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Healthcare Reform Across State Lines Exploring differences by state

Healthcare Reform Across State Lines Exploring differences by state

Healthcare Reform Across State Lines Exploring differences by state


A recent webinar examined how different providers approach the opportunities and challenges
brought by the Affordable Care Act (ACA). Industry leaders in Florida, Massachusetts, Mississippi,
New Jersey and Pennsylvania shared their views. Below are highlights.


Visit our Healthcare Reform Across State Lines webinar replay for more insights.


Each state interprets the ACA in its own way, driving provider strategy and impacting coverage,
rates and costs. Massachusetts decided early on to maximize access via state health reform.
Access in some other states has been more challenging, with physicians not accepting
Medicaid or Federal Exchange beneficiaries. For Florida, one solution has been proactively
negotiating out-of-network rates for unique services.


Massachusetts’ early adoption of Medicaid expansion in 2006, plus coverage expansions that
served as a precursor to the ACA, have seen reductions in uninsured individuals and lower costs:


  • Per capita health spending growth is lower than the U.S. generally
  • Expansion enabled preventative care and reduced per-member per-month costs when
    compared to other states
  • Insurance participation is more stable than in other parts of the country


  • Massachusetts’ early healthcare expansion allowed it to focus on costs and prices as far
    back as 2008. By 2012, its strategy focus was reducing expenditure and encouraging
    alternative payment methods
  • In Mississippi, over 60 hospitals came together to form MississippiTrue, the first
    multi-provider plan in the state
  • Innovations have also emerged in response to the Mississippi Telemedicine Parity Act,
    which mandates that all health insurance and employee benefit plans must provide r
    emote care


Some states have taken pre-emptive measures to cope with a lack of clarity. For example,
53,000 Mississippi residents rely on the Federal Exchange for their health insurance.
There’s uncertainty over whether Cost Sharing Reductions (CSR) will end, which could
increase premiums by 25% in 2018. In response, the state has taken a number of measures:


  • It’s allowed exchange providers to submit two sets of rates, one assuming CSR continues,
    and one assuming it doesn’t
  • It has issued waivers to ensure the continuation of coverage through 2018 and to curb
    increases in rates for children under 14




A key challenge for providers nationwide is the uncertain outlook for the ACA.
The House of Representatives passed the American Health Care Act (AHCA) to
“repeal and replace” the ACA. It is estimated to achieve more than $100 billion
in Medicaid reductions by 2027.
Being informed and formulating strategies is now more important than ever.


  • Each state interprets the ACA differently, impacting strategy, coverage and costs
  • Challenges have led to strategy and technological innovation
  • Uncertain state and federal reimbursement, and regulatory changes to the ACA
    make being informed more important than ever


Insights into Risk-Based Reimbursement

Insights into Risk-Based Reimbursement

Healthcare leaders discuss impact and opportunities

Bank of America Merrill Lynch


Five technologies set to transform the healthcare industry

Five technologies set to transform the healthcare industry

Five Technologies Set to Transform the Healthcare Industry

Written by John Hesselmann, Specialized Industries Executive, Global Commercial
Banking at Bank of America Merrill Lynch

The future of healthcare will streamline the way we diagnose and treat health problems. We are already seeing signs of that today: from patients who receive diagnoses and treatment at home via
telemedicine and heart-monitoring wearables, to artificially intelligent therapists diagnosing
PTSD in veterans. Innovation in healthcare can decrease our
dependency on physician availability. To that end, we’re seeing emerging technologies that
deliver diagnoses directly from an app, such as MobileODT, a mobile cancer screening tool,
and Biomeme, which aims to conduct genetic testing for certain diseases within an hour.
Investors should be aware of the innovation set to transform the healthcare industry in the
next few years. Here are five areas expected to undergo tremendous growth:
1. Robotic Surgery: According to WinterGreen
Research, annual sales of robotic surgical
assistants are expected to rise from $3 to
$20 billion over the next five years. While the
notion of a robotic surgeon seems frightening,
it may actually be safer. Robot-assisted surgery
is typically faster and smoother, making
more precise incisions and reducing blood
loss. Currently, the machinery costs a million
dollars or more, however, the advancements
are expected to trim healthcare costs due to
reduced patient stay and aftercare.
2. Genomics: According to MarketWatch, the
international genomics market is estimated to
grow from $12.5 billion in 2015 to $20 billion
in 2020. Advanced genetic testing can help
people discover whether they have inherited
diseases so they can begin treatment before
symptoms occur. Advanced gene editing
has the potential to fight cancer and other
diseases by altering genetic instructions at
the cellular level. Genetic Engineering and
Biotechnology News reports that in the next
10 years it will be possible for every new baby
to have their genome sequenced and stored
with other health records.

