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A Mystery Mission in LA: Aetna, Apple, and a Vision of Digital Health’s Future, Part 1

The Healthcare Blog - Thu, 08/17/2017 - 10:33

It was an invitation too intriguing to refuse: fly to LA to participate in a “top-secret mission” related to digital health. Instructions? Bring workout clothes. Don’t disclose your location. “We can’t say much. Just enough for you to quickly pack your bags, fly to California and participate in an exclusive Apple Watch from Aetna event – all expenses paid.” Generally, I’d file this type of message in the junk mail folder, but knowing that Apple takes secrecy seriously, I did some background sleuthing and decided it looked legit.

The mystery unfolded last week as I stepped into a black car at LAX with a secretive driver who joked that I and his other two passengers (who had received similar invites) would have to cover our faces as we drove through town. (Yikes!) When we arrived at a hip “concept” hotel I felt more at ease, and relaxed into enjoying the so-called mission with a glass of wine and some discussion of trends in the digital health industry. Over the course of a couple of days I was fortunate to join a group of new (and some old) friends to exchange ideas, take a challenging hike to the peak of Runyon Canyon Park, interact with Apple and Aetna execs, try out some new technologies, and get a glimpse of what both Aetna and Apple are envisioning for the future of digital health. I was assigned to one of several teams named after famous movies (in keeping with the Tinseltown theme) a personalized agenda, and some critical tools for the modern adventurer, including a bandana, water bottles, a phone charger, and, naturally, a selfie stick.

For about a year Aetna has used the Apple watch as part of an integrated wellness program available to its 50 thousand employees and those of several partner organizations it insures, such as Hartford HealthCare, which was represented among the participants in the mystery mission. Both companies are poised to expand the program.

Why all the secrecy? For Apple, it’s par for the course (and mission participants still can’t disclose all the details of what Apple shared), but this event was primarily arranged by Aetna for its own employees and a few key partners. Most of the 25 or so participants were staff from divisions throughout Aetna who had contributed to its partnership with Apple to date—some by inspiring others. For example, an Aetna employee named Nora lost more than 100 pounds in a year with support from the program. A handful of Aetna outsiders/digital health insiders were also included in the mission order to provide diverse perspectives and help generate new ideas.

In my opinion (though truthfully it remains a bit of a mystery) the top-secret approach was intended to enhance the fun factor for participants—and it worked. The experience was exciting, playful, and edgy, with a generous sprinkle of Hollywood glitter. If Aetna and Apple can harness that kind of energy to motivate people toward better health, more power to them. While I don’t imagine Aetna and its partners will be rewarding large numbers of people with glitzy Californian adventures comparable to this one, the tone and content of the so-called mission shows that they are thinking outside of the proverbial box. Just as the Apple watch takes health and healthcare outside of the hospital and onto your wrist, Aetna is taking traditional workplace wellness programs well beyond the walls of the office.

Stay tuned for further thoughts on the Aetna Apple partnership and its implications for digital health.

Lygeia Ricciardi is President of Clear Voice Consulting, LLC. www.lygeia.com @Lygeia

Author’s statement of conflict of interest:  I am not employed by Aetna or Apple. While my participation in the event described was paid for by Aetna, I was not required or asked to write about her experience.

Categories: OIG Advisory Opinions

The Best Part Of The Health 2.0 Fall Conference Agenda

The Healthcare Blog - Wed, 08/16/2017 - 12:54

There’s still time to secure your ticket before prices increase to this year’s Health 2.0 11th Annual Fall Conference. Whether you’re a Health Provider, Entrepreneur or Investor; the Fall Conference is the place to see the latest health technology, to hear from some of the influential innovators impacting the landscape, and to network with hundreds of health care decision makers. Click here for the full agenda.

Health Providers Agenda Highlights  Entrepreneurs Agenda Highlights 
  • MarketConnect: A live matchmaking event designed to accelerate the health tech buying and selling process by curating meetings between pre-qualified healthcare executives and innovators.
  • Exhibit Hall: Gain access to 90+ exhibitors, including Startup Alley, is the premier gathering of innovative companies and individuals. The exhibit floor is also home to MarketConnect Live.
  • Developer Day: Expect your day to be filled with strong technical sessions in relation to interoperability and user testing as well as opportunities to network from others in the industry.
  • 2 CEOs and a President Session: Three top health tech executives sit down for separate intimate interviews with a journalist. They will be dishing on both their personal and company journeys.
Investors Agenda Highlights 
  • Investor Breakfast: Bringing together leaders in the Health 2.0 investment community and our innovative startup network for an exclusive breakfast meeting.
  • Investing in Health 2.0 Technologies: Panel experts will address what’s in store for the rest of the year and predict the next big bets in Silicon Valley and beyond.
  • Launch!: Ten brand new companies unveil their products for the very first time and the audience votes on the winner!
  • Traction!: Annual startup pitch competition that recruits companies ready for Series A in the $2-12M range. Teams will compete in two tracks, consumer-facing, and professional facing technologies.

Click here to register for the Annual Fall Conference! Prices increase after September 4th!

Categories: OIG Advisory Opinions

CMS Cancels Two Mandatory Pay Models and Scales Back a Third

Medical Coding News - Wed, 08/16/2017 - 05:59

The CMS on Tuesday said it will toss two bundled-payment models and cut down the number of providers required to participate in a third, citing providers’ requests to have more input in the models’ designs. The agency slashed the number of mandatory geographic areas participating in the Comprehensive Care for Joint Replacement, or CJR, model […]

The post CMS Cancels Two Mandatory Pay Models and Scales Back a Third appeared first on MedicalCodingNews.Org.

Categories: Healthcare News

A New Pothole on the Health Interoperability Superhighway

The Healthcare Blog - Tue, 08/15/2017 - 13:23

On July 24, the new administration kicked off their version of interoperability work with a public meeting of the incumbent trust brokers. They invited the usual suspects Carequality, CARIN Alliance, CommonWell, Digital Bridge, DirectTrust, eHealth Exchange, NATE, and SHIEC with the goal of driving for an understanding of how these groups will work with each other to solve information blocking and longitudinal health records as mandated by the 21st Century Cures Act.

Of the 8 would-be trust brokers, some go back to 2008 but only one is contemporary to the 21stCC act: The CARIN Alliance. The growing list of trust brokers over our decade of digital health tracks with the growing frustration of physicians, patients, and Congress over information blocking, but is there causation beyond just correlation?

A recent talk by ONC’s Don Rucker reports:

One way to get data to move is open APIs, which the 21st Century Cures Act mandates by tasking EHR vendors to open up patient data “without special effort, through the use of application programming interfaces.”

Rucker emphasized the distinction—without quite naming what it is—between open APIs for vendors and open APIs for providers. “We’re hard at work at defining those,” he said. One difference is how the APIs are implemented: Vendors must allow for the APIs technologically, in their products, and providers must actually take advantage of the APIs.

Trust brokers on the health information highway are like the checkpoints of militias in a war zone. What gets through is limited in scope to the lowest common denominator and limited in distance to the path that crosses the fewest boundaries.

