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The Primary Cares Initiative: How Value-Based Payment Models Aim to Strengthen Primary Care

By CHRIS JAEGER MD, MBA

In April 2019, the Centers for Medicare & Medicaid Services (CMS) announced the Primary Cares Initiative, which is expected to reduce administrative burdens and improve patient care while decreasing health care costs. Learn more about the Primary Cares Initiative and its proposed value-based payment models in part one of this two-part blog series. 

Introduction

While the health care landscape has never been static, rarely has it seen such radical changes as it has within recent decades. The population of the United States continues to age, and the prevalence of chronic conditions such as obesity, diabetes, heart disease, and anxiety or depression contribute to a substantially increased demand for care. These factors are pushing a shift from a provider-centric model toward more efficient outcome-based models that put the patient at the center and heavily rely on primary care as the steward of patient care.

Primary care is a vital resource in dealing with the many factors altering the health care landscape. A 2019 study published in JAMA Internal Medicine found that for every 10 additional primary care physicians (PCPs) per 100,000 people, patients saw a 51.5-day increased life expectancy.

To promote further adoption of primary care-based models, the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) recently announced a set of payment models meant to further transform primary care through value-based options under the new Primary Cares Initiative. This voluntary initiative will test financial risk and payment arrangements for primary care physicians (PCPs) based on performance and efficiency, including five new payment models under two paths: Primary Care First (PCF) and Direct Contracting (DC). These models, slated to hit 20 states in 2020, seek to address the many difficulties in paying for, and incentivizing, valuable primary care within current payment models.

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Healthcare in the National Privacy Law Debate

This article originally appeared in the American Bar Association’s Health eSource here.

By KIRK NAHRA

This piece is part of the series “The Health Data Goldilocks Dilemma: Sharing? Privacy? Both?” which explores whether it’s possible to advance interoperability while maintaining privacy. Check out other pieces in the series here.

Congress is debating whether to enact a national privacy law.  Such a law would upend the approach that has been taken so far in connection with privacy law in the United States, which has either been sector specific (healthcare, financial services, education) or has addressed specific practices (telemarketing, email marketing, data gathering from children).  The United States does not, today, have a national privacy law.  Pressure from the European Union’s General Data Protection Regulation (GDPR)1 and from California, through the California Consumer Privacy Act (CCPA),2 are driving some of this national debate.  

The conventional wisdom is that, while the United States is moving towards this legislation, there is still a long way to go.  Part of this debate is a significant disagreement about many of the core provisions of what would go into this law, including (but clearly not limited to) how to treat healthcare — either as a category of data or as an industry.

So far, healthcare data may not be getting enough attention in the debate, driven (in part) by the sense of many that healthcare privacy already has been addressed.  Due to the odd legislative history of the Health Insurance Portability and Accountability Act of 1996 (HIPAA),3 however, we are seeing the implications of a law that (1) was driven by considerations not involving privacy and security, and (2) reflected a concept of an industry that no longer reflects how the healthcare system works today.  Accordingly, there is  a growing volume of  “non-HIPAA health data,” across enormous segments of the economy, and the challenge of figuring out how to address concerns about this data in a system where there is no specific regulation of this data today.

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Leading Mental Health Platform on DTx Reimbursement, Scaling | Ken Cahill, SilverCloud Health

By JESSICA DaMASSA, WTF HEALTH

Digital mental health platform SilverCloud Health is the digital-therapeutic-of-choice for mental health services in the UK’s National Health Service (NHS) and serves nearly 250 healthcare organizations around the world, racking up 1.5 million therapy hours and 5 million clinical interactions. CEO Ken Cahill stops by to catch us up on SilverCloud Health’s impressive clinical outcomes and how he’s tackling challenges around reimbursement that are common for many digital therapeutics startups. His unique approach (spoiler alert: he partners with providers to approach payers for exception codes) may give some inspiration to those in a similar situation, but tune in for Ken’s full explanation and details on how the company plans to double over the next year.

Filmed at Frontiers Health in Berlin, Germany, November 2019.

For Your Eyeballs Only

By KIM BELLARD

There’s so much going on.  There’s the coronavirus: It’s now a pandemic!  China can build an entire hospital to treat coronavirus patients in under two weeks!  Or there’s primary care: One Medical’s IPO boomed!  AmazonHumana and Walmart are testing their versions!  People are flocking away from primary care!  Or, on a completely unrelated note, Tesla wants to disrupt auto insurance too. 

As interesting as all those are, it’s augmented reality (AR) that I want to talk about. 

Stop thinking about Snap Spectacles or Pokémon Go as what you think of when you think about AR.  Stop thinking about the supposed failure of Google Glass.  Start thinking about AR being ingrained in our daily lives.

Facebook CEO Mark Zuckerberg believes “at some point in the 2020s, we will get breakthrough augmented reality glasses that will redefine our relationship with technology.”  He went on to elaborate:

Instead of having devices that take us away from the people around us, the next platform will help us be more present with each other and will help the technology get out of the way. Even though some of the early devices seem clunky, I think these will be the most human and social technology platforms anyone has built yet.

