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Author: Chris Hadley

Head to Head: health Policy and the Next Governor

Head to Head: health Policy and the Next Governor

This article was originally published on the Colorado Health Institute website, and is reprinted here by permission.

colorado health institute

Neither candidate for Colorado governor is happy with the state of local health care. But they differ dramatically on the best way to fix it.

Democrat Jared Polis, a five-term congressman from Boulder, describes health care as a human right and says too many Coloradans go without it. His goal is for Colorado to enact universal health care within eight years, a move he says would save money and improve care.

Republican Walker Stapleton, the state treasurer since 2011, sees the Affordable Care Act and the accompanying expansion of Medicaid as uncontrolled budget-busters. He supports structural changes to Medicaid to reduce costs and does not believe the state’s insurance exchanges will last.

The candidates are competing to replace term-limited Gov. John Hickenlooper, a Democrat. Election Day is Nov. 6, and voting by mail begins Oct. 15.

The governor’s race once looked like a proxy fight in the national debate over health care, with Republicans pushing to undo the Affordable Care Act and Democrats promoting a single-payer system financed by taxes that would cover the costs of health care for all residents. But both Polis and Stapleton have moderated their positions since winning the nominations in June and are now proposing more incremental changes.

For example, Polis now talks as much about cutting health care costs as extending government coverage. Stapleton says he will reject any attempts to penalize people with pre-existing health conditions or not allow young adults up to age 26 to stay on their parents’ insurance — two key tenets of the Affordable Care Act. Stapleton also has bucked religious conservatives by endorsing free long-term contraceptives to cut teen pregnancies and abortions.

The candidates split on marijuana regulation and their belief in government’s ability to effectively manage health care.

Polis: Universal Coverage Would Cut Costs

Polis endorsed Medicare for All — a national proposal to expand government-run health coverage for everyone, regardless of age — long before it became a political rallying cry for liberals. He opposed Colorado Amendment 69, a 2016 ballot measure that would have created a system of universal care, saying it was flawed in its approach.

Now, Polis is pushing for a multi-state universal coverage system. He says he would enact residency requirements, like those for college students who pay in-state tuition, to prevent Colorado from becoming a magnet for the sickest patients and those whose care is most expensive. He does not favor mandates to buy health insurance.

Polis also wants Colorado to partner with other states — he mentions Minnesota, Nevada and New Mexico as possibilities — to negotiate cheaper prices from pharmaceutical companies and create a larger pool of insurance customers to hold down costs for consumers and government.

“We’re generally about increasing access and reducing costs,” Polis said. “The two go hand in hand because when people have access to health care, they’re less likely to wind up uninsured and uncovered in an emergency room with a very high cost of care.”

If state and local elections go his way, Polis believes he could lead Colorado to “achieve close to universal coverage over the next eight years, or two terms as governor.”

What about costs? Polis won’t say specifically who would pay what. “It should cost less. We’re paying too much today,” Polis said. “I mean, in effect, the only reforms that I support are ones that save money.

“If you look at health care as a percentage of the GDP (gross domestic product) in our country, it’s roughly twice what it is in any other western industrialized nation that has universal health care. Again, there’s no health care system that’s perfect, but fundamentally, we should be spending less, and if we do, we should be able to cover everybody,” Polis said.

When asked if his goal was for Coloradans to stop paying premiums to private insurers and instead pay taxes to the government for health care coverage, Polis replied, “That’s sort of a very vague 20,000-foot concept. … I think what people are interested in, what voters are interested in is paying less in health care, saving money on prescription drugs, and however we do that — and there’s a whole variety of ideas — is fine.”

Among those ideas: Resurrecting a customer-owned cooperative insurance company and opening the state employee benefit plan or Medicaid to expand coverage options for people who currently don’t qualify for either program. Colorado had an insurance co-op that was launched by Affordable Care Act grants, but it folded in 2015 after just two years.

Jared Polis

Jared Polis
Democrat

Age: 43

Residence: Boulder

Experience:

  • Congressman 2009 – present
  • Colorado State Board of Education: 2001-2007
  • Businessman who co-founded greeting card company Bluemountain.com, and founded online florist ProFlowers and Internet provider American Information Systems

Education: Princeton University

polisforcolorado.com

Stapleton: Universal Coverage Would Break the Bank

Stapleton is far more skeptical that government is the answer. Pointing to a legislature that has been known to fight endlessly over programs that cost a few million dollars, Stapleton questioned the ability of state government to manage a massive universal care program, which he said could cost $25 billion.

“If you’re going to propose universal care, it should be incumbent on you to explain how you plan to pay for it,” Stapleton said. He expressed concern that it would be “easier to qualify for health insurance than it is to get a driver’s license. From a cost standpoint, it’s an unlimited pool of potential people that would be covered.”

Colorado is one of a minority of states that fully embraced the Affordable Care Act. It expanded eligibility for Medicaid to include low-income adults without children, and it created its own online health insurance exchange. (Thirty-three states and the District of Columbia have expanded Medicaid. Only 11 states and the District of Columbia run their own exchanges. The rest rely on the federal exchange, at least to some degree.)

Stapleton believes it’s “inevitable” that the state insurance exchange will fold, and he thinks Medicaid expansion is unsustainable. He predicts Congress eventually will react to the rising cost of insuring people with lower incomes by ending Medicaid expansion and providing states with block grants to figure out their own coverage options.

