Living With Healthcare Reform
Everyone agrees that there is a sense of overwhelming change in the financing and delivery of healthcare in the US and in our state of Rhode Island. This change is loosely referred to as reform, suggesting a positive direction with improvements in the now iconic triple aim—better outcomes, a better experience for the consumer, and lower overall costs. I have been thinking a lot about how it feels as the leader of a small health system to live with this change. (By the way, I favor reform as healthcare in the country and in our state is not delivering value and costs too much.) I thought it might be helpful to try to articulate those feelings and see how other healthcare leaders and consumers are experiencing this change. So, here are some fairly random thoughts:
So far, “reform” feels a lot like receiving less for each unit of service or bundle of services ( a hospital admission or the hospital stay associated with pneumonia). Medicare payments aren’t keeping pace with inflation and commercial rate increases are capped by guidelines issued by the state Office of the Health Insurance Commissioner;
The shift from volume to value entails the collection, submission, and publication of tons of data, not all of which seems to truly measure the quality of care provided;
Most providers are still being paid on a fee-for-service basis so the measure of productivity is volume, although there are penalties for missing quality targets;
Most of the contractual arrangements with insurers involve “upside gain” only (providers retain savings if per capita spending is below a target);
“Downside risk” (having to pay money back to insurers if per capita spending is exceeded) is still in the future, but it is frightening to providers;
Consumers are not engaged in population health. Most of the arrangements with insurers are based on an “attribution” model, which means patients are included in gain or risk sharing arrangements based on their primary care physician relationship. In other words, patients aren’t opting into these arrangements by purchasing a specific product;
“Accountable Care Organizations” formed to coordinate the care of doctors, hospitals and other providers represent another level of complexity, albeit one with the promise of providing real time data to help better manage the care of populations;
There is a lot more emphasis on the “high risk” or “rising risk” patients. These are patients who either currently use a lot of services or who are predicted to use a lot of services based on their profile. Many of these patients have behavioral health issues along with medical conditions. These patients are targeted for interventions because it is felt that providers can improve their lives, but also because they offer great opportunity for shared savings;
The populations in “population health” are largely defined by which payer is responsible for paying the bills as opposed to which community they reside in.
If I sound a little skeptical or even cynical it is more to reflect that this shift is messy and replete with ambiguity. I definitely think the changes being introduced are forcing providers to think about what and how we serve patients. I also think we are seeing results, such as lower hospital readmission rates due to better management of transitions of care and better coordination and communication around the care of people with congestive heart failure. But we have a long way to go in demonstrating significant progress in moving the needle on the triple aim.
As a provider or consumer, how are you experiencing healthcare reform?