Bank of America Merrill Lynch




Brent McDonald
Head of Healthcare Strategic Advisory,
Managing Director
Bank of America

In the face of seismic industry shifts, challenging
regulations, and constant uncertainty in Washington,
providers are reshaping the healthcare
landscape themselves by entering into strategic
mergers, acquisitions, and partnerships. Today’s
deals are reflective of the times, says Brent
McDonald, head of healthcare strategic advisory
and managing director at Bank of America Merrill
Lynch. “Most providers who are looking to merge
are focused on achieving powerful and costly
objectives such as transitioning to a value-based
payment model, growing a population health initiative,
and improving clinical integration,” notes
McDonald. “They are seeking partners with the
right combination of capital, infrastructure, intellectual
property, and technology.” McDonald discusses
the benefits of integration and how providers are
structuring today’s complex M&As.
What types of strategic partnerships
are common in the current
healthcare climate?
Brent McDonald: We are seeing mergers that
have clear built-in synergies. Oftentimes, the two
organizations don’t just mirror, but rather they
complement each other in strategic ways. When
they merge, it becomes one plus one equals three,
allowing them to more effectively meet the Triple
Aim. For example, one hospital may have spent
more time developing an urgent care network, a
freestanding emergency room, or a micro-hospital
network, while the other recruited and invested in
developing a network of high-acuity specialists.
It’s common to see an urban or academic medical
center that has invested in tertiary subspecialists
integrate with a successful community hospital that
is associated with more primary care physicians.
And it isn’t necessarily that they have economies
of scale available, but they are a very complementary
clinical fit. Partnering with an organization that
has built scalable competencies makes it easier
to justify the execution risk of integrating. If you
merge with a hospital that has spent the time and
resources on a clinical integration network that is
already functioning with the governance, accountability
measures, and physicians in place, then you
don’t have to take on that risk in building your own
network, which could fail.
What are the primary financial benefits
in a merger or acquisition?
McDonald: Overhead is still the most straightforward
and nonclinical financial economy of scale.
Organizations formed through a merger or acquisition
can expect to gain efficiencies in accounting,
human resources, revenue cycle, supply chain, and
other back-office services. These deals also allow
you to spread the cost of investment in health
information technology and population health over
a broader set of hospitals and a larger net revenue
base. Moreover, there may be clinical core competencies
that benefit the two parties post-merger,
including complementary service lines and geographic
ambulatory access points.
What do leaders hope to gain clinically
when entering into a new partnership?
McDonald: Quality is always top of mind. Without
quality and a reputation of quality, your earnings
and growth will suffer, as well as your ability to
reinvest and continue to be a high performing
organization. That being said, when considering a
partnership today, providers are often looking for
specific clinical competencies. For example, having
expertise in case management and physician
integration, as well as having advanced technology
is desirable. Simply having an electronic medical
record (EMR) isn’t enough anymore. How you use
the EMR to make a difference in providing care
is important to a potential partner. An organization
that has mature physician integration and is
advanced in how it uses its EMR system to impact
care likely has physician leaders who have worked
through the data sets to create best practices,
and has clinical care decision matrices embedded
in the medical record, which enables greater standardized
“Without quality and a
reputation of quality, your
earnings and growth will
suffer, as well as your ability to
reinvest and continue to be a
high performing organization.”
How are mergers and acquisitions
helping organizations meet advanced
population health goals?
McDonald: Achieving population health requires
an investment, and if you are precarious from a
balance sheet or a profit-loss perspective, meaning
you don’t have enough margin to reinvest in the
hospital, then you won’t be able to execute on key
initiatives. Infrastructure and technology are the
two critical components that make up the backbone
of population health. They allow a hospital to
measure clinical information and present cohesive
and timely information back to its clinicians. Both
of these competencies require heavy capital investment
and know-how. Having a strong internal
framework and state-of-the-art IT are not something
that smaller, community hospitals can generally do
alone—typically, because they don’t have sufficient
margin to invest in such initiatives across their
subscale network. For example, if a community
hospital is trying to create a center of excellence
in a clinical service line, they may have trouble in
areas such as recruiting the key specialists and
subspecialists. A larger partner will typically have
the technology, case management, and a better
4 Bank of America Merrill Lynch I Sponsored Material
pipeline of doctors. Our Bank of America Merrill
Lynch analysis reflects that there is a correlation
between scale (or size) of an organization and higher
investment-grade credit ratings.
The goals of MACRA include radically
shifting payment models from fee-forservice
to value-based payment. How
does a merger or acquisition support
and accelerate this shift, as well as
help an organization bear
downside risk?
McDonald: MACRA adds more complexity, which
will probably cause more physicians to organize into
larger groups. Clearly, being able to handle value-based
payment is a different way of practicing.
It requires different skill sets. But, the model is still
being shaken out. Will it be hospitals, physician-organized
super groups, or a hybrid of the two that
will be best positioned to transition physicians to
value-based care? We still don’t know.
In the meantime, a traditional independent physician
practice that has to rely on a high volume of
patients just to keep their office open does not
have a lot of excess capacity in their day to deal
with changing payment and care models. It is an
almost impossible task for independent physicians
to influence the health of their patients when they
leave their office and go to the hospital or to an
urgent care center. It requires competencies they
don’t have to compete in this advanced care and
payment system, including an optimized EMR and
the ability to undergo a care redesign. Therefore,
it is difficult to manage downside risk. You will be
more successful having scale and leverage for
these considerations and, also, for weathering the
unexpected revenue ebbs and flows of value-based
care. In a merger or alignment with a larger, capable
organization, physicians become part of a
larger entity that has a sophisticated EMR and
other advantages. These advantages include case
managers and other staff who are available specifically
to follow and enhance that patient’s journey
across different care environments. A larger system
can track someone who visits the ER, making sure
they receive the right follow-up care, do not have
an unnecessary hospital readmission, and have
a positive experience with their provider and the
healthcare system.
Improving the patient experience is
important in a merger or acquisition.
As organizations come together, how
can they address common challenges?
McDonald: There are betterment and integration
hurdles in this area. Most hospital systems are
constantly working toward a better position when
it comes to improving the patient experience. To
get there requires having the right skills to invest in
all of the resources you need. On the other hand,
mergers are disruptive and patient satisfaction
can be damaged as you integrate to a new culture
or platform. It’s important to have a plan for key
patient perception areas such as scheduling, registration,
and medical records. You need a unified
approach when integrating the patient experience.
For example, patients will be frustrated if the process
is disorganized and they have to register three
times in a visit to the hospital. It requires vigilant
attention to get this right.
Bank of America Merrill Lynch