However, Stapleton is not calling to repeal the state’s health insurance exchange, Connect for Health Colorado, because closing it down abruptly could cause tens of thousands of people to lose their health insurance. And he doesn’t plan to reverse Colorado’s Medicaid expansion.

One way to trim the state’s Medicaid bill, he said, is to reduce unnecessary visits to the emergency room. He pointed to a UnitedHealthcare subsidiary, Optum, a health and technology company he said “can now perform 90 percent of the services an emergency room can perform at 10 percent of the cost in an individual’s home. Why would we not take advantage of that innovation and work with a company like Optum to reduce the cost of Medicaid in Colorado?”

Stapleton said a serious problem with any expansion of Medicaid and Medicare is that the programs “chronically underpay” physicians for medical services. Stapleton said he is concerned an expansion of those two government health programs will lead doctors to leave Colorado.

In 2016, Medicaid and Medicare in Colorado reimbursed hospitals just over 70 percent of their costs of treating patients in the programs, according to the Colorado Healthcare Affordability and Sustainability Enterprise.

Stapleton also supports requiring random drug tests of Medicaid members. “I think if you are getting subsidized federally, and you’re on federal assistance, and you’re using drugs, the state should have the right to test you,” Stapleton said. An aide later explained that Stapleton’s drug-testing criteria extended only to Medicaid patients and not Medicare recipients or others receiving various federal benefits.

Walker Stapleton

Walker Stapleton
Republican

Age: 44

Residence:
Greenwood Village

Experience:

  • State Treasurer 2011-present
  • Businessman who served as former chairman of the commercial real estate company Sonoma West Holdings

Education: Williams
College, London School of Economics, Harvard University (MBA)

stapletonforcolorado.com

Regulating Marijuana

The candidates hold very different views on state regulation of marijuana.

Polis voted yes on state ballot initiatives in support of medicinal and recreational marijuana. In Congress, he has become one of the leading supporters of marijuana legalization.

By contrast, Stapleton voted no on the cannabis initiatives. Though he would not support repealing legalization — “Given the number of states that have legalized now, I don’t think that’s practical” — Stapleton does want to raise the legal age for medical marijuana from 18 to 21 and tighten restrictions for other consumers.

“I don’t think that you should be 18 and qualify for a medical card when you need to be 21 as a retail buyer of marijuana,” Stapleton said.

He also would raise taxes on medical marijuana, which currently is not subject to the steep excise and sales taxes of retail marijuana.

Polis said it would be unwise and unfair to boost the age for medical marijuana from 18 to 21. He sees medicinal pot as a painkilling alternative to addictive opioid prescriptions.

“Seventy-five percent of opioid addiction begins with a prescription,” Polis said, “and so if there are less addictive and harmful alternatives to opioids that can work for pain management in certain cases, medical marijuana can be one of those (treatments).”

Polis’ priority related to marijuana would be “driving any remaining drug dealers out of business.” He said the state could do a better job of monitoring the safety of the product sold in dispensaries, but that “by and large Colorado’s model is an example to other states.”

Both candidates expressed support for state investigations of pharmaceutical companies selling opioid painkillers to Coloradans.

Views on Other Health Issues

Stapleton says he believes that health care can be improved by integrating primary care and behavioral health. Increasing access to integrated physical and behavioral health care is a major goal of Colorado’s State Innovation Model, which is run by the Hickenlooper administration with funding from the federal Centers for Medicare & Medicaid Services.

The candidates differ on how they talk about abortion. Polis supports abortion rights. Stapleton declined to say what he would do if the Supreme Court overturns Roe v. Wade and returns the issue to states to decide. “That’s a federal issue,” he said. “When I became the treasurer of Colorado, I swore to uphold the Constitution, and you don’t get to pick and choose the parts of it that you like and don’t like.”

Both Polis and Stapleton expressed support for the Colorado Family Planning Initiative, a state program that provides low-income women with access to long-acting reversible contraceptives (LARCs) at reduced or no cost. It is credited with sharp reductions in teen births and abortions, although some Republicans in the legislature oppose funding for long-acting contraceptives because they consider it a form of abortion.

The two men also agree that they personally pay too much for health insurance. Stapleton estimated he pays $15,000 a year as a state employee to cover himself, his wife, and their three children on a UnitedHealthcare policy. Polis said he pays $16,944 a year for unsubsidized Anthem coverage on the Colorado health exchange for himself, his partner, and their two children.

In 2017, the average premium in Colorado for family coverage through an employer was $19,300 per year. Businesses paid most of the price, and the average employee share was about $5,300.

Conclusion

The election presents a choice between two candidates with different ideas about the role of government in health care. Polis envisions a greater role through the creation of a multi-state single-payer system. Stapleton thinks the state government is already too heavily involved through Medicaid, which now covers nearly a quarter of the state population.

But neither candidate seems likely to immediately dismantle the current system. Stapleton is not calling for major cuts to Medicaid or a repeal of Affordable Care Act programs. Polis is taking a measured approach on switching to a single-payer system, saying it may take nearly a decade to achieve. So don’t look for Colorado’s health policy in 2019 to be Republican red or Democratic blue. It’s more likely to remain a shade of purple.

