While Washington now seems consumed with the mess swirling around the White House that was triggered by the abrupt firing of the FBI director, I want to get back to the mess swirling around the latest effort to “repeal and replace” the Affordable Care Act.
Although the President stated that “nobody knew that health care could be so complicated,” his apparent surprise is surely based on his own profound, willful ignorance. Anyone who has paid even the most cursory attention to American health care delivery and financing knows that our “system” is uniquely complicated (actually, it is complex). The complexity has been driven by many forces including, among others, the historical accident of employer-based health insurance, a mythic belief in “the market” to improve everything it touches, a corresponding skepticism that government can do anything effectively, and a lack of national consensus about what we, as citizens, owe each other to “promote the general welfare.”
The net result has been well documented. Health care in America is characterized by huge disparities in access to care, major failures of quality and safety, and unsustainable costs. It is, of course, also characterized by amazing life-saving and life-sustaining technology and millions of dedicated, compassionate people who struggle daily to overcome the dysfunction to deliver great care. So how to fix the bad without destroying the good?
Continue reading Back to Health Care
We held a retreat last week for the Board of Governors of Northwell Health Physician Partners. Because we have matured as an organization, the agenda was different from recent years. Instead of asking “big questions” about what the group is and should be, we focused on providing information to the Board, and on addressing ways in which we could reduce physician burnout.
Given the imminent inauguration of the new president, and his party’s pledge to repeal the Affordable Care Act, one of the informational sessions was devoted to how the changeover in Washington may affect health care policy. We heard from Northwell Health’s head of government affairs, and from a former senate staffer who now works for a firm that provides our organization with insight into what is going on inside the beltway.
The speakers were knowledgeable and engaging, and I am confident that their description of the incoming administration and of the plans being laid by the new congress was accurate and insightful. It is no criticism of them to also say that I found their description appalling, frightening, and depressing.
Here are a few “highlights”:
Continue reading Repeal and… Then What?
Policy makers who are responsible for shaping how the federal government (the country’s biggest payer of health care services) pays physicians are pushing CMS on a rapid path away from traditional fee-for-service (FFS). As I discussed last year, CMS intends to have 50% of its payments flow through “alternative payment models” such as ACO’s and bundled payments by 2018, with nearly all of the rest of the FFS payments linked to quality measures.
While I believe this is generally a good thing, I pointed out recently that changing how the dollars flow is not the same as changing how the care gets delivered. Changing payment models facilitates redesigning care, but it doesn’t automatically create new care models. That only happens when physicians, liberated from the constraints of FFS, lead the way to do the right things for patient.
Continue reading Capitation? What Capitation?
I spent a couple of hours today discussing a topic that has become increasingly important in the world in which we live, and which would have completely mystified an earlier generation of physicians. The subject was “attribution.” Simply put, how should one decide which patients “belong” to which doctors? On a more technical level, what algorithms should be employed to connect patients, or episodes of care for those patients, or specific quality measures pertaining to those patients, to particular physicians?
Here’s why this is a hot topic. CMS is moving rapidly to alternative payment models. Medicaid is transitioning to a capitated system. Commercial payers are entering into “risk” arrangements with providers. All around us, fee for service is losing sway and is being replaced by a spectrum of new ways to pay for care. In the “old world” of fee for service, whoever provided the service got the fee. There was no mystery about how the dollars should flow. In the “new world” all that changes. In many instances, payments are linked to quality measures. So, for example, physician groups or integrated health systems may be subject to penalties or earn bonuses depending on how “their” patients do. Too many readmissions? Penalty. Excellent blood pressure control? Bonus. Simple enough in theory but complicated in practice.
Continue reading Who’s in Charge Here?
When the Affordable Care Act (ACA) was passed in 2010, the most contentious provisions – which are still the subject of challenges in federal courts – were the establishment of state-wide insurance exchanges, the “individual mandate” that compels eligible citizens to buy insurance, and the expansion of state Medicaid programs. Less well appreciated, but arguably more important, were a wide range of reforms to the Medicare program. Summarized here, they touch on almost all aspects of the program, but I want to concentrate on just one.
The law directed CMS to move Medicare from a strictly fee-for-service (FFS) payment model (“paying for volume”) to one in which the quality of care was factored into the payment received by hospitals and physicians (“paying for value”). As I have written previously I believe this is the right move. There are just too many challenges to improving care and lowering costs that derive from “straight” FFS that is disconnected from any assessment of quality. And while you may not have known that they grew out of the ACA, the payment reforms themselves have gotten a lot of attention. Penalties for readmissions, requirements for physician quality reporting, pilot programs for bundled payments and accountable care organizations are just of few of the Medicare reforms. Even though they currently influence a small percentage of overall Medicare spending, these changes may already be having a big impact on how care is delivered.
Continue reading Not Your Father’s Medicare