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- callcenter972 on Call Center Metrics Reporting Should Be Robust and Actionable
- Sione Ayers on Diagnosing the ObamaCare Glitches: Who Farted and Is Pointing at the Dog?
- Tim Leary on New ACO Reg has some zingers
- Lisa Jefferson on What Happens to Medicare/Medicaid If There’s a Government Shutdown?
- Fred Hamlin on Big News: A Health Care Cost Indicator Went *DOWN*. AGAIN!
The National Coalition on Health Care (a nonprofit organization representing 80 organizations who support comprehensive health system change) and the Partnership for the Future of Medicare (a bipartisan organization supporting the long-term security of Medicare) have a new lobbying message – don’t kill the golden goose. Recognizing the upcoming budget battles this year and next, these organizations presented their lobbying strategy which will feature Medicare Advantage plans as the model for a sustainable Medicare program. John Rother from the National Coalition, Lanhee Chen from Stanford University, and Ken Thorpe from Emory University highlighted the innovations in Medicare Advantage plans that should serve as the model for reforming Medicare fee-for-service. These innovative programs focus on beneficiaries with multiple chronic conditions that drive Medicare costs and include care coordination, disease management, team-based care, transitional care, medication management, prevention, health coaching, and evidence based lifestyle programs. They argued that Medicare Advantage plans are already facing a 6.7 percent payment reduction in 2014 and that any further cuts will lead to threats to these innovative initiatives that should be encouraged and not penalized. They discussed research studies showing that MA plans had higher quality scores in 9 of 11 HEDIS measures compared to FFS, 13 – 20 percent lower readmission rates, lower hospital costs including a spillover effect to the overall health system in areas with high MA enrollment, and lower mortality rates.
Since returning from summer vacation I’ve been making the rounds with friends and spies on Wall Street to see what the nation’s checkbook is thinking about the seismic changes coming to our health system starting on October 1. Usually these guys are like long-tailed cats in a roomful of rocking chairs about disruptive events like ObamaCare. But a consensus emerged: 2014 is going to be a big year for health insurers.
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.
What we learned in Medicare + Choice is still true today, we don’t need narrow provider networks; we need aligned provider networks, aka Smart Networks. We have also learned that narrow networks often cause ill-will with your health systems and uncontrolled leakage. A Smart Network builds a mini-healthcare community similar to an ACO in your healthcare delivery ecosystem. A Smart Network can focus on a health system and it’s provider feeder system or it can better engage your Primary Care Physicians (PCP) and “rendering” PCP. Smart Networks typically are invisible to members; however some payers may differentiate copay to encourage Smart Network utilization.
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.