By Mark Obmascik, special to the Colorado Health Institute. Other CHI staffers contributing to this report: Brian Clark, Cliff Foster, Joe Hanel, Allie Morgan, Jackie Zubrzycki

The Colorado Health Institute is a nonpartisan, independent research institute. We do not lobby for legislation, and we never endorse or oppose candidates for office. This report is intended to help inform voters on the health policy stances of the two major-party candidates for Colorado governor.

This report pulls from the candidates’ position papers and interviews conducted in August 2018.

Integrating Medical Care With Behavioral Health In Pain Management

Integrating Medical Care With Behavioral Health In Pain Management

When suffering from chronic pain, symptoms affect more than just the body. Physical pain also affects mental health, emotional well-being and quality of life. Chronic pain may also cause or increase worry, anxiety, frustration, anger and depression, making the physical pain worse and hampering abilities to cope. In addition, prescription opiates,  which are commonly used to treat chronic pain, can pose a challenge for some patients, including hyperalgesia (increased sensitivity to pain) and a risk for addiction. Needless to say, physical, emotional and mental health care are connected, especially for patients with chronic pain.

That is why a whole-person, comprehensive approach is the optimal model of care treatment. Yet, despite mounting evidence that integrating behavioral medicine can offset the ongoing cost of chronic pain treatment [1], the two disciplines tend to operate in silos.

New Health Pain Treatment Center has implemented an integrated traditional medicine and behavioral health model that allows patients to experience optimal pain relief and feel empowered to more fully participate in their lives. Patients learn valuable tools and skills to help minimize or avoid opiates while practicing how to successfully navigate the mental and emotional difficulties that almost always accompany physical pain.

This is critical now more than ever since as a country we are seeing a high risk for opiate addiction in patients with chronic pain as well as the overuse of opiate medications. In our state alone, more than 22,000 Coloradans report dependence on opioids.[2]

Components of Integrated Pain Treatment

Pain treatment – like many other areas of health care – has historically operated in isolation, with different entities providing diagnosis and treatment planning, imaging, physical therapy, surgery and other services.

Under traditional models, patients are often referred to different providers for different symptoms, increasing the likelihood of incomplete and fragmented care, delays in care, gaps in communication and less-than optimum outcomes.

Almost always missing from the equation is behavioral health.

The following approach describes an integrated approach to medical care, designed to improve outcomes and patient experience, while reducing cost.

Medical and Behavioral Health Assessment

During the initial visit, a medical and behavioral health assessment helps identify the physical, psychological and social factors impacting health.

The medical assessment is a comprehensive assessment of the patient’s history of pain, followed by the initiation of therapeutic modalities. The medical history includes a detailed intake of the initial causes of the patient’s pain, the exacerbating factors of the pain over time, any previous medical and surgical interventions that have been offered or administered to the patient and an assessment of which previous modalities of treatment have been most and least successful.

In addition, the state’s Prescription Drug Monitoring Program is a valuable tool that can be leveraged to improve prescribing and protect patients who may be at risk of addiction. New Health uses the database to generate a comprehensive, three-year historical report of which pain medications the patient has tried in the past, and this report is reviewed in detail with the patient. A comprehensive physical exam is performed, and patients provide a urine sample for a toxicology screen. The medical team also makes an initial evaluation of the patient’s risk and history of addictive behaviors related to medication use.

Incorporating Behavioral Health into Treatment Planning

The behavioral health assessment is an extensive intake regarding all aspects of the patient’s mental health. It incorporates elements from the Substance Abuse and Mental Health Services Administration’s Eight Dimensions of Wellness (Figure 1).

Source: Substance Abuse and Mental Health Services Administration

The medical and behavioral assessments inform the individualized treatment plan that is developed cooperatively by the medical and behavioral health teams. Patients’ individual treatment plans may include a mix of medical interventions, which may include medication management and/or interventional treatment such as nerve blocks, or epidural steroid or joint injections. The medical team can also coordinate referrals for other treatment modalities, such as physical therapy or massage therapy, as needed. The behavioral health team coordinates behavioral health therapies, including individual or group therapy.

During therapy sessions, patients receive non-pharmacological coping skills that include: stress reduction, mindfulness techniques, dialectal behavioral therapy skills and other tools for managing pain. DBT skills and techniques may include: mindfulness or focusing skills; distress tolerance, including self-soothing using the five senses through aromatherapy, hot showers and baths, etc.; opposite action, where a person identifies the feeling he or she is experiencing and takes an opposite action; and emotion regulation (employing deep breathing, etc.).

These approaches help improve interpersonal effectiveness and increase patients’ “recovery capital” or healthy life resources. These resources may include social resources, as well as better overall health and well-being, all of which help patients move through pain successfully. Throughout treatment, medical providers should follow up on patient adherence not only to medical treatment but also to the use of coping skills and other techniques to navigate pain.

The Importance of Group Therapy

People experiencing chronic pain also often may experience diminished cognitive skills, especially as it pertains to executive functions, which may limit the effectiveness of individual cognitive therapy.  Group therapy allows patients to begin working on emotion regulation and distress tolerance, while enjoying the support of other patients with similar struggles. In a group setting, peers offer support while holding each other accountable. Group members are able to empathize and identify with each other’s challenges, which in turn helps eliminate stigma and address feelings of loneliness and isolation.[3]

Group therapy also provides an opportunity to practice and refine healthy social and relationship skills before taking them back to their family and community systems.

