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ARE YOU WORKING WITH PEOPLE OR THROUGH PEOPLE?
One of the mentors I feel very fortunate to have had in my life was the late Richard Neustadt, a founding professor of the Kennedy School of Government at Harvard and author of the classic book Presidential Power. When I was a student at the Kennedy School in the mid-80’s, I had Dr. Neustadt for a couple of classes, got to work with him on some special projects and was part of a group of students he’d occasionally have over to his house to teach us about the subtleties of scotch whiskey.
There are a lot of insights that Dick Neustadt is remembered for but the one that is probably the most cited is that, in spite of the awesome resources at his (and, someday soon, her) command, the true power of the President of the United States is the power to persuade. To really be effective in accomplishing their agenda, the President must influence different stakeholders and constituencies to work with him or her.
Note the key preposition in that last sentence. It’s with. As an executive I was talking with recently reminded me, great leaders work with people, not through people. You may, at first, think that the dichotomy between with and through is a distinction without a difference. Not so fast, my friend. Let’s dig a little deeper on the difference between these two prepositions, with and through, and the impact they have on effective leadership.
We can start with definitions. The primary definition of with is “accompanied by.” The primary definition of through is “moving in one side and out of the other side of.” Maybe I could end this post right here. If you’re the colleague, the follower or some other stakeholder, would you rather be accompanied by or moved through one side and out the other? My guess is that for most people the answer is self-evident. You’d rather be accompanied. That’s likely at the essence of the power of persuasion that Dr. Neustadt wrote and talked about.
So, what are other markers of a leader who works with people instead of through people?
As the executive I was recently talking with told me, when you’re working with people, you start with respect for your colleagues. Unless proven otherwise, you assume that they, like you, are acting in the similar best interests of the enterprise. You assume that they’re highly motivated and qualified until proven otherwise.
You also have a focus on what they need as much as on what you need. If you only come in with what you need and what you have right and everyone else has wrong, over the long run you lose your effectiveness.
When you don’t have total control, you have to have influence. Influence – the power to persuade – takes root when you work with people rather than through them.
Cartoon – Job Reminds Me of Being in Therapy
Cartoon – Importance of Concise Explanations
Cartoon – Easier said Than Done
Cartoon – Honest Presenter
Cartoon – Rumor Management
Kaiser Permanente just invested in a housing complex. Here’s what it’s doing with it
Kaiser Permanente has gotten into the business of housing.
The health system announced in May that it would put $200 million toward initiatives targeting housing insecurity and homelessness in the communities it serves. On Tuesday night, it announced the first investment is the $5.2 million purchase of an affordable housing complex in Oakland, California, through a fund in partnership with Enterprise Community Partners and the East Bay Asian Local Development Corporation.
The 41-unit building is in an Oakland neighborhood “on the brink of gentrification” which puts the existing residents at risk for displacement. By purchasing the building, it will be blocked from redevelopment that prices out the existing residents, preventing displacement, Kaiser Permanente CEO Bernard Tyson said at a press event on Tuesday.
Preserving buildings like this is a “key component to addressing the national homelessness crisis,” he said. “We know that preserving affordable housing is more effective than building new units.”
It’s part of a comprehensive strategy, officials said, to invest in addressing the economic, social and environmental conditions that ultimately affect the health of their patients.
Kaiser also announced it is “adopting” 500 homeless individuals in the city, Tyson said. He said that several of the system’s employees focused for 12 weeks to expedite a strategy to partner with community groups to house older homeless patients with chronic conditions.
All 500 people identified by the system have at least one chronic condition. The system is working with local groups to secure housing and other needed services for this group.
The plans unveiled by the system on Tuesday also expand beyond Oakland and the Bay Area, where Kaiser is headquartered. On top of the two initiatives focused in that region, Kaiser and Enterprise are teaming up to launch a $100 million loan fund to create or maintain affordable housing units in all of the communities Kaiser Permanente serves.
