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Obamacare for idiots: The quest for "skin in the game"Mar 11, 2013 18:06 EDT
At the end of the Monday 8 am presentation entitled, "Obamacare: Does it matter to me?" an audience member stepped to the microphone and said, "Thank you for this informative and petrifying presentation." Nervous laughter rose from the crowd, because we knew the cardiologist had located the pulse of this presentation aptly. Drs Jerome Hines and Frank Mikell of Illinois chaired today's session. The speakers included Michael Schroyer, RN, MSN, MBS, of St Vincent Heart of Indianapolis, Cathie Biga, president and CEO of CV management of Illinois, Suzette Jaskie, CEO of MedAxiom Consulting, and Michele Molden, executive VP and chief transformation officer for Piedmont Healthcare in Atlanta. These folks have a keen sense of what Obamacare really means to America, and they understand that a key component is to understand what Obamacare means to cardiologists, the keepers of the biggest DRG on the planet and the one that will either save or kill healthcare systems in the first wave of managed care. So, if you know all about Obamacare already, no need to read further. This is a real primer with several macros and a few specifics thrown in for good measure.
Obamacare for idiots, macro 1
Example: A "big East Coast" hospital has this actual scenario: The total Medicare reimbursement for heart failure was $4.2 million/year before Obamacare. Pay attention here! Based on its 30-day readmit rates, it incurred a 1% penalty on all Medicare receipts (not just CHF receipts, but all Medicare receipts). It incurred a $3.1-million dollar penalty for that year. Things didn't change, so the next year, it was penalized at 2%—losing $6.3 million in total Medicare receipts, making CHF patients an instant liability. In 2015 it is projected to lose 3%, which will total $9.4 million in revenue. After a long gestation and and even longer labor, born kicking and screaming will come palliative-care programs across the country—teams of doctors, nurses, and healthcare extenders, highly trained babysitters for the frail, the elderly, the noncompliant, and the frequent fliers, whose ultimate goal is to keep those patients at home.
Likes: It's not safe to be an inpatient in many hospitals across the country right now, so you are better off at home if you can manage it. Patients like staying out of the hospital for the most part, so satisfaction might improve with the "medical home." Per capita expenditures might go down.
Dislikes: Some patients who require admission will decline (become more ill, die, lose their independence, etc) because their inpatient needs may be marginalized by this approach. The patient must understand that although the goals of these programs have an altruistic component, their main purpose is to decrease expenditures for the system. If carefully managed though, the end can serve the means and vice versa.
Obamacare for idiots, macro 2
In 2015 COPD, CABG, and PCI penalties for readmits will likely be added. So, hospital systems had better "cut their teeth" on the CHF DRG.
Likes: Hospitals will begin to realize the importance of nurse callbacks for daily weights, sodium and fluid restriction, medication compliance, and follow-up. We will no longer turn up our noses because a certain measure fails to affect mortality. We will seek out measures that affect 30-day readmit rates.
Dislikes: For those who can't convince their care providers to put them in the hospital, they may actually be hurt by the very system devised to protect them. It will be up to the legal system to balance the issue when harm comes to patients. In extreme cases, the fear of malpractice and negligence suits may be all that balances the trend in our current healthcare system. It's a shame we don't have true risk management instead of offices that are "called" risk management.
Obamacare for idiots, macro 3
We all will bow to the "triple-aim paradigm"—otherwise known as the three-headed beast. This requirement is of biblical proportions. No system will succeed without heeding the call of each of the three components, which include: population health, per capita costs, and experience of care. OMGosh—where to start?
Per capita cost is the most concrete of the components. It can be measured, tweaked, tracked, mapped, and affected by robbing Peter to pay Paul. It's likely the easiest to understand but still difficult to contain. Suzette Jaskie said, "We've eliminated the investment income, and now we are trying to make it on operations. Though operating margins for all hospitals have ranged at around 7.1%, collectively we are happy to be doing around 5.5%, and for some systems, it's even a positive thing if it's a 2% to 3% margin."
In order to survive, system success will require heeding the basic tenants of resource management, non–labor-cost management, alignment of labor and productivity, purchase contracts, etc. Staying away from huge purchases and leaving behind our past affection for new bricks and mortar, land acquisition, chandeliers, brass fixtures, and the like will be paramount. "All the marble buildings, we are depreciating them today," Jaskie said.
And they must be careful who the system purchases and what they do with their new laborers. Michele Molden said, "At Piedmont, we are a five-hospital system with two big physician companies, a primary-care and a heart institute. We can't ignore our primary-care brethren. The way to not fail in that business is to pay them on a revenue-expenses basis, treating them like they are still in private practice. They have high reimbursement but they are not incentivized for growth. We have calculated it takes seven primary-care physicians to support each cardiologist," a point I found interesting. "There is an inherent disconnect in that the specialty structure has an enormous thirst for growth. We need to consider how both of their compensations can come together, and I don't think many organizations have figured out how to rationalize compensation as an accelerant for change." She then added, "Time is not our friend. Our payments will be reduced."
