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Reducing Churn to Increase Value in Health Care: Solutions for Payers, Providers, and Policymakers

Saeed Aminzadeh
Niko Lehman-White

By NIKO LEHMAN-WHITE and SAEED AMINZADEH

Introduction
Every day and in every corner of the country, innovative health care leaders are conceiving of strategies and programs to manage their patients’ health, as an alternative to treating their sickness (see Figure 1).

The value-based contracts that have proliferated in this country over the past decade and which now account for about half of the money spent on healthcare allow these wellness investments to make good financial sense in addition to benefiting patient health.

However, a phenomenon in health coverage in the US is increasing costs, destabilizing care continuity and holding back the potential of value-based care. It prevents us from making the long-term investments we desperately need.

Understanding Churn

Churn refers to gaining, losing, or moving between sources of coverage. Every year, approximately a quarter of the US population switches out of their health plan. Reasons can be voluntary or involuntary from the perspective of the beneficiary (see Table 1) and vary from changes in job status, eligibility, insurance offerings, and preference, to non-payment of premiums, to unawareness of pending coverage termination.

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MedPAC’s Latest Bad Idea: Forcing Doctors to Join ACOs

By KIP SULLIVAN, JD

At its April 4, 2019 meeting, the staff of the Medicare Payment Advisory Commission (MedPAC) asked the commission to discuss a very strange proposal: Doctors who treat patients enrolled in Medicare’s traditional fee-for-service (FFS) program must join an “accountable care organization” (ACO) or give up their FFS Medicare practice. (The staff may have meant to give hospitals the same Hobbesian choice, but that is not clear from the transcript of the meeting.)

Here is how MedPAC staffer Eric Rollins laid out the proposal:

“Medicare would require all fee-for-service providers to participate in ACOs. The traditional fee-for-service program would no longer be an option. Providers would have to join ACOs to receive fee-for-service payments. Medicare would assign all beneficiaries to ACOs and would continue to pay claims for ACOs using standard fee-for-service rates. Beneficiaries could still enroll in MA [Medicare Advantage] plans. (p. 12 of the transcript)”

The first question that should have occurred to the commissioners was, Are ACOs making any money? If they aren’t, there’s no point in discussing a policy that assumes ACOs will flourish across the country.

But only two of the 17 commissioners bothered to raise that issue. They asserted that Medicare ACOs are saving little or no money. Those two commissioners – Paul Ginsburg and commission Vice Chairman Jon Christianson – did not mince words. Ginsburg said ACO savings were “slight” and called the proposal to push doctors into ACOs “hollow” and premature. (pp. 62-63) Christianson was even more critical. He said the proposal was “really audacious,” and that no “strong evidence” existed to support the claim that ACOs “can reduce costs for the Medicare program or improve quality.” (pp. 73-74) Ginsburg and Christianson are correct – ACOs are not cutting Medicare’s costs when Medicare’s “shared savings” payments to ACOs are taken into account, and what little evidence we have on ACO overhead indicates CMS’s small shared savings payments are nowhere near enough to cover that overhead.

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LIVE — #SPM2018

Here’s the live stream of today’s Society for Participatory Medicine’s conference in Boston:

Health in 2 Point 00 Episode 54

On Today’s episode of healthin2point00, Jess asks me about the CVS & Aetna’s merger, CSweetner & HIMSS new partnership in women’s health care, HLTH’s new pledge with Parity.org, Noona Healthcare getting acquired by Varian Health Systems. And as Jess point out, all health tech deals somehow involve me! Jess also did an interview with AHIP, you can watch her here: If you are in Boston, join us at Society of Participatory Medicine’s conference at #CHC2018- Matthew Holt

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Health in 2 Point 00 Episode 51

In this Episode of #healthin2pt00 Jess & I do a real recap of the Health 2.0 Conference. I mention some of the startups that I thought were great, including Supportiv, Tag.bio, Nebula Genomics, Bluestream Health, Medically Home, b.well, and Medsafe. I also want to highlight Krista from Project HEAL that started an organization to raise awareness about mental health & eating disorders. We also discuss #CMS and Ro receiving $88 million in its funding round- Matthew Holt

The First Post: What’s Wrong with Medicare?

By MATTHEW HOLT

So The Health Care Blog  (which I like to think of as the first proper health care blog whatever Jacob Reider says about his Docnotes which started in 1999!) is 15 yrs old this month.  This is the start of our little anniversary celebration. We are going to be running some of the earlier classic posts. The very first post on “What’s wrong with Medicare” still rings true- Matthew Holt

For the first post, don’t expect a big essay despite that subject line. It came up because while I was away from the US for the first part of this year, yet another incarnation of NME or HCA — the two original for profit hospital chains of the 1970s that amalgamated into Columbia (now calling itself HCA again!) and Tenet — got caught with its hand in the cookie jar.  You’ll remember NME getting bad press and worse in the 1980s for imposing unwanted inpatient stays on “psychiatric patients”. After that NME morphed into Tenet. Columbia of course said that “health care had never worked like this before” and they were right — to the extent of the upcoding and fraudulent billing going on in its hospitals in the mid 1990s.  I remember one cover of Modern Healthcare in which Tenet’s strategy was encapsulated as “We’re not Columbia”.  Apparently only slogan deep. Last week they settled with the state and feds in California due to massive amounts of upcoding and worse at Redding Medical Center. Several other settlements are pending.

