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MESA: An Innovative New Value-Based Health Insurance Plan
https://altarum.org/about/news-and-events/MESA
https://altarum.org/our-work/MESA
Click to access ALTARUM_MESA_BLUEPRINT_BRIEF.FINAL__0.pdf
Click to access ALTARUM_MESA_BLUEPRINT_BROCHURE_FINAL_0.pdf
MESA Will Improve Quality and Lower Costs for Those Who Use Health Care the Most;
Pilot Sites Will Test Model
To provide consumers with an affordable alternative to high deductible health plans (HDHPs), Altarum has created an innovative new model for those who use health care the most. The Medical Episode Spending Allowance (MESA) plan, developed with support from the Robert Wood Johnson Foundation, is especially well suited for those with chronic or serious health conditions, and takes value-based insurance design to a whole new level, improving quality of care while lowering costs.
“Employers and consumers are looking for alternatives to increasingly unaffordable health coverage, and finding a solution that works is essential,” said François de Brantes, vice president and director of Altarum’s Center for Payment Innovation. “That’s what our MESA Blueprint is all about. By turning the high deductible health plan on its head, the MESA plan significantly reduces the potential for people with on-going illnesses from foregoing needed care.”
How Does MESA Work?
MESA’s incentives are finely calibrated to encourage consumers to seek out high value care and for providers to deliver it. The plan is based on a reference pricing model, so consumers can choose service providers that offer high quality care at a lower price.
Members pay out-of-pocket only when the cost of care extends above the specified allowance for a given episode of care. Plan members who select network providers that have accepted financial risk—for example through a bundled payment—could potentially avoid out-of-pocket expenses entirely. MESA also arms consumers with tools to research procedures, identify providers in their area, and view providers’ costs and quality ratings, so they can select the best care.
“As Americans are being asked to pay more for their health care, health insurance innovations, such as the Medical Episode Spending Allowance (MESA), that align consumer and provider incentives on quality and cost measures are an essential step forward,” said A. Mark Fendrick, MD, director of the University of Michigan Center for Value-Based insurance Design. “Strategies that reduce the patients’ out of pocket cost burden for clinically indicated services provided by from high performing clinicians are a necessary and important strategies to achieve the Triple Aim.”
“The Kentuckiana Health Collaborative, a coalition of employers, payers, providers, and consumers of health care, supports alignment of incentives to reduce barriers to high-quality, high-value care. We strongly encourage efforts to drive adoption of rational, creative alternative payment models and commend Altarum’s efforts to innovate with MESA,” said Stephanie Clouser, Kentuckiana Health Collaborative data scientist.
A New Path Forward
Each MESA benefit is finely tuned to incentivize the physician/patient relationship towards mutual cooperation and motivation to do the right thing, at the right time, in the right place—in a fully transparent marketplace. Information on the benefit model is available in the MESA blueprint, which provides employers and payers with a practical understanding of the framework, including compliance with legal and regulatory statues and actuarial equivalence to existing group health plans.
“MESA provides a comprehensive plan that marries payment reform with benefits reform, provider engagement with consumer engagement, and physician accountability for costs of care with patient accountability for managing their health and costs of care,” said Emmy Ganos, program officer at the Robert Wood Johnson Foundation. “Many of the concepts aren’t new—they are tried and tested—but their combination is, quite simply, a better solution.”
That solution will be tested in selected pilot sites throughout the United States in years to come. The criteria for sites to become pilots include willing employers and providers, current engagement in and familiarity with alternative payment models, and a commitment to price and quality transparency. Those interested in becoming pilot sites should contact Altarum at press@altarum.org.
From Payment Reform to Benefit Reform
Over the past ten years, the Center for Payment Innovation’s PROMETHEUS Payment® model has revolutionized the way we pay for medical care. PROMETHEUS packages payment around a comprehensive episode of medical care that covers all patient services related to a single illness or condition. The model has been used as a basis for most of the public and private sector bundled payment models that are implemented in the United States today. One of its offshoots is the PROMETHEUS Analytics® software, which can help power the MESA model and now revolutionize health benefits.
