Tag: Vince Kuraitis

ACOs: Is There a “There” There?

Nov 29, 2012• 2

By Vince Kuraitis, JD

A recent analysis of the ACO market by Oliver Wyman market suggests we’re well on our way toward being “there.”

My personal take on this report:

Provocative, fresh, thoughtful, well reasoned, expansive — albeit a bit of a stretch

However, I suspect many others will describe it as:

Speculative, harebrained, unsupported, overly extrapolative, out-to-lunch, wishful to the point of being woo woo.

So now that I hopefully have your attention, what’s this report all about? In a nutshell:

The healthcare world has only gotten serious about accountable care organizations in the past two years, but it is already clear that they are well positioned to provide a serious competitive threat to traditional fee-for-service medicine. In “The ACO Surprise,” our analysis finds that 25 to 31 million Americans already receive their care through ACOs—and roughly 45 percent of the population live in regions served by at least one ACO.

Let’s dig in to the report. In this blog post, I’ll summarize their math, surface their critical assumptions and observations, and comment on their reasoning. I’ve indented direct quotations from the report.

While I don’t agree with all of Oliver Wyman’s math and assumptions, I applaud them for the process they have gone through. Please take my commentary as “quibbling at the edges” and that overall I’m on board with their methodology and conclusions.

Are Hospital Business Models on a Burning Platform? Not Yet, But It’s Inevitable.

Sep 6, 2012• 8

By Vince Kuraitis

From reading recent headlines, one might easily get the impression that hospitals are resistant — or at least ambivalent — in their pursuit and adoption of accountable care initiatives.

Are Hospitals Dragging their Feet on Accountable Care?

Commonwealth Fund: “only 13 percent of hospital respondents reported participating in an ACO or planning to participate within a year”

KPMG Survey: “(only) 27 percent of [health system] respondents said current business models were either not very or not at all sustainable over the next five years”

Health Affairs: “Medicare’s New Hospital Value-Based Purchasing Program Is Likely To Have Only A Small Impact On Hospital Payments”

The Bigger Picture

Do hospitals today perceive their current business model on the metaphorical “burning platform” — when the status quo is no longer an alternative?

The answer from the headlines above might suggest “no”, but I believe the correct answer is “not yet, but it’s inevitable”. Hospitals are feeling the heat, but it’s just not yet hot enough to jump off the platform and abandon existing business models.

Hospitals…Thinking About Getting Into Health Insurance? 6 Reasons To Lie Down Until the Urge Goes Away.

Aug 28, 2012• 10

By Vince Kuraitis

Gregg Masters reports on a recent Kaiser Health News article: Hospitals Look to Become Insurers, As Well as Providers of Care”.

This is the dumbest idea I’ve heard since “I’m going to invest all my money in Facebook’s IPO and get rich!”

Here are six reasons why:

1) You’re too late. Health insurance was an attractive and profitable business in the 00s, but after passage of the Accountable Care Act it’s been commoditized.

First, the health plan business model of the past decade is dead. That model was — “Avoid and shed risk” — or more simply, avoid insuring people who are already sick (preexisting conditions) and get rid of people who become sick (rescissions). Under the ACA, health insurers must take all comers and they can rescind policies only for fraud or intentional misrepresentation.

Second, the ACA institutes medical loss ratio restrictions on health insurers. Depending the the type of plan, insurers now must spend at least 80-85% of premium dollars on paying medical claims; if they spend less, they must return these “excess profits” as rebates to customers. As a result, health insurance has become a highly regulated quasi public utility.

This is why you see health plan CEOs like Mark Bertolini of Aetna declaring “Health insurers face extinction”. The old health insurance model is on a burning platform, and health plans are reformulating themselves as companies involved in health IT, analytics, data mining, etc.

2) You have bigger fish to fry. Focus on developing accountable care capabilities. The AHA estimated that hospitals will need to spend $11-25 million to develop an ACO. Get going.
Continue reading…

A Field of Dreams?

Jun 28, 2011

By VINCE KURAITIS

A study released last week by the Massachusetts Attorney Generalcontains surprising data to challenge two commonly held ACO (accountable care organization) ”Field of Dreams” assumptions. These assumptions relate to patient ”leakage” — out-of-network patient care and referrals.

1) Hospital administrators assume that tighter physician-hospital integration (e.g., through employment of physicians) will result in ”captive referrals” by physicians back to the mother-ship hospital.

2) Medicare administrators are assuming that Medicare Shared Savings ACOs will be able to coordinate patient care even without limitations on patients’ choice to go to providers outside of the ACO provider network.

Here’s the data that challenges the validity of BOTH of these assumptions:

Particularly for provider systems where hospitals and physicians are jointly at risk for the quality and cost of patients’ care, and have worked together to coordinate and improve care, we would expect to see physicians referring to their partner hospital more often. However, for the two physician-hospital provider systems in Massachusetts with the most years of experience managing referrals for HMO/POS patients under a global payment, one health insurer’s 2009 referral data shows that only 35-45% of adult inpatient care, as measured by revenue, goes to the partner hospital. That percentage can be even lower for providers with little to no experience managing where their patients receive specialist/hospital care, or under plan designs that do not require referrals. [emphasis added]

Continue reading…

A Rebuttal to PHR Luddites

Apr 27, 2011• 4

By VINCE KURAITIS

Unlike some of my colleagues, I’m not losing ANY sleep over whether personal health record (PHR) systems ultimately will be adopted and used by patients.

