As healthcare gradually tilts from volume to value, physicians and hospitals fear the instability of straddling “two canoes.” Value-based contracts demand very different business practices and clinical habits from those which maximize fee-for-service revenue, but with most income still anchored on volume, providers often cannot afford a wholesale pivot towards cost-conscious care. That financial pressure shapes investment and procurement budgets, creating a downstream version of the two-canoe problem for digital health products geared toward outcomes or efficiency. Value-based care is still the much smaller canoe, so buyers de-prioritize these tools, or expect slim returns on such investment. That, in turn, creates an odd disconnect. Frustrated clinicians struggle to implement new care models while wrestling with outdated technology and processes built to capture codes and boost fee-for-service revenue. Meanwhile, products focused on cost-effectiveness and quality face unexpectedly weak demand and protracted sales cycles. That can short-circuit further investment and ultimately slow the transition to value.
To skirt these shoals, most successful innovators have clustered around three primary strategies. Each aims to establish a foothold in a predominantly fee-for-service ecosystem, while building technology and services suited for value-based care, as the latter expands. A better understanding of these models – and how they address different payment incentives – could help clinicians shape implementation priorities within their organizations, and guide new ventures trying to craft a viable commercial strategy.
A mere two decades ago, the headlines were filled with stories about the “HMO backlash.” HMOs (which in the popular media meant most insurance companies) were the subject of cartoons, the butt of jokes by comedians, and the target of numerous critical stories in the media. They were even the bad guys in some movies and novels. Some defenders of the insurance industry claimed the cause of the backlash was the negative publicity and doctors whispering falsehoods about managed care into the ears of their patients. That was nonsense. The industry had itself to blame.
The primary cause of the backlash was the heavy-handed use of utilization review in all its forms –prior, concurrent, and retrospective. There were other irritants, including limitations on choice of doctor and hospital, the occasional killing or injuring of patients by forcing them to seek treatment from in-network hospitals, and attempts by insurance companies to get doctors not to tell patients about all available treatments. But utilization review was far and away the most visible irritant.
The insurance industry understood this and, in the early 2000s, with the encouragement of the health policy establishment, rolled out an ostensibly kinder and gentler version of managed care, a version I and a few others call Managed Care 2.0. What distinguished Managed Care 2.0 from Managed Care 1.0 was less reliance on utilization review and greater reliance on methods of controlling doctors and hospitals that patients and reporters couldn’t see. “Pay for performance” was the first of these methods out of the chute. By 2004 the phrase had become so ubiquitous in the health policy literature it had its own acronym – P4P. By the late 2000s, the invisible “accountable care organization” and “medical home” had replaced the HMO as the entities that were expected to achieve what HMOs had failed to achieve, and “value-based payment” had supplanted “managed care” as the managed care movement’s favorite label for MC 2.0.
As physicians and healthcare leaders, we are already well aware that the majority of patients do not have the information they need to make a medical decision or access to appropriate resources, so we didn’t need to hear more bad news. But that is precisely what new research once again told us this spring when a new study showed that almost half of the time, patients have no idea why they are referred to a GI specialist.
While the study probably speaks to many of the communications shortcomings we providers have, across the board our patients often don’t know what care they need, or how to find high-value care. Last year, my organization commissioned some original research that found that while a growing number of patients are turning to social websites such as YELP, Vitals, and Healthgrades to help them find a “high quality” specialist, the top-ranked physicians on these sites – including GI docs – are seldom the best when we look at real performance data. Only 2 percent of physicians who showed up as top 10 ranked on the favorite websites also showed up as top performers when examining actual quality metrics. (The results shouldn’t surprise you as bedside manner has little to no correlation with performance metrics such as readmission rates).
As providers and health care leaders, we lament that our patients are not better informed or more engaged and yet across the board, we have not given them the tools or resources they need to navigate our complex system. But now for some good news: all hope is not lost, and patients can become better consumers, albeit slowly, if we all do our part.
