No more excuses! We need a long-term strategic plan to address our nation’s healthcare challenges

Our track record to date has been mostly promises, and not enough results

As we as a nation, struggle to address escalating healthcare costs, inconsistent quality, and access to care issues (especially in rural America and our inner cities), we keep looking for the silver bullet solutions - the solutions that would address all three of these challenges in a painless manner.?Conversely, it has been just as prevalent to cast blame on the opposing side of the political spectrum and lay all the healthcare problems at their feet.

The fact is, there is no silver bullet and there is no single cause of the challenges we are facing in healthcare.

As noted in my health?economics?discussion in prior blogs, given the?scarcity?of resources, it is critical to find an optimal balance between our healthcare needs as a society and the balance of our nation's priorities?(opportunity costs)?(defense, environment, jobs, education, etc.).

I believe the biggest healthcare challenge facing us as a nation is that we continue to have no consistent strategy. This includes the Affordable Care Act (ACA) which mainly focuses on access to care but has had little or no impact on our escalating healthcare costs as well as our inconsistent quality of care. ?While the ACA did create The Center for Medicare & Medicaid Innovation (CMMI) to address issues such as healthcare cost and quality, its impact to date has been disappointing.?One of the key initiatives of CMMI was developing value-based payment models.?The issue has never been that CMMI did not develop models, the issue was that in most cases the impact of these reimbursement models was minimal, at best, and our escalating healthcare costs continue to be driven by our fee-for-service payment system (the more you do the more you make). We will focus on this issue further in this blog.

To address our healthcare challenges both in the short-term, but more importantly from a long-term perspective, we need to address our healthcare cost, access, and quality goals in a strategic manner.

What we have as a nation is a patchwork of initiatives and policies that many times negate each other or run in cross-purposes.?We also may espouse a policy objective, but the actual follow-through is either stifled or delayed.?The cause of most of these inconsistencies and lack of commitment is usually the result of lobbying of Congress and the Administration by incumbent healthcare stakeholders to protect, or even grow, their piece of the healthcare pie.

I am a big believer in analogies, and I really like the puzzle analogy.?There are many puzzle pieces, or external factors, that directly and indirectly impact our healthcare system. In order to complete your puzzle you need to first identify the end picture (e.g. care for the elderly) or goal and then determine how you would incorporate all of the applicable puzzle pieces (e.g. National/State health policy, Medicare, Medicaid, long-term care sector, hospitals, home health, pharma, telehealth, etc.) to achieve success.

The key puzzle pieces fall into the following categories:

• National and State health policy and regulations
• Governmental programs that directly and indirectly impact our health system:

1. ?Traditional Medicare
2. Medicare Advantage
3. Traditional Medicaid
4. Medicaid Managed Care/PACE

• The key healthcare stakeholders and sectors:

1. Hospitals
2. Physicians
3. Commercial insurance companies
4. Pharma
5. Long-term care
6. Other

• The purchasers of healthcare services:

1. Employers
2. Consumers

In developing a long-term healthcare strategic plan, one must not narrowly focus on just one of the identified puzzle pieces above but understand the impact on all the puzzle pieces.?For example, identifying health policy objectives to create a more competitive healthcare market (e.g. provider price transparency), while at the same time not effectively enforcing that policy and, in addition, having Medicare reimbursement policies that incent provider consolidation, is counterproductive.

We must also recognize the interrelationship between our cost, access and quality goals and the need to understand how initiatives addressing one of those goals could adversely impact that other two goals. For example, providing governmental subsidies to the uninsured to lower the cost of insurance, without addressing the cost side of healthcare, will have a positive impact on access to care, but will also result in a further subsidization of our high-cost health system.

Examples of our inconsistent national health policy (We have found the enemy and it is us)

Currently, we have a mixed model of both free market and governmental programs and stakeholders that, in theory, could complement each other, but many times results in a stalemate that ultimately just perpetuates the status quo. In fact, many of the policies in place are counterproductive and negate any potential positives that are attempting to be achieved.

All of this is not to say that there could not be strategies that incorporate complementary roles for both the free market and governmental initiatives, but that requires a comprehensive strategy that is not side-tracked by political lobbying of healthcare stakeholders.

