AHIP Steps Up With Their Version of Health Reform

While HHS Secretary Sebelius reassures the House Republicans that the Fed's health insurance exchanges are on track, that the implementation of the Affordable Care Act will not be a "train wreck" and flies around the country touting Obamacare, Disease Management Care Blog readers may want to check out this 3 page article by the notorious anti-Sebelius a.k.a. AHIP's CEO Karen Ignagni.  In it, she mounts a vigorous defense of her trade association's commercial insurer members.

She points out:

1) Commercial insurers' versions of accountable care organizations include a variety of prospective payment approaches that are tailored to the provider's willingness to take on insurance risk.  What's more, commercial insurers can "calibrate" the benefit so that consumers', physicians' and hospitals' economic incentives are all aligned.

2) Health plans are quite able to share data and analytics support that translates into early identification of trends, accurate payment designs and the targeting of programs at patients who are at greatest risk.

3) AHIP's members are routinely providing health risk assessment tools, predictive modeling, medication compliance programs and care management services.

4) AHIP is well aware of the difference between true cost savings versus mere cost shifting.  As a result, they are asking for greater transparency on commercial and government fee schedules so that the potential impact of cost shifting can be better understood.

5) While Washington DC deserves a lot of credit for promoting a quality agenda, it could do a better job of working with all insurers to come up with a set of universally used quality measures.

6) While commercial plans are required to use uniform billing systems, providers are under no obligation to submit their claims electronically.  While this certainly helps physicians over the short term, the long term inefficiencies are not cheap.

7) Commercial insurers would rather cover treatments that have been shown to work. The "Patient-Centered Outcomes Research Institute" is not mentioned by name, but you get the idea.

8) AHIP supports letting non-physicians practice "to the top of their license."

9) State-based "laboratories of democracy" are a useful way to try out a variety of health reforms before they are adopted by Washington.

The DMCB's take?

AHIP and Karen Ignagni have been mostly out of the public eye.  Could this be a sign that they're less wary of the Administration's anti-insurer bluster?

While Medicare's Innovation Center continues to get high marks, the commercial insurers appear to be advantaged by having more leeway to test new payment and care management strategies.

AHIP's members are aware that many providers could fold if they mismanage the risk that underlies prospective payment systems.  Unike Washington's one-size fits all approach, they seem prepared to adapt their contracting accordingly.

Care and disease management programs?  The commercial insurers have rolled this into standard operating procedure.

An Update On Population Health Management: It's Working!

CMS, MA Plans & Disease Management?

It's a good day when Health Affairs has nice things to say about population health management (PHM).  After all, Health Affairs is one of the bedside reading options for inside-the-beltway health care elites. So, when hostility to Ver. 1.0 disease management turns into a reasoned summary of Ver. 2 PHM, that's not only evidence of PHM's success but waning anti-vendor ideology. While the ultimate success of PHM is a function of market demand, this kind of endorsement can't hurt.

Using the Care Continuum Alliance's definition of PHM, researchers from America's Health Insurance Plans (AHIP) and Brandeis University conducted a written and then telephonic survey of 42 out of 72 larger Medicare Advantage (MA) Plans. While the results were interesting, what caught the Disease Management Care Blog's eye was that.....

Disease and case management are "routinely used." These programs are made up of nurse hotlines, telephone visits, increasing access to social services, meeting patients' psychosocial and providing care coordination. An accompanying infographic says "100%" offer "teaching chronic disease self-management."

Health risk assessments are also used "universally" and target self-identified individuals with outreach designed to educate and/or enroll in programs that reduce risk factors.

Care managers for the frail elderly are available in "100%" of plans. A second infographic points out that home safety, in-home visits and community services referrals are among the top used interventions. And, as testimony to a lingering sense of skepticism over remote home monitoring, the infographic says that was only used in 56% of plans.