Automation to Optimize Receivables In A Changing Payment Landscape

Automation to Optimize Receivables In A Changing Payment Landscape

Key Bank

Adoption of  fully electronic transactions varies significantly according to Key Bank’s white paper “From Crawl to Walk to Run”. From Streamlining business processes with new tools abounding, there are five questions CEOs should ask about their current payment management strategies. You can also educate the healthcare consumer with five strategies for improving patient relations in the front office.

Look for best practices for communicating with patients about prices, billing and payments. Ultimately, you will be able to lower the cost of staff time formerly devoted to largely fruitless pursuit of mostly small balance accounts after the procedure is completed.

Learn more about how to do this from Key Bank in the link below:

Automation to Optimize Receivables Healthcare White Paper

Thanks to our sponsor, Melissa Whitmer, Senior Vice President, Healthcare Banking, Key Bank, for providing the above white paper.

Melissa can be reached at:
720-904-4250 (Office)
303-931-2404 (mobile)


SIM Recruits Final Cohort, Helps Practices Integrate Behavioral and Physical Health

SIM Recruits Final Cohort, Helps Practices Integrate Behavioral and Physical Health

SIM recruits final cohort, prepares practices for success with APMs

Sustainable healthcare reform requires new skills and a different understanding of how practices articulate their unique value to succeed in alternative payment models that reward the value (not volume) of care delivered. The Colorado State Innovation Model (SIM), which is recruiting for its third and final cohort, helps practices integrate behavioral and physical health, use data in actionable ways and retool processes to provide team-based, patient-centered care. One example of how this federally funded, governor’s office initiative helps practices prepare for success with alternative payment models (APMs): SIM practices have a “glidepath” with the new Health First Colorado APM.

