MCOL Blog

Health Care Is Personal: In Memory of Karen

Just a few months into my first administrative position at a hospital in 1981, just a year out of college, I remember feeling pleased with myself as I edited the Radiation Therapy Center feasibility study I had just spent countless hours and days preparing. It was a thick report full of projections, tables, charts, and narrative. Then in the background, I could year the sobbing outside my office.

My office had been converted from an admissions room, and was situated next to a quiet area for families, off the main lobby. I had never really paid attention my surroundings. I was too into my new job. But the sobbing persisted, and at some point I had to leave my office for a meeting. As I rounded the corner I spied the family, grieving for a loved one that had just passed away upstairs.

In the years to come, as I progressed in my career, becoming CEO of a regional provider owned health plan, I was typically far removed from the actual rendering of health care. Instead I was immersed in the business of it: budgets, monthly reports, department head meetings, actuarial projections, marketing campaigns, contract negotiations, board meetings, personnel issues.

Now and then, but never often enough, I tried to remind myself of that day outside my hospital office, so early in my career, when I first learned that health care is personal, and can not so lightly treated as just another business or commodity.

During my more than dozen years running that health plan, I had the great pleasure of working every day with Karen (Hutcheson) Speziale. She was the Chief Operating Officer of the plan, and she made the plan run, and run well. Karen passed away this past week, after a six and a half year battle with cancer. Karen should have been with us for at least a couple of more decades.

I remember sitting in my health plan office with Karen and our Medical Director, making decisions on proposed benefit and coinsurance levels for the coming plan year. We set a higher coinsurance level and benefit limitation for Total Parenteral Nutrition (TPN), which was at the time increasingly being used in the treatment of Crohn’s Disease. Years later, one of my children would be diagnosed with Crohn’s. We also set various new benefit parameters for several different prescription and treatment options for cancer.

Health care is personal.

After I left that health plan to start MCOL, Karen went on to take a position with Kaiser Permanente, developing and then managing their expansion in our market. Kaiser is now the dominant health plan in our area. Later, Karen moved away to San Diego, and really flourished there.

Karen volunteered significant time in elementary school classrooms. She became the advisor for the local chapter of her Sorority at the university. She spent countless hours on other civic activities. Several of her former department heads from our old health plan remained the closest of friends with her, taking really cool vacations together, and staying in constant touch. She also kept very close ties with her family. When Karen’s illness required that she fully retire from her job, she continued all her contributions to the community.

I very recently took a quick trip to visit with Karen. She had just returned from a visit to the Kindergarten class where she helped the kids learn to read. They had put on a program just for her. On the wall in her office was a plaque recently given to her by her Sorority as the national “Alumna of the Year.” The perpetual annual award will now bear her name.

Karen’s investment in community time should serve as a wake up  call to all of us working on the business side of health care, to put and keep some balance in our lives, as Karen did.

Karen shared with me how recently at the hospital she had an hour long conversation with a nurse on what was wrong with health care. Karen laughed about it, but its hard to argue that there is something significant that needs to be done with health care. We can start by remembering how personal it is.

Anyone reading this who knew Karen Speziale might be interested to know that donations in her memory can be made to San Diego Hospice at www.sdhospice.org

International Health Care Data and Comparisons

With this election year, health care is a central topic of discussion for Presidential and Congressional candidates. Inevitably, references are made inferring either superior or inferior performance of the U.S. health care system compared to various other countries.
So just what kind of current data is out there reflecting various attributes of international health care? Below is collection of selected international health care factoids, compiled by Global Health Resources this year:

For More Information:

Global Health Resource
www.globalhealthresources.com

Capitation and Medical Homes Or Is this the return of the Staff Model HMO?

While Primary Care seeks new ground as medical homes and insurers look for ways to share risk between providers and insurers using global/tied to episodes of care, we are reminded of the original foundation of HMOs in the early 1970s.

In the original HMO Act of 1973 the federal government intended to encourage formation of group practices through grants and loans. The promise of assembling these efficient prepaid group practices was to have them paid on a capitated basis allowing for a margin if these groups came in under the capitation rate. The intention was to have PCP groups receive full cap and “provide or arrange to provide care for a voluntarily enrolled patient population in exchange for a fixed periodic payment.”

Thus, the original definition of an HMO in the early 1970s applied to a broad variety of delivery systems sponsored by new and existing medical groups.

In today’s world, Primary Care salaries are flagging and capitation is split to sub cap for PCP, specialty and hospitals. So instead of a full payment per episode PCPs get a small amount for a couple of office calls.

Once reimbursement split, it was further split by parts A, B, C and D of Medicare, and then the original value of PCPs was also split. The Primary Care services became a commodity as PCPs were convinced over time that they had no hope of effectively managing primary, specialty, hospital and ancillary services.

They did not have knowledge of claims and information systems, severity measurement tools or care standards and guidelines to shoot for.

