The Health Care Blog – Page 341 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Making Accountable Care Organizations Great Again

Oct 22, 2016• 8

By ANISH KOKA, MD

Test your Accountable Care Organization knowledge:

Select all of the options that are True

If you belong to an ACO you qualify for the alternative payment model track in MACRA
Most ACO’s are enrolled in to a two sided risk model – (They share profits and losses with Medicare)
In 2015, ACO’s saved Medicare more than a billion dollars
None of the above

I have been mystified by Accountable Care Organizations ever since I first heard of them almost a decade ago. ACO’s have had a hallowed place in the world of health care policy for some time now. Everyone knew they were coming, and everyone knew they would be the answer. Traditional fee for service medicare that paid based on volume was thought to be the driver of rising health care costs. Regional variation in medicare expenses even when controlling for underlying population risk suggested that lower costs were possible without sacrificing quality. Imposing a capitated model of reimbursement tied to quality metrics seemed to be the answer and ACO’s were the vehicle to make this happen.

I was on board, though I freely admitted to everyone who asked, that I had no idea how they would work. To be fair, I was far more stressed about learning coronary anatomy in the cath lab, than I was about health care policy. By the time ACO’s finally started in 2012, I had been in practice for a few years, and I was paying slightly more attention. The passage of time now allows for the assessment of the value delivered by ACO’s and is a health care policy researchers dream. Clinicians, however, continue to be blissfully unaware of the construct. ACO’s exist in some alternate universe that is interesting and worthy of name dropping to establish your policy-cred, but even the coarse details are shrouded in mystery for most clinicians and patients. What follows is a brief primer and analysis of some recent data that doesn’t require an understanding of linear regression modeling.

Who Cares? Lots of People Do, and This New Podcast Celebrates Them

Oct 22, 2016

By DOUG WALKER

Sometimes in healthcare it’s easy to get caught up in the negative. Rising costs, patient frustrations, challenges for hospitals and providers as we evolve toward value-based care.

So it’s been a great pleasure recently to be involved with something that celebrates the positive things and people in healthcare. We, with the help of the great folks here at The Health Care Blog, recently launched a new healthcare industry podcast called “Who Cares? Hospital Talk.” The podcast gives a voice to people who are passionate about making patient care and experience better.

The Who Cares? Hospital Talk podcast builds positive awareness about the people in all types of roles “who care” and commit to improving patient care and experience. It provides a forum to lead the conversation about people improving healthcare in big and small ways with thoughtful, innovative approaches to advancing care quality, the patient experience, and efficiency in care progression. Continue reading…

MACRA Needs to Use Evidence-Based Interventions

Oct 21, 2016• 15

By NIRAN AL-AGBA, MD

Whether applied to policymaking for individuals, large populations, or administration of health services nationwide, it is imperative regulatory decisions be anchored to empirical evidence. The official MACRA rule has now been released. It is 2,000 pages based on the opinion of many non-practicing physicians, Dartmouth economists, and government administrators with input from a few doctors on the front line. In my opinion, what began as a certain death sentence has commuted us to life in prison; MACRA will regulate physicians without representation.

Let me acknowledge my opinion is limited by my own “small” practice bias. 380 thousand “small” practices (having 15 providers or less) will be exempted if they have less than 100 Medicare patients. Your definition of small and mine are strikingly different. Every single independent practice in my hometown of that “quasi-small” size, has sold to the local hospital already. The “small” practices remaining in my community have 1 or 2 physicians, so I will refer to those as micro-practices for clarity. My micro-practice serves more than 400 Medicaid patients, with a waitlist of more than 50. MACRA rules do not seem to have an answer for when there are not enough micro-practices remaining with which to form a “virtual” group.

MACRA: We Can’t Expect the Feds To Be The Key Lever of Change

Oct 20, 2016• 3

By JOE FLOWER

The final MACRA rules are out. There is plenty of room for debate about them, but one thing is clear: They are a fine example of why we cannot expect the federal government to be the key and most powerful driver of change in healthcare.

This is not a political statement, not an anit-government slogan, not a libertarian assertion. This is a systemic observation.

This is not because the law or the CMS rule-makers are not well-intentioned. To the contrary, MACRA seems like a noble enterprise. Congress is to be congratulated for at least temporarily getting itself unstuck long enough to pass it. CMS is trying their mightiest to push healthcare in the direction of actually offering value for all the money we keep shoveling into it.

But just look at it: Over 2,000 pages, full of complexities, exceptions, subsidiary re-payment clauses, labels and circles and arrow that will keep healthcare lawyers and consultants in fine shape for quite some time to come. As THCB’s Kip Sullivan has pointed out, MACRA is supposed to be rewarding good “volume to value” behavior and punishing its opposite, but it is so complex that few physicians will be able to honestly tell whether they will get rewarded, how much, or for exactly what.

Operant Conditioning

Or when. Have you ever tried to train a dog? If you want them to stop some behavior, like digging in the garden or jumping up on you, you have to catch them in the act and give them a negative response right then. If you want to reward them for something, you have to give them the treat (or the clicker click that signals a reward) the moment they do it, so that they know what the heck you are talking about and how compelling the reward or punishment is. (My lab used to be all, “If it’s not cheese, don’t even bother.”)