In identifying the impact of some of our inconsistent national health policy, I will cite a number of sources including Medicare Payment Advisory Commission (MedPAC), the December of 2018, Health & Human Service (HHS) report titled,?“Reforming America’s Healthcare System through Choice and Competition” and additional sources as well as my own thoughts and perspectives.?

• Healthcare provider market consolidation is a key factor in escalating healthcare costs:

A.???Per HHS 2018 Report:?

1. “Empirical evidence on the impact of mergers on competition in healthcare markets—based on studies by FTC staff and independent scholars—shows that healthcare consumers benefit from competitive markets and the associated lower prices and higher quality services.
2. Economic studies also consistently demonstrate that reducing hospital competition leads to higher prices for hospital care. These effects are not limited to for-profit hospitals: mergers between not-for-profit hospitals can also result in substantial anti-competitive price increases.
3. In sum, consolidation in well-defined antitrust markets can harm competition and consumers. Retrospective studies of healthcare mergers provide credible examples of harmful consolidation. These studies lend support for vigorous antitrust enforcement to prevent the accumulation of market power in healthcare markets.”

B.???Per MedPAC’s March 2020 report to Congress

1. MedPAC stated, “Increased prices were largely responsible for spending growth in the private sector. One key driver of the private sector’s higher prices has been provider market power. Hospitals and physician groups have increasingly consolidated, in part to gain leverage over insurers in negotiating higher payment rates. Studies have found that prices tend to increase as consolidation increases.”
2. “Vertically integrated physicians tend to refer a greater share of their patients to hospital-based facilities, in general, and particularly to the hospital that employs them.” (Chernew et al. 2018, Koch et al. 2017).”
3. MedPAC cited the following: “Findings help underscore the importance of exploring antitrust policy and other efforts that may reduce hospital concentration and help keep Marketplace premiums affordable’ (Boozary et al. 2019). The calls in 1984 and 2019 for FTC enforcement highlight how little change there has been in observers’ concerns. The recent history of FTC enforcement was summarized by Capps, who divided efforts by the FTC and DOJ into three decades (Capps 2019).”

C.???As noted in this article, “FTC to probe physician practice consolidation and impact on market competition” (January 2021)

1. “The federal government plans to study the impact of?physician group and healthcare facility consolidation during the past six?years. The Federal Trade Commission (FTC) has sent?orders to six health insurance companies?for six years' worth of patient claims data to inform the review.
2. The study results should aid the FTC’s enforcement mission by providing much more detailed information than is currently available about how physician practice mergers and healthcare facility mergers affect competition," the FTC said. "The study results will also aid policymakers by providing important evidence documenting how mergers and acquisitions of physician groups and healthcare facilities affect the proper functioning of healthcare markets."

D. Tom’s perspective on provider consolidation:

1. As noted above, HHS and MedPAC cite a long history of concerns, which were not acted on by the government, relating to hospital consolidation and the negative impact on healthcare costs and, potentially, quality. Both the HHS and MedPAC also cite the need for more aggressive involvement by the Justice Department and FTC in anti-trust enforcement.?
2. Finally, as noted above, the Biden Administration has instructed the FTC to study the impact of physician practice and healthcare facility mergers on competition.?The open question is how long will this “study” take and what “action” will result from it.

• Governmental reimbursement policies and regulations that incent further provider consolidation:

A.????Per 2018 HHS Report:

1. “Many of the services delivered by hospital outpatient departments such as evaluations and management visits (E&M codes), endoscopies, and imaging services are also delivered in physician offices and ambulatory surgery centers (ASCs).?
2. The Bipartisan Budget Act of 2015 modified how campus outpatient services are paid. Effective January 1, 2017 services furnished by certain off-campus provider-based departments can no longer be payable under OPPS (which is a higher payment level than would be received by physician offices and ASCs) and would generally be paid under the Physician Fee Schedule. However, clinics purchased by hospitals prior to November 2, 2015, or which were located less than 250 yards away from a remote location of the hospital, were grandfathered and continue to have services rendered paid under OPPS at a higher payment level than independent ASCs and physician offices.”