SIM practices that are designated primary care medical providers don’t have to submit quality measures for the first year of the Medicaid APM and get full credit on the Medicaid APM point scale. Please encourage primary care practices to apply for the last SIM cohort by Jan. 19 to get the coaching and support they need to succeed in APMs, deliver whole-person care and use data more effectively:


Why hospitals need to do more than just pen a sexual harassment policy

Why hospitals need to do more than just pen a sexual harassment policy

Even among the majority of practices that have a policy, current training methods are too passive, MGMA experts say.

Beth Jones Sanborn, Managing Editor, Healthcare Finance News

According to a recent MGMA stat poll, more than 80 percent of healthcare organizations have a sexual harassment policy. However, experts say just having a policy isn’t enough. It all comes down to training and enforcement.

The poll conducted on December 12 analyzed 1,237 responses. Of those who responded, 84 percent said their organization had a policy that specifically addresses sexual harassment. Of the remaining 16 percent, 12 percent said their organization had no policy and four percent weren’t sure whether they had one.

[Also: Why hospitals can’t ignore their ‘Harveys’, must create supportive culture for reporting sexual harassment]

MGMA also asked how training was delivered to staff. The most common method was through a new employee orientation and an annual repetition of the training, often via online training at staff meetings that also includes an assessment, test or role-playing exercise.

Other respondents said the policy was only outlined in the employee handbook.

[Also: California medical board president under fire over business deal following sexual misconduct vote]

Simply having a policy just doesn’t cut it, said Judith Holmes, cofounder of the Compliance Clinic and an expert cited by MGMA. She cautioned practice leaders to “take a serious look at handling harassment” as the number of EEOC complaints and charges mounts, not to mention the numerous high profile figures and organizations that have come under an unwelcome spotlight amidst sexual harassment allegations in recent months.

She said now is the time to draft and implement policies, and that hospitals and practices must train employees on how to handle complaints and get a clear picture of what happens when you don’t take such steps.

“It’s going to be harder for that practice to defend a lawsuit if they can’t show that they had a policy, that they applied it, that they trained people on it and they followed it,” Holmes noted.

She suggested that the best training is usually accomplished by bringing in an outside expert, especially one that really understands the law surrounding harassment, and doing a separate training for upper management, supervisors and physicians that hones in in on how to properly and responsibly handle these types of investigations.

Handling a report the wrong way can make for a toxic work environment that can resonate with other staff and even patients.

“Ongoing bad behavior, it can just devastate a practice in the long run with high turnover, low morale — and if you think patients don’t sense the tension, you’re wrong,” Holmes said. “They see what’s happening underneath often, and you may not know you’ve lost patients to this kind of underlying stress and tension that your staff feels because there are all these problems going on that no one’s addressing.”

Another MGMA expert and member, consultant Will Latham, cautioned practice leaders to look out for behavior not just that violates policy, but also actions that impact staff morale. That includes degrading comments, inappropriate jokes, profanity, yelling, lack of cooperation or refusal to follow protocols and spreading nasty rumors.

It’s not okay to explain these behaviors away with excuses of stress, heavy workloads or past bullying. The presence of disruptive behavior, Latham said, is because it’s been tolerated in the past.

In addition to confronting the behavior when it happens, the hiring process can be an opportunity to stop a problem before it starts. Evaluating candidates thoroughly and gauging their willingness to accept and support an organization’s culture can help establish that zero-tolerance approach from the start, Latham said.

Twitter: @BethJSanborn
Email the writer:

No Repeal. No Replace. How About We Agree to Amend?

No Repeal. No Replace. How About We Agree to Amend?


Dea Robinson, FACMPE
Independent Healthcare Consultant
Doctoral Student
Colorado State University
Organizational Learning, Performance & Change


Either way, “Obamacare” will most likely change in the near future and while there have been speakers, debates and numerous articles on what could happen, there are other factors that are being neglected.  To this point, let’s just go with what the last speaker, T.R. Reid said at the last Denver Medical Study Group meeting.  T.R. predicted that the US healthcare industry will end up with a single payer system.  And, to my point, regardless of what the system is from a leadership and administrative lens for healthcare, business as usual is, well, business.

Healthcare is personal, and healthcare is a business and this is where we have a rub.  Some forget that choosing a plan to offer employees affects the person making the recommendation and choice and must balance the decision within the parameters of an accountable budget to owners or a board of directors.  One fiscal reality is as healthcare expenditure continues to rise, we see employees who ‘work for benefits’.  So, instead of working for a paycheck, workers are working for healthcare coverage.  Just imagine if workers did not work for benefits, and instead worked because they wanted to and healthcare coverage was just as normal as having a latte on Monday morning.  A recent Health Affairs  blog provides a good overview of Obamacare and the differences between the two plans, but let’s suspend some of the unknowns for some knowns  We know the Baby Boomer generation and Generation X will continue to consume more healthcare services as they age, and the next generation (Millennials) will continue to push the healthcare consumer needle into places we haven’t been before that will require healthcare leaders to consider different staffing, utilization, and reimbursement models.  As we continue with our suspended unknown mindset, let’s discuss what we know.

