26 PMApproximately 12 million Americans utilize some type of home health care every year.  From home health aides visiting the infirmed in their homes, to physical therapy services to aide in recovery, to medical equipment being used to treat the chronically ill, home health has been a critical component of care management for decades.

One of the Medicare payment requirements for these services is for the prescribing practitioner to have a “face to face” encounter with the patient within a reasonable timeframe. This has widely been viewed as a burden on patients, many of whom face mobility issues and other barriers to meeting this obligation. It has also been a barrier for our overburdened physician supply.

Just recently, CMS published a new rule extending this requirement to states – stating that home healthcare matching Medicaid funds will be linked to this same requirement.  But, there’s another component of the rule which mirrors Medicare and will have a tremendously positive impact on the home health care community – the face-to-face requirement can be met through telehealth.

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Optimistic Skepticism About the Future of Consumer Healthcare

Screen Shot 2016-03-08 at 9.23.41 AMHealthcare options are changing dramatically. Technological and market developments give people the power to take control of their own health and wellness, now more than ever before. Companies are constantly creating new consumer applications that seek to solve problems across the full spectrum of the healthcare lifecycle. These products include everything from contact lenses that measure blood glucose levels to an application that lets me chat with a psychiatrist at a moment’s notice. But despite recognizing the added convenience and personalization, I’m surprised by how frequently I ignore the sheer variety of products at my disposal in favor of doing things the old-fashioned way. Just this past week, I had to schedule my yearly checkup. Instead of booking my appointment through a service like ZocDoc or DocASAP, I instinctively grabbed my phone and tried to call a doctor. Why?

One reason is that just knowing about the existence of those services didn’t mean they immediately came to mind. Companies in other sectors such as entertainment or e-commerce can habituate customer behavior because their products cater to consumer needs that reoccur on a daily, or at least weekly, basis. This means that, if you can routinely provide a better user experience than your competitors, you establish customer loyalty. This is why when I want to binge watch TV shows, I immediately go on Netflix. Or when I need to buy a new pair of shoes, I always use Amazon. However, changing customer behavior regarding health is challenging because the nature of the behavior is infrequent and sporadic. Most people don’t get sick that often and, when they are healthy, it’s hard to convince them to remember to use app X, Y, or Z in preparation for the future. For a healthcare product to successfully disrupt the status quo, the added benefit or user experience has to be so formative that the person will remember the product the next time around, which could easily be months.

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Empathy and Shame

flying cadeuciiHow we respond to patients who are feeling, or at risk of feeling shame can make or break a therapeutic relationship. This is about how I try to respond.

Shame is a negative moral judgement about oneself. Unlike guilt or embarrassment where someone thinks that fundamentally they are a reasonable person who has done a bad thing, someone who feels shame thinks that they have done a bad thing because fundamentally, they are a bad person.

Guilt is when, for example, you feel bad that you forgot to call your mum on her birthday, but you might reasonably conclude that this doesn’t make you a bad person and so you decide to make up for it and call her the next day. Shame is when you conclude that you are (and have quite likely always been) a hopeless son or daughter who is always forgetting the important things in life and feel too despondent even to call the next day.

We should suspect shame in the following situations. A patient misses an appointment because they are afraid of being judged on the basis of their blood tests . Another fails to attend a follow-up appointment after having disclosed a history of child sexual abuse. The mother who took her child to an A&E department takes them to a different department the next day with the same feverish symptoms in order to avoid the clinician who said they were time-wasting the day before.

Situations where patients blame themselves for their perceived failure to take responsibility either for themselves or their dependents can arouse shame. Healthcare professionals have, in addition to their clinical authority, a moral authority and consciously (or more often not) and intentionally (or not) pass moral judgement on their patients’ behaviour if they do not acknowledge shame and self-blame.

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Quality v. Quantity

A few weeks ago, the medical community received unexpected good news from the government about a “simplification of quality measures:”

Strictly speaking, and contrary to what Mr. Slavitt’s tweet would lead us to believe, the agreement to the new rules was primarily between commercial insurers and CMS, the Center for Medicare and Medicaid Services. Physicians were not actually party to the deal.