Home Visiting Programs Are Vital for Maternal and Infant Health
When 19-year-old Rosa went into labor three months early, she had to be taken 60 miles to the nearest hospital, according to a 2013 video interview with the organization Save the Children. Her baby, Sirena, was born premature and needed immediate and constant medical attention. Days after giving birth, Rosa was discharged to the home she shared with seven other family members in her small, economically challenged California community. Sirena stayed in the hospital’s intensive care unit to continue receiving treatment, miles away from her mother.
Even in the best circumstances, parents’ joy at greeting a new baby is tempered by stress and worry during a child’s first months. But mothers like Rosa face many additional stressors, including preterm birth, inadequate housing, economic uncertainty, and being young themselves. Fortunately, Rosa did not have to navigate these challenges alone. Diana, a dedicated home visitor—someone specially trained to provide support to new or expectant parents—immediately arranged Rosa’s transportation to and from the hospital to visit Sirena. This helped Rosa and her daughter bond during a crucial period and soothed Rosa’s heartache over their separation. Once Sirena was healthy enough to go home with her mother, Diana continued to visit them regularly, bringing books and educational tools to help Rosa support her baby’s development.1
Home visitors like Diana are support professionals, such as nurses or social workers, who are well-versed in child development, parenting, and family functioning. Local agencies—such as tribal organizations and departments of health, human services, or education—match home visitors with new or expectant parents interested in receiving services.2Home visiting is a voluntary, home-based service-delivery strategy that provides services to parents and children that help the whole family.3 Parents often learn about home visiting through their children’s pediatricians, social workers, and other support professionals. Although home visiting can benefit any family, it can be especially helpful for families who need additional support during stressful periods of economic insecurity or health concerns. Decades of research prove that home visiting can promote healthy child development and academic success, improve health outcomes, and support families’ economic security in both the short and long terms.4
This issue brief explores how home visiting programs—specifically, evidence-based programs funded by the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program—address three key maternal risk factors that directly influence maternal and child health and disproportionately affect mothers who participate in home visiting: postpartum depression, domestic violence, and tobacco use. Each of these risk factors negatively affects a mother’s physical and emotional health, which in turn can produce worse outcomes for children, including low birth weight, prematurity, and even death. Although families face many more challenges, these health indicators highlight the diverse ways home visiting can benefit mothers and children. The brief also demonstrates how home visiting programs contribute to women’s economic security and, therefore, to the economy as a whole. Finally, it examines continued challenges to funding these programs, as well as potential solutions.
Click to access MaternalHealth-brief.pdf
Despite strong patient interest, only 8% are offered no- or low-interest loans
A majority of healthcare providers fail to discuss pricing and payment options prior to providing care, despite patient demands, according to the HealthFirst Financial Patient Survey.
The survey, conducted by ORC International, took place Aug. 7-9 among 1,011 adults.
Here are seven findings from the survey.
1. The survey found 77 percent of respondents believe it’s “important” or “very important” they know healthcare costs prior to care, and more than half of respondents (53 percent) want to discuss financing options prior to treatment.
2. Additionally, a majority of respondents (63 percent) indicated it was “important” or “very important” for providers to publish prices of common procedures.
3. But only 18 percent of respondents said any of their healthcare providers had discussed patient financing options with them at all in the past two years.
4. More than half of respondents (57 percent) reported it’s “important” or “very important” their healthcare provider offer no-interest payment extension options. But only 8 percent of respondents received zero- or low-interest financing from a healthcare provider, according to the survey.
5. Respondents also indicated availability of payment programs affect their choice in provider. The survey found 40 percent of millennials, ages 18 to 36, would be “very likely” or “likely” to change providers if another provider offered low- or zero- interest financing for medical payments, and 29 percent of respondents overall indicated they would change to a provider with attractive payment programs.
6. Patients seek these discussions and options as they are concerned about medical costs. The survey found 42 percent of respondents are “very concerned” or “concerned” about being able to cover out-of-pocket medical bills in the next two years. More than half of respondents (54 percent) with annual income of less than $35,000 said the same.
7. HealthFirst Financial said 53 percent of respondents indicated they are worried about being able to pay a medical bill of less than $1,000. For a bill of that amount, the survey also found 52 percent of respondents would initially have interest in a multiyear, no-interest financing option from their healthcare provider.