B.???Medicare Payment Advisory Commission 2015 Report to Congress:

1. “These referral and admission patterns suggest that one motivation for hospitals’ acquisition of physician practices is to ensure a steady stream of referrals. This referral pipeline can make it more difficult for competitors to enter the market.
2. Whether the shift of ambulatory care toward hospital outpatient departments has created better quality of care or lower internal costs is not known conclusively. However, most studies on hospital–physician integration show ambiguous or no effects on quality (Post et al. 2018).
3. Because not every type of vertical integration appears to improve quality, the Commission has recommended paying for quality directly and setting rates for nonemergency Hospital Outpatient Department (HOPD) services that can be provided in physician offices equal to the rates paid in physician offices.”
4. Per MedPAC’s March 2020 report to Congress, “Government policies have played a role in encouraging hospital acquisition of physician practices. For some services, taxpayer and beneficiary costs can double when services are shifted to a physician office that is deemed part of a hospital outpatient department.”

C.???Per Brookings Report:

1. A key catalyst for independent physician practices being forced to sell their practices to hospital systems has been the fact that Medicare, and most commercial payers, pay hospital outpatient departments significantly more than their competitors for the same service.
2. Therefore, CMS has implemented its site neutral initiative which as noted in this Brookings Report should be broadened to most outpatient services.

D.???Per Becker Healthcare 2021

1. Catherine Retzbach, Director of Ambulatory Surgery Center (ASC) Operations for Virtua Health (Marlton, N.J.): “The worst thing CMS did was remove already approved procedures from the ASC-approved procedure list. The procedures had been performed safely in surgery centers. There were no studies showing they could not be performed safely in them.”.
2. Trudy Wiig, Administrator and Managing Officer of Kerlan-Jobe Ambulatory Surgery Center (ASC) (Los Angeles):?“The single thing that CMS waffled and fell on, in deference to their alleged mission of saving money, was giving in to the hospital lobbyists related to the types of procedures that can be performed safely in an ASC setting. Hospitals continue to hang on to the final vestiges of surgical procedures that should be performed, for most, in an ASC setting.”

E.???Tom’s perspective on governmental reimbursement policies and regulations that incent provider consolidation:

1. I am a believer in competition.?A level playing field in the outpatient arena between hospitals and independent providers should result in enhanced focus on competition; for patients with better value being the carrot.
2. As noted above, Traditional Medicare, through its reimbursement policies and regulations, has played a key role in stifling competition in local healthcare markets through its reimbursement policies that favor hospital-based outpatient facilities over free-standing independent physician practices/ambulatory surgery centers.?Also, with the growth of services being provided in the outpatient setting, ASCs play a key role in creating a more competitive market in our communities.?As noted above, limiting services that can be safely provided in an ASC setting stifles competition.
3. All the above are examples of how Medicare/CMS reimbursement policies and regulations run contradictory to the stated governmental goal of supporting competitive healthcare markets.

• Fee-for-service payment methodology incents over-utilization, not value.

A.???As the Medicare Payment Advisory Commission (MedPAC) has stated for years in different ways, historically, Medicare payment policies and regulations have been a major catalyst to our high healthcare costs.

1. The following statement is from MedPAC’s June 2020 report to Congress: The Commission contends that unless changes are made to how Medicare pays for services, the cost of the Medicare program will become unsustainable for the country, which could necessitate dramatic changes to the Medicare program and/or its financing. FFS contains inherent incentives for the delivery system to provide more services and thus receive more payments. The FFS system increases Medicare costs, based on higher than necessary use of services, and in some instances, the provision of care at higher cost sites of service. Fee-for-service payment also encourages providers to pursue the technologies that result in higher volume and payment regardless of value. This can bolster the “arms race” mentality that providers must pursue the latest technologies to remain financially successful relative to their peers.
2. In June of 2021, MedPAC also had a specific recommendation for The Center for Medicare & Medicaid Innovation (CMMI). Per MedPAC: “Most of the Alternative Payment Models (APMs) to date layer bonuses and other payments on top of traditional FFS payment systems, many of which have financial incentives to increase the volume of services delivered. Many APMs attempt to counter these FFS incentives by rewarding providers who reduce total spending per beneficiary while maintaining quality. But because FFS systems are used to pay for services in many of these APMs and any performance payments earned are usually paid several years after any savings are generated, those models can send mixed signals to APM participants.