The 8 trust brokers did not arise by popular demand of the physicians and patients. Before the era of big EHR vendors for big hospitals, information flowed among physicians and patients over mail, fax, and phone using open and public interfaces and without the “added value” of trust brokers. Faxes are free, universal, and there’s no blocking on the basis of “trust”. When faxes fail, it’s typically obvious, and coupled with a phone call, reliability is high. The current situation is worse for patients as the new digital alternatives add confusion because they vary greatly from provider to provider and add frustration by being unpredictable and unreliable.

It’s hard to put a toll booth in a forest. But as the health information highway became paved (with massive taxpayer subsidy), a growing list of rent-seeking intermediaries have seized the opportunity to put a checkpoint and associated toll booth where none existed before. Hindsight is always 20/20 but the massively bipartisan 21stCC (the Act passed with 392 votes in the House and 95 votes in the Senate) gives the new administration’s ONC the opportunity to begin to take down the checkpoints.

One way to take down the trust broker’s checkpoints is called patient-directed exchange. (The word patient is preferable to consumer because patients have significant legal rights beyond mere consumers and because clinicians have a relationship with us as patients, not as consumers.) Under HIPAA, Meaningful Use Stage 3, and ONC’s API Task Force recommendations, patients get a free pass down the paved health information highway. The pass is literally free in that patients, unlike providers, cannot be charged for sending information down the new digital highway to anyone they specify. It’s as if the toll booths apply only to trucks and private cars are free. Could patient-directed exchange spell doom for trust brokers by giving patients a pass on the highway we already paid-for with taxes?

Here’s where CARIN comes in. An unaccountable and unpublished list of members gets together as an “alliance” to develop yet another set of trust rules as new potholes in the information highway. These rules don’t directly create a checkpoint but they damage the road enough to add costly maintenance to patient-directed exchange. Part of this maintenance cost is to have alliance process closed to non-members. This practice distinguishes CARIN from standards groups and other private industry collaborations that are allowed to coordinate without running afoul of antitrust law.

As the API Task Force concluded, the law is clear that “trust” and “trust framework” do not apply to patient-directed exchange. Epic, holder of medical records for 54% of the US population, provides a leading example of this under their Open.Epic API initiative. More than 30 hospitals using their most recent software are already listed on the Open.Epic website. One of them happens to have records for my 91 y/o mom and, as her proxy, I had a password to that major hospital’s patient portal for many years. After a 30-second online verification of my own name, I was able to use that portal password to access the hospital’s FHIR API and send live EHR information to a new app without any trust framework or other information blocking interference. This is not a fluke. I checked with the hospital’s CIO after the fact.

CARIN’s claim to “Consumer-Directed Exchange” is just the latest attempt to slow-walk and confuse interoperability. Trust frameworks do not apply to patient-directed exchange. Elimination of the trust framework by Open.Epic is only the critical first step in implementing the “without special effort” clause in 21stCC. The HEART workgroup, co-chaired by ONC, recently issued the first specifications for how to improve the patient experience of interoperability, including standards for automated app registration and a refresh capability to allow the patient to determine how long it is before they are asked for their portal password again. ONC should hail the Open.Epic demonstration as an example of making patients first-class citizens in control of our own data and a first step toward a new approach to interoperability based on patient rights.


The public comment period for the Trusted Exchange Framework and Common Agreement will end on ­­­­­­­­­August 25, 2017. A version of this post will introduce the specific comments of Patient Privacy Rights. If you care about the promise of digital health and would like make longitudinal health records a reality, please consider submitting your comments as well.

Categories: OIG Advisory Opinions

Learning ICD-10: Documenting Type 2 Myocardial Infarction

Medical Coding News - Tue, 08/15/2017 - 08:39

I am in the middle of a heads-down project, but I popped my head up long enough to read the new ICD-10-CM guidelines for 2018 (thanks for the notification, Gloryanne Bryant!). I had to take a moment to comment on the Type 2 myocardial infarction (MI) guidelines. The reasons we should be documenting and coding […]

The post Learning ICD-10: Documenting Type 2 Myocardial Infarction appeared first on MedicalCodingNews.Org.

Categories: Healthcare News

Final Fiscal Year 2018 Payment and Policy Changes for Medicare Inpatient Rehabilitation Facilities

Medical Coding News - Mon, 08/14/2017 - 11:26

Overview On July 31, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a final rule outlining fiscal year (FY) 2018 Medicare payment policies and rates for the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) and the IRF Quality Reporting Program (IRF QRP). The FY 2018 final policies are summarized below. Updates to […]

The post Final Fiscal Year 2018 Payment and Policy Changes for Medicare Inpatient Rehabilitation Facilities appeared first on MedicalCodingNews.Org.

Categories: Healthcare News

Sifting Through the Masses to Find Relevant Tech

The Healthcare Blog - Mon, 08/14/2017 - 11:08

Much of the time, finding the right partner to test your technology can be difficult and time consuming. From an enterprise healthcare organization’s perspective, identifying innovative technology that fits the strategic needs of the organization can be difficult due to the overwhelming number of startups entering the market. From a startup’s perspective, there are a few major roadblocks including:

  • Finding organizations ready to pilot new health technology
  • Completing a first pilot/proof of concept (or second, or third…) to gather the much needed data to grow commercial partnerships
  • Identifying the right individual in an enterprise organization who will champion new technology
  • Gaining an insider’s perspective about the potential clients’ strategic needs

Enter MarketConnect Enterprise: expediting the matching and vetting process for both the startup and enterprise healthcare organization.

One of the largest health insurers in the United States is looking for innovative technologies to integrate into their organization. From technology to support member communication to solutions that support providers when processing claims, they are looking to find relevant, innovative solutions that are ready to be piloted within a large organization, with no request for equity or IP. Think your technology may fit their needs? Check out the priority areas below, then complete an application here for the opportunity to be introduced.

  1. Consumer/member communication tools to improve engagement experience
  2. Provider tools to improve their experience for processing claims/obtaining prior authorization
  3. Solutions to assist consumers/members navigate & understand insurance billing
  4. Tools to help individuals find the right health insurance plan for them & their families
  5. Tools for consumers to improve, maintain and monitor their own health and wellness especially those that support specific groups of consumers (special needs, hearing impaired, dementia, caregivers, etc.)
  6. Solutions to improve claims processing

With MarketConnect Enterprise, we want to make sure both the health technology company and potential client find the right partners without the hassle. Complete an application to let us know how your technology fits the above priority areas and we will be in touch if there is a strong potential for partnership.

Alyx Sternlicht is a Senior Program Manager at Catalyst @ Health 2.0.

Categories: OIG Advisory Opinions

As Bipartisan Plans for ACA Fixes Emerge, Will Congress Act? Probably Not.

The Healthcare Blog - Fri, 08/11/2017 - 16:25

By STEVEN FINDLAY

A bipartisan group of health policy experts has issued a call to action and well-thought-out consensus plan for insurance market stabilization and incremental reform.

The effort adds to the gathering momentum in Washington for urgent fixes to Obamacare, plus additional reforms that might bring conservatives into the fold and appeal across the partisan divide.   What’s still unclear, however, is whether the Trump administration and Republican leadership in Congress will go along.  Outward signs suggest they won’t, but this game is still changing by the day.

