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Importance of Inspiration
Cartoon – Sign of the Times
Denver Provider Market at ‘Tipping Point,’ Study Finds
The report expects employers and health plans to exert more influence in demanding market power going forward.
Health systems and physician groups have dominated the Denver healthcare market in recent years, but a new study indicates that employer-purchasers and health plans are poised to disrupt that dynamic.
Supported by existing legislation, activism from local businesses, and the efforts of Gov. Jared Polis, the Denver market is at a ‘tipping point,’ according to a Catalyst for Payment Reform (CPR) and the Colorado Business Group on Health (CBGH) report released Thursday morning.
The study specifically referenced the RAND report from May which found that payers were paying rates to providers well above Medicare levels, noting that employers have an opportunity to pressure insurers to engage providers in contract arrangements that better align with care rendered.
Researchers believe that payment reform is achievable in Denver, suggesting six policy recommendations to business groups, lawmakers, and insurers, including the expansion of price transparency measures and promotion of benchmarking prices relative to Medicare.
Corralling healthcare prices has been a primary issue in Colorado this year, with the state most recently pursuing a reinsurance program that Polis expects to lower premiums by 18%.
The study found that four major health systems, HCA Holdings, Centura Health, UC Health, and SCL Health, accounted for 85% of patient admissions in 2017. On the Herfindahl-Hirschman Index, this level is considered “moderately concentrated” but the report highlights that it also means the market is “concentrated enough to stifle price competition.”
While providers have concentrated in the market through continuous merger activity, the study found that insurers are governed by strict regulations. The result has been Coloradans facing 13% higher prices compared to the national average and 5% high utilization rates.
Two of the recommendations offered by the study were to align two-sided risk arrangements with Medicaid and the Polis-Primavera “Roadmap to Affordability,” the governor’s strategic initiative to make care more affordable, as well as to implement benefit designs to “encourage consumers seek higher value care.” The study also urges that employer-purchases to pursue value-oriented programs that hold providers accountable to the listed targets.
However, in an interview with HealthLeaders earlier this year, Centura Health CEO Peter Banko said the system was going to “pause on the mad rush” to value-based care models, citing the direction the market was taking on the issue.
As highlighted in the RAND report, CPR and CBGH believe that building on purchaser momentum through a statewide purchase cooperative can be an effective method at changing the market dynamics in Denver.
Similar to the Employers’ Forum of Indiana, an employer-led healthcare coalition which collaborated on the RAND report, the Peak Health Alliance, a Summit County-based purchaser cooperative, has sought to combat rising healthcare prices in the Denver area. The report states that Peak Health, which represents 6,000 covered lives, has already negotiated a “very aggressive” reduction in rates with Centura.
Bob Smith, MBA, executive director of CBGH, said that the report gives employer-purchasers “the tools to make changes” to the Denver healthcare market and stem the tide of rising prices.
“Healthcare costs, primarily driven by high prices and seemingly unwarranted increases, are edging out salary growth and economic development,” Smith said in a statement. “These trends are taking a toll on every employer from school districts to manufacturers and are simply not sustainable.”
Smith urged lawmakers to act on the report’s suggested reforms but also said that employers now have “the responsibility to act.”
CEO Kevin Spiegel Leaves Erlanger Amid Physicians’ Rancor
https://www.healthleadersmedia.com/strategy/ceo-kevin-spiegel-leaves-erlanger-amid-physicians-rancor
The exiting president and CEO has been credited with leading the nonprofit system’s financial turnaround. But he has also seen his share of controversy.
The top executive of Erlanger Health System, based in Chattanooga, Tennessee, has left the organization after months of smoldering conflict with some of the nonprofit’s physicians.
President and CEO Kevin Spiegel’s departure was immediate, according to a statement released Wednesday by board chairman Mike Griffin, who offered his well-wishes to the departing leader.
Spiegel, who had been on the job more than six years, reportedly said his separation from the organization was a mutual decision.
“We’re still working out the details, and hopefully that’ll be complete by the board meeting in two weeks,” Spiegel told the Times Free Press‘ Elizabeth Fite. “This is a great hospital, and it’s a great organization, and it’s only going to do better and better things.”
Erlanger’s board is expected to pick Spiegel’s successor in two weeks, at its regularly scheduled board meeting, according to Griffin’s statement.
Spiegel’s exit comes less than two weeks after the board held a special public meeting to talk about physicians’ concerns and criticism of Erlanger’s senior leadership team.
Spiegel is the third high-ranking Erlanger executive to leave since Fite reported in June on a letter from the Medical Executive Committee explaining its reasons for a unanimous vote of “no confidence” in the current executive leadership team. The other two were Executive Vice President and Chief Operating Officer Rob Brooks and Vice President of Patient Safety and Quality Pam Gordon.
