Health System Ed

In the US, a single-payer or national health plan is usually regarded as politically unfeasible. It may not be the politicians who lead the charge, however. It is the people working in the system, specifically physicians, who are being squeezed by the increasing number of rules, concurrent reductions in income and patients who can’t afford them, that are looking for solutions.

A group of Harvard Medical School physicians wrote an editorial for the American Journal of Public Health  advocating a national health plan, one that simplifies payment for healthcare providers and organizations and opens access to care for all. The authors suggest creating a seamless system with multiple points of access largely financed with public funds

In a critique of the Accountable Care Act, the authors say that the ACA has fallen well short of its promise to make healthcare affordable.

“A decade from now, according to the Congressional Budget Office, 27 million Americans will remain uninsured despite full implementation of the law. Many more are underinsured or constrained by “narrow networks” of providers that limit choice and rupture longstanding therapeutic relationships. Doctors and nurses contend with growing requirements for mind-numbing electronic documentation^1b in a health care marketplace increasingly tilted toward giant insurers and hospital conglomerates that amass power through consolidation. Finally, the system’s administrative complexity, which robs patients and providers of time, money, and morale, was further fueled by the ACA.”

The authors write for a group of 2,000 physicians who are advocating for a national health plan, the Physicians for a National Health Program (PNHP).

The ACA moves the country in the direction of some elements of single payer by incrementally driving providers to bundled payments. The country’s healthcare bill is increasingly covered by the government as the number of people covered by private, employer coverage falls. The government – federal, state, local – now funds about 50% of care, and that percentage has continued to grow over the last 20 years. The people who crafted the ACA legislation created a reimbursement system that edges the US closer to single payer, and makes payment justification through documentation requirements so unwieldy as to interfere with the practice of medicine.

Another report released last week showed that hospitals with higher revenue did not perform better on a group of outcomes. This study of several hundred California hospitals supports the idea that pricey healthcare is not better healthcare.

These two unrelated studies move toward the idea that a simple, low-cost system focused on patient care might better serve patients and the economy. Healthcare is close to accounting for 20% of GDP in the US, and that is a mighty engine for growth but also a very dangerous place because it encourages a lot of entrenched interests to preserve their piece of the pie. From a broader perspective, healthcare may also be siphoning resources that could be used to bolster other industry sectors to create a more balanced and resilient national economy.

In a post from the last Health Wonk Review, Health Access blogger Anthony Wright crafted a well-reasoned case for ways to move the single payer discussion forward in politics. Wright, as the Executive Director of Health Access California, plays in political waters every day to move forward broad visions within political realities. Single payer, as he points out, is a term to describe a healthcare system that is “more universal, progressively financed, cost-effective, streamlined and efficient, comprehensive, and prevention-oriented.”

Those goals are all achievable, over time, incrementally. But they require buy-in from an entrenched sector of the economy whose lifeblood is dependent on a massive influx of dollars from all participants to keep it alive.

“The long national nightmare is going full throttle.” – Anonymous Health Wonk Review Commenter

Hillarity…huckstering.

The Donald…quacking.

For the best in presidential pictorials, and health policy thrown in to make it palatable, you don’t want to miss Brad Wright’s Health Wonk Review roundup at Wright on Health. Let the games begin!

She came to the urgent care center with a sprained ankle. The primary care provider gave her excellent care, expertly applying evidence-based evaluation guidelines to her situation, and, thereby, avoiding unnecessary x-rays. By all measures, the provider’s care was excellent, but the interaction still ended up reducing his salary. You see, that patient’s only medical interaction that year was for this ankle sprain, and the provider was therefore held accountable for all of her primary care needs. Since she had not received a mammogram that year, or received a diabetes screening, he incurred an end-of-the-year penalty for failing to meet these quality standards.

-Peter Ubel, MD from KevinMD.com

In an article entitled MACRA-economics 101: Prepare today for tomorrow’s outcomes in Healthcare IT News, author Arien Marec gives one of the cleanest and most concise roundups of the new quality-driven, outcomes-based value reimbursement system that came out of the Medicare Access and CHIP Reauthorization Act of 2015. Under MACRA, providers will be taking on risk for patient outcomes. Marec tells us that providers who aren’t ready to provide data showing their patients are being treated according to guidelines, have good patient satisfaction scores and an effective electronic health record system are going into the new payment world ill-equipped to survive.

After the final MACRA rules were issued on Monday (May 2), the Medical Group Management Association senior vice president of government affairs, Anders Gilberg, warned that solo practitioners and physicians in small groups of 24 or less probably will be on the downside of the risk scale. He said only those in larger groups stand to get bonuses in this payment scheme designed to be “budget neutral” – that is government-speak for the losers will pay the winners.

In MACRA-economics 101, Marec advises physicians to do a few things to get ready now.

Get ready: Prepare with education, analytics and a focus on quality:

1. Educate. Providers need a firm understanding of their population health approach, robust productivity strategy, and an awareness that use of certified EHR technology is written into legislation.
2. Incorporate data & analytics. Annually, the amount of healthcare data grows by 48 percent. Clinicians need to think about how they are acquiring and aggregating the data they need to get the full view and manage the whole patient. 
3. Preplan and refocus on clinical quality. If not already part of an ACO, providers should put together an application for one of the CMS models. If you already have strong analytics, identify the areas you need to improve.

Be Ready Now

And, by the way, all this needs to be ready to go now.  Future reimbursements starting in 2019 will be based on physician performance in 2017 – a mere 7 months away.

The chances that anyone is really ready to play according to these rules is about as good as the chances that anyone was really prepared to get those tasty little Meaningful Use incentives. While MU technically goes away with these changes, the broad parameters regulating use of electronic patient records have made it into the MACRA rules.

Already, we are seeing some pushback from sectors in the provider community that felt they weren’t treated fairly under the Hospital Compare star rating system, delaying release of those ratings a few months while CMS reassesses its calculations. I’m just taking a guess that as these reimbursement rates are announced, other providers who end up on the losing side of the risk equation are going to assert a challenge to the way physician payments are calculated.

Already, some are saying pay-for-performance initiatives are set up to fail as reported in the last Health Wonk Review  because of the many and conflicting metrics. While HHS’ National Coordinator for Health IT Karen DeSalvo and AHRQ President Marilyn Tavenner held a joint presser discussing streamlining of quality metrics that you can read here, right now the urgency is on and providers are running hither and yon unsure which outcome to chase.

My prediction: prepare for legal challenges. The electronic health records needed to support stringent rules backing something as serious as payment are just not where they need to be. Without the solid data, clear benchmarking and reasonable outcomes that take into account the reality of caregiving in widely diverse regions with wildly diverse patient populations, quality- and outcomes-based payment just isn’t ready for prime time.