So, think tanks had better fill up quickly and will require examination of both system and individual behaviors and practice patterns.
In addition, Cathie Biga asked, "Can we have quality in a payment reform world?" Then she explained, "Public reporting, physician compare, confidential feedback reports, payment adjustment, aka value modifiers—they will all impact compensation. Physicians will all be scrutinized on the 'green, red, and yellow report card,' where we will see our average cost per each Medicare beneficiary and then the total cost of care per CAD, COPD, DM, and HF patient." Whether integrated or not, this is for you unless you are in a rural health clinic, federally qualified health center, or critical access hospital. Then she said, "This is all very fluid. We don't really know how it's going to roll up."
Experience of care is where it seems some hospital systems have fallen down. Their focus has been so intent on getting their physicians purchased and their corporate folks lined up for the big Obamacare assault that they took their eye off the bouncing ball: the patient. Those who have felt orphaned by systems they've known or harmed by the system they entrusted their lives to for years are fleeing to other facilities, embracing care from total strangers, chancing their future on the unknown rather than continuing in a system that seems broken. Michele Molden made the point that we must focus on "service excellence," and it is imperative that each system develop a "culture of safety and reliability, increased quality, employee engagement, and community value." I couldn't agree more.
Now for the "Kraken."
We've covered two heads of the "triple-aim-paradigm" beast, but this last one is a monster, a veritable "Kraken" (the legendary giant squid with scores of tentacles), and it has its grasp firmly around the throat of every community, medical home, and healthcare system in the country. It is "population health," code for patient accountability, or what Michael Schroyer refers frequently to as "skin in the game." "Where is the skin in the game?" he asked rhetorically. "Where is the incentive for compliance? Somehow we have to put skin in the game for the American public to meet our goals."
The key to understanding population health is fourfold: The first consideration is the patient who is already ill. Since 50% of our population is noncompliant with medications, we have to motivate them with coddling, follow-ups, engaging families, etc. They have to have clinic access and phone access to avoid preventable readmissions.
The second consideration is for those who are not yet manifesting illness, ie, the 30-year-old moderately obese individuals, smokers, undiagnosed diabetics, the middle-aged hypertensives, and dyslipidemics. Those folks require some nudging by their third-party payers—ie, higher premiums and higher penalties. We must drive what we think is "primary prevention" when in fact for many, it's probably already secondary prevention that will require discussion of medical budgets and threats of out-of-pocket costs. (These same threats might work for some Medicaid folks, too.)
The third component is the redesign of health education in our elementary schools and high schools. Although it's totally fascinating to high schoolers to learn about STDs and how to use a condom properly, it won't keep them off the cath tables or out of the CHF clinics. Those types of topics are important to discuss at home and at school, but we need more nutrition programs, parental engagement, and participation in daily exercise programs, too. We need to teach our young the signs and symptoms of such things as appendicitis, gall-bladder disease, reflux, sleep apnea, heart disease, stroke, etc. They need to know the difference between a fat and a carb. It's more important than learning how to troubleshoot their laptop . . . really it is.
The fourth wave is where we as system and provider may need to concede some component of defeat. These are the frequent fliers: The brain-injured who smoke, the noncompliant schizophrenics, the homeless guy who keeps coming in with chest pain just to get warm, the smokers who, "by golly, want to exercise their constitutional right" to 14 angioplasties, or as one audience member put it today, "the ones still smoking while using their oxygen." There was much laughter as he quipped, "It's okay to keep doing that as long as they just get everyone else out of the house." And finally, but so heart wrenching, the fourth wave also includes those who are just so sick, no matter what they do or what we do, they just can't help those frequent returns. One option is to offer more outpatient services to herd some of these unfortunate individuals away from the inpatient sieve that drains so many resources for society. Palliation, hospice, adult day care, all may have some role in many of these very difficult issues.
The secret to our success in medical America will be the ability of each physician and hospital system to see its worth in driving community healthcare. As a team, we must reach out to the barbers and beauticians and put BP cuffs in their shops. We must send nutritionists out to groceries to lead healthy shopping sprees. We will shore up our PCI without surgery on-site programs to reduce the need for device therapy. We will go to legislators to convince them that school systems must "teach teachers how to teach" about impactful health issues, prevention, and therapy; we must provide the teaching curricula for mini–med schools or survival programs, so to speak. We must call our patients back on days 1, 2, 3, or whatever to make sure they not only received the proper discharge instruction but help them to follow it. We will go into factories and churches to offer prevention programs.
As physicians we will continue to do our part because most of us really got into this game for the love of it. We know how to diagnose and treat; that's the easy part. Systems will learn the rules and tweak the bottom line. In this new wave of healthcare, those are the easy parts.
The difficult part is understanding or perhaps accepting that Obamacare isn't just for the fortunate 32 million Americans who stand to gain healthcare coverage by the end of 2013 or only for those who have "skin in the game."
Obamacare is coming for everyone.