Trump continues to tweet-shame McConnell and the Senate Republicans for failing to repeal and replace the ACA, and conservatives in the House and Senate continue to insist they’ll oppose any “bailout” of the insurance industry. (In no way is stabilizing the insurance marketplaces an insurer bailout, any more than tax support of Medicare Advantage plans are a bailout.)

Most recently, on August 11, the House Freedom Caucus called on House Speaker Paul Ryan to bring a “clean” Obamacare repeal bill to the floor this fall.

While this tense and chaotic game of chicken persists, insurers, state insurance commissioners, exchange administrators, most of the health care industry, and millions of consumers fret, wait for clarity, explore options, ready contingencies, and prepare for the worst for open enrollment 2018.

Hope rests largely on two efforts underway in Congress:

(1) Pledges by a growing number of Democrats and moderate Republican Senators to step in and act, led by Sen. Lamar Alexander (R-Tenn.), chairman of the Health, Education, Labor and Pensions (HELP) Committee.   He’s planning hearings in Sept. aimed at quickly crafting bipartisan legislation to shore up the exchanges.

(2) A proposal by a bipartisan coalition of 43 House members dubbed the “Problem Solvers Caucus.”   The proposal shares a central thrust and actions and ideas with the policy experts’ plan, as listed and discussed below.

The problem is time. When Congress returns from summer recess the week of Sept. 4, it has only a few weeks to approve legislation before the Sept. 27 deadline for insurers’ to submit final proposals to states and the federal government to sell marketplace plans in 2018. The Trump administration can extend that deadline but that’s viewed as unlikely. Open enrollment for 2018 starts Nov. 1 and ends Dec. 15.

Some observers think it’s already too late to affect premiums for 2018. Insurers in almost every state have added supplemental premium increases (above those already planned) due to the uncertainty.   Some states, like California, plan to telegraph loud and clear to consumers which plans are being hiked the most.

Courtesy of The Washington Post’s Paige Cunningham and the Kaiser Family Foundation (KFF), out of 20 states (plus DC) that have released enough information to analyze, insurers in 15 have proposed rate hikes in the double digits. Insurer participation in the marketplaces is also down but not as much as anticipated a few months ago. An average of 4.6 carriers intend to sell plans in 2018 compared to 5.1 carriers this year and 6.2 in 2016 in those same 20 states and DC.

HHS predicted this month, however, that as many as one third of U.S. counties—and especially those in the rural western states—might have just one insurer in the exchange in 2018.

The policy think-tankers—from organizations as diverse as the Hoover Institute, Families USA, The American Enterprise Institute and Brookings—recommend the following:

* Fund the cost sharing reduction (CSR) payments. These payments to insurers help reduce deductibles and co-payments for low-income exchange enrollees—critical to affordability.   The cost: $8 to $10 billion a year in 2018 and 2019.   The Trump administration has been paying the CSR bill month-by-month amid litigation over the legality of the payments dating back to the Obama Administration. Trump has personally threatened to cut the CSR payments off unless Congress repeals the ACA. It’s mainly these payments that some Republicans call a “bailout.”

* Reassess the “3 Rs”—risk adjustment, risk corridors and reinsurance—as tried-and-true ways to stabilize the exchange markets. All were in the ACA and played a key role in holding premium increases down from 2014 to 2016. But the reinsurance and risk-corridor programs terminated at the end of 2016. Risk adjustment is permanent but has been administered poorly. HHS should “give states wider latitude to tailor risk adjustment methodologies for their particular markets,” the group advises. HHS secretary Tom Price supports reinsurance, having invited all 50 governors in March to consider it as they sought to restrain premium increases.

* Continue enrollment assistance programs that inform consumers about the ACA benefits, and aid their enrollment.

* Address the needs of consumers in counties with no participating insurers in 2018 by permitting people to enroll in a plan sponsored by the Federal Employee Health Benefits Program (FEHBP).   FEHBP has a presence in every state because there are federal employees in every state.   Insurers could be required, for example, to offer such plans in “bare counties” as a condition of FEHBP participation.

* Permit states to explore alternatives to the individual mandate. A compromise could involve “combining incentives to purchase health insurance with effective sanctions for not enrolling or not maintaining coverage, including financial penalties and waiting periods,” the group said. The ACA’s Section 1332 currently allows states to propose waivers to explore alternatives to the mandate.   The group also recommends that Congress modify Section 1332 to allow states to “integrate federal funds used to cover low income children, adults, and families under Medicaid and CHIP and private insurance to improve coverage and care delivery.”

* Permit states, more generally, to experiment with their health insurance markets. “We support enhanced financing flexibility for states that seek to increase access to affordable coverage for their low and moderate-income populations. Though we differ in our views regarding the scope of the guardrails that should be established, we encourage Congress to consult with states and others on how to refine the guardrails to provide enhanced flexibility.”

* Extend federal funding through 2019 for the Children’s Health Insurance Program (CHIP) and community health centers.

* Expand, judiciously, health savings accounts (HSAs) and health reimbursement accounts (HRAs), including using HSA funds for premium payments and reforms that make pre-funded HSAs available to lower income people who choose to enroll in high-deductible health plans.

Categories: OIG Advisory Opinions

Fax This to Washington: Hospital Consolidation Threatens Our Healthcare System

The Healthcare Blog - Fri, 08/11/2017 - 14:05

As hospital consolidations sweep the nation, the monopolies being created are having a profound impact on life in small town America.  Lee County, in Southern Georgia, is a little place with big dreams; they are resolutely determined to build a 60-bed community hospital and provide local residents with real choices. For years, two competing hospitals served the population of 200,000 spread over six counties: Phoebe-Putney and Palmyra Park. Phoebe-Putney Memorial Hospital put an end to that by securing a 939-bed hospital monopoly and an ample market share.

Their efforts began in 2003, when Phoebe-Putney Memorial Hospital in Albany, Georgia successfully opposed a bid for a Certificate of Need (CON) to open an outpatient surgery center. Frustrated from a free-market perspective, accountant Charles Rehberg and a local surgeon, John Bagnato, began sending anonymous faxes to local business and political leaders, criticizing the financial activities of the local hospital.  These faxes quickly gained notoriety, becoming known as “Phoebe Factoids.” Concerned about negative publicity, Phoebe Putney executives hired former FBI agents to intimidate these men.

Undeterred, these two renegades discovered Phoebe-Putney Hospital was charging uninsured patients far more for services than insured patients.   This brought widespread attention to the plight facing millions of uninsured Americans. Many began to question what obligation a nonprofit hospital has to provide charity care for those in need. Phoebe-Putney was caught using aggressive collection tactics, such as wage garnishment and the placing of liens on homes of patients unable to keep up with payments. Their experience inspired a documentary called “Do No Harm.”

In-depth research uncovered millions hidden in offshore bank accounts disguised under the auspices of a non-profit— not only at Phoebe, but also at other non-profit hospitals across the country. As whistleblowers, Rehberg and Bagnato were subsequently targeted by Phoebe and indicted on fraudulent charges of telephone harassment, aggravated assault and burglary; charges without merit which were dismissed in 2006.