In my mind, the issue isn’t WHETHER, but WHEN.

Yes, I know that adoption has lagged and that surveys suggest 7% or less of the U.S. population has used a PHR.

Stay with me on this one for a minute. You’d have to have two underlying beliefs to conclude that PHR systems won’t eventually emerge:

That health record data will persist in non-electronic formats, i.e., paper
That people won’t have interest in accessing or using their health record data

Please think about this a moment. If you truly believe PHRs will continue to remain a non-starter, then you MUST logically believe in one or both of these assumptions.Continue reading…

Why Direct is a Hit and PCAST is an Outcast

Apr 15, 2011• 2

By VINCE KURAITIS

Regular readers know that I find Professor Clay Christen’s theory of disruptive innovation to be a useful lens to explain industry evolution. Let’s look at two recent health IT initiatives and see why one is working and the other is stalled.

Characterizing the Direct Project — why it’s working:

A low-end industry disruption. The Direct Project takes transactions that are routine but inefficient — fax, telephone, mail exchanges between health care providers — and specifies standardized, Internet based technologies to conduct them electronically.
Incremental change — a few specified transactions.
Bottom up — ONC hired a capable project manager (Arien Malec) who choreographed a small team of volunteers working under short deadlines.
Implementing “better, faster, cheaper” technology on the fly (i.e., Internet transactions replace fax, phone).
Under the radar — invoking little response from incumbents. Direct was seen as focusing on transactions that were peripheral to the core EHR.Continue reading…

The Thing to Watch in the Medicare ACO Regulations

Mar 30, 2011• 6

By VINCE KURAITIS

Health care lobbyists and advocates are bracing for six pages of the health care reform law to explode into more than 1,000 pages of federal regulations when the Department of Health and Human Services releases its long-delayed accountable care organization rules this week. Politico

What should you be looking for as you snuggle by the fireplace this weekend reading the draft ACO regs?

Rob Lazerow writes a helpful article listing 5 Things to Watch in the Medicare Shared Savings Program Proposed Rule. His list of five key design issues includes:

How will patients be assigned to ACOs?
To what cost benchmark will ACOs be compared?
How will bonuses be calculated and paid?
For which quality metrics will ACOs be responsible?
What is the application process?

I’d like to add a sixth item — which actually would be #1 on my list.

As I’ve previously written, IMHO the central issue around ACOs is:

Are (hospitals and doctors) viewing ACOs as a way to truly develop patient centric, collaborative care or as a means toward consolidating market power against payers? We really don’t know.Continue reading…

Doctors Love iPads. What Does it Mean? What Does it Mean?

Mar 6, 2011• 21

By VINCE KURAITIS

After attending HIMSS 11 the largest annual health IT conference of the year, John Moore reported that “nearly every EHR vendor has an iPad App for the EHR [electronic health record], or will be releasing such this year.”

Doctors love iPads…not surprising? But, how might you explain this?

There are at least two different possibilities:

Coincidence Theory
Conspiracy Theory

The Coincidence Theory

So doctors want to access EHR software through the iPad…what’s the big deal?

Apple has built a great new hardware platform with the iPad. There’s nothing else like it in the marketplace. While other companies are building competing tablets, Apple’s has been the only viable option in the market for over a year.

The iPad is intuitive, easy to use, reasonably priced, easy to carry around, and has a lot of apps that have been developed for the platform. People — not just doctors — love the experience of using an iPad.

Doctors just happen to be one group of zillions buying iPads. Why wouldn’t they? Doctors are smart, affluent, and many are opinion leaders. Doctors like cool new technologies just like anyone else.

Doctors also are mobile. They want to access EHRs in different exam rooms, from the hospital, from their homes. The iPad is the perfect hardware platform to take with you as as a doctor goes about their day.

Why are nearly all EHR vendors making their software work on the iPad?

Because doctors are demanding it.

The Conspiracy Theory

The iPad is Apple’s Trojan horse to create new revenues in an industry in which the company has had minimal presence — health care.

Apple has developed a very appealing hardware platform in the iPad. Recognizing the market strength and lock-in to their walled garden they are creating with consumers, Apple is targeting key market segments to create new revenue streams and business models. Health care is the next target for Apple’s aggressive smarts.

Is Economic Credentialing A Tool for Primary Care to Lead ACOs?

Feb 24, 2011• 4

By VINCE KURAITIS, JD

Is economic credentialing — the use of economic factors such as loyalty and utilization rates in the physician credentialing process — a potential tool for primary care physicians to lead ACOs? and reestablish the vitality of primary care in American health care?

Keith Wright and Gregory Drutchas’ incisive article Economic Credentialing: A Prescription To Secure Shared Savings Under Accountable Care provides useful history and context about economic credentialing:

For many years, the use of economic factors by hospitals in making medical staff credentialing decisions has been the subject of much discussion and debate among physicians, groups such as the American Medical Association (AMA), healthcare providers, payors, and attorneys….the implementation of healthcare reform is likely to bring the debate over economic credentialing to the forefront once again.

While economic credentialing has been talked about a lot, it’s rarely been used.

The controversy over economic credentialing arises again with ACO’s…and this time the answer might be different — and opportunistic for primary care.Continue reading…