Access the full survey here.
Courage: Critical Leadership Characteristic
Our new year is bringing ample challenges to the healthcare industry, from strategies to deal with the Affordable Care Act, to the realities that deficit reduction will require additional cuts in Medicare reimbursement to providers.
Congress is still in denial about the biggest problem with deficit spending – Medicare, but healthcare executives should not draw any hope that they will somehow escape the pain.
Cuts in payments inevitably will spark conflict on a national basis, as various healthcare groups bicker over how to divide the smaller financial pie. These “who wins and who loses financial conflicts” will almost certainly “trickle down” to local relationships between hospitals, physicians, and other providers. When money is involved, there will always be tension, and tension will lead to conflict.
This tension, and the conflicts that surface, will be the second biggest contributor to CEO turnover during the next five years, after the Baby Boomer retirement effect. Today, annual hospital CEO turnover is about 17 percent. I predict that will escalate to more than 20 percent in that five-year timeframe.
As I considered these probable developments, I began to rethink my beliefs regarding the competencies and ideal characteristics of the senior leaders who run hospitals.
As I thought about this over the holidays, I realized that the leadership characteristic that kept moving to the top of my list was courage. Yes, communication and relationship management, industry knowledge and business skills are all critical, as is integrity, but I think courage is very important.
These next several years will produce unprecedented change. This change, in addition to concerns about finances, will produce enormous unrest as we redefine how healthcare must be delivered. Hard choices, very hard choices, will be the norm.
These tumultuous times will require leaders who are smart, who possess a deep understanding of healthcare operations who are proven performers, and who are excellent communicators. But more importantly, these men and women must have the courage, the courage to promote innovation and change. They must possess the courage to do the right thing when, career-wise, it would be easier to take the easy way out.
The Hidden Dangers of Leading Change
People hate change. They dislike it so much that otherwise nice people will resort to some uncharacteristic behaviors — gossiping, lying and personal defamation against the person leading the change. This is a real threat to senior executives, especially those involved in organizational turnarounds.
Important progress can be slowed or derailed. Executive careers can be tarnished if not ruined.
This negative phenomenon is not new. In fact, evidence can be found in the Old Testament of the Bible. What is new is that we live in a digital age where malicious rumors and gossip can be spread, sometimes anonymously, over the Internet like wind-fed wildfire. It can blow up so fast that an unsuspecting, perhaps naive, executive can be tried and convicted before they are aware that the malignant campaign to discredit them even exists. Their attention, after all, is focused on more pressing issues.
Everyone has strengths and weaknesses, including the opponents of change, those who typically use a leader’s weaknesses to stop that which they distrust and makes them uncomfortable. Now here is where I think executives can and must do a better job in protecting themselves against repetitional attacks — they must become more self aware and to begin using the digital tools and modern communications strategies to their advantage. Unfortunately, far too many CEOs, especially those who engage in challenging business turnarounds, are so focused on their plan that they fail to insulate themselves from the inevitable pushback. In fact, it is surprising how many CEOs reject any involvement in social media activities until they have lost their job and are looking for a new one.
Years ago, during the course of a major CEO search, an extraordinarily qualified candidate disclosed a background issue that was potentially problematic. He was such a superb candidate that I refused to eliminate this individual from the field. I disclosed it to the board of directors and, with an open mind and the recognition of this person’s outsized talent, they asked me to vet the issue more thoroughly. In the end, he got the job. Ultimately we made the decision to disclose the background issue, no longer material to leadership performance, because we knew that those who would most certainly oppose the changes that had to be made — some entrenched employee groups — would use it against the executive when it inevitably surfaced. They would have attacked the leader using the information as a blunt weapon to slow or halt changes and they would most certainly have accused the board of an unconscionable cover-up. We neutralized that issue and this executive went on to lead a highly successful turnaround.
The advantage in this situation is that we knew about the issue and took action. Far too often executives are the last to learn that they are the targets of a smear campaign. They frequently find themselves in a reactive mode and that alone can aggravate the bad optics even more.
HENRY KOTULA 