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ACO 552: The Advanced Class

May 4, 2016• 28

By ANISH KOKA, MD

flying cadeucii Lisa Bari, a Master of Public Health candidate at Harvard, attempts to take me to ACO school in her response to a piece I wrote. I welcome the discussion. Game on!

Lisa’s initial point, and the one she ends on, seems to say my argument falls apart because I somehow don’t understand the difference between a commercial ACO and a Medicare ACO. I beg to differ. She states that CMS cannot be held responsible for a commercial non-governmental agreement between a private insurer and a group of health care providers.

I guess you do need to go to Harvard to decipher this stuff. Is the implication that the only ACO model the architect of the ACOs are responsible for is the initial Pioneer model? It makes no sense. To recap: CMS was instructed to create ACO’s. There are 2 programs to do this. The Pioneer model, and Medicare shared savings program (MSSP). As I understand it, the large regional ACO next to me is set up as part of the MSSP. Someone makes a payment to these ACOs when there are cost savings, right? By the end of her first paragraph, one almost has the impression that ACO’s are a renegade program that emerged from thin air between insurers and health care providers. Yes, a commercial insurer decides to make an agreement with an ACO and they set a $4 rate. I guess I am to assume if the govt/CMS did it directly it would be much more. And I do realize that ACO’s are for PCPs, and not designed for specialists. The only reason I think I have any ‘contract’ at all is because I have a PCP I work with. My point with regards to the ACO payment was that I have no clue where that $4 is going – but that compensation for care coordination at that level is inadequate, and would require quite the mix of healthy:sick to make that work. Is there another number you can give me so I can take an opinion on the matter – or should I just continue to trust our fearless leaders?

ACO 101: Koka Completely Misses The Mark on Medicare ACOs

May 3, 2016• 9

By LISA BARI

flying cadeucii Recently, Anish Koka, MD, a Cardiologist from Pennsylvania, posted his anti-Accountable Care Organization (ACO) manifesto here on The Health Care Blog. [1] Koka argues that ACOs don’t work and are doomed to fail because they were designed by non-practicing physician policymakers and academics in ivory towers. He appears to be basing his judgment on a commercial ACO contract that only pays him $4 per month extra for care coordination and requires that he meet specific quality measures. He is also conflating his experience in a commercial ACO with Medicare ACOs, and interprets the initial results of one Medicare ACO program to mean that all ACOs are a failure. Finally, he relays an anecdote of caring for one of his patients, Mrs. K, a patient with chronic illness who doesn’t want to take her medication.

In his post, Dr. Koka calls out “well-meaning, hard-working folks that own a Harvard Crimson sweater…[whose] intent is to fundamentally change how health care is provided.” As luck would have it, I do own a Harvard Crimson sweater, and I’d like to respond.

Measuring Hillary

May 2, 2016• 10

By STEVEN FINDLAY

Screen Shot 2016-05-02 at 8.18.04 AM Hillary Clinton is now the presumptive Democratic nominee and the odds-on favorite to be our next president.

For healthcare, that could be a very good thing, not just compared to a Trump (or Cruz) presidency but for the following reasons:

(1) Hillary knows and cares deeply about healthcare.

Even if you don’t support or like her, she’s been a tireless advocate for reform and coverage expansion for decades. She worked, for example, in the 1980s with the Children’s Defense Fund and other groups to enhance coverage for children.

As first lady, of course, Bill put her in charge, in 1991, of developing a health reform plan. Though the process had its flaws, she was steeped in the subject for over a year and learned it inside and out.