After successfully blocking the surgery center CON, Phoebe-Putney set its sights elsewhere looking to acquire the only other hospital facility in the surrounding six-county area: Palmyra Park. In 2011, the Federal Trade Commission (FTC) attempted to block this proposal on the grounds that the combined entity would control in excess of 85% of the market share. Phoebes’ CEO insisted hospital consolidation was necessary to deliver cost-effective, high-quality medical care, calling the merger “the right thing for citizens.’’   The FTC argued the deal was anti-competitive (which it was) and health costs would increase significantly (which they did.) The FTC secured a preliminary injunction but Phoebe prevailed, arguing Georgia CON laws prohibited the sale of Palmyra Park to an independent entity.

Ultimately, the FTC was obligated to settle with Phoebe, making the dream of a hospital monopoly a reality. However, the settlement had three stipulations: 1) Public acknowledgement the acquisition would substantially lessen competition within the six-county market; 2) Phoebe was required to provide the FTC with prior notice of transactions acquiring any part of a general acute-care hospital, or controlling interest in other facilities; and 3) Phoebe was precluded from opposing CON applications from other entities for five years.

Barring Phoebe from challenging CON applications was an innovative solution to a monopolized region; however, Phoebe already handily dominated the market. The Certificate of Need process is expensive and time-consuming; therefore, legal experts anticipated this limitation alone would be ineffective in enticing new competitors to enter the region. Yet, predictions can sometimes be incorrect.

Enter the little county that could, a.k.a Lee County, Georgia, with its population of 29,000 and land mass of 362 square miles. The community and their steely resolve have yielded unexpectedly positive results. Lee County officials filed a Certificate of Need application for a 60-bed hospital earlier this year. The Lee County Development Authority will own the hospital structure and a separate entity will lease the facility. Services offered will include acute and emergency care, including an ICU, medical/surgical unit, inpatient and outpatient beds, and full radiology capabilities, such as CT and MRI. The hospital will create more than 350 “good-paying jobs” and provide access to health care for all, regardless of their ability to pay.

While Phoebe Putney agreed not to challenge a CON application until 2020, the settlement does not preclude engaging in “sneaky” public relations tactics. Phoebe commissioned a study to calculate the effect the Lee County Medical Center would have on the financial outlook for Phoebe-Putney. DHG Healthcare projected Phoebe will lose more than $250 million in revenue over five years.  The firm found by the third year of operation, annual losses will be $30.1 million for inpatient care, $23.7 million in outpatient care, and $6.4 million for emergency care at Phoebe.

Lee County is on their way to achieving something extraordinary; challenging the dominance of a hospital monopoly. On July 21, 2017, the CON application for Lee County was deemed complete by the Georgia Department of Community Health. A decision is anticipated by Nov. 15. If granted, the county plans to break ground on the new structure in early 2018. The CEO of Lee County Medical Center, Mr. G. Edward Alexander, stated “Our goal is to ensure that decisions for the hospital are made locally by people who live and work in Lee County.”

Lee County, I salute you. Medically underserved communities everywhere are supporting your efforts to transform the healthcare landscape for the better. May your success inspire a revolution, proving that healthcare can be repaired by patients, physicians, and communities – working together.

 

Categories: OIG Advisory Opinions

Dear Humans, Diverse Social Networks are the Answer

The Healthcare Blog - Thu, 08/10/2017 - 12:47

In biology, it is clear that access to more genes leads to greater overall health. This is true because it allows for a greater likelihood that a genetic defect can be compensated by a gene from a different pool. This is the reason that inbreeding leads to more genetic diseases. This same phenomenon exists in social science. Complex social networks are healthier than more narrow (constrained) ones. Dr. Amar Dhand of the Brigham and Women’s Hospital’s Department of Neurology has, for example, shown that people are more likely to get to the emergency room in time to receive a clot busting therapy for stroke if they are part of a more complex, rather than constrained, social network.

The probable reason for this effect is the diversity of ideas that are available in the complex social networks is greater than in the narrow ones. Despite these advantages, human beings tend to resist diversity, depending instead on a competing drive to create cliques and clubs.   In Arlie Russell Hochschild’s book, Strangers in Their Own Land, she attempts to understand what she sees as a paradox.   Why do people vote in manners that seem to be contrary to their own self interest? In fact this is not a paradox, but rather simply a competition between two deeply ingrained human traits; one biological and the other sociological.

The phenomenon of professional burnout is a case in point. It is generally defined as a sense of cynicism, depersonalization and ineffectiveness. Some believe that we are in the midst of an epidemic of burnout, affecting as many as half of medical doctors, for example. The causes of burnout are protean, but at the core of the problem is the perception of unfairness; that one is the subject of a form of bias or prejudice whereby certain resources are unfairly distributed by a powerful force, such as the employer or the government. Any individual or group may be subject to this perception. Much of the conflict that is being expressed around the world can be understood as an analogue to professional burnout, in other words, caused at its root by a perception of unfairness. So what is perception and from where does it arise?

It is useful to employ a theory of mind. By theory of mind, I mean the capacity to put oneself on another’s position. It is different than sympathy or even empathy in that it allows one to understand other viewpoints without actually experiences them oneself. There is neuroscientific evidence that there are some nerve cells in the brain (mirror neurons), which are specialized to respond to actions performed by another individual. These cells may or may not exist in humans, but it is definite that certain neurological conditions damage the theory of mind, making it difficult or impossible to perceive the perspectives and feelings of others. In related conditions, one may even become disconnected from one’s own body or thoughts, such that even major deficits, such as paralysis, cannot be perceived, a condition called anosognosia (denial of deficit). In other words, we live in virtual reality. What the brain experiences is, in fact, reality.

Diversity is the solution to the apparent paradox. If one cannot perceive an aspect of the world, it can be helpful for another person to provide that insight. The more an individual, a group or society can provide diversity, the stronger it will become. This principle is not limited to one or another group. It is a basic biological and sociological trait of humans. Rather than a “republican” or “democrat” pollster, as they are always identified, what is needed is a diverse representation of the largest possible numbers of opinions, views and perspectives. Such an approach is the most effective immunization against burnout and its core cause, the perception of unfairness. The counterpoint to the narrow (constrained) network is the complex, diverse one. Wouldn’t it be nice if our media and our leaders could embrace this simple solution?

In the words or Robert Burns:

And would some power the gift would give us
To see ourselves as others see us
It would from many a blunder free us,
And foolish notion
What airs in dress and gait would leave us
And even devotion

Martin Samuels is a professor of neurology at Brigham and Women’s Hospital.

Categories: OIG Advisory Opinions

Why Smart Pill Bottles and Financial Rewards Don’t Improve Medication Adherence

The Healthcare Blog - Wed, 08/09/2017 - 12:07

A study published recently in JAMA Internal Medicine showed financial rewards and connected pill bottles don’t work. One explanation suggests that “other patient concerns about potential adverse effects of these medications, such as impotence or fatigue, were not targeted by this engagement strategy.”

What?!!!!!??

