Insurers and Providers Collaborating on Value Based Care Delivery

In late January when I presented to the American Hospital Association's Board of Trustees on Redefining the H, I focused on Value-Based Care Delivery through Total Patient Revenue.  That morning, the first speaker was Joe Swedish, the CEO of WellPoint, one of the nation's largest insurers.  He spoke refreshingly of WellPoint reaching out to providers and working together to jointly manage the care of patients.  Yesterday, WellPoint announced that they will be working with Emory Healthcare in Atlanta revamping the care of Medicaid patients.  Joe, a former health system CEO, is walking the talk as he is forging ties with providers across the U.S. in WellPoint markets.  

What WellPoint is doing is exactly what WMHS has been doing for the last three years, but we have been doing it alone.  It would be helpful to have a partner from the insurance side; and we do in our relationship with Aetna through Maryland Physicians Care, but no where near this magnitude.  Maybe, it's time for a change.

Redefining the H

As I have blogged previously, at the end of January I had the opportunity to speak at the American Hospital Association's Board Retreat.  The title of the retreat was "Redefining the H.”  As Rich Umbdenstock, President and CEO of AHA explained, "that big H on those blue and white signs denoting "Hospital" always carried the promise of help, hope and healing; the hospital of the future will continue to extend that promise but in new ways by improving quality while lowering cost.”  

Prior to my presentation, Rick said that the environment in which hospitals are operating is extraordinarily challenging, but by becoming proactive rather than reactive and keeping people healthy, by moving care out of the hospital and into the communities, by increasing the use of medical and information technologies and by using / applying evidence-based practices to better manage all illnesses more effectively, hospitals will continue to meet their commitment to their respective communities.  

His opening was a great lead in for my presentation on our transition to value-based care delivery and the success that WMHS has achieved through the Total Patient Revenue demonstration project that is now the standard in Maryland health care delivery.  As WMHS has successfully demonstrated, we are still there providing care under that big H in the Emergency Room 24 / 7, in our operating rooms that are still fully staffed and equipped, and in our heart program that remains one of the best in the state and the patient is now at the center of everything that we do through the Perfect Circle of Care.  But, we have also transitioned well ahead of the rest of the hospitals across the U.S. by delivering care in the most appropriate location, whether it's in the home, in a skilled nursing facility, in an outpatient clinic or a physician's office.  We have demonstrated that the big H is more about the delivery of care under a value-based approach rather than a building, a nice new hospital building that is now only one component of our new coordinated system of care.

Between Two Ferns (Warning: Contains Sensitive Material)

The other day, I saw that video that President Obama did with Zach Galiafianakis to promote his health care plan to young adults.  It was entitled "Between Two Ferns" and quite honestly, it was brilliant.  It was funny and I, for one, liked it.  The President has a big problem in not getting enough healthy young adults signing up for HIS health care plan (can't blame this one on W).  The Between Two Ferns clip has had millions of hits since it aired on Monday and the healthcare.gov website had over a 40% increase in traffic with nearly a million hits the day after the video aired.  (You can watch the video on theverge.com.)

Now, many are absolutely apoplectic over the decline of the Presidency as a result of this video.  Quite honestly, the traditional means of communication are a bit outmoded and when in desperate times one has to take desperate measures.  These are desperate times for the Affordable Care Act aka Obamacare, so whatever can be done to promote getting millennials to sign up for health care should have been done yesterday.  

As I have blogged before, the care delivery aspects of the Affordable Care Act are right on target; however, the insurance side of the ACA has been an unmitigated disaster.  So, borrowing on the success from Obama's election and re-election campaigns makes a great deal of sense under the circumstances.  Actually, I thought the healthcare.gov toll free number 800.318.2596 should have gotten a lot more play in the media based on the letters that equate to that number. I am not making this up and if you don't believe me call
800. F 1 U CK YO.  Now that's inappropriate and puts the President, the White House and his health care plan in a not so positive light.  The Obama White House is far too sharp to have let the telephone number slip by.  One could assume that it was designed as a message to the Republicans as they try to repeal the Affordable Care Act.  Nevertheless, there would have been far better ways to get that message out.  

Not To Get Too Personal, But Cancer Sucks

Less then two weeks ago my son-in-law Terrell was diagnosed with osteosarcoma.  Thinking that he had a tear of some sort in his right knee, he went to see an orthopedic surgeon.  The surgeon took an x-ray and didn't like what he saw so, he scheduled Terrell for a MRI.  The radiologist's interpretation of the MRI shocked everyone to the point that the follow up specialist didn't think that it was possible to have that diagnosis in a healthy 32 year old.  He predicted a giant cell tumor (non malignant), but scheduled Terrell for a needle biopsy and a chest x-ray just to be sure.  The chest x-ray eventually came back clear (osteosarcoma metastasizes in the lungs pretty quickly), but the needle biopsy was inconclusive.  It was definitely not a giant cell tumor.  Next was a surgical biopsy.  It was shortly after the surgical biopsy that we all got the news and the radiologist's interpretation of a high-grade osteosarcoma was confirmed.  The treatment was pretty cut and dry: ten weeks of chemotherapy with a two day hospitalization for each treatment, then reconstructive surgery to include the knee and part of the femur and then ten more weeks of chemo.  Terrell's chemo starts this Thursday, but the "adventure" began with that initial x-ray of his knee.  

