By PAUL KECKLEY

The election results are in and Donald Trump will be the 45^th president of the United States. His appeal to “Make America Great Again” resonated across the heartland sparking an unprecedented political upset that surprised even the most astute prognosticators and pundits.

When he takes office in January, he’ll face enormous challenges domestically and globally. Healthcare will be at the top of the list: he promised to “Repeal and Replace” the Affordable Care Act, and he pledged changes that strengthen the system in his campaign’s seven-point plan. In this effort, his team will face harsh realities:

• Containing health cost will to be the dominant issue.  Total healthcare spending will increase 6% annually for the next decade. Utilization is up. Demand is increasing and traditional reimbursement is not keeping pace with underlying costs. That’s not sustainable. Something’s got to give.
• The fundamental structure of the health system is shifting. Healthcare is no longer a cottage industry. Mega deals across the board are pending: the Anthem-Cigna, Aetna-Humana, Dignity-CHI and more. And in most communities, half of the physicians are employed by hospitals that are affiliated with multi-hospital systems. The health system’s future will play out against new ways of competing.
• Alternative payment programs (APMs) are changing incentives for providers. With MACRA payments to physicians and mandated bundled payments for heart failure, coronary artery surgery and joint replacements for hospitals coming on line next year, providers are anxious. What’s next? What’s their future?
• Competition from non-traditional entrants is increasing. Investors are flocking to start-ups that challenge the status quo in healthcare. Their ranks include retail clinics, micro-hospitals, telemedicine, urgent-care centers, disposables, smart implantables, hybrid insurance models and others that challenge stakeholders to innovate faster and more effectively. It’s a huge industry that’s historically made its own rules and kept outsiders out. That’s changing.
• And the public is divided about the Affordable Care Act: half believe it a necessary impetus for expanding insurance coverage and lower costs, and half feel it’s an over-reach by federal bureaucrats that want a government-run health system.
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By TOM LANG, MD

Recent government incentives have gone a long way toward bringing digitization to healthcare, with  particular benefits seen in the PACS/ digital radiology areas and digitally archiving data for better access.  A 2016 AMA survey (1) has shown that the biggest desires for physicians from digital health are increasing patient safety and improving work efficiency.

I would like to propose that the most important aspects of patient safety are as follows:

• clinical workers (that is, doctors, nurses and other members of the caregiving team) need to maximize their time ‘at the bedside’
• clinical workers need to maximize their communication and interaction within the patient care team to optimize patient care

• clinical workers need to minimize distractions from the two activities above.

Health IT systems need a complete overhaul, guided by these principles, in order to optimize patient safety with its use. One way to look at health IT from a clinical perspective is to break it down into 2 pieces: data aggregation (that is, the ‘anytime, anywhere access’ to digitized health information) and data entry: the time and distraction from patient care that data entry tasks require for clinical workers.  The big wins so far with health IT has been with the former, the big problems with the latter.

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By KIP SULLIVAN, JD

Jacob Hacker, the godfather of the “public option,” and Donald Trump have much in common. They both think the solution to high health care costs is more competition within the insurance industry. They both acknowledge that the insurance industry is highly concentrated, and yet for reasons they don’t disclose they both think it’s possible for new insurance companies to break into such a highly concentrated industry. The only difference between their theories of competition is that Trump wants insurance companies to create insurance companies from scratch, while Hacker wants the government to create insurance companies from scratch.

In my last post , I criticized Hacker for not explaining how the “public option” (PO) will come into existence. All Hacker can say is the PO will be “like Medicare.” Hacker and other PO proponents don’t tell us how the PO will become “like Medicare.” We are simply supposed to believe the PO will leap into existence and, when it does, it will be big like Medicare and enjoy Medicare’s low overhead and payment rates. [1]

Trump’s “explanation” is just as empty. He simply asserts that insurance companies in one state will open shop in other states if the regulations in some states are reduced. [2] Here is how Trump “explained” his proposal during the second presidential debate  on October 19: “We have to get rid of the lines around the state, artificial lines, where we stop insurance companies from coming in and competing, because they want – and President Obama and whoever was working on it – they want to leave those lines, because that gives the insurance companies essentially monopolies….”

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By KIP SULLIVAN, JD

In an earlier post, I criticized managed care proponents for promoting concepts defined only by the aspirations of their proponents.  HMO, ACO, “medical home,” and “patient-centered this and that” are examples.

The “public option” (PO) is the latest example of a buzzword defined only by the aspirations of its proponents. The PO, first introduced to the public a decade ago by Jacob Hacker, Democratic presidential candidates and advocates of what would become the Affordable Care Act, has been revived by Democrats over the last five months. [1] Hacker, Hillary Clinton, Barack Obama and others say a PO would reduce premium inflation. But they refuse to define the PO, which makes it impossible to determine whether it could survive, much less reduce premium inflation. It’s not even clear whether proponents are proposing a PO open to all Americans or just to those who shop on the state exchanges established by the Affordable Care Act. The best they can do is say the PO will be “like Medicare.” That’s not a definition. That’s an aspiration.

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By THCB STAFF

THCB would not be possible without the generous support of our corporate supporters. Today’s shout out goes out to the good people at HealthCatalyst, one of our favorite Health IT companies. Visit the HealthCatalyst Knowledge Center for great tutorials, walk-throughs and explainers on value-based care and the Affordable Care Act. You’ll also find online sessions like this week’s highly useful MACRA FAQ.

By THCB STAFF

Speaking of frequently asked questions, THCB will be collecting yours this fall going into the New Year.  Send us (or tweet) your questions about MACRA, value-based care and payment reform and we’ll publish them. While much of our coverage of payment reform centers on the big picture issues around the Affordable Care Act, the what-ifs and the whys and why nots, our readers also want practical advice and insight on how best to manage the transition to this important new payment model.

If you’ve had an experience with an early ACO you’d like to tell us about, feel free to write. You can also post your comments in this place. Be sure to include your organizational affiliation if you’d like credit for your ideas, although anonymous contributions will be accepted as always.  To get started, you can check out the online session on  MACRA Frequently Asked Questions here. Come back to THCB for posts in the weeks to come.