B.???Innovation at The Centers for Medicare And Medicaid Services: A Vision for The Next 10 Years

1. In a Health Affairs blog post published on Aug. 12 of last year, Brooks-LaSure, Fowler and two other senior health care policy officials wrote about the Innovation Center’s vision for value-based care for the next decade.?
2. They noted that CMMI had launched more than 50 alternative payment models (at least 54, according to MedPAC), and that beneficiaries, providers, and other stakeholders were calling on the center to leverage the lessons learned from all those models.?
3. Just six of those models generated statistically significant savings to taxpayers and Medicare, according to the blog post’s authors. Four of the models met the requirements to be expanded in duration and scope, they noted. Those are not exactly stellar results.?

C.???Tom’s perspective:

1. We need to get beyond pilot programs and implement real payment reform to create financial incentives for providers to transform their organizations and services to be value-based.
2. If we want to evolve our healthcare system to be more value-based, we need to start with substantial changes to Medicare's payment policies and regulations. While there has been much rhetoric relating to Medicare (as well as commercial payers) transforming its payment system to be value-based, the sad fact is that it has been mostly rhetoric. I also get nervous when I hear about 10-year plans.
3. The power of "self-interest" takes over when Medicare (through Medicare Advantage) and Medicaid (through Medicaid Managed Care) primarily reimburse providers of care with a value-based payment methodology with both upside and downside risk (ideally capitation)?which redirects the providers’ focus to the overall health of the patient and the community.
4. Those providers that embrace risk/value-based payment methodologies such as capitation will take a giant step in their evolution to becoming a value-based organization. The quickest and best way to break down the silos that have existed forever in healthcare is to embrace payment systems that reward providers for doing so.
5. Finally, I also recognize as we transition to value-based care and attempt to optimize the utilization of healthcare services, we must also take a hard look at medical malpractice laws at the state and federal level. A cause of unnecessary services being provided is not only our fee-for-service system, but also defensive medicine.?

• Accountable Care Organizations (ACOs): While showing promise, ACOs have still not delivered on their promise of value-based care

A.???HHS 2018 Report:

1. One-sided financial risk arrangements (no downside risk) do not promote or incent better value, as would two-sided risk arrangements.
2. ACOs may hold the promise of improved care coordination and better aligned financial incentives, they may also encourage provider consolidation that increases market concentration, drives up prices, and decreases competition between providers. This may occur as hospitals purchase physician practices (vertical integration), or through mergers between hospitals or between physician practices (horizontal integration).
3. This may be why greater physician-hospital integration has been linked to higher commercial prices for outpatient care and hospital prices.?

B.???MedPAC’s June 2020 Report to Congress:

1. “The Commission plans to conduct further analysis to identify specific policy changes that will improve ACOs and ACO-like models. There is some concern that hospitals have relatively weak incentives, or counterincentives, to reduce program spending under the ACO approach. One potential alternative that could give hospitals stronger incentives, but also raises challenging design issues, would be for Medicare to pay hospitals using global budgets that cover all their inpatient and outpatient services.
2. As policymakers develop accountable entities, they may need to consider whether Medicare should support the use of value-based payment by specifying the mechanisms that those entities use to pay individual providers.”

C.???Why Aren’t Value-Based Payment Models More Successful? A Failure To Confront Market Dynamics

1. “CMS should deploy mandatory accountable care organization models targeting the highest-cost providers in a market. To identify participants, CMS could use data on actual commercial prices, or proxy metrics such providers’ non-compliance with the?Price Transparency Rule,?or failure to attest they are not engaging in other anti-competitive behavior in commercial contracts. Mandatory models, which have shown?promise?in feasibility and success, should put high-cost providers on a path to two-sided risk within three years or less.”

D.???Tom’s Perspective:

1. As noted above, government policies created ACOs which incented further consolidation of our healthcare markets.?As also noted above, while the theory behind the creation of ACOs was to create an infrastructure that would support value-based care, in fact, to date that goal has not been achieved primarily as a result of how ACOs have been reimbursed for the services they provide.
2. The government should transition to only two-side risk arrangements with ACOs which should focus less on their historical costs, and more on optimal costs.
3. This transition to a risk/value-based payment methodology (two-sided risk) will have a positive impact on both the cost of our healthcare system and the health of the population.?