Generational forces.  In a recent MGMA Stat poll of 1,487 respondents that asked the question regarding telehealth services, 74% of medical practice administrators respondents reported their personal physicians did not provide this type of service, but were willing to use the service (49%) if offered.  Of note, the MGMA data provided earlier was not stratified so we could not soft test respondent demographics in the respondent sample, but this is the kind of information needed for forward thinking healthcare leaders need to consider.  The next generation of healthcare consumers are the Millennial generation, a cohort birthed when the internet was implemented (born between 1981 -1995).  This group of individuals defines their generation by technology use (Hershatter & Epstein, 2010).  It is possible that the demand for telehealth services has not matured in practice because the patients most comfortable with this practice do not constitute most of healthcare patients -yet.

How to get paid and for what.  A shift in technology-driven healthcare requires a shift in mental models for healthcare system leaders to let go of old payment models for physicians and staff leading to more knowledge work.  The payment models in place today are still predominantly based on a per patient or RVU model combined with hours spent in an office.  We may always have a bricks-and-mortar place for patients to go and I think this is a good thing, but here is the challenge.  Could we starting to think creatively on how to use RVU’s and hours worked as part of reimbursement instead of the only metrics of production?  I have had numerous private discussions with colleagues over the ‘value’ issue in healthcare.  Typically, the conversation ends with submission to what HHS will decide what value will be, or what the hospital decides it will be, and so on.  What is value in your healthcare system?  What do your patients value and are you rewarding the right people or teams?  Typically, the answer is, yes, but if you can’t measure it, it doesn’t exist.  I get it and my response is look to ‘patient experience’ for some ideas and your internal medical staff for the other half of value.  Are you rewarding poor behavior because RVU’s are high but no one wants to work as a team because of the culture in your organization?  Let’s also not forget that patients typically file malpractice claims based on how they were treated by the physician, not the medical outcome.  What is value for your patients, employees, physicians, and staff?

Patient record disconnectedness.  Given the mobility telehealth delivery provides, services can be delivered from any global location and this trend will challenge tightly held ways of working for providers.  Are you ready to manage people you don’t see?  Are you ready to pay people you don’t see when healthcare services happen in a cloud?  And, are you ready to assess effectiveness and outcomes of virtual medical teams?  Baby Boomers have done some great things for healthcare delivery.  They insist on living longer and doing more as they age and their lifestyles reflect expectations of their health.  A few years ago, I heard Atul Gawande, MD talk about healthcare complexity and one of the takeaways from his talk was about the challenges of systems.  He claimed one of the biggest challenges to healthcare is the complexity of systems to ‘talk’ to one another.  While some of the biggest advances have been in technology; alternatively, some of the biggest obstacles to care and customer service are also the result of technology.

I recently observed an orthopedic surgeon dictate into his Dragon dictation system and it was one of the most painful displays of human-technology interaction I have experienced in a long time. (Full disclosure:  I was a medical transcriber for many years to put myself through college and it is a struggle not to grab the keyboard and just type the words.)  He had great coping skills, however, as administration had provided a little stuffed animal to squeeze and throw in the air when his ‘Dragon’ didn’t work.  And then, when the dictation system started to transcribe his words, his computer shut down to restart and install new software.  Sound farfetched?  This is the kind of ground-level, front line frustrations that can prevent us from moving forward to providing the right care, at the right time.

Obamacare will morph and change, but we have things we can address now in a proactive way to move the healthcare needle on our own.




Plaintalk Blog: Quality Matters – How Do You Know if The Health Care You’re Getting is Good?

Deciding where to get health care is a pretty big deal. But, unlike most other big-deal purchases, today’s industry doesn’t allow us to comparison shop.

When you’re getting ready to buy a new car, the price point is only one of the things you take into consideration. You likely research the safety ratings of the vehicle, how many miles per gallon it gets, the size of the engine, how much horsepower it has, and whether the cup holders are big enough to secure your coffee mug. All of these factors combine to help you to determine the quality of the car and decide how to spend your money.

