Category Archives: Initiatives

CMS to consolidate Medicare quality reporting programs | Healthcare Dive

As readers of this blog have noticed in the past, I have been very critical of CMS’ introduction of myriads of models, programs, and schemes to improve quality reporting and physician performance, so it is no surprise that I look upon this new initiative with a bit of skepticism. But I’ll let you the reader decide if this is just another wasted effort by CMS or if it has a chance to actually work this time. After all, after forty years of tinkering, the American health care system is no better off than it was before CMS got involved.

One of the quality networks CMS wants to roll into a single contract concerns something your humble writer is going through, ESRD.

Here’s the article:

Quality Improvement Networks and Organizations, End Stage Renal Disease Networks and Hospital Improvement Innovation Networks are all being bundled into a single $25 billion contract.

Source: CMS to consolidate Medicare quality reporting programs | Healthcare Dive

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Three Strategies for Improving Social Determinants of Health

A shoutout to Irving Stackpole for bringing this to our attention today on LinkedIn. This is an important topic that can address the serious issue of poverty in our inner cities.

The topic of food deserts first gained national attention thanks to the efforts of former First Lady, Michelle Obama, who not only created a vegetable garden on the White House grounds, but championed the creation of other gardens in inner city elementary schools.

One in particular was created at a Washington, DC school, and Mrs. Obama invited Chef Robert Irvine of Restaurant: Impossible to cook for inner city school children at Horton’s Kids, a local community center that provides after-school meals for kids.

So an article last week in Managed Care magazine, discussed the three strategies health care systems and payer organizations are trying to address patients’ social needs.

The first strategy, Tackle a neighborhood, focuses on the work ProMedica, a 13-hospital not-for-profit system in Toledo, Ohio is undertaking.

In the UpTown neighborhood of Toledo, the average median household income is less than $21,000 a year, and more than a quarter of all adults have not completed high school. Few residents have homes or vehicles, and healthy food options are hard to come by.

One way they are dealing with the food deficit in the neighborhood is by opening a grocery store called Market on the Green, and is a joint project of ProMedica and the Ebeid Institute.

They also initiated a job-training program, a financial opportunity center, and personal-finance advice and programs.

Last year, ProMedica doubled down and announced a 10-year plan to invest $50 million to create a national model for neighborhood revitalization. In March, they announced a partnership with a New York City-based nonprofit to invest additional capital to spur further economic growth.

Lastly, they expanded their screened 4,000 Medicaid patients who use the food clinic, and found that emergency department utilization decreased by 3%, and 30-day readmission by 53%, with a modest increase in utilization of primary care.

They also expanded screening  to include housing, transportation, and other social needs.

The second strategy is Tackle the top problems.

Here, Humana has been working on its Bold Goal, a population health strategy to improve the health of the communities it serves by 20%.

Humana wants to increase the number of “healthy days” in seven markets: Louisville, KY; Knoxville, TN; San Antonio, TX; Broward County, Fl; Baton Rouge, La; New Orleans; and Tampa Bay.

In the first year, the San Antonio market showed a 9% increase in healthy days, which was attributed to several initiatives, namely a telepsychiatry pilot to increase access to behavioral health services, food insecurity screening at primary are offices, and a collaboration with other organizations to improve diabetes management,

Finally, the third strategy is Develop a social determinants workforce.

Trinity Heatlh, a 93-hospital health care system in Michigan, and one of the largest Catholic systems in the country, has been addressing their patients’ social needs through a series of small experiments.

Trinity’s strategy is to develop a cadre of community health workers who will use pathways, regimented, evidence-based multistep protocols to help individuals address their specific needs.

Trinity found that by focusing on patients covered by Medicare, Medicaid, or both, and assisted by community health workers, they reduced their emergency department and hospital utilization considerably.

Trinity also hired AmeriCorps workers to serve as community health workers in nine markets. They focused on the social determinants of health of a narrow group of patients: high-utilizing eligibles in an ACO or other at-risk contract.

The strategies these organizations are undertaking are bold initiatives that show some promise of success, but time will tell just how successful they will be.

Yet, in an era of huge tax cuts going to the wealthy, and budget cuts  eliminating many government programs or severely limiting them, these companies are taking decisive action to reverse decades of neglect and despair in our inner cities.

But they won’t be effective unless there is greater cooperation from the communities they wish to serve, and from the rest of the health care community, and those in other institutions.

There is an accompanying story here: Social Determinants of Health: Stretching Health Care’s Job Description.

Illogical!

Picking up where I left off last week with my post, Regulation Strangulation, regarding too much regulation, a series of articles from earlier this week, published in various health care journals and magazines, discussed a new scheme the good folks at CMS have cooked up to make our health care “system” better. (Or worse, depending on whether you have drunk the kool-aid yet)

You may recall my post from late last year, Models, Models, Have We Got Models!, that reported that CMS was launching three new policies to continue the push toward value-based care, rewarding hospitals that work with physicians and other providers to avoid complications, prevent readmissions and speed recovery.