• Quality measures should primarily focus on outcomes and not be administratively burdensome to providers

A.???HHS 2018 Report:

1. Medicare’s regulations and reporting requirements that add to the business operating expenses of independent physician practices that many times force them to sell their practices to local integrated healthcare systems.
2. In the past, the government has often failed to establish sensible metrics, creating significant reporting burdens for providers and metrics that are not informative for patients or industry and can easily be gamed when reimbursement is tied to them.

B.???Tom’s perspective:

1. If you want a healthcare system that that is based on consistent quality, you need to pay for it, but the focus should be on outcomes, not on a myriad of quality matrixes that focus on processes. The measures for value-based programs should focus on patient-centered outcomes or processes that only are tightly linked to patient-centered outcomes. Patients do not care that you followed all the appropriate processes, they care about a quality outcome. Also, excessive, and unnecessary quality measures not only add to the administrative cost burdens of providers, they also divert their attention from quality outcomes.
2. There has been some pushback from providers when quality is focused on outcomes since a key factor in a health outcome is also patient engagement.?While I agree with this assessment, we still need to focus on outcomes.?In focusing on outcomes, providers will need to address patient engagement more aggressively, which is usually not the case.?Also, the effective utilization of telehealth could play a key role in enhanced patient engagement and education.

• Physician-owned hospitals – Health policies that have a negative impact on competitive markets

A.???HHS 2018 Report:

1. Many studies suggest that physician-owned hospitals provide high quality care, and by competing with other hospitals they also increase quality in the market and lower costs.
2. HHS 2018 Report recommendation: Congress should consider repealing the ACA changes to physician self-referral law that limited physician-owned hospitals.

B.???“Why physicians don’t have more power in healthcare policy”

1. Per the American Medical Association, “Physicians were largely left out of Affordable Care Act discussions, which put a moratorium on physician-owned hospitals and added regulations that sparked consolidation in many specialties, which also raised prices.”?

C.????Tom’s perspective:

1. I am a big believer in competition that ultimately leads to better value in healthcare.
2. As noted above, many studies have shown that physician-owned hospitals provide quality health care and can create more competitive markets that lead to lower costs in the community.
3. Also, as noted above, if the government believes in the value of competitive markets, Congress will consider repealing the ACA changes to physician self-referral law that limited physician-owned hospitals.

• Consumer-driven healthcare

A.???HHS 2018 Report:

1. There is less incentive to shop if someone else is paying the bill (moral hazard).
2. Expand?HSAs? and?HRAs?(realign incentives).
3. Allow any plan with an actuarial value below 70% to be considered an HSA-qualified plan, raising the contribution limit on HSAs, allowing HSA qualified plans to pay non-group premiums.
4. Allow HSAs greater ability to cover preventive low-cost treatments for chronic diseases.
5. Increase usability of HRAs.

B.???Tom’s perspective:

1. The devil is always in the detail.?Overall, I believe that HSAs and HRAs serve a positive role to incent consumers to be prudent purchasers of healthcare services.
2. A community of prudent purchasers of healthcare services will also help shape a more value-based health system attempting to respond to their needs.
3. Access to care is also critical, and HSAs and HRAs should not be structured in a way to be a barrier to needed care.
4. In theory, if appropriately developed, HSAs and HRAs would promote a more value-base health system.?It could also have a positive impact on population health if it incents the consumer to participate in their own well-being more proactively.
5. The concern, as stated above, is when HSAs and HRAs become a barrier to needed health.?We cannot make a blanket statement as to their appropriateness in all cases. Therefore, there needs to be continued debate on this topic involving experts, not just politicians.

• Lack of availability of user-friendly cost-quality information:

A.???HHS 2018 Report:

1. Consumers cannot effectively shop for services since there is a lack of availability of user-friendly cost-quality information.
2. One study classified 43% of healthcare spending as shoppable.
3. Meaningful and timely consumer access to prices can supplement benefit designs to help consumers choose lower-cost, higher-value providers. In a competitive, functioning insurance market,?insurers?would have an incentive to use such approaches.