Nevertheless, doctors were expected to greet the news with cheers. As Rich Duszak reported, Adam Slavitt, acting administrator for CMS, also declared that “patients and care providers deserve a uniform approach to measure [sic] quality.”

Indeed, we all deserve uniform quality measures. Equality in quality!

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Liberty Mutual: A Blow to Health Care Transparency

Charles OrnsteinThe U.S. Supreme Court dealt a blow this week to nascent efforts to track the quality and cost of health care, ruling that a 1974 law precludes states from requiring that every health care claim involving their residents be submitted to a massive database.

The arguments were arcane, but the effect is clear: We’re a long way off from having a true picture of the country’s health care spending, especially differences in the way hospitals treat patients and doctors practice medicine.

It also means that, for the time being at least, we’ll remain heavily reliant on data being released by Medicare, the federal health insurance program for the elderly and disabled, to study variations in health care. ProPublica has used Medicare data to study differences in medication prescribing, surgeons’ complication rates and use of services by doctors, but it’s still not clear that Medicare is representative of all health care in the country.

The court’s decision involves a case from Vermont, one of 18 states that created so-called all-payer claims databases. Vermont’s law called for health insurers, health providers, medical facilities and government agencies to report data on health care costs, prices, quality and use of services to the state. That included employers who pay the costs of their workers’ treatments themselves, and not through an insurance contract. (Self insurance is common for large companies.)

But Liberty Mutual Insurance Co. objected, saying the Employee Retirement Income Security Act of 1974, or ERISA, prevents states from imposing such a requirement on self-funded plans. The idea is that companies that have operations across the country shouldn’t be subjected to 50 different state laws, but instead should only have to abide by rules from one agency, namely the U.S. Department of Labor.

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Homo Ex Machina

flying cadeucii‘Temet Nosce’ or know thyself.

This is what The Oracle tells Neo when they first meet in The Matrix. Who we are and how we learn is a combination of our biology and our personal experiences. The plasticity of our minds and our genes make us individual persons in the world. Our individual mind and experiences are hard to offset. Sometimes we make decisions counter to our long-term wants because the wiring of our minds and our conditioned responses. Often it seems as if we are a slave to our desires and incapable of realizing our long-term goals. Would knowing myself better help me make better decisions?

Let me give you an example. As someone who has struggled with my weight, I would like nothing more than to make only healthy, evidence-based decisions when it comes to diet and exercise. But sometimes I don’t. A few months ago, I decided I needed to tip the scales in my battle against my desires. I downloaded a weight loss app, started counting steps and continued a lifelong practice of mindfulness, all in an effort to override those short-term desires and work toward my long-term goals. And I, like Oprah, lost 26 pounds over several months (both of us eating bread)!

Most of us struggle in one way or another with some sort of addiction, desire, impulse or emotion — by just being human — and understand all too well what it means to be enslaved to the biological machine. The awesome thing is now we seem to have digital tools to help set us free.

While walking (miles according to fitness tracker) at the HIMSS16 conference, something dawned on me. Many of the enterprise health IT software solutions that I saw at the conference and have spent most of my professional life with would do little to help me with obesity and to prevent me from developing diabetes. They are very helpful if I end up sick in a hospital but have little to do with preventing me from getting there. The consumer-centric technology counting my steps or my mobile solution helping me become aware of what I am eating might just do it.

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Not Quite DOA: Why Reports of the Demise of the President’s Budget May be Exaggerated

Ceci ConnollyAnyone who has spent a few years in Washington knows the federal budget dance: President stands behind podium with a fancy seal and flags and unveils a giant tome. The next morning newspapers declare the tome DOA, Dead on Arrival. And we all return to regularly scheduled programming.

This year was no exception. Even the White House seemed to acknowledge the fact by releasing the 182-page blueprint on the same day as the Iowa caucuses with Donald Trump, Bernie Sanders and Ted Cruz grabbing the headlines.