Famously, the legislation failed in 1993-94 due to staunch Republican opposition (and, yes, a bungled legislative strategy by the White House). A widespread impression still exists that Hillary slunk back from the issue after the Clinton reform failed. Not true. Continue reading…

The Angry Physician

May 1, 2016• 34

By ANISH KOKA, MD

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I think I speak for most physicians when I say that we did not choose to go into medicine to shape health care policy. Medicine is a calling, and I treated it as such. I immersed myself with taking care of patients, and keeping up with the ever changing knowledge landscape that is medicine. I left the policy making to the folks I voted for the last 8 years. These were the adults, the intellectuals – they would take care of the task of taking out the bad elements of our healthcare system and leaving the good. I truly believed. I eagerly began the ehr/meaningful use saga believing this would result in better care for patients.

It took me two years to realize the meaninglessness of meaningful use. I still can’t believe how long it took me to realize that creating a workflow in my office to print out and deliver clinical summaries to patients didn’t do anything other than fill the trashbin. I still held out hope. I thought – this was a first draft, improvements would come. What came instead were positively giddy announcements of the success of the meaningful use roll out. The administration was actually doubling down. There was no acknowledgment for the mess that had been created – onward and forward on the same road we must continue to march. Except the road would no longer be paved and we would be walking uphill.

You Won’t Believe What Medicare Just Did on Patient Engagement!

May 1, 2016• 8

By MICHAEL MILLENSON

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Sure, I’ve always wanted to write a clickbait headline that sounds like a promo for the bastard child of Buzzfeed and the Federal Register. But, seriously: you will not believe what Medicare just did about patient engagement in a draft new rule dramatically changing how doctors are paid.

And, depending upon the reaction of the patient community, you definitely won’t believe what happens next.

Engaging Responsibly In the Health Care Debate

Apr 30, 2016• 18

By JIM PURCELL

flying cadeucii With no apology offered, I will be venturing into a very subjective realm, namely, a characterization of today’s healthcare dialogue and what, in my opinion, might be an improvement.

I would suggest we have fallen into the trap that was partly enhanced by email and blogs, namely, that we can say outrageous things impolitely and without consequence. With email we tend to be much blunter and impolite than we would be face to face. On blogs, we can be positively toxic. It’s like driving in a car with a tinted windshield that no one can see through. You are anonymous and therefore can act less responsibly.

Another vignette. I grew up in a very small upstate New York town where everyone knew everyone else. You used your car horn to beep “hi” or to warn, and not in anger, ever. When you waved at someone, it was with all five fingers. And so on. I think you get my point.

The healthcare debate always has stoked emotions like almost no other. It is intensely personal, and the stakes are high. We’re all involved and engaged.

As I’ve written in the past, I first earned my stripes as a lawyer representing my local Blue Cross plan in rate hearings. These rate hearings always started with “public comment.” The comment ranged from pure outrage to controlled anger to discontent coupled with suggestions. What did we pay the most attention to? Of course, the latter.

Replacing Meaningful Use, Advancing Care Information

Apr 27, 2016• 31

By ANDY SLAVITT and KAREN DE SALVO, MD

Screen Shot 2016-04-27 at 1.46.53 PM Seven years ago, Congress passed a law to spur the country to digitize the health care experience for Americans and connect doctors’ practices and hospitals, thereby modernizing patient care through the Electronic Health Records (EHRs) Incentive Programs, also known as “Meaningful Use.” Before this shift began, many providers did not have the capital to invest in health information technology and patient information was siloed in paper records. Since then, we have made incredible progress, with nearly all hospitals and three-quarters of doctors using EHRs. Through the use of health information technology, we are seeing some of the benefits from early applications like safe and accurate prescriptions sent electronically to pharmacies and lab results available from home. But, as many doctors and patients will tell you (and have told us), we remain a long way from fully realizing the potential of these important tools to improve care and health.

That is why, as we mentioned earlier this year, we have conducted a review of the Meaningful Use Program for Medicare physicians as part of our implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), with the aim of reconsidering the program so we could move closer to achieving the full potential health IT offers.

The World in 2016: MACRA, a New Era For Meaningful Use and (Yet More) Political Change to come

Apr 27, 2016• 5

BY THE EDITORS

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THCB is pleased to introduce the 2016 Healthcare Town Hall, a special online feature brought to you in partnership with Health Catalyst. This is an experiment. The idea is to open up an ongoing dialogue around the issues that are transforming healthcare in the second decade of the 21st Century.