Medication Monitoring

Treating chronic pain is complex, and the risk of addiction must be factored in to individual treatment plans. In 2016, an estimated 3.3 million people aged 12 or older were current misusers of pain relievers, representing 1.2 percent of that population.[4]

The initial medical assessment is designed to help identify patients at risk for potential abuse, and responsible drug testing during treatment helps inform clinical decisions by providing valuable information about patients’ use of prescribed medications, non-prescribed medications and illicit substances.

Qualified physicians may obtain waivers under the Drug Addiction Treatment Act of 2000 (DATA 2000), meaning they are equipped and trained to identify, as well as treat, those patients identified as having addiction issues. New Health’s physicians have obtained waivers and can prescribe buprenorphine in all its forms, including sublingual and subcutaneous. In some cases, physicians may also arrange for and provide long-acting naltrexone therapy, which blocks opioid receptors in the brain, when indicated.

Interdisciplinary Staff Meetings

To have a truly integrated approach to pain management, medical and behavioral health providers must be able to share information in real time, working together to adjust patient treatment plans to reflect patients’ progress and needs. The American Pain Society has developed a list of desirable attributes of interdisciplinary teams (Figure 2).

FIGURE 2 / Attributes of a Well-Functioning Interdisciplinary Pain Team

Source: American Pain Society

Conclusion

An integrated care model helps patients become physically, mentally and emotionally stronger so they can live happier, healthier lives. It is imperative patients receive tools and skills to help minimize or avoid opiates while learning how to successfully navigate the mental and emotional difficulties that almost always accompany physical pain. This is critical now more than ever since as a country we are seeing a high risk for addiction in patients with chronic pain as well as the overuse of opiate medications.


Newhealthservices.com

New Health provides an innovative way to help chronic pain patients become physically, mentally and emotionally stronger so they can live happier, healthier lives. Our doctors and therapists work together to formulate a treatment plan and make sure each patient’s individual physical and mental wellness needs are met. Our unique model helps minimize or avoid opiates while giving patients the tools they need to feel better and to navigate the mental and emotional difficulties that almost always accompany physical pain.

Dr. Nathan Moore, medical director of New Health, is board-certified in family and addiction medicine. He previously served as president and chief executive officer of MedNow Clinics and ARCH Detox. In that role, he oversaw the development of effective outpatient detoxification programs/protocols for opiates, alcohol and benzodiazepine use disorders. A graduate of the Duke University School of Medicine, Dr. Moore serves on the board of Practice Health and Colorado Care Providers and chairs the finance committees of both organizations.

Osvaldo Cabral has worked in addiction and mental health since 2002 and specializes in addiction treatment, dialectical behavior therapy, skills training, aggression replacement training, cognitive behavioral therapy and trauma-focused therapies. As director of integrated services, he coordinates the operations of New Health’s medical and behavioral health professionals to ensure continuity of care for New Health patients.

For more information, please contact Natalie Lamberton, vice president of business development, at 303.668.2177 or nlamberton@newhealthservices.com.


[1] Chiles, JA, MJ Lambert and AL Hatch. The Impact of Psychological Interventions on Medical Cost Offset: A Meta‐analytic Review, Clinical Psychology: Science and Practice, 6, 2, (204-220), (2006).

[2] T Manocchio. The ABCs of MAT (Medication-Assisted Treatment), Colorado Health Institute, May 31, 2017. Accessed Aug. 2018 at www.coloradohealthinstitute.org/blog/Abcs-mat-medication-assisted-treatment.

[3] Center for Substance Abuse Treatment. Substance Abuse Treatment: Group Therapy: 6 Group Leadership, Concepts, and Techniques. Substance Abuse and Mental Health Services Administration (US), TIP Series, No. 41, Rockville, MD (2005).

[4] Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration, HHS Publication No. SMA 17-5044, NSDUH Series H-52, Rockville, MD (2017).

Foundations’ Role In Creating And Advancing Policies That Prevent Disease And Promote Mental Health And Well-Being

Foundations’ Role In Creating And Advancing Policies That Prevent Disease And Promote Mental Health And Well-Being

 

    • Foundations’ Role In Creating And Advancing Policies That Prevent Disease And Promote Mental Health And Well-Being

Deaths from drugs, alcohol, and suicide are driving the first reductions in life expectancy in the United States in the past two decades.

At the same time, racial/ethnic and socioeconomic disparities in health and well-being have widened since 1980, and a number of emerging trendsthreaten to exacerbate these.

The United States still spends far more on health care than on social services compared to other Organization for Economic Cooperation and Development countries, even though research suggests social services are strongly linked to improved outcomes. And, despite how much we spend, our outcomes don’t stack up to those of other countries.

Thankfully, communities in the United States are working to push back against these trends by actively seeking better health and well-being—not just through their own actions but also by partnering with many others in pursuit of broader changes.

Foundations and their investments (for example, in grantees) often play a unique role in enabling this pursuit of better health. The functions and roles that foundations play are as varied as the communities they serve, and each foundation has a different mission, focus, and interest in policy.

