July 13, 2018

The Weekly Gist: The Won’t You Be My Neighbor Edition

by Chas Roades and Lisa Bielamowicz MD

We’re back! Having enjoyed a much-needed break over the 4th of July holiday, we’ve returned to a busy schedule on the road and a docket full of fascinating developments in the world of healthcare.

We’ll get to the news in a moment, but we’d be remiss if we didn’t point out that our World Cup of Healthcare seems to be playing out just as predicted, with France headed to the final game on Sunday, just as in our healthcare version. As a reminder, success in our fantasy tournament hinged on quality of the nation’s health system relative to the amount citizens pay out of pocket for care—our “Consumer Value Index”. On that measure, France walked away with the Cup on paper. Tune in Sunday to see if their real-world results are as healthy!

Onward.


THIS WEEK IN HEALTHCARE

What happened in healthcare this week—and what we think about it.

Medicare proposes a major overhaul to physician payment

The Centers for Medicare and Medicaid Services (CMS) trumpeted “historic changes” to physicians’ documentation burden and promised to restore the doctor-patient relationship with the release of the 2019 proposed Physician Fee Schedule on Thursday. While unlikely to be a panacea for physicians’ frustrations with electronic medical records (EMRs), we were impressed by the extensive revamp that CMS is considering, and believe the proposed changes provide a meaningful step toward reducing burdens on doctors, which could help to align outpatient visit coding, documentation and payment with the demands of modern practice.

To save you the pain, we’ve been wading through the 1,473-page rule, and want to highlight three critical proposed changes:

1. “Choose your own adventure” solution to reducing visit documentation burdensDoctors have long complained about the volume of irrelevant medical history and exam information required to document a higher-level evaluation and management (E/M) visit. The current process generates reams of checklists in the EMR that fail to capture the true patient problem or nature of the visit. CMS proposes two new alternatives to allow physicians to document visit intensity: time spent with the patient and “Medical Decision Management”, or MDM. (Practices who have successfully designed workflow around checklist templates needn’t worry, doctors can also choose to stick with the old system.) Another big win for clinicians: CMS also proposes removing the requirement for doctors to re-document information entered by clinical assistants or patients. Despite concerns that the proposed options could reward less efficient doctors, feedback from the physician community has been resoundingly positive. Dr. Bob Wachter, Chair of the UCSF Department of Medicine, sums it up: “If this pans out, could be awesome. There’s no more soul-sapping experience than documenting 9 Review of Systems elements & 10 body parts examined to justify a billing level – when what really took time was talking to patient, family, consultants, reviewing the chart, & thinking.”

2. Broad expansion of telemedicine reimbursement. As we’ve discussed, today CMS only pays for telemedicine services when provided to rural patients, through downside-risk ACOs or Medicare Advantage plans. In this rule CMS now proposes to cover telemedicine and telephone visits for brief check-ins, evaluation of patient-submitted images or remote monitoring data, as well as more comprehensive and preventive care visits. Should this move forward, it will be a substantial step toward increasing access for the two-thirds of Medicare beneficiaries who are ineligible for telemedicine coverage.

3. Some “relief” on MACRA—but not as much as doctors wanted. CMS proposes to remove 34 quality measures in the Merit-Based Incentive Program (MIPS) flagged by doctors as “low-value” and to raise the thresholds for doctors to opt out of MIPS, exempting those with fewer than 200 Medicare patients or less than $90K in Medicare revenue. The rule affirms that 365 days of reporting will be required in 2019, dashing hopes for a 90-day window, as supported by many physician advocacy groups. Most critical for systems and physician groups looking to increase their risk portfolio is the inclusion of Medicare Advantage patients in MACRA risk calculations. This change, teed up in the proposed rule, closes a gaping hole in MACRA’s alternative payment model framework that has kept many of the nation’s most progressive physician groups from participating.

Given how much has yet to be defined about the specifics of these changes (including how time and MDM would be documented for E/M visits), feedback from providers and other stakeholders is essential—the comment period remains open until September 10.

Supreme Court pick likely to re-energize healthcare debate

Senate confirmation of Brett Kavanaugh, President Trump’s pick to replace Supreme Court justice Anthony Kennedy, is a near-certainty. Much has already been written about Kavanaugh’s healthcare views and precedents (here are two brief summaries); with few exceptions, his work has been consistent with conservative judicial thinking. The prospect of another reliable conservative on the Court will likely accelerate the movement of several key healthcare cases through the judicial system, enhancing Republican efforts to dismantle key elements of the Affordable Care Act (ACA)—and providing Democrats new talking points in the run-up to the midterm elections.