How can a patient engagement strategy not target the patient’s concerns? Isn’t that the very definition of patient engagement? Impotence and fatigue are a big deal to most people. Would an extra $15 a week compel you to take a medication that made you impotent? $150 a week? Would a pulsating pill bottle in your cabinet get you to swallow a pill that made you feel foggy and tired all day?

We can’t incent or remind someone to do something they never agreed to or intended to do. It would be like Amazon pinging you to buy something you would never consider adding to your cart. Amazon nudges you to buy things that you would put in your cart or things you saved to your cart, but never purchased. Why aren’t we as laser-focused on what matters to patients?

When 1/2 of all people prescribed a medication do not adhere to their plan, we have to consider that they never agreed to it or recognized its importance in the first place. They didn’t forget. (Psychologists, myself included, don’t believe in “forgetting.”) Even the most “forgetful” people do not forget to eat or have sex.

You forget what you don’t want to do. Forgetting is a way of saying “no.” Patients don’t say no to their physician’s face, but they say “NO!” en masse when they don’t fill their prescription or fill it but don’t take it. When I wrote a post recently about the importance of welcoming the patient’s resistance to their care plan, some responded that I wasn’t recognizing the dangers of non-compliance. This couldn’t be further from the truth. I am simply not deluded that we can control, coerce, enforce or even educate our patients into compliance. In light of the recent JAMA Internal Medicine article, we need a different approach.

The Paradox

If we let patients say “no” to their treatment plans, they are more likely to say “yes.”

When they say “yes,” they are more committed.

The conclusion: Let them say “no,” if we want better results.

The physician is the expert at prescribing medication; patients are the experts on why they won’t take it.

I have spent my career working with patients who are making decisions that will determine whether they live or die, whether they lose limbs to disease, contract diseases that can kill them or destroy their lives and bodies through addiction. It’s a harrowing drive on a road with hairpin turns.

We clinicians are in the passenger seat no matter what we do. And the driver has never been down this road before.

When I teach residents in psychiatry, I tell them that learning to let patients drive is like training yourself to accelerate into a skid on an icy road. At first, every muscle in your body wants to resist, pull away, brake, as you feel the loss of control when the car slips on the ice. Then, you remember the facts: you are supposed to accelerate into the skid, so you let go off your tight grip on the wheel, you accelerate, you hang in the balance horribly for an instant and then the car rights itself almost effortlessly. And then, you realize you never held the wheel at all, you were in the passenger seat the whole time working with an imaginary set of controls! It takes years of experience and profound discipline to accelerate into these skids with our patients.

How does a patient-driven approach work in practice?

In 15 minute visits, providers need to get right to the point, by saying things like:

Dr. S: Look, I am prescribing this medication because I believe it can help you, but 1/2 of patients don’t end up taking it. So, before I give you this prescription, tell me all the reasons you might not take this medication and how this plan we just made is going to fail.

Patients will be surprised by this. Good! The surprise gets them thinking and engaged. They are being called on as the expert in their own care.

Mr. X: No, I am going to take it. I know I need to.
Dr. S: Some people who take this medication say it affects their sex drive and it makes them feel foggy. What will you do if that happens to you?

Mr. X: Seriously? Well, first, I am going to be very mad at you, Dr. Smith (laughs). No, but I get it, it’s important. I guess I could come back you? I’m not saying I would like it if that happens, I might have to come back to you though if that happens.

Dr. S: Of course you can come back to me. But I can’t promise that I can solve it.

Mr. X: Are there any other options? I’ve heard some people change ____ and they don’t have to take any medication at all.

Dr. S: Yes, we can talk about that and they might reduce the amount of medication you have to take and some of the side effects, but you likely still have to take medicine.

What just happened? The doctor acknowledged the patient was the one behind the wheel, the patient was surprised but intuitively started driving and making decisions and commitments. By letting the patient say no, the doctor let the patient say yes. And the patient’s yes is a critical step to improving adherence. The patient starts making suggestions, problem-solving, and asking for alternatives. This is one interaction that needs to be repeated again and again.

Patients don’t need reminders, extrinsic motivators, or incentives. They need help identifying intrinsic motivations and personal barriers, and they need their internal problem-solving abilities mobilized. All of our well-meaning education, instructions and attempts at coercion are noise from the passenger seat – distracting the driver.

What does this mean for digital health?

Digital health technologies are not doomed, in fact, this study marks a major turning point. We see what doesn’t work and we can move on. Fail fast and learn.

Digital technologies are well-suited to a patient-driven approach. At Vital Score, we have turned a disciplined patient-driven methodology into a codified method of delivering thousands of digital conversations with patients. We call our method Motivational Indexing™ because we capture and categorize what motivates people, we let them navigate a pathway to health, and we learn from the paths they create. Motivational Indexing™ works because it learns from the experts on non-adherence: patients.

We should welcome the news that reminders and incentives don’t work. It turns out the experts in medication adherence are not behavioral economists, physicians (or psychologists!). The experts are patients and we will learn if we listen to them.

Hilary Hatch is Founder and CEO of Vitalscore. 

Categories: OIG Advisory Opinions

The Next Visionary Entrepreneurs In Health Tech

The Healthcare Blog - Tue, 08/08/2017 - 12:12

For each of the nearly 11,000 health technology companies in the Health 2.0 Source Database, there have been countless more that have failed. Sometimes it’s small companies with good ideas that never quite get off the ground — remember Zeo? — and sometimes it’s big, well-funded experiments that suddenly fall flat, like the recent closing of Qliance. There is no magic formula for success in this industry, and the so-called “graveyard” of health technology companies continues to grow. Yet, somehow, there exists this legion of entrepreneurs that never fails to produce the next passionate CEO willing to reach for those deceptively low-hanging health care fruit.

This year, at Health 2.0’s 11th Annual Fall Conference, the crowd favorite 2 CEOs and a President Panel returns to our main stage. We’ll hear from three visionary entrepreneurs who are tackling three diverse segments of health care: consumer health and wellness, data transparency, and patient education. Saeju Jeong, the CEO of Noom, will share how Noom’s intelligent health coaching apps that focus on fitness and nutrition are staying relevant in a crowded market that includes the likes of tracking giant MyFitnessPal, or the health coaching app Vida. David Vivero, the CEO of Amino, will also appear to discuss how Amino is tackling the long-standing transparency problem in health care by using data to help consumers find better doctors, book appointments, and estimate their costs. Finally, this year’s addition of a president comes in the form of Shradha Agarwal of Outcome Health. The Chicago-based startup has reportedly raised more than $500 million at a valuation of $5 billion, which means we’ll have no shortage of questions for Agarwal about scale, growth, and how Outcome’s patient education technology is actually helping to improve health outcomes.

Register now for the 11th Annual Fall Conference to join us, and to hear these leaders’ stories.

Categories: OIG Advisory Opinions

Does a CDI Program Improve Physician Engagement?