Tyson said the health system will make future announcements about specific plans under that fund. Tackling this issue, he said, “ties into who we are and what we’re about as Kaiser Permanente.”
“This is the beginning of us being in traffic and backing our talk that we want to help to make a difference in Oakland, in the Bay Area, in this great country,” Tyson said.
Trump wants to bypass Congress on Medicaid plan
Block grants for states would achieve conservative dream on health program for poor.
The Trump administration is quietly devising a plan bypassing Congress to give block grants to states for Medicaid, achieving a longstanding conservative dream of reining in spending on the health care safety net for the poor.
Three administration sources say the Trump administration is drawing up guidelines on what could be a major overhaul of Medicaid in some states. Instead of the traditional open-ended entitlement, states would get spending limits, along with more flexibility to run the low-income health program that serves nearly 75 million Americans, from poor children, to disabled people, to impoverished seniors in nursing homes.
Capping spending could mean fewer low-income people getting covered, or state-designated cutbacks in health benefits — although proponents of block grants argue that states would be able to spend the money smarter with fewer federal strings attached.
Aware of the political sensitivity, the administration has been deliberating and refining the plan for weeks, hoping to advance an idea that Republicans since the Reagan era have unsuccessfully championed in Congress against stiff opposition from Democrats and patient advocates. During the Obamacare repeal debate in 2017, Republican proposals to cap and shrink federal Medicaid spending helped galvanize public opposition, with projections showing millions would be forced off coverage.
In addition to potential legal obstacles presented by moving forward without Congress, the administration effort could face strong opposition from newly empowered House Democrats who’ve vowed to investigate the administration’s health care moves.
“Hell no,” Sen. Bob Casey (D-Pa.) wrote on Twitter on Friday evening, vowing to oppose the administration’s block grant plan “through legislation, in the courts, holding up Administration nominees, literally every means that a U.S. Senator has.”
The administration’s plan remains a work in progress, and sources said the scope is still unclear. It’s not yet known whether CMS would encourage states to seek strict block grants or softer spending caps, or if new limits could apply to all Medicaid populations — including nursing home patients — or just a smaller subset like working-age adults.
A spokesperson for CMS did not comment on the administration’s plans but indicated support for the concept of block grants.
“We believe strongly in the important role that states play in fostering innovation in program design and financing,” the spokesperson said. “We also believe that only when states are held accountable to a defined budget — can the federal government finally end our practice of micromanaging every administrative process.”
Republicans have sought to rein in Medicaid spending, especially as enrollment swelled under Obamacare’s expansion of the program to millions of low-income adults in recent years. CMS Administrator Seema Verma has warned increased spending on the Medicaid expansion population could force cutbacks on sicker, lower-income patients who rely on the program.
The administration wants to let states use waivers to reshape their Medicaid programs, but the effort could face legal challenges in the courts. Waivers approved by the Trump administration to allow the first-ever Medicaid work requirements for some enrollees, for example, are already being challenged in two states.
Also complicating the administration’s push: the newfound popularity of Medicaid, which has grown to cover about one in five Americans. Voters in three GOP-led states in November approved ballot measures to expand Medicaid, which has been adopted by about two-thirds of states. Newly elected Democratic governors in Kansas and Wisconsin are pushing their Republican-led legislatures to expand Medicaid this year.
Verma has been trying to insert block grant language into federal guidance for months but has encountered heave scrutiny from agency lawyers, two CMS staffers said. She mentioned interest in using her agency’s authority to pursue block grants during a meeting with state Medicaid directors in the fall but did not provide details, said two individuals who attended.
There is some precedent for the federal government capping its spending on the entitlement program. Former President George W. Bush’s health department approved Medicaid spending caps in Rhode Island and Vermont that would have made the states responsible for all costs over defined limits. However, those spending caps were set so high there was never really any risk of the states blowing through them.