Discussions will likely center on two key cases: the New Mexico federal court ruling against risk adjustment methodology, which resulted in CMS recently halting payments to insurers; and the pending case filed by the Texas Attorney General questioning the severability of the individual mandate from other tenets of the ACA, endangering protections for pre-existing conditions and other elements of the law. Some experts feel that Kavanaugh’s rulings on these cases may not be easily predictable (as a career Federal judge, he has limited case history on states’ rights), and the greater risk to the ACA may stem from Kavanaugh’s clear support of executive power, making him likely to uphold executive actions and agency rules that attempt to dismantle the ACA in a piecemeal fashion. Regardless, expect Kavanaugh’s appointment to be used as leverage for both Republicans and Democrats to put the fate of Obamacare at the heart of yet another election cycle.

The imminent demise of a national healthcare resource 

Outside of a small community of healthcare quality mavens, few have heard of the National Guideline Clearinghouse (NGC), a division of the Agency for Healthcare Research and Quality (AHRQ). The NGC has painstakingly vetted, synthesized and summarized tens of thousands of clinical guidelines across dozens of specialties. Clinical leaders looking to develop standards often use the NGC as a starting place, describing it as a “go-to source…nothing else like it in the world”. With its funding stripped in the current AHRQ budget, this public repository and its twenty years of evidence-based standards is set to go dark on July 16th. The annual operating budget for the NGC is a paltry $1.2M, a “rounding error” in the larger Health and Human Services agency budget—and challenges to the NGC appear to be motivated by politics and special interests rather than finances or efficacy. Funding for the NGC has been threatened several times before, as former AHRQ medical officer Dr. Kenneth Lin details. As early as 1994, AHRQ was nearly shuttered after issuing a guideline stating that surgery was often ineffective for back pain management. Congressmen with ties to the North American Spine Society and others who stood to lose if the guideline was broadly implemented mounted a challenge to the agency’s funding.

NGC leaders are working to find an outside stakeholder to take over the data set and website operations. Developing evidence-based clinical standards is central to the cost and quality strategies of nearly every health system we work with—wouldn’t it align with their non-profit missions to be part of a consortium taking on the continued work of NGC? (One could also surmise that the many healthcare consultants working in quality improvement—who have surely benefitted from free NGC resources—might also take a role in rescuing the resource from extinction.) As the need to deliver consumer value and reduce healthcare cost grows, an independent source of vetted, evidence-based care standards has never been more important—and the loss of decades of knowledge represented in the NGC would be a huge blow to American healthcare.


GRAPHIC OF THE WEEK

A key insight or teaching point from our work with clients, illustrated in infographic form.

Expanding telemedicine access to the Medicare masses

Medicare has long lagged behind commercial payers in supporting coverage for telemedicine and other kinds of “virtual” care. It’s not surprising: commercial insurers see telemedicine as a way to foster consumer loyalty and engagement. Medicare has no need to build a loyal customer base and has expressed concerns that telemedicine visits add to rather than substitute for office visits, raising costs.

Prior to this year, CMS paid for virtual visits in a just a handful of situations, primarily to increase access for rural patients. But as we show here, the passage of the Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2017, or CHRONIC Care Act, expanded telemedicine coverage for an additional 21.7M beneficiaries who are part of Medicare Advantage plans or downside-risk ACOs. New coverage proposed in the 2019 Physician Fee Schedule could bring coverage to the remaining Medicare population, supporting nearly-universal access to many kinds of virtual medicine for America’s seniors.


THIS WEEK AT GIST—ON THE ROAD

What we learned this week from our work in the real world.

Are doctors the true customers of health systems? 

Lisa:
We’ve been helping a multi-state health system create a new five-year strategic plan. In meetings this week with a group of executives, I asked a simple question: Who are your customers? While there was universal agreement that patients and consumers are the system’s core customers, there was debate and dissent among the group about how they viewed the role of physicians. Many felt doctors, like other caregivers, are not the system’s customers but critical stakeholders in providing high-value care. A smaller but strongly opinionated group of leaders advocated for a continued view of physicians as key customers, drawing attention to elements of physician-centered strategy that had been successful in driving growth.