Medical Coding News - Tue, 08/08/2017 - 11:32

Last month, the American Health Information Management Association (AHIMA) released a practice brief titled “Impact of Physician Engagement on Clinical Documentation Improvement Programs.” The brief contains some extremely valid and interesting points. Genuine, consistent physician engagement is essential for any clinical documentation improvement program meant to achieve scale and long-term sustainability. The practice brief starts […]

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Categories: Healthcare News

A Line in the Sand

The Healthcare Blog - Mon, 08/07/2017 - 12:21

Eventually, the share of the American economy absorbed by healthcare will stop rising. The question is when, and how much more collective damage will be inflicted in the process. As it turns out, there is a solution under our noses that is nearly ubiquitous in business, personal finance, and government programs worldwide. It can be used to bring manageable, relatively predictable transformation, rather than sudden wrenching change. It is a called a “budget.” It is well past time to embrace the discipline of budgets in healthcare financing.

The basic idea is clear: set a limit on how much money can be spent for healthcare. Almost every wealthy nation disciplines its spending with a budget for healthcare expenditures. The United States does not, still retaining for the most part an open-ended model in which rates for individual services are set, without overall limits on what is spent. The discipline brought by budgets allows other nations to spend roughly half what the United States does per person, despite the fact that life and health are valued in France, The United Kingdom, Israel, and Germany no less than in the United States.

Global healthcare budgets aren’t a policy of the left or the right. The use of budgets has become associated with the political right in America, despite the fact that nearly every socialized universal healthcare system in the world has one. The fact that this isn’t about left or right becomes clearer when considering that even in America both sides have advanced their own versions of capping healthcare expenditures by a budgeting mechanism.

The darling of conservatives for over 30 years has been the “block grant” for Medicaid. Starting with the Reagan administration in 1981, the basic idea has been to set a budget for a program according to a formula (say, last year’s cost plus an allowance for inflation). The block grant is given to a state, which then spends the money how it sees fit to accomplish program objectives. Since the state won’t see more dollars simply because providers are billing for more expensive services, or drug prices are increasing, the state has a strong incentive to find ways to manage those costs rather than simply pass most of them on to the federal government under the current system.

There are several problems with the basic block grant design, one of which is that it is not flexible with changes in economic conditions, such as a recession that brings a surge in the needy. To address this limitation, in their most recent proposals to cap the Medicaid program conservatives have adopted a modified approach that sets a spending limit per recipient rather than for the state overall. This is the “per capita” capped model which became the default in both the Ryan plan passed by the House of Representatives in April and the Senate version that came a few votes shy in July. For the per capita cap, the state’s budget effectively goes up in bad times and down in good times, so that the state can focus on how much is spent per Medicaid eligible person.

Seemingly unrelated to the Republican plans, the approaches preferred by progressive policy experts typically goes by the names “global budget” or “global cap.” New York, an azure blue state, has had a global cap for its Medicaid program since 2011. This cap on state Medicaid expenditures has brought great discipline to spending and saved New York taxpayers billions. The cap was part of a larger set of reforms initiated by New York’s Medicaid Redesign Team (MRT) in 2010 during a budget crisis brought on by the unsustainable growth of the Medicaid program. Over 270 of these reforms have been fully or partially implemented as of 2017. The other reforms enabled New York to live within the cap, and the cap in turn helped ensure the continuation of the reforms. The reforms cover benefit designs, rate changes, the expansion of managed care and new reimbursement methodologies, like value-based payment to reward outcomes over the volume of services. Every year new initiatives are proposed to stay within the budget.

And it has worked. Since 2011, New York has increased its Medicaid enrollment by over 1 million people while lowering the cost by about $1,000 per person. For a couple of those years, New York added large numbers of members to its rolls while at the same time lowering total program cost. This is unheard of in American healthcare, and the global cap was essential to making it possible. Lowering cost was temporary, but even now costs are growing much more slowly than prior to the global cap.

Maryland is another blue state that under Democratic leadership embraced global budgeting. Maryland, uniquely, had been living under some version of all-payer hospital rate setting in Medicare for over 40 years. Recently costs started to creep beyond the level approved by CMS, so Maryland moved to adopt true global budgeting to provide additional discipline. The new global budgets continue to set hospital payments for all payers, but they do so at the level of total hospital expenditures for the population, both inpatient and outpatient. Essentially, each hospital is given a pot of money based on its attributed patient population and other factors, and it is up to the hospital to spend it wisely (within limits). The new model produced nearly $116 million in savings in its first year of operation. Potentially avoidable readmissions dropped by 26% (nearly reaching the 30% five-year reduction target in the first year).

In Maryland the all-payer hospital growth rate is set at 3.6%. In New York, the services covered under the global cap are allowed to grow at the 10-year average Medical Consumer Price Index (CPI-M), which is about 3.6% currently. The House ACA-repeal bill capped Medicaid growth at the CPI-M from 2016 to 2019, with up to 1% additional growth allowed, which at current rates would be up to 3.7% annually. The Senate draft bill set the allowed growth rate at CPI-M for those not elderly or disabled from 2020 to 2025, after which it would switch to the general CPI for all urban consumers (CPI-U), which is historically over a percentage point lower.

While the Senate proposal is the stingiest, it’s clear that these caps are not far apart. Other initiatives, such as the all-payer statewide ACO in Vermont, also have growth caps in the range of 3.5%.The rhetoric presented in national debates unfortunately obscures the fact that these targets are closely related. But there’s a good reason they are similar: over the last 10 years GDP grew on average by less than 4% per year. In contrast, the 10-year average growth rate for Medicaid is 5.9% (partly due to Medicaid expansion under the ACA), and the overall growth rate for healthcare in the U.S. over that period was 4.9%. By staying below 4%, all of the proposals would reduce the share of the national economy devoted to Medicaid.

Of course, there are reasons that the rhetoric gets so heated. One of these reasons is that the budget is not created in a vacuum, and policies surrounding the cap can differ enormously. For example, Republicans didn’t just want to limit the rate of growth, they wanted to eliminate Medicaid’s expansion to new populations provided under the Affordable Care Act by slashing the funding available for those individuals, leaving an expected 10-15 million more people uninsured. And for Democrats, that is something worth fighting for.

In a battle to save coverage for millions, from a bill that they had no say in, it didn’t pay to be nuanced and single out parts of the legislation for compliment. But if that battle is over and voices of compromise can be heard, then global budgets provide the most promising path forward. Once on that path, and both parties agree that the solution is not to engage in dramatic cuts to eligibility but instead to reduce federal expenditures in the long term by capping growth, this would still save hundreds of billions of dollars over the next 10 years. There is much that Democrats and Republicans would still need to work out. For example, will states be allowed to pocket savings and not reinvest them into health promoting objectives? Will there be an escape hatch if states find themselves to manage some aspect of their costs (like pharmaceuticals), or even an option to revert to the older model? How much flexibility will states, insurers and providers have under such a system?

Failure is an option, of course. In adopting some version of global budgeting, we need to avoid what happened to the Sustained Growth Rate (SGR) formula in Medicare. The SGR set a growth rate in Medicare fee for service rates pegged to the actual total FFS expenditures in the prior year, but it was a formula that didn’t result in actual budgets. Once the actual reimbursement trend increased faster than the formula allowed, the framing around SGR almost immediately became that it was too harsh. Rather than rebalance rates, the standard refrain became that a “doc fix” was needed. Because the SGR wasn’t a true budget, the cuts it proposed were delayed year after year until eventually the SGR rule itself was rescinded. There are two lessons in this experience. First: guidelines don’t work; true budgets are needed. Second, and even more importantly: you can’t put a cap on just one of the three main pillars of American Health insurance (Medicare, Medicaid, and commercial) without the other two as well. If you’re a physician and your Medicare fees go up 1% every year while your fees for private insurance go up 5% every year, no matter how much more Medicare pays than what is typical in other wealthy nations, it is going to look like a “cheap” payer in the American context.