Determining quality in health care isn’t so simple. In 2001, the Institute of Medicine published a report called Crossing the Quality Chasm, where they defined – for the first time – the different components of quality health care:

  • Safety: avoiding injuries to patients from the care that is intended to help them.
  • Effectiveness: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.
  • Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
  • Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care.
  • Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.
  • Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

Great. These are definitely things that make up good health care…but how do we know if they are being done? Measuring patient safety isn’t exactly the same as measuring miles per gallon.

The Agency for Healthcare Research and Quality (AHRQ) identifies three types of quality measures:

  • Structural Measures – the tools used to provide care
    • Whether the health care organization uses electronic medical records or medication order entry systems.
    • The number or proportion of board-certified physicians.
    • The ratio of providers to patients.
  • Process Measures – the ways care is provided
    • The percentage of people receiving preventive services (such as mammograms or immunizations).
    • The percentage of people with diabetes who had their blood sugar tested and controlled.
  • Outcome Measures – the impact of care provided
    • The percentage of patients who died as a result of surgery (surgical mortality rates).
    • The rate of surgical complications or hospital-acquired infections.

Even better! These examples could be really helpful when trying to decide where to get treatment. Yet, here’s the catch: most of these measures are not readily available for folks on the street trying to get health care. According to AHRQ, industry professionals use these measures in four ways:

  • Program Management – Overseeing key functions to ensure that program goals are met and resources are used efficiently.
  • Accountability – Demonstrating achievement of identified goals.
  • Quality Improvement – Devising and tracking the impact of targeted interventions designed to improve health services.
  • Reporting Results – Reporting to a variety of stakeholders and other audiences.

Bummer. While all of these are valuable ways to use quality information, there are many out there who would love to use these measures to help choose the place to spend their health care dollar.

But, there’s hope! Organizations across the nation are working to make public-facing quality reporting a reality. CIVHC, and others like us, are developing ways to show quality information next to cost data so regular folks are empowered to choose high value care and take charge of their health care journey.

New Health Transformation Alliance—38 of America’s largest Companies Look at Fixing Healthcare

New Health Transformation Alliance—38 of America’s largest Companies Look at Fixing Healthcare

A Group of Leading Private Sector Companies Is Working to Fix a Broken Health Care System

The Private Sector Won’t Wait

-Health Transformation Alliance Now Has 38 of America’s Largest Companies on Board-

New Partnership for Prescription Drugs; Focus on Converting Data into Insights; Creation of Medical Networks to Begin

(New York, NY – March 7, 2017) – As government officials consider their next steps in health care reform, a large and growing group of America’s leading corporations is moving ahead with major changes in how millions, and potentially tens of millions, of workers get their health care.
“Fixing health care is something everyone is talking about,” said Kevin Cox, chairman of the Health Transformation Alliance and chief human resources officer for American Express. “The employer-provided health care marketplace, which supplies a substantial portion of the profit margins to the entire health care system, is looking for meaningful change. We’re moving ahead to help companies take better care of the people who take care of us.”
Just one year after 20 corporations united to build a new way of delivering quality health care for their workers, millions of employees will soon benefit from a new partnership these companies are putting in place to purchase prescription drugs, the first of three major reforms the newly formed Health Transformation Alliance is undertaking. The other two reforms focus on translating big data into cognitive insights and setting up new medical networks.
Through a partnership with IBM Watson Health, the HTA will leverage data, analytics, and cognitive insights to support its transformational initiatives. Better understanding data, trends, and results, the HTA believes, has the potential to predict and prevent disease, improve outcomes, increase the value of health care for its members and employers, and enable the integration and collaboration of all stakeholders in the health care ecosystem. These three reforms (Pharma, Big Data/Cognitive Insights, and Medical Networks) are all expected to be in place beginning in 2018.
Today, 38 companies belong to the HTA, up from 20 last year, and collectively they spend more than $24 billion a year to provide health care to more than 6 million employees and family members, up from 4 million covered lives last year. Through the HTA, these companies have forged alliances with a variety of companies in the health care sector to change how health care is delivered to employees—and lower costs.
“Our job is to fix our broken health care system,” said Cox. “While it’s not yet clear what actions the federal government will take, we are working together toward a clear path to positively change health care for tens of millions of people in the private sector.”
Rob Andrews, CEO of the HTA, said, “We recognized last year that privately provided health care can’t go on the way it’s been. While costs for non-health care related expenses have risen 40 percent since 1999, costs for employer-provided coverage are up 191 percent and employer contributions for premiums are up 213 percent over the same period. If private sector companies don’t change the system, employer-provided health care is at risk of becoming unaffordable for companies, and for their employees and families.”