The focus on the CMS rules on information blocking continues on THCB. We’ve heard from Adrian Gropper & Deborah Peel at Patients Privacy Rights, and from e-Patient Dave at SPM and Michael Millenson. Now Adrian Gropper summarizes — and in an linked article –notates on the American Hospital Association’s somewhat opposite perspective–Matthew Holt
It’s “all hands on deck” for hospitals as CMS ponders the definition and remedies for 21st Century Cures Act information blocking.
This annotated excerpt from the recent public comments on CMS–1694–P, Medicare Program; Hospital Inpatient Prospective Payment Systems… analyzes the hospital strategy and exposes a campaign of FUD to derail HHS efforts toward a more patient-centered health records infrastructure.
Simply put, patient-directed health records sharing threatens the strategic manipulation of interoperability. When records are shared without patient consent under the HIPAA Treatment, Payment and Operations the hospital has almost total control.Continue reading…
A ‘single-payer’ plan is a target on the back of its supporters. But what about a ‘Medicare Public-Private Partnership’?
MOUNT VERNON — In February 2017, President Trump famously said: “Nobody knew health care could be so complicated.” Nobody other than about 99.9 percent of the almost 300 million people in the U.S. with insurance, that is. Yesterday, I received a copy of “Get to know your benefits,” the 236-page “booklet” for my new health plan. Like most people, I’ll never read the book, but its weight alone says “complicated.”
And it’s safe to guess that Trump also will never read his Federal Employee Health Plan information, even though one Aetna choice available to him has a “brochure” of only 184 pages. Thinking about the amount of information available to health insurance plan consumers, I began to wonder what Health and Human Services Secretary Alex Azar meant, also last February, when he said, “Americans need more choices in health insurance so they can find coverage that meets their needs.”
Presumably, were we to have more choices, we could study the hundreds of pages of information about each available plan and make better choices. According to the federal Office of Personnel Management, federal employees who live at 1600 Pennsylvania Ave., Washington, D.C. 20500, have a choice of 35 monthly plans. Too bad the president doesn’t live in Maine, where he’d have only 20 plans to study!
I’ve been a proponent of marijuana legalization since I heard about it in high school. I lived in the UK in the 1970s when it was not easily available! So I was a legalization proponent before I’d ever touched the stuff. Nearly four decades later, it’s legal in many states, Canada and Uruguay and most — but by no means all — of the drug war hysteria is recognized for the idiocy it is. But while anyone who’s got stone and had the munchies knows that pot is a good appetite enhancer and antiemetic, there are now a bunch of claims being made about cannabidiol (CBD). So I thought we’d explore them. We’re including a video from ZdoggMD which gives a balanced view of the (appalling lack of) data so far, and an article from Donna Shields, co-founder of the Holistic Cannabis Academy. Donna, as you may guess, thinks it’s pretty useful. And while you think this may still be on the edge, a CBD company called Sagely Naturals won the recent G4A contest held by old world big Pharma company Bayer—Matthew Holt
It’s come onto the healthcare scene like a rocket yet most people don’t really understand what cannabidiol (CBD) is, how to use it and the results one can expect. Here’s a primer on the basics you need to know.
Do you know about the endocannabinoid system
We all have an endocannabinoid system; a network of receptors throughout the body whose job is to maintain homeostasis and well-being for all our organs. Like a master control system. And while our bodies make their own cannabinoids, life, through stress, toxins, poor diet and illness, has a way of depleting the in-house supply or making those receptors “less receptive”. This is when adding cannabinoids, such as CBD, can be a helpful boost.
Marijuana vs Hemp
The mother plant, called Cannabis sativa, can be cultivated to grow marijuana (the plant containing THC, CBD, and other cannabinoid compounds) or hemp, a crop with many uses from food products to building materials. Hemp also contains CBD (cannabidiol), but less than 0.3% THC. CBD is just one of over 80 different cannabinoid compounds found in both marijuana and hemp. Hemp-derived CBD products are available at retail stores and online; while marijuana-derived CBD products are available cannabis dispensary stores.