B.???As noted in the following article in Health Leaders Media?

1. “It's been four months since the Centers for Medicare & Medicaid Services’ (CMS) price transparency mandate for hospitals went into effect and, so far, compliance has been all over the map, with no enforcement to speak of. But there are signals lately that hospitals should expect increased attention and scrutiny as journalists, academic researchers, lawmakers, and tech companies train their spotlights on hospital compliance.
2. ?Among the most notable is an investigation from?The Wall Street Journal? which revealed that hundreds of hospitals used an embedded code to hide their price lists from online search engines.”
3. “Prompted by the?Wall Street Journal?report about blocking prices from search engines, the Health Affairs study about widespread noncompliance, and other reports, bipartisan leaders of the House Committee on Energy and Commerce and its Subcommittee on Health?wrote a letter?to U.S. Health and Human Services Secretary?Xavier Becerra?urging the agency to conduct "vigorous oversight and enforce full compliance with the final rule."?

C.???Tom’s perspective:

1. This is like “mom and apple pie” - who can argue against increased transparency related to cost and quality?
2. The key will be user-friendly transparency tools and the ability to do apples-to-apples comparisons between providers of care and services provided. If implemented correctly, enhanced transparency will have a positive impact on the cost of the health system and overall population health.
3. Meaningful and timely consumer access to “real” prices can supplement benefit designs with appropriate incentives to help consumers choose lower-cost, higher-value providers.
4. To have a competitive marketplace, purchasers of healthcare services need to be aware of the price and quality differences between suppliers of healthcare services.?One way to stifle the influx of disruptive competitors is to block employers’ and consumers’ ability to know the price differences between incumbent non-profit hospitals systems and existing and new entrants in the marketplace. As noted above, the government needs to have "vigorous oversight and enforce full compliance with the final transparency rule."

• Medicare Advantage Plans and Medicaid Managed Care Plans that continue to rely on fee-for-service payment methodologies as their base reimbursement to providers

A.???MedPAC’s March 2020 Report to Congress

1. Medicare Advantage and Medicaid Managed Care plans that enter risk relationships with CMS and states should play a lead role in entering in risk/value-based contracts, especially capitation with providers.?Currently though, these plans mostly rely on fee-for-service as a payment methodology to their downstream providers.
2. MedPAC asserted that historically Medicare Advantage plans are being overpaid by CMS vs. Traditional Medicare.

B.???Tom’s perspective:

1. Assuming that MedPAC’s assertion is correct concerning Medicare Advantage Plans historically being paid more by CMS vs. Traditional Medicare, there does need to be enhanced incentives for Medicare Advantage Plans to enter into “real” risk/value-based payment arrangement with their downstream provider partners such as integrated hospital systems.
2. To-date, most of the arrangements that Medicare Advantage plans have with providers are based on the fee-for-service model which, as noted above, creates no incentives for cost-effective care and keeping Medicare members healthy, as would be the case in a capitated payment model. Also, since Medicare Advantage Plans have been mostly profitable even because of utilizing costly fee-for-service arrangements with providers, it further validates MedPAC’s assertion that they are being paid too much.
3. Ultimately, a reduction in payments to Medicare Advantage plans by CMS would probably result in narrower provider networks which lends itself to risk-based payment models and creates incentive for integrated hospital systems to be more cost-effective.
4. As recommended by MedPAC, CMS should require hospital based ACOs to accept global budgets or capitated financial arrangements. As MedPAC stated, this requirement would go a long way in making these ACOs not only more cost-effective, but also proactive about keeping Medicare members healthy.