In recent years, governors have complained about the rising costs of Medicaid, which is eating up a bigger share of their budgets. States jointly finance the program with the federal government, which on average covers 60 percent of the cost – though the federal government typically shoulders more of the burden in poorer states. The federal government covers a much higher share of the cost for Medicaid enrollees covered by the Obamacare expansion.
An official from a conservative state, speaking on background to discuss an effort not yet public, said states would consider a block grant as long as the federal government’s guidance isn’t overly prescriptive.
CMS is hoping to make an announcement early this year, but it could be further delayed by legal review, which has already been slowed by the prolonged government shutdown.
Some conservative experts said the administration’s plans ultimately may be limited by Medicaid statute, which requires the federal government to match state costs. However, they say the federal government can still try to stem costs by approving program caps.
“There’s no direct provision of authority to waive the way that the federal government pays the states,” said Joe Antos of the American Enterprise Institute, a right-leaning think tank. “However, that doesn’t mean that you can’t try to have some of the effects that people that like block grants would like to see, in terms of encouraging states to be more prudent with the ways they spend the money.”
Payer, provider trends to watch in 2019
https://www.healthcaredive.com/news/payer-provider-trends-to-watch-in-2019/545612/
Ripple effects from 2018 will continue well into the new year as players deal with some massive policy and business shifts.
The coming year for healthcare will see the industry reckon with some of the massive changes set in motion last year, such as megamergers like CVS-Aetna and Cigna-Express Scripts and a judge’s declaration that the Affordable Care Act is no longer constitutional.
On the policy front, newly-installed Democrats in Congress (and the party’s 2020 presidential candidates) will be pushing for more comprehensive health coverage plans while the GOP considers tougher Medicaid restrictions at the state, and potentially federal, level.
Meanwhile, some familiar storylines are likely to continue. Effusive digital health funding and increases in mobile and telehealth services show no signs of abating, and neither does general M&A activity.
Here’s a snapshot of a few big trends for the payer and provider crowds to watch for in 2019.
Providers: Behavioral care goes primary, investment in digital
1. Narrowing gaps in population, behavioral healthcare
Historically, behavioral health services have been mostly disparate, but increased spending in digital health and a focus on lowering out-of-pocket costs will help spur greater connectivity, Sandra Kuhn, national lead for behavioral health consulting at Mercer, told Healthcare Dive. She predicted “more partnerships between traditional medical and behavioral health carriers on smaller, targeted point solutions” as the industry already began to see last year.
The trend more broadly fits into the push to recognize and act on social determinants of health.
One partnership is the Utah Alliance for the Determinants of Health, a coalition of providers, community organizations and government agencies banding together to reduce the impacts of SDOH. Their plan seeks to address socioeconomic stressors like housing instability, food insecurity and transportation — circumstances with a direct effect on mental and physical health — before patients show up in the ER lobby. Intermountain Healthcare, a primary stakeholder, invested $12 million in the initiative.
Early efforts include experimental EHR technologies, value-based payments for even more population health management programs and wraparound services. Health Affairs highlighted two separate initiatives, each making inroads on social determinants by carrying out existing population health programs in tandem with trusted community partners.
Overall, Kuhn said, more organizations will step up with tactical solutions to what has otherwise been an intractable problem. That includes payers like state Medicaid programs, many of which have begun value-based payments for behavioral health services.
Progress on behavioral and population health is happening in tandem with — or perhaps existing symbiotically alongside — the growth of telemedicine. At Riverside Health System, a rural health network in Newport News, Virginia, a long-term telebehavioral health initiative has improved coordinated care among psychiatrists and clinical social workers, as well as replaced a chunk of services offered at the system’s nursing homes.
Riverside isn’t the first to find success with telebehavioral health, but the system’s wider experimentation with programming, a happy accident triggered by a psychiatrist shortage, has certainly shown there’s a market for it — one that Quartet, Lyra and Teladoc have been quick to capitalize on. This year will see a swath of players from across the industry tackle behavioral health gaps by complementing primary care with telemedicine.