In short they were flying blind and this meant they would eventually lose money unless they had a health plan partner to manage all this for them. The successful plans (Marshfield, Gisenger, Lovelace, Kaiser and Harvard and Tufts) all built an insurance partner that they owned and, as such, were able to turn this process into an asset to build market share and compete with other insurers who eventually entered the market with loose-knit networks and PPO arrangements that were HMOs – but in name only.

These anti risk models failed one after another, while those that truly did manage care, reorganized and did the work to build a care system that was fully integrated with the reimbursement system. These made whole dollars for successful care and redeployed savings into these medical groups to hire staff, buy equipment and expand the reach of their practices.

Medical Home

So where do we go from here? Medical homes, a new conceptual formation of a medical practice, recently emerged in the literature.

These homes are hailed by government and practitioners as a more comprehensive approach to Primary Care and Primary Care management. Some of these homes emerged as practices newly forming out of old hospital owned practices and some are forming with insurers as sponsors, seeing the need and the opportunity to truly change care delivery but only by becoming a provider.

This is a switch away from the IPA and network models. Employed physicians exclusively work for the health plan, and are indeed employees, insulated to the extent possible by employer-employee relationships, or in some cases by the medical group that the insurer partly owns. Insurer owned medical groups have been around in the worker comp area and also with the resurgence of interest by manufacturers owning PCPs as the company doctor.

The savings for insurers and employers is obvious when the PCP builds a referral network of specialists and hospital services that are only needed when and if the PCP cannot perform the service directly.

Recent expansion of CVS, Target and Wal-Mart into the Primary Care area shows how needed the services are. But again these professionals treated as a commodity leaves much to be desired in terms of continuity of care, so the medical home has been created and is a new definition...

• each patient receives care from a personal physician;
• the personal physician leads a team of providers who are responsible for a patient's ongoing care;
• the personal physician is responsible for the "whole person";
• a patient's care is coordinated across the health system and community;
• quality and safety are hallmarks of the practice;
• enhanced access to care is offered through open scheduling, expanded hours, and new care options such as group visits; and
• the payment structure recognizes the enhanced value provided to patients.

Newly developed NCQA standards for these homes as credentialed contractors for Bridges has furthered the interest by payers to link up with PCP.

Capitation

On January 22^nd the Boston Globe announced that Blue Cross would be returning to capitation. The spokesperson for the Blue Cross organizations stated that it was more of a globally packaged program but, as with most reimbursement schemes, there needs to be a top line and a bottom line of reimbursable dollars to make the cost predictable for insurers to construct premiums.

Although the “one size fits all” capitation calculation of the past created large controversies over what to do with sicker patients, the direction capitation has been going is much more towards a flexible dollar amount tied to diagnosis.

This risk adjusted amount based upon the patient’s health status, diagnosis, overall age and complications, seems to make more sense as patients with a greater burden of care needs are given a budget for their providers that reflects this greater need.

This amount also reflects the broader variety of services from diagnosis to a plateau of healing following generally accepted guidelines. These episodes of care are gradually replacing the word capitation but in fact represent a risk model and not to exceed cost for providers. So, again the providers do have some risk to make sure they are prescribing necessary outpatient care and hospital services.

The follow-up care in many of these episodes is a tremendous value as physicians, both primary and specialty, are financially rewarded for follow-up care and a form of case management reporting that goes back to the insurer and the attending physician.

As we see further risk adjustment play an important role in performance payment systems, we see PCPs being able to operate medical homes on a salary plus performance incentive thereby sharing in savings created through their own accurate diagnosis and care management skills.

To date FFS and former capitation models offered little savings back to PCPs, especially for seniors who took the physicians and staff extra time with care and administration. As Medicare experiments with risk adjusters for the chronically ill population and private insurers begin using a form of episodes of care to manage the commercial population, we see that research on guidelines will improve as will outcomes analysis using comparative economics.

End result

What this means for health plans and underwriting is that, with some work, their analysis of health assessments and patients’ previous illnesses will allow plans to forecast with some certainty the potential ailments of a prospective population. Rather than exclude this population for coverage, reallocating care management resources in the direction of stabilizing theses patient or, in some cases, reversing the disease course as is being done in heart disease and diabetes, will be the norm.

For providers, especially PCPs, this means a welcome source of additional payments for the fragile and chronically ill population of Medicare eligibles and a return to a vital role as the front entry point for most care. This role is expanded in the medical home, and a certification as a home differentiates these professionals in the marketplace.

For patients who seek more transparency in their doctor’s pricing and performance, the distinction as a medical home is again a meaningful message to send to new and existing patients that this practice is certified as best practices for Primary Care. Further, this is important as the package or episode of care is driven off of accurate diagnoses.

Payment and structure can come together under this medical home concept, but we still have much to learn about how consumers must also see the Primary Care physician as the essential key to open the delivery system in a productive but prudent manner.

o      You want me to believe that it’s confidential, when I’m reading every week about health insurance data privacy breaches.

o      And you want me to celebrate that it’s “free,” when my premiums and copays have never been higher.