People are not that different, especially people trying to run the increasingly complex business of a medical practice out of one hand while trying to actually practice medicine with the other. If you want them to do something that is both different and difficult, give them an impressive reward the instant they do it, a reward that is significant in comparison to all the other influences on their bottom line, and that happens in this billing cycle.

The Final Rule

Oct 19, 2016• 10

By KIP SULLIVAN, JD

When I read the original MACRA rule that CMS published last April, I was appalled at its complexity, at CMS’s total disinterest in measuring “performance” accurately, and CMS’s willingness to hype the performance of ACOs and “medical homes” (the main prototypes for the “alternative payment models” [APMs] authorized by MACRA). I entertained the faint hope that CMS would come to its senses after hearing the reaction to its original rule and propose something less complex, or maybe even urge Congress to suspend enforcement of the law until it could be rewritten. Foolish me.

I have read a substantial portion of CMS’s final rule, published last Friday. It is clear to me CMS intends to implement its original rule with only minor changes. I predict the implementation process will be a nightmare.

The Privacy Dilemma

Oct 18, 2016• 2

By JOSEPH KVEDAR, MD

Joseph Kvedar I recently had the opportunity to join Boston news media veteran, Dan Rea, on his AM radio program, Nightside with Dan Rea. It was a one-hour call in program, and an eye opening experience for me. Dan and I chatted about connected health and how it can truly disrupt care delivery and put the individual at the center of their own health. Then Dan opened the lines to the fine citizens of New England for questions, and the phones started ringing off the hook.

The overwhelming concern – actual fear — among callers was maintaining their privacy in an increasingly connected world, especially their personal health data. This is a topic I touched upon in my recent book, The Internet of Healthy Things, and one which I will explore further in my upcoming talk at our Connected Health Symposium in a few weeks. But I was so struck by the extent of concern, I thought I’d present a few theories I’ve been contemplating on the subject.Continue reading…

The Trust Gap in Healthcare: Findings from the 2016 Healthcare Trust Index

Oct 18, 2016• 5

BY PAUL KECKLEY

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In Campaign 2016, a recurring theme to date has been the trustworthiness of the leading candidates. As they debate for the third and final time this week, each will attempt to allay voter concern about their trust-gap and widen apprehension about the other’s.

In politics and business, trust is the most valuable asset candidates and companies own. Lacking trust between a candidate and voters or an organization and its customers and trading partners means elections aren’t won and a company’s, long-term sustainability is compromised.

Healthcare is an industry wherein trust is foundational. We trust our physicians to recommend treatments based solely on their effectiveness and appropriateness to our diagnosis. We trust our drugs and technologies are used solely because they work best. We trust our hospitals are safe and our insurance will help pay the bills. When we learn otherwise, we rationalize they’re the exceptions until recurring doubt leads to distrust. Stories about fraud, price gauging, denials of coverage and excessive profit cast doubt on our system and compromise trust in our healthcare system. The frequency of stories about these and social media lend to the growing distrust in healthcare.Continue reading…

The Blockchained Health Record

Oct 17, 2016• 2

BY DAN HOUSMAN

flying cadeucii A couple of weeks ago I was discussing the opportunities for using block chain technology for medical record interoperability with a group of friends who unsurprisingly see their real experience as evidence that we haven’t made it easy to exchange medical records yet. While chatting, one of my friends asked the question – “Isn’t there some sort of security problem with Health Information Exchanges (HIEs), because block chain technology could solve security issues, especially if that is what is holding things back?” I thought about it and my immediate answer was “not really.” The sharing problem is about trust and finding a model that works for sharing records rather than just some underlying security conundrum.

Re-Decentralization of Medicine: The HIE of One

Oct 17, 2016• 1

MICHAEL CHEN, MD and ADRIAN GROPPER, MD

This week, a non-commercial, open source proof of concept called HIE of One becomes the first standards-based patient-centered health record demonstration. It uses the emerging FHIR standard along with established standards for identity and security management to show how a physician-patient relationship can be independent of any particular institution and therefore as de-centralized as your smartphone messages or your Bitcoin payments.

The history of patient-centered health records begins in 1994 with the Guardian Angel Project at MIT and has inspired many of us. Implementations have come and gone over the past 22 years and today’s massively centralized and institutionally controlled EHRs seem to be headed further and further away from a patient-centered vision. Hacking and information blocking are a concern for patients and legislators. EHRs and government meddling are a source of frustration for physicians. Technology, however, is finally catching up with Guardian Angel’s promise.

The Fine Print of MACRA’s Final Rule: Good for Patients?

Oct 16, 2016• 5

By MICHAEL MILLENSON

The Centers for Medicare & Medicaid Services (CMS) just released the final regulations for the most ambitious attempt in U.S. history to transform how medical care is delivered and paid for. But is it good for patients?

The impact of the Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program created a colossal chorus of kibitzers after the draft rule came out last spring: CMS received over 4,000 written comments. The gargantuan, 2,204-page final rule both sets out regulations and responds to commenters’ suggestions.

The rule is meant “to create a more modern patient-centered Medicare program by promoting quality patient care while controlling escalating costs,” says Andy Slavitt, CMS acting administrator, in a letter to clinicians posted online. The rule itself proclaims “high-quality, patient-centered care” as “the bedrock of the Quality Payment Program.”