2. Doubling down on digital
While larger health systems tend to have the means to be early adopters of new and robust healthcare technologies, physicians are beginning to integrate such services into their practices.
Use of telehealth among the commercially insured has been gradually rising since the mid-2000s, having grown 52% annually from 2005 to 2014 before spiking 261% between 2015 and 2017, according to JAMA.
Revenue cycle management firm SYNERGEN Health estimates digital health tech for remote use will grow by 30% this year, allowing patients to better manage their own healthcare, giving clinicians an opportunity to spend more time with more patients and, of course, generating new revenue streams.
As more payers hop aboard the telemedicine train and more services are covered, hospitals will continue see costs fall. A 2017 report from the Rural Broadband Association found that telehealth services were associated with an annual cost savings of $20,841 per U.S. hospital on average. The caveat here for hospitals is the very real possibility that large facilities will become increasingly more obsolete and overhead costs will become too costly as patients find yet another reason to stay away from their doors.
3. Price transparency still a question mark
Many are hoping the days of the $629 hospital bill for a wet towel and a Band-Aid are coming to an end, but it’s not likely to happen in 2019.
Still, legislators and consumers alike are making price transparency an issue in hopes of curbing skyrocketing healthcare costs.
CMS took some action last year by finalizing a new rule mandating hospitals post chargemaster rates online in a machine-readable format. But the rule is effectively toothless. Hospitals were already required to make those prices available, and chargemaster rates only apply to the uninsured and balance billing. And despite the fact that the rule went into effect on the first day of the year, CMS admitted recently that it has no way of enforcing the mandate and would not comment on how many hospitals are currently in compliance with the rule.
“It is [our] expectation that all of them will comply,” CMS Administrator Seema Verma said on a call with reporters.
The rule doesn’t specify where hospitals need to post their charges. The only requirement is that they’re made available online, which has allowed health systems like mega-operator Ascension to bury their charges behind a tangled maze of clicks.
The company has previously defended itself in a statement to Healthcare Dive by arguing the costs can be confusing for patients, as they don’t take financial assistance and charity care into consideration. Chargemaster information, as some critics have pointed out, isn’t a very useful measure of pricing for consumers. It can actually be counterproductive.
Thomas Lee, chief medical officer at Press Ganey, speaking at the U.S. News Healthcare of Tomorrow conference, said economists don’t believe price transparency has a noteworthy impact on cost and efficiency.
“I’m predicting not much will happen and people won’t pay attention to it because the charges aren’t actually relevant to the vast majority of people,” Lee said. “If people are uninsured, I doubt they’re looking at these things either.”
If the ACA taught economists and legislators anything about American consumers, it’s that they want healthcare, but don’t want to take the time to shop around for it. In a recent Health Affairs survey, just 13% of respondents responsible for cost-sharing in their last healthcare encounter sought cost information before receiving care. Only 3% compared prices of different providers.
History seems to be repeating itself, as CMS hopes its “first step toward price transparency” will be picked up by market forces. By mandating the information be made available in a different file format, CMS believes it has “set the stage” for that data to be used by private third parties that can develop tools for consumers to use.
“There’s nothing in the rule that prevents hospitals from going further with this,” Verma said. “Hospitals can do that today.”
But they aren’t. In fact, the percentage of hospitals unable provide patients with price information jumped from 14% to 44% between 2012 and 2016, according to a JAMA study.
In short, the CMS rule is much more of a light nudge than a forceful shove into price transparency, and without regulation and the means of enforcing it, hospitals have little to no incentive to change. But expect the wheels of the price transparency conversation to continue turning in 2019, regardless.
Payers: Contract fights, a focus on value and more managed care
1. Contentious negotiations and contract disputes
As insurers have bulked up in scale after blockbuster mergers last year, Fitch Ratings expects relationships between providers and payers to be even more contentious during contract negotiations even in a value-based payment setting.