As some savvy readers of this article have no doubt been objecting for some time, that is also an insurmountable problem with the current Republican proposals to implement a budget-based cap on Medicaid expenditures alone. If Medicaid lives under a fixed budget but Medicare and commercial insurance do not, Medicaid will become even more of the poor-cousin payer. It will create more insolvent safety net hospitals because they are stuck in an environment where they have to compete on salaries, facilities and other matters with richer hospitals in a money-bloated system fueled by Medicare and especially by employer-based commercial insurance. More physicians will drop out of the program because they can be paid a multiple for their time elsewhere and their cost of doing business is in part set by the other forms of insurance.

And so at the same time as Medicaid switches to a capped, budget-based system, Medicare should as well. If Medicare does not follow, the cap in Medicaid will fail, sooner or later. Amazingly, New York Medicaid has been able to continue under a cap for 6 years, while Medicare and employer-based insurance grow with no such constraints. But partly that’s because New York started with one of the richest Medicaid programs in the nation and had room to cut excesses. There has also been an escape valve, in that parts of New York’s program have been outside the cap and allowed to grow at a higher rate, and CMS allowed some of New York’s savings to be recouped through a delivery system transformation program called DSRIP (over $6 billion dollars, in fact). But after 6 years of a global cap for most expenses, the Medicaid program in New York is feeling the strain. The collapse of the safety net provider network is inevitable if New York’s Medicaid program continues to stand alone.

As a bonus, once Medicaid and Medicare are locked together in a capped budget system, the environment will be conducive for employers and individuals who purchase commercial insurance to be open to a similar capped growth system to provide relief, creating an all-payer global budget approach that finally starts to look like the universal healthcare systems of Germany, The Netherlands, Israel, Switzerland and many other nations. (These are not single payer models. Those nations have robust, highly-regulated health insurance markets covering part or all of their health care expenditures.)

So why do budgets work? Normally when CMS or a private payer attempts to control some aspect of healthcare spending, it micromanages part of the delivery of care. Typically, this is effective for a short time until providers figure out a way around the barrier and alter the services delivered, or increase revenue by changing coding practices. But a budget puts an overall constraint on all spending, or a large enough portion of it to effectively prevent gaming.

Global budgets are consistent with many other objectives of healthcare reform. In fact, as shown in New York and Maryland, they can be a powerful stimulator to execute other reforms improving the quality of care, such as reducing avoidable ER visits and readmissions. By pushing responsibility for the financial management of care to providers, external parties (government and private payers) can start to get out of the business of micro-managing the practice of medicine and its administrative hassles, like utilization management.

A global budget can be formulated at many levels. Politically it can exist at the national, state, and regional level, with further distributions to individual managed care companies and/or providers, such as hospitals. To provide stability, a budget program should operate by a formula that can be projected out multiple years. The funds can be distributed to payers who are tasked to work with providers to stay within the caps. Or, the funds can be allocated centrally to specific provider organizations that are responsible for the spending of an attributed population, with insurance playing more the role of a pass-through. There are benefits and drawbacks to each approach. New York uses a mixed model of payer and provider responsibility, while Maryland and the rural Pennsylvania project focus on setting budgets for hospitals directly, while leaving office-based physicians in more traditional relationships with payers. Whatever the starting point, hospitals and other providers will need to take on risk for the cost of care and align their incentives with the efficient delivery of appropriate care. The move to budgets continues the transition to “value” that has dominated health care policy for over a decade.

Despite the political inertia that resists any major reform, the move to global budgets seems highly likely, eventually. It need not be a triumph of the pocketbook over the heart. Affordability is not a dry goal for lifeless bean-counters. The high cost of healthcare brings bankruptcy, despair, suicide, and diverse dreams deferred or abandoned for the uninsured and poorly insured, and even for some who thought they were well-insured. A long term healthcare budget growth rate that is 0.4 percent less than the long term growth in GDP will mean that every year healthcare costs get a little easier to bear. After some years, the belt-tightening period would be over and growth would increase again to match the overall economy. Rather than one-time cuts that hurt those with few resources most, Republicans should focus on doing what they campaigned on: keeping everyone covered at a lower cost…modified with the boring but essential caveat that “lower cost” is relative to the growing economy, not a big one-time drop in nominal dollars. Democrats know that it is not in the national interest for healthcare to keep absorbing more and more of every dollar earned, and that it undermines Democratic objectives such as achieving universal healthcare. They should embrace the discipline of budgets to accomplish this. We don’t need to keep taking the path of maximal pain.

Jonathan Halvorson is a consultant on healthcare policy and strategy for Sachs Policy Group. He is formerly the Director of Operations and Systems for the New York State Office of Health Insurance Programs, which administers New York’s Medicaid program. The views expressed here are his own.

 

Categories: OIG Advisory Opinions

Moving Your Practice Past Industry Benchmarks

Medical Coding News - Mon, 08/07/2017 - 09:24

I often get the question, “What should my monthly numbers be?” My first response is, taking into account collections among other things affecting their practice, “What are your minimum requirements, annual goals, and what amount of time and energy are you willing to put in, in order to reach those results?” This is not the […]

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Categories: Healthcare News

Nixon Went to China. Can Trump Go to Single Payer?

The Healthcare Blog - Fri, 08/04/2017 - 12:40

There is an old Vulcan proverb saying that only Nixon could go to China. Only a man who used to work for Joseph McCarthy could set America on a path to better relations with a virulently Communist country. A few years after Nixon went to China, Menachem Begin, the Israeli Prime Minister who represented people believing that the state of Israel should start at the Nile and end at the Euphrates, gave Egypt back all the lands conquered in a recent war and made a lasting peace with Israel’s largest enemy. They said back then that only Begin could make peace with the Arabs.

Today, I want to submit to you that only Trump can make single-payer health care happen in this country. Only a billionaire, surrounded by a cabinet of billionaires, representing a party partial to billionaires, can make that hazardous 180 degrees political turn and better the lives of the American people, and perhaps the entire world as a result. Oh, I know it’s too soon to make this observation, but note that both Mr. Nixon and Mr. Begin were deeply resented (to put it mildly) in their times, by the same type of people who find Mr. Trump distasteful today. The liberal intelligentsia back then did not have the bona fides required to cross the political chasm between one nation and its ideological enemies, or as real as death immediate foes. The liberal intelligentsia today lost all credibility in this country when it comes to providing a universal solution to our health care woes.

Free health care (and free college) are not solutions. These are rabble rousing slogans to gin up the vote, slogans that end up in overflowing trashcans left in ballrooms littered with red white and blue balloons after everybody goes home to get some sleep before the next round of calls to solicit funds from wealthy donors for the next campaign. Providing proper medical care to the American people is a monumental enterprise that engages tens of millions of workers from all walks of life, every second of every day, in every square mile of habitable land, littered with the hopes and fears of hundreds of millions of invisible men, women and children who call this great country their home. This is not something that can be made free. Nothing is free in our times, not even sunshine and fresh air.