Yet, despite these differences among funders, policy is the one thing that often undergirds foundations’ work across these concerted efforts to improve mental health and well-being. For instance, the financial backing of foundations often supports the innovation that started in communities. But that is not the end of the road—these efforts frequently live and die by the larger systems and policies that are needed to enable, support, scale, and sustain the work.

That said, while it is essential that foundations play a role in policy, it is often unclear how best for them to do so, and even less clear how to do so with other foundations, grantees, and partners. There appears to be a need for thoughtfully designed and tightly knit strategies that foundations can use to meaningfully affect policy. For example, consider the following case studies.

The Hogg Foundation for Mental Health in Texas launched its Mental Health Policy Academy and its Fellows programs in 2010. Policy fellows are placed at nonprofit, government, or higher education organizations across Texas to increase individual and organizational capacity to advance mental health policy in Texas and to better engage consumers in mental health policy development and implementation. In addition, the Hogg Foundation produces a Mental Health Guide, for advocates and policy makers, to coincide with each Texas legislative session (held every two years), and the foundation follows up after each session with a summary that provides an overview of mental health– and substance misuse–related legislation filed during that session.

The New Hampshire Charitable Foundation has invested in public policy and advocacy to reduce and prevent alcohol and substance misuse—its work has included launching and supporting New Futures, a nonprofit organization that “advocates, educates and collaborates to improve the health and wellness of all New Hampshire residents through policy change.”

The W.K. Kellogg Foundation has supported policy efforts including the development, implementation, and evaluation of a Mental Health Impact Assessment tool to assess the effect of public decisions and actions on the social determinants of mental health in low-income communities. (The Robert Wood Johnson Foundation (RWJF) and the Pierce Family Foundation also support the tool.) Additionally, Kellogg has supported a mental health policy development working group focused on promotion of mental health in schools, child care, and early education. That work has been described in prior Health Affairs Blog posts.

The Lutheran Foundation formed and launched the Regional Mental Health Coalition of Northeast Indiana in 2016, which aims to improve mental and behavioral health and wellness by advocating for policy and systemic changes, developing campaigns to reduce stigma, and ensuring collaboration across government, mental health, health care, judicial, education, faith-based, and workplace communities.

And, in 2017, Trust for America’s Health (TFAH) and Well Being Trustembarked on a joint effort to advance policy solutions to the drug, alcohol, and suicide epidemics. The first product of this partnership was a report, Pain in the Nation: The Drug, Alcohol and Suicide Epidemics and the Need for a National Resilience Strategy, funded by Well Being Trust and the RWJF, and published by TFAH.

That report focuses specifically on practice and policy solutions to reduce deaths from drugs, alcohol, and suicide—ranging from expanding the use and availability of rescue drugs, sterile syringes, and diversion programs, to limiting hours and density of alcohol sales, to supporting state suicide prevention plans, to expanding social-emotional learning and mental health services in schools. The report also calls for—and provides recommendations for building—a National Resilience Strategy, which would take an effective, comprehensive, continuum approach to addressing these epidemics, from prevention and early identification, to connection to services and supports, to treatment and recovery.

What We’ve Learned

The following highlights specific actions mentioned in the report that could be taken to solve some of the problems around substance misuse and mental health. We understand that there are multiple layers of policy action required at each level—local, state, and national—and that each layer will have different types of action that can be taken.

  1. Investing in prevention and creating more resilient families and communities must be a higher policy priority—especially for foundations.

In recognition that many of the issues we face as a society around mental health and substance misuse are grounded in social factors, simply dedicating our attention to working on closing the treatment gap (which is important but is being addressed by many other organizations) is insufficient.

Well Being Trust and our grantees, including TFAH, are investigating policies that can go upstream and prevent mental health and substance misuse problems from even beginning in the first place. We will help support the investment, policies, and practices necessary to enhance protective factors and close the prevention gap.

  1. Foundations can be instrumental in helping their communities create consistent standards for identifying and treating mental health and substance misuse for multiple conditions and across community and clinical delivery settings.

Currently, there are no consistent standards for mental health and substance misuse treatment in the United States. This means that receiving care differs greatly depending on certain critical variables like insurance type, location of service, and type of clinician providing care.

One of the first steps for creating a more equitable and comprehensive system is to have consistent standards for mental health across multiple clinical settings. Foundations and grantees have a critical role to play in identifying these standards and advancing the policies that codify them in practice.

  1. We must make accessing services for mental health and substance misuse conditions easier and make services more affordable for everyone.

Utilizing mental health and substance misuse services requires access to the appropriate clinician and ability to afford the care and treatment. Sadly, both of these items remain problematic in the United States.

The country must consider novel approaches to improve access, rather than simply depending on a referral to a mental health or substance misuse clinician. Redistributing mental health and substance misuse clinicians throughout the health care system is one way to increase access.

And, when we consider that mental health and substance misuse services remain unaffordable for many people, both access and affordability will require us to rethink our strategy and develop innovative policies and solutions.

Certain populations face particular barriers to access. Blacks, Latinos, and American Indians are more likely to be uninsured. Those living in rural areas may not live near treatment and other services. And low-income residents throughout the United States face a number of obstacles to care including the potential loss of income when seeking treatment.