Lots of speculation, lots of ups and downs leading up to and since the diagnosis.  So why am I blogging about a cancer diagnosis in a loved one?  Because I am amazed at a couple of things: how consuming it all is on Terrell,  Jessica, his mother, his step father, his sister and her family as well as our immediate family.  This kind of stuff happens to other people, not us.  Well, that's no longer the case.  It's here and we are all dealing with it as best as we possibly can.  Next, it is wonderful to see the immediate reaction from family and friends toward both of them.  The outpouring of thoughts, prayers, support and genuine kindness has been overwhelming.  My only hope is that they both allow the rest of us to carry some of the burden that they are facing.  This will be one hell of an ordeal and the hard part only gets worse for some time to come.  So I ask, keep Terrell and Jessica in your thoughts and prayers.  Even if you don't know them, they can still use your thoughts, your prayers; hell we'll even take those positive vibes and good mojo.  

Every cancer is different as is every person who gets it.  The staff at WMHS remind me that they see miracles every day in our Cancer Center, our ICU, our heart institute and the list goes on.  I am hopeful that those same kinds of miracles make their way to Charleston, SC.  God speed, Terrell.

Falling Victim to the Hackers

Last week, Pamela goes to the grocery store and attempts to pay with her debit card.  The clerk tells her that her card has been rejected.  She asks, "Try again, this is my debit card that is tied to my checking account and if I don't have enough money to pay for my groceries, then I have a much bigger problem."  The card rejects a second time.  Pamela pays with a credit card and heads home to check on what has happened to our checking account.  She calls customer service on the back of the debit card and waits and waits.  Right before she hangs up, she gets to talk to a person who tells her that her debit card and our account have been hacked.  Someone tried to use her debit card in San Diego to make three minor purchases, even though the debit card never left her possession.  The bank stopped the transaction, flagged the card and our checking account remains in tact.  

So, we then tried to piece together how this happened.  In a matter of minutes, we realize that we fell victim to the recent hacking at the University of Maryland.  You see we are helping our daughter Lauren with her graduate school tuition. Last month, there was a mix up with the payment, so Pamela called University of Maryland and made the payment with her debit card over the phone--only to learn shortly thereafter that there was a data breach at the University of Maryland.  Fortunately, the bank caught the attempt of some minor purchases by the hackers so it could have been far worse.  Then I ask whatever happened to the Lifelock notification that I pay for each year for added protection.  It will be worth checking into but kudos to the bank for stopping the fraudulent activity and protecting our assets.

Medicare Appeals

Talk about beating a dead horse. I am once again blogging about my what has become my new favorite topic, Medicare appeals or the Recovery Audit Contracting process.  Today, I read a great article by our RAC consultant, Tom Herrmann in the January - February edition of the Journal of Health Care Compliance.  The article is on the latest announcement from the Office of Medicare Appeal Hearings on delays in adjudicating cases due to the massive backlog of appeals.  Tom also provides a great overview of the RAC process.  

The item where I take issue is where he describes what we as providers need to do to facilitate the ALJ adjudication process.  It's always about what we as providers can do.  What is rarely mentioned is the albatross created by Health and Human Services to root out improper Medicare payments, i.e, catch fraudulent providers to facilitate the process.  

Very little of the Government's role related to the RAC process is automated.  They open mail and process appeals manually; can you believe it in this day and age?  They are well over a year away from any automation and we know how well the Feds are at bringing systems up these days.  

They created a RAC process that is wrought with problems.  As I have blogged previously, they expected hospitals to roll over and simply budget for the RAC process in our operating budgets as most hospitals did initially.  We never did at WMHS; we challenge every case where we believe the correct care was provided.  Isn't it interesting that we have never won an appeal by the RAC auditor who is incentivized by the number of cases that they target?  We have never won an appeal at the Qualified Independent Contractor level either.  We have won almost every case at the Administrative Law Judge level as have most hospitals because the ALJs are not incentivized.  They adjudicate the cases appropriately and as a result, the appeals at this level have proliferated. So, why not restructure the process up front.  

Marilyn Tavenner, the CMS administrator, is now trying to convince us that CMS is exploring ways to improve  the RAC process.  I am sure they are but it's time to ask the people who they are burdening financially and administratively with this boondoggle for our advice and guidance.

Separating the Useful Information from the Gibberish

I read Dr. Mark Thoma’s blog over the weekend that 120 computer-generated, non-sensical research papers were published in scholarly journals.  Apparently, MIT created software that presents nonsense information in a correct format with tables and graphs along with references for the "papers.”  These papers, which are computer generated fakes, have found their way into both the scholarly journals but also cited at various conferences around the world.  Is this new, no?  But, it is increasing.  

After reading the article, it made me wonder if the same thing can be said for the thousands of pages in Congressional bills or bills before the Maryland General Assembly.  Have you ever read some of these bills?  Some of the contents many times appears to be gibberish, but then again these bills still become law even with the actual specifics of the contents being unknown to so many, including those who are required to vote on them.   

It also made me wonder if publications like the Harvard Business Review (HBR) intentionally publish non-sensical gibberish from time to time.  I am half kidding.  There are many excellent articles in the HBR, but there are times that I read an article and I have absolutely no idea as to what the author is trying to say.  Then I think, are these authors simply trying to convey just how much smarter they really are or do I need to simply eliminate the distractions around me and better concentrate on the article that I am reading?  Nine times out of ten, it is the latter.  

Anyway, I find it amazing that computer generated fakes can be cited in the work of "bonafide" researchers and academic institutions around the world. Their credibility has to be and should be shaken in letting these fakes into their academic publishing.