Our view on this issue is unequivocal. Of course, physicians are essential to care delivery and perhaps the most important partners in achieving a health system’s goals, but they should not be viewed by the system as a customer. As a doctor, I would argue that that the idea of “physician as customer” may even be demeaning to physicians. Doctors should want to be leaders and full partners in care delivery, not objects of a strategy built around satisfying physician needs to bolster revenue growth. Instead, doctors and health systems should view each other as partners with a shared objective of delivering care that maximizes consumer value. Almost all of the critical needs of doctors—a sustainable practice, effective workflow, top-notch resources and clinical support—are central to a consumer-focused health system. But where the interests of an individual doctor and the goal of consumer value are in conflict, health systems and physician leaders will find long-term success in using consumer value as the North Star in guiding the decision.

Uncovering a lack of shared strategic vision

Chas:
As Lisa said, we’re working with a large, multi-market health system to support the development of their new, five-year strategic plan. As part of that exercise, we had the chance this week to conduct a series of one-on-one meetings with each of the system’s key executive and operational leaders. In our interviews, we were seeking each leader’s evaluation of the last strategic plan—what worked and what didn’t—as well as their views on future priorities and challenges for the system. At the CEO’s direction, the executives were encouraged to be completely open and honest: no holding back. What struck me most about the interviews was the wide diversity of views on both the system’s performance against the past strategic plan, and the actual content of the plan itself.

Each leader had a different way of describing the system’s strategic priorities, and views on the system’s performance ranged from glowingly positive to downright depressing. Some of this variability was to be expected, given different areas of responsibility. But the overall impression was one of blind men describing the proverbial elephant—surely not an ideal situation. And given that discord, views as to future priorities were all over the map as well. We’re in a moment of complexity and transition in the healthcare industry, and setting future course is far from a straightforward proposition. But systems stand little chance of navigating the changing environment if even their senior-most leaders can’t clearly articulate where the organization is heading. At the root cause of this system’s strategic confusion: too many “top priorities”, and too many conflicting objectives. Easy to throw stones, but we’ve seen lots of organizations give equal importance to “cranking the fee-for-service engine” and “transforming the delivery model”, as an example. Coming back to first principles, as our client CEO is trying to do, and getting to shared consensus on identity and purpose, is a critical exercise for organizations looking to build a sustainable future.


QUICK GIST FLICK PICK 

Sometimes we work, sometimes we go to the movies.

In the midst of this hot, political summer, when our country’s care and treatment of children has become the latest flashpoint in an increasingly ugly public discourse, it was like a long, cool drink of water to sit in a movie theater recently and take in the gently soothing words of Fred Rogers, reminding us that “Love is at the heart of everything…love or the lack of it.” Those words come midway through Won’t You Be My Neighbor, a new documentary from filmmaker Morgan Neville that tells the story of one of television’s most unlikely stars. “Mr. Rogers’ Neighborhood”, the PBS children’s show that launched in 1968, imprinted a generation of young Americans with Fred Rogers’ vision of kindness, dignity and respect. The show went off the air just a month before 9/11, and this new film is both a love letter to Fred Rogers and a reminder of how much we’ve missed his calming presence in the years that have followed. Less a biopic than an unpacking of the show’s radical premise—take children seriously as individuals and meet them where they live—this 90-minute documentary reminiscence of Mr. Rogers’ work is must-see, even for (especially for) the most hardened consumer of today’s cynical culture. For those who grew up with the show it’s a visit to a lost era, and for those that didn’t it’s a reminder that a better, more decent world is possible.


WHAT WE’RE READING

Stuff we read this week that made us think.

More promising evidence for Medicare Advantage

The research and analytics firm Avalere Health released a new study this week, conducted independently but funded by the insurance industry association Better Medicare Alliance, showing that Medicare Advantage (MA) plans deliver superior outcomes for seniors with complex care needs as compared to traditional Medicare. The analysis, which looked at cost and outcomes for representative samples of 1.8M MA enrollees and 1.4M traditional Medicare enrollees, showed that for a similar level of expenditure, Medicare Advantage enrollees experienced 23% fewer inpatient admissions and 33% fewer visits to the emergency department, with lower avoidable utilization rates and higher utilization of preventative services. This finding is particularly noteworthy, as the study points out, because the MA population has a higher incidence of clinical and social risk factors compared to traditional Medicare enrollees: higher rates of disability, higher rates of substance abuse, a much higher rate of mental health issues, and a higher proportion of racial and ethnic minorities. Looking specifically at a high-risk cohort of complex diabetic patients, the study found that MA enrollees experienced 52 percent fewer complications at 6 percent lower cost than similar patients enrolled in traditional Medicare.