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A Hospital Chief Pharmacy Officer on Innovation Needs | Jennifer Tryon, Wake Forest Baptist Health

By JESSICA DaMASSA, WTF HEALTH

Health system pharmacists are frustrated with the lack of time they spend connecting with patients. Why? Jennifer Tryon, Chief Pharmacy Officer for Wake Forest Baptist Health breaks it down for us by talking specifics about the outdated processes and old-school tech that are underpinning many health systems’ medication management programs — and holding back their pharmacists as a result. When she’s sourcing innovative new solutions for her pharmacy at Wake Forest Baptist Health, what are the pressing priorities that are getting her attention (and her budget)? Jennifer’s description of the challenges and opportunities for innovation in the health system pharmacy and medication management space is a MUST watch for anyone looking to learn more about taking their tech into this space.

Filmed at the American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting in Las Vegas, December 2019.

Patient Worries as a Central Feature of their Health Care Experiences

By JOHN JAMES, ROBERT R. SCULLY, CASEY QUINLAN, BILL ADAMS, HELEN HASKELL, and POPPY ARFORD

Political forces trying to shape and reshape American healthcare without hearing the voice of patients provided the rationale for this work. Our experiences as patients, caregivers, and users of media sources cause us to worry. The Patient Council of the Right Care Alliance developed 6 questions to form a national survey of Americans to guide policy makers. The questions and our rationale were as follows:

1) Finding a doctor I can trust. Trust in our doctors is not as high as it once was. There are stories of serious patient abuse that appear in the media; two of the more notorious examples include a neurosurgeon harming many patients before being stopped and an oncologist who was deliberately misdiagnosing cancer to sell chemotherapy. Patients perceive this as the reluctance of the physician community to effectively ‘police their own.’

2) I will be misdiagnosed. Misdiagnosis happens far too often at all levels of healthcare. The problem is so common that the National Academy of Medicine turned its attention to the problem and published Improving Diagnosis in Health Care in 2015. The solution to the misdiagnosis problem is complex and has yet to arrive at the clinician-patient interface.

3) I will get an infection while receiving treatment. Healthcare-associated infections have dropped somewhat in the past decade, yet there are still about 720,000 infections and 75,000 deaths per year from healthcare-associated infections. Many of these are becoming nearly impossible to effectively treat. The improper use of ordinary antibiotics continues to be a problem in clinical settings.

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The EU-Backed Community of Health Innovators Transforming Health | Katharina Ladewing, EIT Health

By JESSICA DaMASSA, WTF HEALTH

Financially backed by the EU, EIT Health is a pan-European network of health innovators and 150+ corporate and academic partners across the continent who pool their assets to support widespread health innovation across Europe. We caught up with Katharina Ladewing, Managing Director for EIT Health Germany, about the group’s priorities, how they enable early and late stage startups to find funding and business partners, and how digital health has been evolving (rapidly) in the EU over the past few years. Wondering what the differences are between the health tech startup ecosystems in Europe versus the US? Katharina shares some of the insights she’s gained after four years watching this space mature.

Filmed at Frontiers Health in Berlin, Germany, November 2019.

Health in 2 Point 00, Episode 108 | OneMedical IPO, Hinge Health, & Humana

Today on Health in 2 Point 00, we’re starting out with a riddle: what’s the similarity between the 49ers Super Bowl performance and digital health? Find out on Episode 108, where Jess and I discuss other news in health tech starting off with another IPO, OneMedical. Now worth more than Livongo at $2.7 billion, this went better than anyone could’ve expected. Hinge Health raises $90 million in a Series C round, offering physical therapy at home and tapping into the loads of waste that goes towards back surgeries. Finally, Humana partners with a private equity company to expand primary care centers, what is the deal with this? —Matthew Holt

To Improve Patient Care, Think Both “Zebras” and Golf

By MICHAEL MILLENSON

Super Bowl Week ended with the San Francisco 49ers and 161 U.S. hospitals having something in common.

Both were publicly penalized, both lost money as a result and both passionately believed the process was unfair. Unfortunately, it’s not easy to decide whether their objections were sensible or sour grapes and, in the case of hospitals, the real-life consequences are not a game.

The penalty that pained the 49ers occurred shortly before halftime of Super Bowl LIV, when offensive pass interference was called on tight end George Kittle. The call negated a big gain that might have enabled the 49ers to take the lead.

Replays showed that the referees – nicknamed “zebras” for their black-and-white striped shirts – were technically correct in their decision. Nonetheless, controversy erupted over whether given other possible penalties called or overlooked, this one deserved a yellow flag.

Hospitals call that kind of context “risk adjustment.” A few days before the Super Bowl, the Medicare program blew the whistle on a group of hospitals having high rates of infection and other patient injuries. The hospitals who are outliers in what are blandly labeled “hospital-acquired conditions” (HACs) suffer a cut of one percent in their Medicare payments over next fiscal year.

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The Digital-First Health Insurance Startup Changing Healthcare in Nigeria | Femi Kuti, RelianceHMO

By JESSICA DaMASSA, WTF HEALTH

RelianceHMO is a Nigerian-based health insurance startup that aims to turn the traditional health insurance world upside-down. CEO Femi Kuti delves into how his company is using mobile phones, telemedicine, data science, and even underwriting (!) to make health insurance cheaper — and more accessible. With more than 1800 hospital partners across Nigeria, RelianceHMO is making a name for itself, but how does it plan to scale throughout Africa? And, what can payers around the world learn from their approach as they seek to make health insurance easy and affordable for Nigeria’s 190M uninsured? We love talking about disrupting payment models in healthcare and after hearing Femi’s story, you’ll understand why.

Filmed at Bayer G4A Signing Day in Berlin, Germany, October 2019.

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