New Pharmaceutical Partnerships

In February, HTA launched partnerships with CVS Health and OptumRx to change how companies provide prescription drug benefits through prescription plan management companies, known as pharmacy benefit managers (PBMs).
Rather than having individual companies contract with these PBMs, HTA forged an innovative approach with CVS and OptumRx that focuses on partnerships and transparency, resulting in lower prices for the same medicines and allowing HTA members to achieve considerable savings. These changes go beyond what group purchasing coalitions have been able to achieve. It’s a path-breaking approach for the way companies deliver prescription drug benefits to their workers.
In addition, the HTA will work with its PBM partners to create better formularies, which list the prescription drugs commonly agreed to be used by the medical profession and the insurance industry. The solutions will not only result in increased savings to HTA member companies, but also help individuals select the most appropriate and cost-effective prescriptions to meet their medical needs.
“Beginning January 1, 2018, these prescription drug reforms alone are projected to save participating HTA member companies, their workers and, in some cases, retirees, at least $600 million over three years,” said Andrews. “We are moving ahead with similar reforms in payments for other medical care and are confident that the HTA can change the way health care is priced so our members and workers can benefit.”

Changing Medical Outcomes with Medical Networks

In addition to Pharma, HTA is focused on working in partnership with some of the nation’s leading health care provider systems to improve medical outcomes. HTA selected United Healthcare and Cigna as partners in administering this effort.
HTA’s medical reforms, scheduled for launch in 2018, will focus on the best treatments for several conditions that contribute greatly to health care spending, including Type 2 diabetes, hip and knee replacements, and treatment for back pain. These four conditions are among the most commonly treated ailments, accounting for as much as 40 percent of health care spending of HTA companies.
“The goal of these initiatives,” said HTA Vice Chairman Dr. Glenn Steele, “is to combine what HTA is doing with data and prescription drugs to create new medical networks that provide top-quality care for workers, retirees and their family members. These better health outcomes will reduce costs for families as well as employers, all while improving the health and well-being of employees.”
Dallas/Fort Worth, Phoenix and Chicago have been selected as the first markets in which these new networks will be created.

Data-Driven Transformation

The HTA selected IBM Watson Health as its data and analytics partner. The HTA will use the IBM Watson Health cloud-based cognitive platform to aggregate data from across the participating members and provide descriptive, predictive and cognitive analytics. The insights from these data and analytics are expected to help HTA members lower the costs of care, reduce waste, and improve health outcomes and experiences for the population, including their employees, dependents and retirees.
Analytic priorities will focus on medical and pharmacy utilization, predictive insights for more proactive health management, and risk-based segmentation to identify appropriate opportunities to improve employee health care. When viewed collectively, these insights let employers approach the market collectively to truly transform the way care is delivered.
“A playbook for ‘personalized population health management’ is emerging, replacing outdated care management approaches, performance measures, and payment models,” said Deborah DiSanzo, general manager for IBM Watson Health. “This monumental shift creates an entirely new dynamic among employers and their employees, providers and payers. Working with the HTA, Watson Health has the opportunity to transform health by applying IBM’s distinct blend of domain knowledge, which includes a 360-degree perspective of health care; a century of experience managing large, complex data projects; and Watson cognitive computing.”
“The private sector can’t afford to wait to get this done,” said Cox. “Through the HTA, we can change health care for the better, in a way that none of us would be able to do as individual companies. Employer-provided health care is important to our employees and retirees. We’re proud of what we’ve done in just a year, and we look forward to delivering for our workers, retirees and their families.”
Want Healthcare LLC —Thoughts on The Next Phase of Health Care Reform

Want Healthcare LLC —Thoughts on The Next Phase of Health Care Reform

Five things I think I think about the next phase of health care reform

March 28, 2017 at 1:13 PM Leave a comment

argument by jon collier

Photo by Jon Collier

This is not the end of Obamacare; it’s the beginning

In a surprising move, Paul Ryan pulled the American Health Care Act, the Republican ACA repeal and replace bill, last Friday.  It had become clear that there was no movement to the left or the right that would garner enough votes to allow passage in the House.  Even if it had passed in the House by moving right, much of that movement was likely to be stripped out in the Senate, where the Republican majority is slimmer, but no less internally conflicted.  The president has stated he is moving on to other issues like tax reform and infrastructure building.