• Employer Healthcare

A.????Large Employers Are Suiting Up to Fix Healthcare

1. Large companies want and need the existing healthcare system to work. But to date, too many solutions to fix what's broken have amounted to a version of MTV's "Pimp My Ride." We take a chassis and engine in bad shape and bolt advanced technology to a frame that is tired, old, and ineffective. Large employers are?no longer willing?to play this game or continue to extend blank checks to hospitals, doctors, health plans, and consultants with no regard for quality and proof of outcomes.
2. Large employers will continue to scrutinize further consolidation in the healthcare system, despite the unfounded argument that it is somehow better for the consumer. And they'll push for limits on anti-competitive business practices that have needlessly and intentionally increased costs, using the?Sutter Health lawsuit?as a template.
3. Finally, with support from skilled coalitions, large, self-insured employers are more vigilant in looking for policy solutions where the market has failed. This has been the route to success in advocating for an end to surprise billing, demand for hospital price transparency, and provisions in the Balanced Budget Act to extend negotiated pharmacy discounts to commercial payors.

B.???Tom’s perspective:

1. I do not disagree with any of the assertions noted above by Elizabeth Mitchell, CEO of Purchaser Business Group on Health and Ian Morrison, PhD.?

• Health information technology including Electronic Medical Records -EMRs:

A.???HHS 2019 Report:

1. Limited state of interoperability. Patients have very limited ability to obtain or move their records.
2. Providers have significant barriers to get health information from other providers.
3. The 21st Century Cures Act (December 2016) provides powerful tools to increase interoperability of health data and, by extension, market competition. Administration needs to enforce the CURES law.
4. CMS should champion interoperability across the healthcare sector.

B.???Also, as noted in an article in JAMA,

1. “Challenges remain given that patient data have been treated as a commodity owned by EHR vendors, potentially leading to reluctance to share data due to a desire to maintain vendor market share as well as increasing barriers for smaller companies to enter the interoperability space.”
2. “As it stands now, the current state of interoperability lies between policies promoting interoperability and the forces of commerce pushing against it and between the sentiment that information sharing is good with the reality that health systems and professionals do not have the tools needed to access or use shared information meaningfully. Bold policies and innovative technologies that affect these tensions in a powerful way will be required to move US health care toward an interoperable future.”

C.???Tom’s perspective:

1. We have been espousing that potential value of interoperability of Electronic Medical Records (EMRs) and the sharing of data to enhance both individual patients’ health, but also community health for decades. While we have had progress in this arena, we still have a long way to go, especially as pertains to the integration of independent providers, social service agencies and public entities into the interoperable EHRs.
2. This in one of my pet peeves.?We talk about patient-centered care.?As a result of the lack of interoperability across the healthcare system, “patient-centered” takes on a new meaning.?As a patient, I need to be the one responsible to make sure my providers communicate with each other.?I am the one who must make copies or push for faxes between providers.?I am the one who goes to my primary care physician, the so-called healthcare hub, without having a complete picture of my health be available for my physician.
3. For all the reasons noted above, I am a strong believer in having the Administration enforce the CURES law to promote greater interoperability.
4. I believe that interoperable EHRs will spur innovation between vendors and entrepreneurs that will positively impact our society.?I also believe that interoperability along with price and quality transparency requirements will also spur competition and innovation in the provider space that will benefit our communities and society overall.

• Support for Primary Care Physicians:

A.???Commonwealth Report:

1. Primary care is vital to a high-quality, high-functioning health care system.?The U.S. health system, however, is not centered around primary care. While the United States spends about 5 to 7 percent on primary care as a share of total health care spending, other high-income countries devote about 14 percent.?This difference may be one of the factors that contribute to the comparatively lower life expectancy, fewer physician visits, and more frequent hospitalizations seen in the United States, despite the U.S. spending more on health care as a share of gross domestic product than its peer nations.
2. The Medicare Payment Advisory Commission (MedPAC) has determined that, like the rest of the health care system, the Medicare fee-for-service physician fee schedule undervalues primary care services relative to other services.?And because the fee schedule is focused on discrete services, it may not be suited to supporting primary care, which includes coordination of multiple, patient-centered services for a longer period.
3. This situation contributes to troubling access issues for Medicare beneficiaries. MedPAC reported that in 2020, 38 percent of Medicare beneficiaries who tried to find a new primary care provider had a problem doing so.
4. Primary care remains undervalued compared with specialty care, and no primary care–focused models have been expanded to the entire Medicare program.