• The relationship between OOP costs, medical errors and drug interactions
• The higher risk of unidentified ME/DI among patients with multiple conditions/polypharmacy
• The opportunities for improved outcomes that multiple conditions can obscure
• The importance of a “medical home” in reducing ME/DI
• What a health coach actually does, and indications that having a coach might help; how the coach and the medical home can support each other

• Why I am on two drugs that are supposedly “contraindicated” in combination?
• Does anyone at the MCO know or care about all that treatments I’ve had?
• Isn’t a health coach going to refer me to a doctor for the tough calls anyway?
• How will a stranger get me to do all the things I already know I should do?
• Why can’t the health plan just find me a better physician?

1. Is it clear what you are asking members to do?
2. Is a coherent value proposition for them to take this action presented and are potential objections addressed?
3. If members to whom your request is directed are not appropriate candidates, how will they know?
4. Is there a high ratio of important content to buzzwords like “personal,” “healthy” and “wellness”?

What’s Going on at ChangeNow4Health:

We’ve written before about ChangeNow4Health, the open coalition committed to improving the nation’s health care system through the facilitation of action. Below is their latest press release, which announces their Innovation xChnage, inviting and even funding new ideas on how to fix health care today:

ChangeNow4Health, an open coalition committed to improving the U.S. health care system, today launched a series of new online programs to further drive dialogue and transformation in the health care system. Announced at the World Health Care Congress in Washington, D.C. , these programs range from Health Expert Blogs led by national health care consultants to the new “Innovation xChange,” which is an ongoing campaign designed to invite and reward new ideas that address issues in our current health care system.

“ Our health care system is seriously dysfunctional and it’s time we all come together and do something about it,” said Jacque Sokolov, a nationally recognized health care consultant and one of ChangeNow4Health’s founding partners. “T he U.S. spent almost $2.2 trillion in 2007 [1] , but we are not seeing corresponding improvements in quality of care. ChangeNow4Health is designed to be an online, real-time catalyst and clearinghouse that action-oriented individuals can use to propose solutions and start solving problems now.” [ [1] “Health Spending Projections Through 2017: The Baby-Boom Generation is Coming to Medicare,” Health Affairs 27, no. 2 (2008): w145-w155 (published online 26 February 2008)]

ChangeNow4Health is dedicated to improving the way consumers receive, and the industry delivers and administers health care services. The coalition seeks to incubate, expand and make available solutions that are working in one part of the industry and can bring positive change to others.

Through the Innovation xChange, ChangeNow4Health is inviting all participants in health care system to submit practical ideas and solutions. All participants, from providers and health plans to consumers and government, can join in the discussion by simply logging on to www.ChangeNow4Health.com and submitting their ideas in the Innovation xChange. Solutions can be entered in the following four categories:

1. Helping Consumers Make Smarter Health Care Decisions

2. Simplifying the Business of Health Care

3. Preventing Sickness and Maintaining Health

4. General Innovations in Health Care

A panel of industry experts will evaluate all ideas based on criteria, including feasibility for implementation, potential to yield tangible, measurable results and to bring about meaningful change in a reasonable time frame.

All entries submitted on www.changenow4health.com will be open to voting by the coalition’s online communities. The top 20 entries will be published in the ChangeNow4Health e-book, Tomorrow’s Health Care, and finalists will be awarded up to $10,000. (Up to three entries will be awarded $10,000.)

In addition, Humana Inc. (NYSE: HUM), one of the founding members of the coalition, will consider the possibility of a joint venture to incubate the winning idea and bring it to reality through the company’s Innovation Center. Winners will be announced by Aug. 31, 2008.

“The basic premise behind this Innovation xChange is that no one entity can fix the system and a good idea can come from anyone,” said Beth Bierbower, vice president of Product Innovation, Humana. “ The technology and structure of the Innovation xChange allows anyone, regardless of age, sex, professional background, to be part of a solution. The virtual forum and workgroups encourage collaboration, focused thinking and the development of easily actionable solutions.”

In addition to the Innovation xChange, the coalition announced two other online programs to drive dialogue and build support for various solutions. These include:

· National Healthcare Expert Blog Topic Forum : Starting June 1, Dr. Jacque Sokolov, a nationally recognized health care consultant, will launch a new blog bringing together some of the nation’s leading health care thinkers to discuss critical health care issues in one common forum. The blog will feature prominent health care experts and touch upon various topics, including the need for successful quality initiatives, hospital-physician productivity enhancement and a sustainable national health care financing model.

· Point-Counterpoint : To further spur discussions in various ChangeNow4Health communities, the coalition will launch a new Point Counterpoint forum where prominent health care bloggers and experts can put forth dissenting opinions and build actionable consensus on key solutions. During each online forum, two health care bloggers will present differing positions on an issue and members can join in with their opinions.

For more information or to join in the conversation, please visit www.changenow4health.com.