For the jaded, the cynically inclined, and those who are simply too afraid to jump off this cliff, and therefore argue that single-payer is not politically feasible, I have a simple question. Did you all think a couple of years ago, that a President Trump is politically feasible? Okay then. Here is what I believe could be a relatively plausible scenario enabling this one-of-a-kind administration to use its unconventional political capital (if you can even call it that) to get us on the road to making health care great again, greater than ever before.

Step 1: Disaster

The current system, held together with string and duct tape must undergo a seismic shock, preferably a moderate shock and one that does not involve war and famine. The way things look now, the most likely implosion will be the Obamacare individual market. If the Trump administration holds back ransom money from insurance companies (a.k.a. CSRs), or engages in other mischievous behavior, and the individual mandate is not enforced, we may very well have a minor disaster on our hands. In addition, the President’s Commission on Combating Drug Addiction and the Opioid Crisis is requesting that the President declare the opioid epidemic a national public health emergency. Put these two together and you see how lots of people are, or will shortly be, in dire need of medical services not currently available to them via existing “insurance” channels.

Step 2: Relief

The opioid crisis will need much more than providing care for its current victims, but we will need a coordinated effort to provide all necessary medical services to people addicted to opioids who are uninsured, or whose insurer is refusing to pay for the extensive programs needed for recovery. People who were able to afford insurance under Obamacare without, or with minimal, subsidies and are now left hanging to dry will also need a solution, and if they are sick, they will need immediate relief. This would be the perfect time to cut through the red tape and institute the Disaster Relief and Emergency Access to Medicare (DREAM) program. The DREAM will open Medicare to the victims of Obamacare and the victims of the opioid epidemic. This will be put in place as a temporary disaster response program, subject to extension of course, until a more permanent solution can be found. I doubt too many people in Congress could vote against such measure.

Step 3: The DREAM

No matter how short lived, all government programs including temporary ones need rules and regulations to execute now, and to be replicated in future emergencies as needed. Besides, any respectable bill needs more than just a title. How do we define opioid addiction? How do we define Obamacare victim? How do they sign up? What do they get? How much will it cost?

Opioid Crisis

  • Congress will appropriate $45 billion for this program for a period of five years to cover administrative costs, medical costs and program analysis costs.
  • Emergency funding will be provided to Federally Qualified Community Centers (FQHCs) to set up a process for opioid addiction screening. FQHCs are non-profit clinics, funded by the Federal government to serve low income populations regardless of ability to pay. All physicians and staff are salaried. The funding will be administered by the Health Resources and Services Administration (HRSA) and defined by the Secretary of Health and Human Services (HHS).
  • Any American citizen or lawful permanent resident will be eligible to access any FQHC and undergo opioid screening as specified by the Secretary at no cost. Individuals eligible for relief, based solely on clinical criteria, will need to provide information about their insurance status. Upon receipt of consent from the individual or legal guardian if the screened individual is a minor, eligibility results and insurance information will be sent from the FQHC to CMS for enrollment in the DREAM program.
  • If the eligible person (EP) is currently covered by commercial insurance, CMS will contact the EP’s insurance plan and require that the plan contacts the EP or legal guardian and obtains proper consent to transfer the EP’s coverage to the DREAM program. Following EP consent, Medicare will become the primary payer for the EP. Medicare at its sole discretion may discontinue eligibility for the EP and the commercial plan must reinstate coverage for the EP at that time. All subsidies paid by the Federal government to the insurance plan, if any, will be paid into the Medicare trust fund for the duration of DREAM participation.
  • The EP will pay to Medicare premiums equal to the last monthly amount the EP paid to the commercial plan. Medicare will cover all opioid related services with zero deductible and zero copay. For other services the EP deductible and copays will be equal to those of traditional Medicare beneficiaries (parts A, B and D). Medicare will end DREAM eligibility for an EP who missed 3 consecutive monthly payments.
  • If the EP is insured, or eligible to be insured, through Medicaid or any other public program, Medicaid or any other public program, will transfer into the Medicare trust fund estimated monthly premiums as calculated by the Secretary for the duration of DREAM participation. Medicaid will become the secondary payer for EPs previously enrolled, or eligible to be enrolled, in Medicaid.
  • If the EP is uninsured and not eligible for public insurance, the EP will be enrolled in Medicare (parts A, B and D), under the same terms as beneficiaries 65 years or older for the duration of DREAM eligibility, except that all opioid related services will be covered with zero deductible and zero copay.

Obamacare Crisis

  • Congress will appropriate $45 million for this program for a period of five years to cover program administration, evaluation and analysis. All other program costs, if any, will be absorbed by CMS budgets.
  • Any American citizen or lawful permanent resident who is not offered employer sponsored insurance, and is not eligible for Medicaid or another public insurance plan, and is not eligible for Federal subsidies on the Obamacare exchanges equal to at least 50% of total costs of the current benchmark plan, or resides in a county where no Obamacare plans are available on the exchange on the first day of the open enrollment period, will be eligible to enroll in Medicare parts A, B and D, at an annual rate of average Medicare spending per beneficiary (MSPB), adjusted for EP age.
  • The Secretary shall publish a list of DREAM premiums for three age bands, 0-21, 22-45, 46-64, no later than one month before the first day of open enrollment for the Obamacare exchanges. All DREAM rates will be assessed and billed for each individual EP. No family rates will be available and no Federal subsidies will be given to DREAM enrollees.
  • The EP, or a legal guardian if the EP is a minor, is responsible for premium payments to Medicare. EP deductible and copays will be equal to those of traditional Medicare beneficiaries (parts A, B and D). Medicare will end DREAM eligibility for an EP who missed 3 consecutive monthly payments.
  • For each program year the Secretary shall conduct and publish comparative analyses of Federal spending on Obamacare exchange enrollees and DREAM program enrollees to inform Congress and the public on the merits of each program.

Step 4: Consequences

See? Wasn’t that bad now, was it? Defining the program is relatively easy and the above is just an abbreviated example. Other details will need to be added, removed or changed, but the main idea here is to open Medicare in the short term to people who are hurting and are underserved by the commercial health insurance markets. There will of course be consequences. First, the Obamacare exchanges will most likely go bust, and we will have to expand the DREAM to allow enrollment of people who will bring their subsidies with them. Second, employers may decide to fund Medicare premiums instead of dealing with health insurance in house. Third, the folks who don’t qualify for the DREAM program may start chomping at the bit, seeing how DREAMers get to choose pretty much everything without breaking the bank.

Yes, yes, I know. I’m being too clever by half, but surely someone who professes to be the voice of the forgotten men and women, could see his way clear to make this happen. It will, after all, lead to a complete repeal and replace of Obamacare. And for all timid liberals enamored with the poetry inscribed at the feet of Lady Liberty, let’s help the President erect a statue of liberty at the gates to Medicare.

 

 

 

Categories: OIG Advisory Opinions