Unlike Medicare fee-for-service (FFS), hospital readmissions have been a top concern of the MA Plans for years. They know there is no single "silver bullet" and have long relied on a combination of nursing, social services, home-health visits, medication reconciliations, follow-up care coordination programs and home visits. Survey respondents were convinced their programs were "effective."

In other examples of MA Plans being light-years ahead of Medicare FFS, if providers need data, MA Plans will make it available. If payment reform is necessary, MA Plans will make deals involving global risk arrangements, bundled payments and shared savings.

Evidence? Regretfully, say the authors, there is a lack of "systematic evidence" supporting PHM's effectiveness.  They also believe that there is conflicting evidence on whether MA Plans achieve better outcomes versus Medicare FFS.

The Disease Management Care Blog's take:

While skeptics continue to believe that Medicare Health Support "proved" that "disease management" doesn't work, the MA Plans correctly surmised that MHS only proved that early versions of disease management in Medicare FFS settings doesn't work.  The MA Plans have figured out how to improve on disease management.

While published data may be lacking, the people who run MA Plans are not dunces.  They have internal data showing that it works, or they wouldn't be using it.

While the Medicare Advantage program is controversial, the Health Affairs post suggests the MA Plans are useful laboratories for seeing what can be of benefit in the care of Medicare-eligible seniors.  If ACOs flop, perhaps CMS will go back to the future with their MA Program for ideas on what can work.

AHIP Releases Health Reform Recommendations: Read the Condensed Version Here

Read the America’s Health Insurance Plans' (the association that represents the nation's health insurers) comprehensive reform proposal here – or, speed read this exclusive Disease Management Care Blog summary. Go ahead, call them self serving, call them obstructionist, call them names but unless these guys are at the table, meaningful health reform is going to be very very difficult. What's more, if you're going to expand insurance, it makes sense to listen to these guys. They know what they're talking about.

Here's the summary. Ready? Go....

Reduce projected costs though evidence-based medicine, reward quality, streamline administrative processes (1), wellness, prevention and chronic care coordination, uniform quality reporting standards, an advisory group (2), an ‘independent comparative effectiveness entity’ (3), strengthened public health infrastructure, combining a community rating with individual mandate (4), tax equity for individuals and small businesses, high risk pools, tax credits, essential benefits plan (5), transparency, first do no harm to the large employer market, avoid unintentional cost shifting, strengthen public programs and partner with the States.

There. You're all done. Now here are 5 details that the DMCB thinks are interesting:

1. Multi-payer portal: instead of dealing with differing billing formats, AHIP’s members are apparently agreeing to share a one-stop web site which would simultaneously handle multiple health insurers. This would reduce the administrative hassles for the physicians. Ironically, this probably represents an additional short term cost for the insurers, who would need to alter their billing work flows. It would need to be outsourced to a third party so that the insurers couldn’t “peek” at each other’s fee schedules. Care to guess if Medicare FFS is going to participate?

2. Public private advisory group: Rather than an all powerful ‘Health Fed,’ AHIP is respectfully disagreeing with and Senator Baucus and former Senator Daschle. They’d rather have an entity develop recommendations on slowing spending, rewarding quality and reducing administrative costs (like the ‘portal'). Recommendations are easier to ignore or modify than Federal regulations.

3. Independent comparative effectiveness entity: You can bet the health insurers would like this. Contentious and sometimes embarrassing coverage decisions/denials over ‘medical necessity’ and the possible ‘investigational and experimental’ dimensions of treatment would become much easier to manage. Count them as being on the NICE bus.

4. Community rating and mandates were covered here. As a regular reader, you’re already expert on this.

5. Essential Benefits Plan: a not so bare bones but minimalist high deductable-health savings account insurance thingy that meets one of the DMCB’s recommendations: the purpose of health insurance is to reduce the likelihood of a financial catastrophe due to unexpected illness, not meet countless mandates.