Spiegel has been credited with leading Erlanger out of choppy financial waters, but he has also been caught up in a number of controversies, as the Times Free Press reported.
Cartoon – Good Meeting
The U.S. has fantastic health care, the problem is….
Click to access wf1341834-cmo-campaign-wyatt-decker-article-part1.pdf
In part 1 of an executive interview series, CEO and physician Wyatt Decker discusses his perspectives on today’s challenges and opportunities for reinventing health care.
IMAGINE THIS SCENARIO: there are 200 people in a room and each person has a serious health condition. Cost is not a barrier to each of these people receiving their prescribed treatment. A question is asked — how many of you would book a flight to a different country to get your care? You guessed it. No hands go up.
Dr. Wyatt Decker is chief executive officer of OptumHealth and an emergency medicine physician who brings more than two decades of service within the Mayo Clinic. He held dual roles as chief medical information officer for Mayo Clinic and CEO of Mayo Clinic in Arizona. Dr. Decker often conducts this experiment with audiences to underscore the quality of care delivered in the United States. We often hear about the problems of health care. No doubt, there are deep and serious problems. However, in scenarios like the one above, we understand that the quality of care delivered by our nation’s physicians is among the finest available. So why do we hear so much about what’s wrong?
According to Dr. Decker, the real opportunities for reinventing health care lie in improving system access, increasing affordability and meeting consumer preferences. “ All of these things really require us to think deeply about how health care is delivered and how can we do it better,” he says. In part 1 of a recent conversation, Dr. Decker shares lessons learned and offers his perspective on where today’s health care executives and clinical leaders should focus.
What is your take on the state of the health care industry today? What challenges are driving the need to rethink health care systems and delivery?
THE CHALLENGE OF HEALTH CARE ACCESS: “ People want to get to a doctor or a health care team and they can’t. Either because they are underinsured or they don’t have the financial resources. They don’t know where to go or sometimes there just aren’t enough doctors or the right type of doctor, whether it’s primary care or a specialist available in their area to see.”
THE CHALLENGE OF HEALTH CARE AFFORDABILITY:
“ We hear a lot about affordability of health care and outof-pocket cost can be very high, but also the health care system itself is very expensive. So how do we make it more affordable for large employers, individuals, consumers and even the government itself? Can we get on a more sustainable path?”
THE CHALLENGE OF CONSUMER PREFERENCES: “ Most people who’ve experienced the health care system feel that it isn’t focused around their needs, schedules or preferences. We’re entering an era where in most other industries there’s lots of personalization and consumer focus. Health care has been very slow to evolve. We need to make it an experience where people feel appreciated, valued and respected. Not just that they’re getting great quality care, but also that their preferences and needs are being met.”
“ Our nation’s care providers are deeply committed and among the best-trained in the world. But I also see them in a system that is struggling. Emergency departments are, at times, the last resort for people who lack resources and access to care. I’ve seen patients struggle to manage chronic conditions without the right support and how the absence of good guidance can create confusion.”
Clearly, the need to reinvent in all aspects of health care is top of mind for many. But it can be difficult to figure out where to start. Can you discuss where you think it’s smart for leaders to focus?
“ We should all be thinking about how we drive towards a health care system that really creates and adds value to people’s lives,” says Dr. Decker. Here’s his advice on key areas of focus.
PAYMENT MODELS: “ Move towards payment models that actually reward the correct behaviors in health care. What do I mean by that? The pay-per-value model — rewarding groups of providers to keep people well and healthy — is far more powerful than the traditional fee-for-service model.”
LOCAL ECOSYSTEMS: “ Recognize that health care is local. It’s important to create ecosystems that deliver great, connected care for individuals throughout the health spectrum. This means the patient and their health data move seamlessly between specialists, hospitals, ambulatory care centers, and so on. These kinds of networks and interoperability of data is crucial to create a successful health care system.”
SOCIAL DETERMINANTS OF HEALTH: “ Health care outcomes are driven not only by the quality and capabilities of the health care provider, but also by social determinants of health. Good health care addresses things like access to good nutrition, social connections, transportation and more that can limit the ability for a person to get and stay healthy. For example, in-home health visits to help patients who have difficulty traveling or easily obtained referrals to social and community services can really enable success.”
From your perspective, what could health care reinvention mean to a patient, provider or health plan?
TO PATIENTS: “ It means a health care system where instead of waiting for something to go wrong, there is a team helping you proactively flourish and be healthy. It means a simple phone call or an app or a video chat could advise you on when you might be at risk of developing a serious condition before you develop it. It means a system that is always there for you, almost like a guardian angel. It helps you navigate the system and your journey towards health and wellness. It means all of this in a health care system that is easy to access, affordable, high-quality and compassionate.”