But budget nuggets have a way of seeping into the policy fabric and eventually taking hold. Legislative staff scrub the document for ideas, not to mention numbers. Candidates steal liberally, adding favorites to their rhetorical arsenal. Eventually, some of those candidates become lawmakers, cabinet secretaries and even president. So the ideas live on.

Happily, President Obama chose his final budget proposal to draw attention to the inexplicable, indefensible rise in drug prices in this country. Our nonprofit, provider-sponsored plans know better than most the clinical value of so many of today’s medications. At ACHP, we have the privilege of partnering with organizations that are in pursuit of the 4Rs – the Right patients receive the Right treatments at the Right time for the Right price. From Capital Health Plan’s Center for Chronic Care, which reduces health costs for the entire community by providing concierge-type care for the sickest one percent of Capital members, to Group Health Cooperative of South Central Wisconsin’s pioneering initiative embedding pharmacists in primary care clinics to track patients who may need additional treatment management, ACHP members are working to ensure patients always receive the medications they need.

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EMR Data show: The ACA has Improved Access to Care for Low-Income Patients

As Barack Obama’s presidency draws to a close, we anticipate growing discussion of his legacy. Much of that discussion will focus on the Affordable Care Act (ACA), his signature legislative accomplishment. The legislation is complex and in some cases ineffective and cumbersome. It can be argued, for example, that the complexity of the ACA favors the same high-cost, legacy health care players that the bill was designed to address.

But one of the major goals of the ACA was to provide more accessible, more dignified, and more effective health care to the poor. And in this respect, we believe that the Affordable Care Act – at least in those states that have elected to expand Medicaid – has been a success.

Our perspective on health care reform comes from ACAView, a joint initiative between the Robert Wood Johnson Foundation (RWJF) and athenahealth to study the impact of health care reform. We have just released our latest report, The Effects of the Affordable Care Act through 2015, which focuses on the impacts of insurance coverage expansion for patients and providers, with an emphasis on primary care. This report analyzes data from 21,900 health care providers on athenahealth’s network for at least five years. These physicians, who serve communities across the nation, are broadly representative of the country as a whole (please refer to the Appendix of the latest report). This allows us to compare physician practice before and after the coverage expansion provisions went into effect in 2014.

In June 2012, the Supreme Court ruled in “National Federation of Independent Business (NFIB) v. Sebelius” that states could choose whether or not to expand Medicaid eligibility. Although the federal government would cover the full cost of coverage expansion through 2016 and gradually decreasing to 90 percent of it thereafter, about half of the states declined to provide expanded Medicaid access to low income people. Since that time, six of those states have changed course and made Medicaid available to more of their residents.

In those states that agreed to loosen Medicaid eligibility requirements, there was no guarantee that the law would improve health care access for low income people. Because Medicaid payment levels are much lower than commercial rates, some observers were concerned that physicians would not open their schedules to see more Medicaid patients. And when patients did come in for care, no one knew whether they would form ongoing relationships with physicians or merely receive one-off care for acute or symptomatic issues.

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Building Virtual Kaisers: Transcending Healthcare’s Tower of Babel

The Tower of BabelTwenty years ago this month, California created an organizational architecture for integrated delivery systems taking global capitation—the restricted Knox-Keene (RKK) license.

At its creation, I envisioned the RKK as a pathway to virtual Kaisers.

This post distills the RKK’s guideposts for provider organizations on that pathway.

It also summarizes a straightforward path to transcend the biggest barrier to fluid, integrated care—healthcare’s Tower of Babel.

Organizational architecture for full risk. Many provider organizations do a very good job delivering patient care; very few have the systems or experience to effectively administer benefit arrangements.

Taking full risk for patient care requires both.

RKK provider organizations meet all Knox-Keene standards governing the provision of healthcare services, including requirements to provide continuity of care, assure timely access to healthcare services and separate medical decisions from fiscal management.

Without a strong financial footing, provider systems taking full risk put their patients at risk for care disruptions.  RKK licensees must maintain a minimum net worth and assure that incurred-but-not-reported claims are reflected in the organization’s books and records.

Licensees also need grievance systems to address patient and non-contracting provider complaints.

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