We’re kicking things off with an online panel featuring THCB Editor John Irvine and the HealthCatalyst leadership including Dale Sanders, John Haughom and Bryan Oshiro.

John Irvine: Let’s start with the recent decision at CMS to transition from the Meaningful Use the program to a new program that will be a component of MACRA. A lot of people were extremely surprised with the news that Meaningful Use is going away. The follow up development, of course, is that CMS has agreed in principle to a new set of core clinical quality measures that will change the way doctors are evaluated. I’m hearing a lot of positive feedback about the Meaningful Use decision. Reactions?

Dale Sanders: I was surprised, yes. As I think you know, I’ve spent a lot of time in Washington. I know how government works. People in government generally do not reverse themselves, unless it is very clear that there is no other available option. That’s Washington 101. Read into that what you will. It’s far easier to allow a program to keep on going than to admit that something isn’t working or that it has outlived it’s usefulness. I think a lot of people are missing the fact that It took political courage to do that. I will say that I was one of the first to publicly call for the suspension of Meaningful Use, and you guys posted the blog that I wrote about it. At Northwestern, we published a one page policy entitled, “Principles of EMR Utilization” that was written and endorsed by our physicians, facilitated by me when I recognized that our EMRs were being used for little more than a multi-million dollar word processor. That one-page document is all we needed to achieve the same concepts as Meaningful Use. The last time I counted, the Meaningful Use regulations totaled over 350 pages. In typical fashion, the government turned a good concept into a mess. So, I’m cautiously optimistic that we are going to return to common sense.

The ACO Delusion

Apr 25, 2016• 28

By ANISH KOKA, MD

flying cadeucii Accountable care organizations (ACO’s) promise to save us. Dreamed up by Dartmouth’s Eliot Fisher in 2006, and signed into law as a part of the Patient Protection and Affordable Care Act (PPACA) in 2010, we have been sold on the idea that this particular incarnation of the HMO/Managed Care will save the government, save physicians and save patients all at the same time. I dare say that Brahma, Vishnu and Shiva together would struggle to accomplish those lofty goals. Regardless of the daunting task in front of them, the brave policy gods who see patients about as often as they see pink unicorns, chose to release the Kraken – I mean the ACO – onto an unsuspecting public based on the assumption that anything was better than letting those big, bad, test ordering, hospital admitting, brand name prescribing physicians from running amuck.

I realize I am being somewhat harsh towards the creators of the ACO morass. But, while they all may be well-meaning, hard-working folks that own a Harvard crimson sweater, their intent is to fundamentally change how health care is provided – this mandates a withering evaluation. As Milton Friedman aptly said, “One of the great mistakes is to judge policies and programs by their intentions rather than their result.” Thus, with little regard to intent, and with an eye on the end result, I say unequivocally : ACO’s do not work.Continue reading…

A Spoonful of Inequality Helps the Medicine go Down

Apr 24, 2016• 14

By SAURABH JHA, MD

The conventional wisdom in the circles I hang out in – pro-Hillary, morally conscious,happy bunnies who pretend to enjoy French wine and opera – is that the greatest scourgeon humanity after the bubonic plague is inequality of wealth. They worship Pope St. John Paul Piketty and canonize Archbishop Paul Krugman. Not only is inequality bad for its own sake, they say, it makes people ill, like medically ill.

Their premise always struck me as specious. I once took them through a thought experiment. Imagine, I said, you time travel to the Bengal famine. There was a lot of equality then – people were equally malnourished. Everyone’s ribs protruded equally because of muscle wasting from marasmus. The loss of protein from kwashiorkor made sure everyone’s belly popped out without prejudice. Starvation because of poverty is a great leveler. It cares little about gender, caste or religion. It is non-judgmental.