Medicare Advantage has rapidly become an important tool in making the Medicare program sustainable as 80M Baby Boomers are poised to enter the program over the coming years. The ability of MA plans to configure networks of providers and manage care more aggressively, as compared to traditional Medicare, promises not just a greater ability to manage the cost of care for seniors, but also the opportunity to improve care coordination and care management for those suffering from multiple chronic diseases. With more than a third of Medicare beneficiaries already in MA plans, and the proportion of the senior population in MA expected to rise to 50 percent over the next five years, the study provides further impetus to policymakers to consider ways to encourage the shift toward Medicare Advantage. As we’ve pointed out before, much of the recent deal-making activity on the part of health plans has been aimed at better positioning them to capture the MA market. Providers evaluating options to care for the growing senior population in a cost-effective manner should also consider the role Medicare Advantage could play.

We already know how to reduce cancer deaths

The American Cancer Society (ACS) published a new study this week in the journal CA: A Cancer Journal for Clinicians that offers a staggering promise: we could reduce cancer deaths by 22% in America without inventing any new therapies or treatments. The study, first in a series from ACS that will lay the groundwork for a national blueprint for controlling cancer, looks at the current “state of the union” of cancer in the US, delivering a report card on progress against the most important measure in the war on cancer—mortality rate. The news is mostly good. There has been a steady decline in cancer mortality since 1991 among both men and women, largely because of the continued decline in death rates for the “big 4”: lung, colorectal, breast and prostate cancer, which fell by 36 percent from 1991 to 2015, compared to a 14 percent decline in death rates from other cancers over the same period. Researchers point to three broad reasons for the decline in deaths: better prevention (largely through smoking cessation and removal of pre-cancerous lesions); better screening and detection; and improved treatment.

As the authors point out, however, there are widespread disparities in cancer death rates among different population groups. While success has been mixed at best in addressing racial and geographical disparities, the study points to the opportunity to address disparities by educational attainment as possibly the most promising in the continued effort to reduce cancer deaths. Educational attainment is a proxy for socio-economic status, and even holding racial and geographic variability constant, differences in educational level are associated with a higher rate of cancer deaths for most types of cancer. At the root of this greater mortality are risk factors such as smoking, obesity, lack of exercise, poor diet, and reduced access to screening and treatment. According to the authors’ analysis, if everyone had the same cancer death rates as college-educated Americans, we would eliminate 22 percent of deaths: 134,000 of the expected 610,000 deaths from cancer expected this year in the US. Put another way, before we spend another dollar on the next expensive new genomic therapy or proton beam center, if we could just deliver current, evidence-based care to all Americans, regardless of socio-economic status, we’d make a significant dent in cancer deaths.

Ochsner shows how high-impact telemedicine can work

profile in the Washington Post of Louisiana-based Ochsner Health System’s virtual hypertension management program caught our eye. The system launched a remote hypertension management program over three years ago, fully subsidizing the cost of monitoring technology and receiving little payer reimbursement. Key to the program’s success was a relatively “low-tech” solution: patients were given an easy-to use, Bluetooth-enabled digital blood pressure cuff that submits measurements via smartphone. Patients took readings one or twice a week—frequently, but not too frequently to be unmanageable for patient or provider. Abnormal readings triggered a call from a caregiver, who could make recommendations or alter medications in the moment. Results were outstanding: in just three months, over two-thirds of patients in the program had their blood pressure under control, compared to just 31 percent in a control group. Given this success, Blue Cross Blue Shield of Louisiana recently agreed to cover the costs of the device and monitoring.

Other research has questioned the efficacy of remote monitoring, such as this NEJM study which found no impact of remote monitoring on weight and health status of heart failure patients. Ochsner may have discovered a sweet spot for remote monitoring of chronic conditions: low-cost, low-tech solutions for conditions that are amenable to a weekly, rather than daily, check-in. Ochsner has expanded telemedicine support to pregnant women, who can substitute virtual visits for in-person check-ups. With this week’s announcement of broad expansion in telemedicine coverage for Medicare patients, understanding the elements of virtual care solutions that deliver effective clinical care with low-cost technology and minimal patient and provider effort will be critical to achieving scale and inflecting long-term outcomes in critical patient populations.


Thanks again for reading the Weekly Gist. We’re simply overwhelmed by how many of you have subscribed, the terrific feedback we’ve gotten, and your suggestions for future improvements. It means the world to us to know that you’re finding our work valuable, and we’re looking forward to continuing to build and grow Gist Healthcare over the coming months—stay tuned!

In the meanwhile, if there’s anything we can do to be of assistance in your work, please let us know. You’re making healthcare better—we want to help!

Best regards,

Chas Roades
Co-Founder and CEO
chas@gisthealthcare.com

Lisa Bielamowicz, MD
Co-Founder and President
lisa@gisthealthcare.com