TO PROVIDERS: “ Providers have high rates of frustration and even burnout with their own profession. Reinvention looks to reduce the very heavy clerical burden driving these trends. Doctors today spend about two hours of clerical and non-visit care for every hour of direct patient care that they provide. However, when you talk to doctors, they find the most fulfillment in engaging directly with patients and making a difference in their care. Reinvention means relieving exhausted providers of administrative and clerical duties that don’t bring enjoyment or result in improved care and outcomes.”
TO HEALTH PLANS: “ Health plans are frustrated because they pay for a lot of care that evidence shows doesn’t improve outcomes or help patients on their journey to health and wellness. Payers are happy to pay for health care if it’s necessary. But it doesn’t make sense to pay for care that doesn’t add value. Reinvention means reducing this financial waste to bring down the cost of coverage for everyone.”
“ We have an opportunity now to make the health care system work better for everyone. Improve access and affordability for patients, allow doctors to spend more time with patients, and increase efficiencies within health plans. There’s an opportunity to help people connect the dots and get everyone working together.”
You’ve been a practicing physician and a business leader. Tell us the lessons learned from this unique vantage point.
“ I have spent most of my career as a practicing physician in busy, level 1 trauma centers and emergency departments. In that environment, you see health care at its finest and also how the health system can be challenging. I think in amazement of the times I’ve seen teams of people — multiple physicians, nurses and technicians — come together as one unit to save someone from a major trauma. I also have great admiration for the persistence of doctors who save lives by diagnosing life-threatening conditions through nuanced symptoms.
I’m a deep believer that in health care, we need to place the patient at the center of everything we do. I always remind young doctors and medical students…imagine for a moment that your patient is you or a loved one. You’d want the doctor to listen and explain things in a compassionate and thoughtful manner. You’d want them to be focused. You’d want them to recognize your unique history and what’s important to you. The notion of putting the patient at the center of everything is something that I have carried with me throughout my career. I have also dedicated myself to developing better models of care and systems that allow doctors and care teams to function seamlessly, be high-performing and deliver great outcomes for patients.”
“ I have an appreciation for how powerful it can be when you work to reduce waste, create care that’s efficient and care that is patient-focused. Today I’m focused on an interesting juxtaposition — creating the right mix of scalable innovations that help our whole nation succeed in health care while also improving the personal and individual patient health care experience.”
STAY TUNED FOR PART 2 of this executive interview series to learn more about Dr. Wyatt Decker’s perspectives on the intersection of technology and health care, the human impact of transformation and physician burn-out.
Rhode Island: A Most-Improved State in Health Performance
https://www.commonwealthfund.org/blog/2019/rhode-island-most-improved-state-health-performance
States use the Commonwealth Fund’s 2019 Scorecard on State Health System Performance to identify places where their health care policies are on track and areas that need improvement. Using the Scorecard, states can compare their improvement to others, and see how they stack up. In the most recent edition, released in June, Rhode Island improved on the most health system performance indicators tracked over time, followed by Missouri, Washington, West Virginia, and Arkansas.
Rhode Island particularly made strides in the areas of coverage and behavioral health. The state uninsured rate among adults dropped from 17 percent in 2013 to 7 percent in 2015 and 6 percent in 2017. In addition, the percentage of adults with any mental illness reporting an unmet need dropped from 27 percent in 2010–11 to 18 percent in 2014–16. The state also saw significant reductions in the percentage of children with unmet mental health needs.
These improvements did not happen by chance. What actions did policymakers take to drive progress and what work lies ahead?
Making Progress Through Clear Priorities and State Leadership
In 2014, Governor Gina Raimondo came into office fully committed to the Affordable Care Act, including Rhode Island’s state-based health insurance marketplace and expanded Medicaid eligibility.
Another early administration priority was making sure behavioral health care was as available and affordable as medical care. The opioid epidemic was hitting Rhode Island hard, making access to treatment for mental health and substance use disorder a top concern.
Coverage expansion. The decision to create a state-based marketplace, HealthSource Rhode Island (HSRI), was instrumental in helping the state make gains in coverage and affordability. The state has its own funding for marketing and navigators who help people understand and choose health plans. This has helped shield residents from federal outreach cuts. The state’s commitment also helped when the Trump administration decided to end marketplace cost-sharing-reduction subsidies. The state’s Office of the Health Insurance Commissioner (OHIC) worked with the state marketplace HSRI to protect consumers by building price increases to cover the loss of subsidies into silver-level health plans and keeping premiums lower in the other plans. HSRI plans offered among the lowest state-based marketplace premiums in the country. During last year’s open-enrollment period, HSRI saw a 5 percent increase in new and overall customers.