B.???Tom’s perspective:

1. The reliance on a fee-for-service payment methodology (“the more you do the more you make”) primarily benefited specialists and was the growth engine for hospitals to the detriment of primary care physicians.
2. The primary care physician was further penalized when Medicare developed the?Resource Based Relative Value Scale (RBRVS)? as a basis for calculating reimbursement for physicians.?This coding system does not adequately account for the work performed by primary care physicians in that it rewards procedural work over cognitive work.?
3. This is another example of the government’s inconsistent policy.?The government states that primary care physicians are a key to value-based care, but Medicare reimbursement policies under-value primary care.

• Population Health/Social Determinants of Health:

A.???Lown Institute – Lown Hospital Index 2021 Community Benefit Ranking

1. Hospitals were ranked based on charity care spending, spending on other community health initiatives, and the proportion of patient revenue from Medicaid (a measure of the hospital’s commitment to taking care of low-income patients).
2. 72% of private nonprofit hospitals had a fair share deficit, meaning they spent less on charity care and community investment than they received in tax breaks.

B.???Tom’s perspective:

1. The focus on population health and social determinants will hopefully further hasten the evolution of the healthcare sector to look beyond the walls of the hospital and into the community.?Currently, as noted above,?“Community Health Benefits”?that are tied to the tax-exempt status of hospitals are mainly focused within the walls of the hospitals (Medicaid short-falls in revenue, etc.).?These resources need to be redirected outside the walls of the hospital as part of a comprehensive strategy to achieve a healthier community.?
2. Adding employers to the mix with both risk/value-based payment methodologies, value-based benefit designs and increased utilizations of cost and quality transparency tools, provides the necessary ingredients for a healthier community for all.
3. As I stated in my?second blog on social determinants of health, we need to?unleash the power?of?"self-interest"?through payment systems that are risk/value-based.?If providers are predominately paid under a fee-for-service system, we will continue to have a "sick-care" system.
4. All the above requires the government to take a more proactive role in supporting population health by expediting the transition to risk/value-based reimbursement and requiring Community Health Benefits to primarily focus on addressing the needs in the community outside of the walls of the hospital.

Concluding comments: Benevolent confrontation

As I discussed in my?first blog, I am a believer in?"benevolent confrontation."?That is,?"A free exchange of perspectives to make things better."

The issues discussed in this blog will potentially create some heated arguments, but the core message is that we can no longer delay this debate related to developing a long-term strategic approach to our healthcare challenges.

I am not na?ve enough to ignore that while, in theory, a competitive marketplace could result in lower healthcare costs and better quality, I also recognize that there is a role for governmental programs and health policies that address health equity and overall population health.

I believe, maybe naively so, that the combination of the unleashing of competitive forces, risk/value-based reimbursement not based off of fee-for-service payment system along with needed government action, as discussed in this blog, will result in some positive steps towards our transition away from our “sick-care” system to a “real health” system.

I welcome any perspectives from the readers of this blog.

Tom Campanella is the Healthcare Executive in Residence at Baldwin Wallace University. Backed by more than 35 years of experience in the industry—particularly the health insurance, physician and hospital sectors—he’s focused on strategic advising and community outreach.

Follow Tom’s articles on LinkedIn for his latest weekly coverage of the healthcare industry.

If you would like to receive a monthly recap of Tom Campanella’s healthcare blogs and webinars, please sign-up by?clicking here. To view archived newsletters?click here.

Baldwin Wallace University would love to partner with healthcare-related employers and their employees to explore ways to ensure both organizational and individual success during this time of disruption and beyond.

Baldwin Wallace University Can Assist Employers and Their Employees in the Following Areas:

• Organizational in-house leadership programs
• Organizational collaborations relating to continuing education for employees
• Organizational, specific programs relating to current and future trends impacting industry sectors and organizations
• Professional development programs such as: process improvement, connecting with your customer, and differentiating your product or service in a competitive market.
• Healthcare-related degrees and programs:
• Undergraduate degree completion
• MBA, Healthcare Management
• Graduate Certificate in Healthcare Management
• MMS, Physician Assistant
• MS, Speech-Language Pathology
• MPH, Master in Public Health
• Music Therapy
• Accelerated BSN, Nursing

For more information about what BW has to offer, please contact Connie King at [email protected], calling (440) 826-2253, or visiting?bw.edu/cpd.