  1. Mental health and substance misuse benefits, services, and policies must be at or above parity for medical benefits, services, and policies.

Undergirding much of what transpires in health care delivery are the benefits that each of us carry through our respective insurer. In many cases, how mental health and substance misuse benefits have been structured make it truly challenging to integrate care in a systemic way. And, in other cases, mental health and substance misuse benefits are not even offered at parity despite federal law mandating it.

Clearly, policies can be strengthened and created to ensure that people have access to the benefits that will help them to realize their fullest potential.

  1. We must redesign how we pay for mental health and substance misuse treatment so as to prioritize prevention, team-based care, and quality and outcomes.

Currently, health care is often driven by disease and sickness. Additionally, fragmented financing keeps mental health and substance misuse services isolated. For the country to solve problems as complex as the deaths of despair, there must be a comprehensive approach that includes simultaneous clinical, operational, and financial changes. As such, alternative delivery and payment models for mental health and substance misuse should be studied, shared, and scaled by foundations. Thankfully, there are new examples emerging each day that highlight innovation in payment reform.

Going Forward

While investing in evidence-based practices and programs—as many foundations are currently doing—is critical to improving health and well-being, a comprehensive, scalable, and sustainable approach requires a greater focus on local, state, and federal policy solutions. Through their grant making, foundations can help change policies or regulations that have implications for health and well-being, as well as influence the direction of government funding in this arena.

In addition, foundations must go further. They need to take risks and be willing to fail.

Government cooperation (and grantmakers’ funding) is, in most cases, critical to having the population-level impacts necessary to close the prevention gap. Yet, government is often required to fund models with an evidence base, which might not always be the most innovative approaches.

At the same time, philanthropies have more leeway to take risks and can put themselves on the line to reduce the risk inherent in certain programs (for example, needle exchange) for government and other foundations. As such, we have to be willing to fail. Not every innovative program is scalable—what works in one town might not work in another town. But we must share our lessons learned—and move forward in a meaningful way together.

Further, to truly move the needle, we must be policy-influencers and advocates. Foundations can harness the power of our endowments through impact investing—using our knowledge of the financial world to ensure that everyone can realize their fullest potential.

It is critical that foundations invest in cutting-edge policies, learn from the case studies highlighted above, and develop novel strategies to engage in this work. Such investment is fundamental to improving mental health and well-being in a comprehensive, scalable, and sustainable way.

This blog post is based on a presentation by the authors at the Grantmakers In Health annual conference, in June 2018, in Chicago.

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.


ACCESS VARIES SIGNIFICANTLY STATE-BY-STATE

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.


EARLY ADOPTER STATES SEE COST BENEFITS

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

STRATEGY/TECHNOLOGY INNOVATION

  • 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

UNCERTAIN STATE AND FEDERAL REIMBURSEMENT

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


 

ONGOING CHALLENGES

 


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.

KEY TAKEAWAYS

  • 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

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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

HOW TODAY’S M&As ARE PREPARING HEALTHCARE ORGANIZATIONS FOR A NEW FUTURE

HOW TODAY’S M&As ARE PREPARING HEALTHCARE ORGANIZATIONS FOR A NEW FUTURE

HOW TODAY’S M&As ARE PREPARING HEALTHCARE ORGANIZATIONS
FOR A NEW FUTURE

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
care.
“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

https://www.bofaml.com/content/boaml/en_us/home.html

US spends too little on social welfare: Fact or fiction?

US spends too little on social welfare: Fact or fiction?

US spends too little on social welfare: Fact or fiction?

As we had alluded to previously (see comments section here), we have been hearing the argument “we don’t spend enough money on social services in the US” for quite some time now. So, let’s dissect this argument one step at a time.

First, what exactly do we mean by social spending and how does the US compare with other developed nations? Since good international comparative data on the topic of social spending are hard to find, it is very easy to adjust available data to suit one’s argument. Thus, rather than trying to come up with a single definition and measure of social benefit expenditures, below we highlight some key categories of spending that fit (at least in our minds) into the broad definition of social welfare expenditures.

In the US, it is politically correct and convenient to count social spending as only public/ government spending. Taking the OECD definition of social expenditures, which includes the following social benefit areas:

“old age, survivors, incapacity-related benefits, health, family, active labour market programmes, unemployment, housing and other social areas…public spending on early childhood education and care up to age 6”

and looking at public expenditures as a percentage of GDP, we find that the US ranks #24 out of 35 OECD members, but still above both Australia and Canada, countries often cited as doing more for their citizens than the US (see Figure 1 here). Moreover, when looking at sub-categories of general government spending, we find that in 2015, US spending as percentage of GDP is ranked (among OECD members) as 1st in health; 2nd in defense; 7th in public order and safety; 8th in education – quite a bit better than our overall ranking.

Moreover, social spending is actually more than public/ government spending alone. Interestingly, when both public and private social spending (as defined above by OECD) are accounted for and include the full range of social benefit transfers, the US ranks second only to France in total net social spending as a percentage of GDP (see Figure 4 in same OECD report).