So you might think that health care reform on the federal level is done for now.  Whether that is true or not, it is also pretty clear to me that there is still a great deal of work to do to stabilize and improve the ACA.  Cost constraints are still lacking, and insurance marketplaces at the state level are still suffering from shrinking insurer participation.  While coverage has vastly improved under the ACA, affordability remains elusive if you don’t qualify for a subsidy.

Where are we going next?  Some (including me) are hoping that this opens the door to real bipartisan negotiation.  Here’s the theory.  The Trump administration cares about the appearance of winning, not ideology.  If you can’t work over the Freedom Caucus to get the votes, you go to the Tuesday Group, a group of moderate Republicans.  Perhaps they’ll even appeal to the next group over from them, moderate Democrats, to get onboard for something.

Here are five things I observed from this last round of negotiations:

  1. The Freedom Caucus has a literal interpretation of the phrase “repeal and replace”. All the rhetoric about removing Obamacare “branch and root”?  Turns out it wasn’t simply rhetoric for them.  They believe that Medicaid expansion to childless adults must be removed entirely, because it is enabling able-bodied citizens to get care without working for it.  All the headlines about 24 million more uninsured shocked many of us, but for conservatives was actually not a bad thing, and for some a desired outcome, judging from the rhetoric surrounding the debate.
  2. Loss aversion works. One of the truisms of behavioral economics is that fear of loss is about three times as motivating as desire for gain.  This has been shown over and over again by people like Amos Teversky and Danny Kahnemann in psychology experiments.  Thus, some people didn’t like the Affordable Care Act until they faced the possibility that they would lose coverage if it was repealed.  For the first time in years, public approval of the ACA is greater than disapproval.  (By the way, now that the immediate threat of repeal is gone, I predict those numbers will reverse again.)  If you want people to value something, don’t try to sell it to them; give it to them and then try to take it away (the Classic Coke strategy).
  3. Trying to sneak legislation through in the age of Twitter is like trying to sneak to the bathroom in your pajamas through Grand Central Station. Hiding stuff so you don’t get criticized for it doesn’t work.  Nor does speeding up timelines for the same purpose.  We may have to do this a few more times before people get it, but the old days of passing legislation that hasn’t been dissected under a microscope I think are gone.  There are too many smart people out there with time on their hands and a Twitter following to feed.  They have an immediate platform to do the Roman thumbs up or down on literally everything in view, and are just waiting for something to tweet about.
  4. The emerging centrist view is that we need to maintain coverage for everybody who has it now, but get to cost containment to make the system sustainable. In a previous post, I talked about the hard truths that both sides are avoiding by blaming the other guy.  But what do we do to control costs?  The conservative answer is market forces, and the progressive one is government regulation.  Neither one has a great track record when it comes to health care.  So what’s an industrial superpower to do?  There was funding in the ACA to set up CMMI, and much of their work has been on alternative payment models intended to bend the cost curve over time.  But pragmatically the experience has been mixed for medical homes, bundled payment, and population-based payment.  Rollout has been slower than many would like, and affect too few providers to declare it a success.   I would love to see a real and thoughtful bipartisan discussion on some hybrid possibilities.
  5. And there is no guarantee the next move is toward bipartisanship. Winston Churchill said, “Americans will always do the right thing—after exhausting all the other possibilities.”  If the last twenty years teaches us anything, it’s that governing from the extremes doesn’t work very well.  So you’d think that the next move would be to try to govern from the center.  But this is one of those Clayton Christiansen moments.  Christiansen says that the winners of the last game are unlikely to be the inventors of the new game, since the new game displaces the old one.  The existing game goes like this:
    1. Point out what’s wrong with any plan offered by your opponents, which is much easier to figure out than how to make things work (boring). It also gets a lot more attention on Twitter.    And, the bonus is that you get to go home to your district and tell people you stood on principle, and that everyone else has the morals of a used car salesman.
    2. Foment anger and frustration, and promise that you are the only person capable of breaking through the mess. Do this, while you are all the while perpetuating the mess.
    3. Repeat, and fund-raise.

Both parties have had the chance to be in the majority and the minority in the last two decades, and both have gotten pretty good at the existing game.   It will take a sea change to find the next game that rewards centrist compromise.  Here’s hoping we exhaust all the other possibilities sooner rather than later.

NOTE: Permission to share the above blog from Want Healthcare LLC granted by Jay Want, MD.