My second foray into Suboxone treatment has evolved in a way I had not expected, but I think I have stumbled onto something profound:
Almost six months into our in-house clinic’s existence, I have found myself prescribing and adjusting treatment for about half of my MAT patients for co-occurring anxiety, depression, bipolar disease and ADHD as well as restless leg syndrome, asthma and various infectious diseases.
Years ago, working in a mental health clinic, we had strict rules to defer everything to each patient’s primary care provider that wasn’t strictly related to Suboxone treatment. One problem was that many of our patients there didn’t have a medical home or had difficulty accessing services. Another problem was that primary care providers unfamiliar with opioid addiction treatment were uncomfortable prescribing almost anything to patients on Suboxone.
WTF Health – ‘What’s the Future’ Health? is a new interview series about the future of the health industry and how we love to hate WTF is wrong with it right now. Can’t get enough? Check out more interviews at www.wtf.health.
How can patients help usher in a better future for healthcare? Start speaking up. LOUDLY.
In this WTF Health interview, meet one of health’s most outspoken patient advocates, Twitter voices (@mightycasey) and podcasters, Casey Quinlan of Mighty Casey Media, who talks about her patient journey as a cancer survivor — and why the awful experience led her to tattoo a QR code linking to her electronic medical record to her chest.
Casey’s ‘physical political protest’ is tied to her passionate views about the lack of data liquidity in healthcare and how patients suffer as a result. She’s launching a new “If-You’re-Selling-My-Health-Data-Cut-Me-In” Movement and weighs in on why more patients aren’t clamoring after their health data to push real change in the healthcare system.
Filmed at Health Datapalooza in Washington DC, April 2018.
Executive Summary of PPR Comments on Information Blocking
Information blocking is a multi-faceted problem that has proved resistant to over a decade of regulatory and market-based intervention. As Dr. Rucker said on June 19, “Health care providers and technology developers may have powerful economic incentives not to share electronic health information and to slow progress towards greater data liquidity.” Because it involves technology standards controlled by industry incumbents, solving this problem cannot be done by regulation alone. It will require the coordinated application of the “power of the purse” held by CMS, VA, and NIH.
PPR believes that the 21st Century Cures Act and HIPAA provide sufficient authority to solve interoperability on a meaningful scale as long as we avoid framing the problem in ways that have already been shown to fail such as “patient matching” and “trust federations”. These wicked problems are an institutional framing of the interoperability issue. The new, patient-centered framing is now being championed by CMS Administrator Verma and ONC Coordinator Rucker is a welcome path forward and a foundation to build upon.
To help understand the detailed comments below, consider the Application Programming Interface (API) policy and technology options according to two dimensions:
API Content and Security
Institution is Accountable
Patient is Accountable
API Security and Privacy
Broad, prior consent
Known to the practice
API Content / Data Model
Designated record set
Bulk (multi-patient) data
Designated record set
Wearables and monitors
This table highlights the features and benefits of interoperability based on institutional or individual accountability. This is not an either-or choice. The main point of our comments is that a patient-centered vision by HHS must put patient accountability on an equal footing with institutional accountability and ensure that Open APIs are accessible to patient-directed interoperability “without special effort” first, even as we continue to struggle with wicked problems of national-scale patient matching and national-scale trust federations.
Here are our detailed comments inline with the CMS questions in bold:Continue reading…
As promised I’m going to be featuring more interesting companies I’m working with on THCB. Supportiv, which is launching today in beta (App store/Play) is a thoroughly modern answer to the problem of scaling peer support in mental health. It’s aimed in the space between the mediation apps like Headspace & Calm, and the online therapy services like AbleTo or Lantern. The target market is anyone feeling stress or wanting support in a quick and easy format–that’s basically everyone! Using the magic of NLP, those looking for support are steered into a chatroom where a trained moderator (usually a Masters student in psychology) making sure the experience is smooth. In its trials earlier this year of the 48,000 users, 96% reported improvement. The business model? It costs 15 cents a minute, or $4.50 for 30 mins (which is roughly the expected length of a session). There’s lots of science behind the idea that peer support works but to hear more Jessica DaMasssa interviewed the co-founders Pouria Mojabi & Helena Plater-Zyberk.