Since spending on health is included in the OECD definition of social expenditures and the US is a known outlier in terms of healthcare spending, a follow up argument we often hear is: “We spend too much on healthcare and not enough on other social services.” While we absolutely agree that US healthcare is in dire need of improvement (both in terms of effectiveness and efficiency), a look at the available data shows that even if we subtract out healthcare expenditures, total spending on “other” social services in the US stands at roughly 13% of GDP and again above some comparison countries (Australia, Canada, Switzerland).

So, maybe the question we should be asking ourselves is not, “are we spending enough on social services?”  Maybe what we should be asking instead is, “are we getting what we are paying for in social solutions?” This is a question of value, that in many ways parallels the one being asked about the state of US healthcare.

Unfortunately, whether one uses broad measures (e.g., overall social spending vs. income inequality) or more specific examples (e.g., spending on education vs. secondary and tertiary graduation rates), Figures 7 and 9 here suggest that we are not getting good value for all the money we spend. Moreover, while the US government spends more on public safety as a percentage of GDP than many OECD nations or the EU28 (see Table 1 here), our rates of incarceration are some of the highest in the world, with some US states spending more money on incarceration than higher education. And while directing some of the “waste” away from healthcare into other social services seems like a sound idea, simply pouring more money into the existing system without any regard for how it is being spent, is unlikely to generate better social outcomes whether the benefit in question is education or income assistance programs.

Rather than spending more money, the US has to look at existing social expenditures as an INVESTMENT and manage these expenditures on an ongoing basis to continuously improve social outcomes, by relentlessly learning from both international and within-US success stories (does that sound familiar?). Social spending needs to be built into a balance sheet (which the US does not currently keep), otherwise everyone will continue to ignore how the funds are managed with no expectations for measurable ROI. This, in turn, will require a shared vision, a shared reality that recognizes the evidence above, and strong leadership from policy makers – all sorely missing in Washington, DC at this time.

Coming to grips with the value of social welfare expenditures is particularly important due to the profound demographic shifts happening around the world over the coming decades. As the OECD social spending report highlights (see Figures 1 and 2) – the vast majority (79%) of public social spending comes in two categories: health and pensions, both heavily influenced by demographics. Thus, rather than focusing simply on the absolute levels of social spending, both the US (with its aging Baby Boomer population) and the EU27 (projected to see a 68% increase in the number of adults over age 65 over the next 50 years) could benefit from a closer evaluation of: a) the sustainability of government social welfare expenditures, given that working age populations will be increasing much less than the older beneficiaries and b) what we get in return for the significant funds already being spent on social welfare.

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“What Maryland’s All Payer Rate Setting Tells Us About Traditional Medicare Payment Rates”

“What Maryland’s All Payer Rate Setting Tells Us About Traditional Medicare Payment Rates”

What Maryland’s All Payer Rate Setting Tells Us About Traditional Medicare Payment Rates

With some political leaders calling for the US to move to Medicare-for-all and California weighing a proposal to have all patient care reimbursed at Medicare rates, it is worth taking a step back to examine the level of traditional Medicare’s provider payment rates. Specifically, do the current payment rates ensure high quality and access for Medicare beneficiaries, while keeping high-value providers in business. Our review of the latest MedPAC report to Congress and statements made by the Medicare Actuary paints a pretty grim picture, as far as delivering on the above objectives.

The March, 2018 MedPAC report shows that aggregate hospital margins from Medicare have gone from -4.9% in 2010 to -9.6% in 2016, and are projected to be -11% in 2018. It is of interest to note that MedPAC looks only at Medicare ‘allowed’ costs – which removes many other expenses incurred by hospitals such as private rooms for patients, telephones and TVs in patient rooms, marketing communications, interest on certain borrowed funds, etc. Thus, true Medicare margins, that are based on total costs, are actually worse than those reported by MedPAC.

Low Medicare payment rates and their implications for both beneficiaries and providers have also been the subject of repeated commentary by the Medicare Actuary, e.g.,

  • “Limiting (Medicare) cost growth to a level below inflation would represent an exceedingly difficult challenge… Providers for whom Medicare constitutes a substantial potion of their business…might end their participation in the program”
  • “…the prices paid by Medicare for most health services will fall increasingly short of the cost of providing such services. If this issue is not addressed by subsequent legislation, it is likely that access to, and quality of, Medicare benefits would deteriorate over time for beneficiaries.”

The CMS Maryland experience
So, how can we estimate the true magnitude of the problem with current Medicare provider payment rates? One state in the US, Maryland, has had all payer rate setting for over 40 years. The Health Services Cost Review Commission (HSCRC), an independent agency established by the Maryland legislature in the early 1970s, is charged with setting uniform hospital service rates. As such, all Maryland payers are charged the same rates approved by the commission (with a modest discount allowed for Medicare and Medicaid). While Maryland can certainly work on improving efficiency (and is moving in that direction with the recent transition to global budgets), one would presume that the present rates are set to meet the following goals of the commission:

  • “Ensure that hospitals have the financial ability to provide efficient, high quality services to all Marylanders
  • Increase the equity or fairness of hospital financing”

If the above presumption is true, then Maryland’s all payer rates can shed light on the adequacy of traditional Medicare’s payment rates to accomplish the same two objectives.