Some recent headline-grabbing squabbles include UnitedHealthcare’s contract impasse with Envision Healthcare, an ER staffing firm. Tenet and Cigna’s contract negotiations stalled and finally reached a multi-year deal this year.
Hospitals can also expect low rate increases from commercial insurers, according to Moody’s.
In markets where there is a dominant insurer and multiple hospitals, “Each hospital will need to demonstrate why it is indispensable to the insurer … and why it should be included in a network,” Moody’s reports.
However, there are potential glimmers of hope. As more states have expanded Medicaid, it puts pressure on other states to do so, which would provide a means of payment for hospitals that have gone without payment caring for the uninsured.
2. Value-based momentum
Payers and providers will continue to enter into value-based contracts in 2019 at varying degrees, according to Moody’s.
Many hospitals are engaging in contracts that offer incentives or alternative payment models for reaching certain quality measures, but very few are taking on full risk, or both the upside and downside risks within a contract, according to Moody’s.
That will continue into 2019: few are likely to take on downside risk, or the possibility of losing money, Moody’s reports.
However, while the popularity and use of these payment models continues, its cost-savings benefits have yet to be realized, according to a recent report.
Meanwhile, CMMI continues to test for ways to drive change in the healthcare by paying for quality as opposed to quantity. For instance, CMMI is testing whether it can reduce utilization and ultimately costs by addressing social-needs such as housing for Medicare and Medicaid beneficiaries. CMMI’s director Adam Boehler said he won’t force organizations to take on risk, but will help them take on a level of riskthey’re comfortable with.
But in an about-face, the Trump administration seems to be signaling that it may institute mandatory payment models that could put providers at risk of losing money.
3. Medicare Advantage still lucrative, popular
Medicare Advantage will continue to be a profit center for insurers, which typically enjoy a 5% margin, according to 2016 data from the Medicare Payment Advisory Commission.
As the population ages, it presents a growth opportunity for payers. Enrollment in MA plans grew by 8% from 2016 to 2017, according to a recent MedPAC report, as many more seniors are choosing to enroll in plans run by traditional insurers. About 34% of beneficiaries choose MA, a significant increase from a decade ago when just 10% enrolled in such plans.
Beginning this year, MA plans have greater flexibility to offer non-traditional benefits such as adult daycare, meals or in-home care to improve the overall health of patients, particularly those will high needs. CMS Administrator Seema Verma previously said 270 MA plans will offer these new benefits in 2019.
These new benefits also pose an opportunity for nontraditional healthcare companies such as Lyft and Uber, which are looking for ways to shuttle seniors to appointments and pharmacies.
Payers including Cigna touted the future growth opportunity it sees for MA. “We are well positioned today and going forward for existing and new markets,” Cigna CEO David Cordani said of MA, according to Forbes.
4. Medicaid managed care growth
As states weigh expanding Medicaid, it’s another potential opportunity for managed care plans to contract with states. As more states expand the program, it puts pressure on the remaining holdouts.
Last year, some red states took the issue to the ballot box and got approval for expansion, potentially providing a roadmap for stakeholders to replicate in other states where the legislatures balk at expansion. California Gov. Gavin Newsom is backing an idea that would expand Medicaid eligibility in his state to undocumented young adults, providing another opportunity for Medicaid managed care firms.
Likely potential winners are Centene and Molina. Centene is the nation’s largest Medicaid managed care firm with operations in 21 states covering more than 8 million people. Molina serves more than 3 million in 13 states and Puerto Rico.
Just recently, Molina CEO Joseph Zubretsky said even without expansion ushered in by the Affordable Care Act, $1 billion of new revenue opportunity exists in Molina’s existing footprint because of states like Illinois that are expanding Medicaid managed care statewide.
HENRY KOTULA 