Access to behavioral health. In 2015, Governor Raimondo issued an executive order to establish the Overdose Prevention and Intervention Task Force, which has guided state reforms. The opioid crisis also has led to more open conversations about mental health and to improved relationships between first responders and communities. To facilitate these relationships, Rhode Island now requires police officers receive training to recognize behavioral health issues and help connect individuals with the care they need.
Rhode Island experienced a decline in overall overdose deaths, from 336 in 2016 to 314 in 2018. Community programs and pharmacies have worked hard to get naloxone, used to counter the effects of opioid overdose, into the hands of people who need it. Rhode Island was also the first state to offer medication-assisted opioid treatment in prison. Community health workers follow up on inmates after release to ensure treatment is continued. Fatal overdoses declined by 60 percent among people leaving detention from 2016 to 2017, and continued to drop in 2018.
OHIC also has prioritized integrating behavioral health into the primary care setting as a cost-effective way of increasing access to such services. Studies have shown that integrated care improves depression and anxiety outcomes, along with quality of life, while reducing the total cost of care.
Additionally, OHIC has been working on encouraging parity between medical and behavioral health in the insurance market by reviewing insurers’ coverage documents. It is focusing on limiting mental health benefit exclusions and ensuring the states’ major carriers are in compliance with the laws related to coverage for mental health and substance use disorder treatment. As a result, the four major insurers have agreed to discontinue prior authorization requirements for certain medication-assisted treatments.
Maintaining Momentum
In 2018 an HSRI/OHIC workgroup was formed to develop policy options to mitigate the potential impact of federal changes on health coverage costs, consumer choice, and access. The group recommended pursuing a Section 1332 waiver to establish a reinsurance program to reduce premium increases in the individual market; implementing a state-level requirement that individuals have health insurance to offset the impact of the federal health insurance mandate penalty repeal; and establishing OHIC’s regulatory authority over short-term limited duration plans. All three recommendations were signed into law on July 5.
In addition, recent state legislation has expanded OHIC’s authority related to establishing behavioral health parity, such as a law giving it authority over health plans and third-party organizations that conduct benefit reviews.
Addressing population health challenges demands a concerted effort. Rhode Island is fortunate to have a culture of collaboration among health care leaders, coupled with strong political commitment to health system improvement.
The latest on US health insurance coverage, income and poverty
New numbers from the U.S. Census Bureau show an uptick in Americans who are uninsured but modest progress on poverty and income — handing Democrats and Republicans data for talking points.
Overall, the percentage of Americans lacking health coverage at any point in the year rose from 7.9% in 2017 to 8.5% in 2018. That’s according to annual numbers released Sept. 10.
The rise in the uninsured spanned demographic groups. Uninsured rates rose between 2017 and 2018 for whites, African-Americans, Hispanic Americans, Asian Americans, native-born Americans, foreign-born Americans, people with disabilities, people without high school degrees, and those under 18.
The 2017 and 2018 figures are not directly comparable with previous years due to changes in how the data is calculated. But a different data set showed that the small rises in the uninsured rate for 2017 and 2018 marked a change for a number that had improved every year since its peak in 2010, when the Affordable Care Act was passed. The law created a national marketplace for individual insurance and allowed states to expand Medicaid to more people.
Democrats pounced on the data release, with House Speaker Nancy Pelosi, D-Calif., blaming “President Trump’s cruel health care sabotage,” including his efforts to pare back the Affordable Care Act through regulations and in court.
But the Trump administration could point to modest gains in other statistics reported by the Census Bureau.
“Americans of all backgrounds are experiencing economic success in the Trump economy,” the White House said in a statement that cited media coverage of the new numbers on income and poverty.
The U.S. poverty rate fell for the fourth consecutive year, from 12.3% in 2017 to 11.8% in 2018. The national poverty rate is currently lower than it has been in any year since 2000, as this chart indicates.
Meanwhile, median household income rose for the fourth consecutive year after adjusting for inflation. It was a small rise, however, from $62,626 in 2017 to $63,179 in 2018, or an increase of less than 1%. And the pace of growth has slowed somewhat since the middle of this decade.
A leading measure of income inequality known as the GINI coefficient dipped slightly between 2017 and 2018. But its decades-long rise toward greater inequality was not greatly slowed.
Under this measurement, a score of 0.0 represents total income equality, while a score of 1.0 represents total inequality.
The overall statistics for poverty and income also mask significant differences by race and ethnicity.
In 2018, for instance, the poverty rate for whites was 8.1%. But it was much higher for African-Americans (20.8%) and Hispanic-Americans (17.6%) and modestly higher for Asian-Americans (10.1%).
The poverty rate fell slightly in 2018 for whites, African-Americans and Hispanic-Americans, while rising slightly for Asian-Americans.