Fortunately, CMS-commissioned evaluation reports of the Maryland All-Payer Model have done some detailed work on this particular topic. Specifically,

  • “The analyses compared the weighted average payment per inpatient admission in Maryland and a comparison group for the same mix of admissions… also examine the weighted average payment per hospital outpatient visit. Using the same mix of admissions and hospital outpatient visits controls for utilization differences between Maryland and the comparison group so the comparison only reflects payment rate differences.”

The latest evaluation report shows that between 2011 and 2016, Maryland Medicare rates for inpatient admissions were 33-40% higher than in the comparison group paid at traditional Medicare rates. The payment gap was even wider for outpatient hospital services, with Maryland Medicare payment rates (FY2013-2016) coming in at 55-62% higher than those of the matched comparison group paid at traditional Medicare payment rates. Clearly, the present policies of increasing traditional Medicare payment rates by less than inflation, have created a major Medicare payment shortfall, which (absent major changes) will get even bigger in the coming years. The rate gap further suggests that the under age 65, privately insured patient population, is currently subsidizing the care of Medicare beneficiaries. Thus, trying to put all patients on traditional Medicare payment rates would make the Medicare Actuary’s worrisome conclusions even more dire. Conversely, assuming Maryland is doing a good job setting payment rates, going to Medicare-for-all using the Maryland model, would require massive increases in rates over what Medicare presently pays everywhere else. Unless there was a change in provider efficiency, there would need to be ~40% increase in what Medicare pays for inpatient admissions and ~60% increase in payment for outpatient hospital services.

Medicare payment policies could benefit from a major overhaul
Based on the various sources of evidence presented above, we believe that Medicare payment rates are too low and getting worse every year. That said, we also believe that it is incumbent on the delivery system to improve efficiency and thus get better value. While providers would certainly welcome increases in Medicare payment rates, changes in payment rates alone will not be sufficient to drive improvement in healthcare delivery.

As we think about what providers should be paid, it would behoove us to remember a Commonwealth Fund blog by Dr. Stuart Guterman and others, which stated that: “… payment levels must be carefully calibrated to ensure providers’ financial viability while providing incentives to reduce costs and safeguards to ensure high quality.” Unfortunately, our conclusion is that traditional Medicare payment rates and policies fall short of the Commonwealth Fund recommendations. The financial viability of the US healthcare provider depends heavily on private payers (and thus the younger and employed population), while traditional Medicare is characterized by wide variation in service utilization, costs, and patient outcomes.

We believe that accomplishing the objectives described by Guterman et al., can best be accomplished by payment structures that ensure the financial viability of high value providers – those getting better patient outcomes at lower than average costs. In turn, the rates should be based on the real costs of doing business by these highest value providers (and not what Medicare currently pays them) plus a 2-4% margin, since even non-profit organizations need reserves to address changing staffing needs, replace aging equipment, etc. With regard to the need for a positive margin by providers, it is of interest to note that the Maryland HSCRC agrees. It has established hospital profitability targets of 2.75% operationally and a 4% total margin.

While we have detailed such value-based payment approaches in previous publications, it may be worth re-iterating a couple of the key components. Again, taking the state of Maryland as an example, Figure 1 shows the distribution of risk-adjusted quality index (based on the 90-day complication rate for hip/knee replacement) vs. the corresponding cost per episode of care. A base payment rate could be set at the 80thor 90thpercentile of the delivery organizations that are in the high value quadrant (i.e., those that get better than average quality at lower than average cost). A further quality withhold (e.g., 5%) could be used to ensure that providers don’t sacrifice effectiveness in the name of efficiency or that we do not reward low quality providers for simply being low cost. HSCRC has an objective establishing “rates sufficient to meet ‘full financial requirements’ of efficient/effective hospitals.” The pay for value approach we outlined above would create a strong incentive for providers to move to high value. If we truly desire a high value healthcare delivery system, we would be more likely to get it, if we actually paid for value.

2 thoughts on “What Maryland’s All Payer Rate Setting Tells Us About Traditional Medicare Payment Rates”

  1. Excellent piece – and the last sentence is so critically important.

    “The pay for value approach we outlined above would create a strong incentive for providers to move to high value. If we truly desire a high value healthcare delivery system, we would be more likely to get it, if we actually paid for value.”

  2. Denis and Bob:

    A great reminder that the Medicare for All advocates do not really understand the financial implications of their aspirations…there also is a hope that administrative savings will arise as marketing, customer service and claims processing needs diminish–really? Hope your summer going well…keep the conversation going…

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Single-Payer Health Care in California: Here’s What It Would Take

Single-Payer Health Care in California: Here’s What It Would Take

“California Voters are Thinking about the Fundamental Values Associates with Single-Payer but Almost Zero Voters have Thought About the Policy Implications.”

I have been out of the loop the past two weeks on vacation back to my “roots”. While I was gone, some news came out from the New York Times on May 25th. The article summarizes political talk in California about Single-Payer Health Care in California.

It brings back some memories of the 2016 Amendment 69 here in Colorado.  The concept is frequently titled “Medicare for All”. It is interesting reading to hear what could happen in California if it becomes reality there.

To check it out click the link below:

https://mobile.nytimes.com/2018/05/25/business/economy/california-single-payer.html

Chris Hadley
President and Founder
Denver Medical Study Group
denvermedicalstudygroup@gmail.com

“Leading Though Learning—-Healthcare Innovation & Reform”