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The Voice of John Nimsky
Here we are on November 15th one day after President Obama unexpectedly delayed a key provision of the Affordable Care Act, which allows insurance companies to continue, for one year, offering health care plans that fall short of the requirements as outlined in the ACA . The next day our “stewards of national well being” elected to pass a bill in the House of Representatives which is intended to allow insurance companies to sell individual health coverage to anyone who wants it, irrespective of any required standards in the ACA. As expected, the vote was justified on the grounds that the House is concerned that people will be left without health insurance under the current law, no consideration at all, wink wink , was given to 2014 reelection concerns.
With the recent announcement by CMS that nine of the 32 Pioneers were dropping out of the program there has been much “Sturm und Drang” about the passing of ACOs into obscurity. A recent article in the Investor Business Daily has gone as far as to predict that not only are all ACOs going to fail, but while in existence they “will diminish the quality of care received” by Medicare patients.
Long gone are the days when the provider contracting functions, the medical economics function and the health services/medical management functions within a Health plan could operate in their own separate environment with limited interaction. Health plans today are pressured to provide improved member access to health services at reduced cost while striving for improved treatment outcomes for their members. Consequently, health plans are being asked to motivate their providers to adjust practice patterns in ways that support performance based outcomes and shifts emphasis from procedure based reimbursement to value based reimbursement. That can only be accomplished successfully if the dynamics between providers and Health Plans evolve from adversarial to one of shared interest, collaboration and shared decision making.
For those of you who applied for the Innovations Awards Program Round One and were denied, or for those of you who didn’t apply, CMS/CMMI is providing you with another opportunity to do so. The program is open to virtually any health organization (the exception is that CMS will not entertain proposals that are primarily focused on inpatient hospital based programs) interested in proposing innovative service delivery and payment models focused on the Medicare, Medicaid and Children’s Health Insurance program (Chips) eligible populations. CMS will fund those proposals that have the greatest potential for driving health care delivery transformation and innovative pricing methodologies. There is approximately $900 million in available funding.
Anyone who has paid attention knows that since 2011 more than 200 Medicare ACO’s have been operationalized. If you add in commercial ACO’s, the number is closer to 400.
Thirty-two Pioneer ACOs sent a correspondence to CMMI in late February, suggesting that they would exit the Pioneer ACO program if CMS did not accept their recommendations for changes to the quality measures employed to determine pay for performance in the Pioneer program. As a group, the Pioneer ACOs suggested to CMMI that because of their collective experience with performance based contracts and performance reporting on quality measures, they — not CMMI – know what works and what doesn’t when it comes to benchmarking quality to reimbursment.
I am old enough to remember cast iron automobile engines, massive, performance driven by basics such as carburators, distributors and spark plugs. No computer assists, no electronic fuel injection and no computer to monitor and identify performance problems. If the engine ran rough, we adjusted fuel and air mixture.Today’s engines are smaller, and have more software/technology embedded than the first and second generation desktop computers.