In that article, I mentioned the various models CMS was implementing. My view then, as it remains today, is that these models have not worked, and have only made matters worse, not better.

So when CMS unveiled their latest scheme recently when Administrator Seema Verma spoke at the Health Care Payment Learning and Action Network (LAN) Fall Summit, this is what she said:

The LAN offers a unique and important opportunity for payors, providers, and other stakeholders to work with CMS , in partnership, to develop innovative approaches to improving our health care system. Since 2015, the LAN has focused on working to shift away from a fee-for-service system that rewards volume instead of quality…We all agree that quality measures are a critical component of paying for value. But we also understand that there is a financial cost as well as an opportunity cost to reporting measures…That’s why we’re revising current quality measures across all programs to ensure that measure sets are streamlined, outcomes-based, and meaningful to doctors and patients…And, we’re announcing today our new comprehensive initiative, “Meaningful Measures.”

Let’s dissect her comments so we can understand just how complicated this so-called system has become.

  1. Develop innovative approaches? How’s that working for you?
  2. Improving our health care system? Really? What planet are you living on?
  3. Financial cost? Yeah, for those who can afford it.
  4. Revising current quality measures? Haven’t you done that already after all these years?
  5. “Meaningful Measures”. Now there’s a catchy phrase if I ever heard one. You mean they weren’t meaningful before?

You have to wonder what they are doing in Washington if this is the level of insanity and inanity coming out of the bureaucracy on top of our health care system.

In an article in Health Data Management, Jeff Smith, vice president of public policy for the American Medical Informatics Association stated the following regarding the new CMS initiative.

According to Smith, “the goals are laudable, but the talking points have been with us for several years’ now…measurement depends on agreed-upon definitions of quality, and in an electronic environment, it requires access to and use of computable data. If CMS is going to turn these talking points into reality, it will need to put forth far more resources and commit additional experts to a complete overhaul of electronic quality measures for value-based payments.”

Mr. Smith’s comments are at least an indication that not everyone goes along with CMS every time they unveil some new initiative, model, or program, but again we see the words associated with the consuming of health care being used in discussing the current state of affairs. Terms like “value-based payments”, and “quality measures”, and “financial/opportunity cost”, etc., only obscure the real problem with our health care system. It is a profit-driven system and not a patient-driven system.

Let’s push on.

A report mentioned Monday in Markets Insider showed that 29% of total US health care payments were tied to alternative payment models (APMs) in 2016, compared to 23% in 2015, an increase of six percentage points. These APMs were discussed previously in Models, Models, Have We Got Models!,

The report was issued by the LAN, and is the second year of the LAN APM Measurement Effort (try saying that three times fast). They captured actual health care spending in 2016 from four data sources, the LAN, America’s Health Insurance Plans (AHIP), the Blue Cross Blue Shield Association (BCBSA), and CMS across all segments, and categorized them to four categories of the original LAN APM Framework. (Boy, you must be tired trying to remember all these acronyms and titles!)

Here are their results:

  • 43% of health care dollars in Category 1 (traditional FFS or other legacy payments)
  • 28 % of health care dollars in Category 2 (pay-for-performance or care coordination fees)
  • 29% of health care dollars in a composite of Categories 3 and 4 (shared savings, shared risk, bundled payments, or population-based)

Speaking of shared savings, an article in Modern Healthcare reported that CMS’ Medicare shared savings program paid out more in bonuses to ACO’s than the savings those participants generated.

As per the report, about 56% of the 432 Medicare ACOs generated a total of $652 million in savings in 2016. CMS paid $691 million in bonuses to ACOs, resulting in a loss of $39 million from the program.

Chief Research Officer at Leavitt Partners, David Muhlestein said, “Medicare isn’t saving money.”

This is attributed to the fact that 95% of the Medicare ACOs (410) participated in Track 1 of the Medicare Shared Savings Program. Only 22% participated in tracks 2 and 3.

Two more articles go on to discuss a Medicare bundled-pay initiative and the Medicare Merit-based Payment System (MIPS) .

What does this all mean?

It has been long apparent to this observer that the American health care system is a failure through and through. Sure, there are great strides being made daily in new technology and therapies. A member of my family just benefited from one such innovation in cardiac care. But luckily, they have insurance from Medicare and a secondary payor.

But many do not, and not many can afford the second level of insurance. From my studies and my writing, I have seen a system that is totally out of whack due to the commercialization and commodification of health care services.

And knowing a little of other Western nations’ health care systems, I find it hard to believe that they are like this as well. We must change this and change this now.

If Medicare is losing money now, with the limited pool of beneficiaries, perhaps a larger pool, with little or no over-regulation and so many initiatives, models, and programs, can do a better job. Because what has been tried before isn’t working, and is getting worse.

The logical thing to do is to make a clean break with the past. Medicare for All, or something like it.