The New York Times’ description (registration req’d) of the level of unnecessary surgery at the Redding Medical Center is quite shocking. But I do recall Alain Enthoven at Stanford telling me in 1991 that one third of carotid andarterectomies in California were found to be counter-indicated after chart review.  Why were they done?  Well everyone — surgeons, hospitals, supplier– made money by doing them. Given the imbalance in knowledge between a patient and a doctor, it’s not too surprising that a very aggressive surgeon can do way more than he or she should.  Medicare is still basically a fee-for-service program with very little oversight, and so this type of thing is going to go on and on. And it has been going on for a while, as this partial list of whistlebower suits shows. Enthoven’s view was that everyone should be put into competing managed care plans which would act as patient (and payer) sponsors, and look after the money better than the government could.  It didn’t happen that way, and the backlash against managed care’s ham-fisted attempts to do so ensured that most health plans gave up on trying to control what providers did.  Medicare never really ever tried, as all its internal review cases were co-opted by providers.  Its only weapons were inquisitions and indictments from the FBI and others well after the fact. Eventually Medicare will have to have more controls, but that will need reform as well as more money. I’ll talk more about this when I get to drug coverage later this week.  Suffice it to say, don’t hold your breath.

Meanwhile, Uwe Reinhardt says in the NY Times article that (despite Wall Street’s desires) hospitals “can’t be a growth industry like some Internet company”. Well maybe not a “growth” sector, Uwe, but look at Yahoo’s stock price in 2000, Tenet’s this year, and tell me that you’re not getting some of that Internet fever coming back!

Matthew Holt is the Founder of THCB.

Susannah Fox on Teens & Digital Health Study

How are teens and young adults engaging with digital health? Results of a national survey asking just that were released today by Susannah Fox (Former CTO at US Dept of HHS) and her research partner, Victoria Rideout.

You can check out the full report of the findings here, but I spoke with Susannah in April, just as she and Victoria were starting to draw some insights from their work.

Hearing her talk about the survey at this stage of synthesis is not only unique (most researchers won’t talk until the findings are published) but more so because it adds a layer of understanding to the final results now that they’re here.

We get her candor about how teens and young adults are a wildly viable – yet very overlooked – market for digital health…

We see how she’s trying to formulate a much larger hypothesis about what healthcare can learn about social media from a generation that has never lived without it and, more importantly, view it as having a positive impact on their well-being…

And, probably most inspiring to me, we see an approach to health data that stands out for its warmth. For it’s love, really. In a world of big data and clinical trials, it’s endearing to hear from someone who is taking a more anthropological approach and who has fallen absolutely, head-over-heels in LOVE with the personal side of her dataset.

As we all clamor for a patient-centered end, we’d be remiss to underestimate the value of a human-centered starting point. Watch Susannah Fox for a strong model of how this can be done in health research.

Filmed at Health DataPalooza, Washington DC, April 2018. Find more interviews with the people pushing healthcare to better tomorrow at www.wtf.health

Medical Care in Rural India

By SAURABH JHA

I’ve humbly realized that doctors aren’t always indispensable. When I was three, a compounder – a doctor’s assistant – allegedly saved my life. Dehydrated from severe dysentery, I was ashen and lifeless. My blood pressure was falling and I would soon lose my pulse. I needed fluids urgently. An experienced pediatrician could not get a line into my collapsed veins. When hope seemed lost, his compounder gingerly offered to try, and got fluids inside my veins on the first attempt. My pulse and color returned and I lived to hear the tale from my mother.

So, on a recent trip to India, I was intrigued by Birju, a compounder in my ancestral village in Bihar, who the villagers revere like a doctor. After assisting a city physician for ten years, Birju had started his own practice. He has no formal training in healthcare. Even his education was partial – he left school at fourteen to help his father, who also was a compounder.

I wanted to see Birju practice his craft. So, I visited his clinic which is actually a shop. Birju sells stationery, conveniences such as shaving foam, and medications, which was just as well, as I needed Imodium to calm my angry Americanized bowel.

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The Past, Present and Future of Health Care

OK, so it’s a tad of an ambitious title… but it was a talk that I gave in Finland last month. I had fun looking at the development of health and technology and suggesting a structure for the future. Plus I got to tell my Neil Armstrong joke. The talk was part of the Upgraded Life Festival in Helsinki and you can see some of the other speakers videos on their channelMatthew Holt

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