Medicare Fee Schedule Cuts, Private Fee For Service, the AMA and Hand Gestures

The Disease Management Care Blog thought Karen Ignagni had cornered the hand gesture market. Ms. Ignagni’s classic two-handed chops, sweeps and grabs in her speeches not only help emphasize her points, but remind the DMCB of a martial artist's kata. Observe Ms. Ignagni’s interview here (once the initial question is over) and this classic kung-fu exercise and see if you can tell the difference.

Well stand back, because Nancy Nielsen, MD, President of the AMA has her own repertoire of jabs, pokes and pushes that accentuate her organization's considerable annoyance at the U.S. Senate’s recent failure to cancel a scheduled 10.6% fee schedule cut by transferring the necessary funding from the private fee for service (PFFS) Medicare plans. Dr. Nielsen and Ms. Ignagni obviously stand on opposite sides on this issue, and the DMCB recommends someone get these two experts together not only for what would be a hugely educational discussion but for an equally entertaining hand gesture smack-down.

Want to learn more about this Republican-Democrat health care kerfuffle? In the opinion of the DMCB, the best summary can be found here at the Health Affairs blog site.

But the DMCB wanted to learn more about hand gestures. This is an excellent article from Scientific American that explains speech and hand gestures are hard wired together in humans. For example, babies who have not yet learned to speak use gestures, while persons with damage to the brain’s ‘speech centers’ lose their ability to interpret gestures. In addition, humans (and primates) are vicariously endowed with ‘mirror neurons’ that are not only activated when we perform a movement but when we observe another person performing the same movement. Numerous studies that have shown speech plus gestures results in far better communication than speech alone.

In fact, this hand-speech connection may be so hardwired, that having your mouth say one thing and your hands do another can be a telling clue to an audience that something is amiss. Unsurprisingly, the best medium for observing this mismatch can be found in politics. Not getting this right can make all the difference in a contender’s career, which is why considerable time and effort may be needed to tie a speech and the movements ‘naturally’ together.

In the meantime, the DMCB has trouble understanding what the Medicare physician fee schedule has to with Medicare PFFS. It has to admit, however, that tying them together and forcing the PFFS supporters to vote ‘against physicians’ was a stroke of partisan genius. Too bad it’s also another example of the manipulative gamesmanship that can get in the way of real health care reform. To the folks in Congress, here’s a gesture from the DMCB to all of you.

'Adopt' versus 'Release.' What AHIP Really Says About the Patient Centered Medical Home

Hat tip to Modern Health Care Online with their June 26 story that ‘AHIP adopts principles on patient centered medical home.’ Interestingly, the AHIP press release does not use the word ‘adopt,’ as in ‘accept,’ ‘support,’ ‘embrace,’ ‘desires,’ or ‘likes.’ Rather, the document itself is a carefully crafted and rather cautious outline of what the risk-bearing health insurers think about this topic at this time. Read it for yourself here and/or consider these quotes (bolding mine) and decide for yourself:

'The Patient centered Medical Home is a promising concept that would replace episodic care.'

'Even though many clinical setting can potentially constitute a patient centered medical home, we believe certain principles are crucial…'

'….ongoing market experimentation regarding designing and implementing the medical home, our community has made a commitment to work collaboratively with other stake holders…..'

'The medical home is not a concept designed to provide one standard of care process…..'

'Learning collaboratives, both physical and virtual, should be encouraged as a way to share early successes….'

'Clinicians…should commit to being accountable for improving clinical outcomes and patient experience, appropriate utilization… and ensuring transparency.'

'The benefits of a medical home only [sic] will be realized if both clinical practice and consumer behavior evolves….'

And what the DMCB thinks is a bottom line:

'Pilot testing…. should be completed before the patient centered medical home concept is broadly implemented to determine which approaches are most effective. Research is needed to determine a sustainable framework for improvement of clinical outcomes, ways to ensure long term affordability for patients and the best methods for implementation to ensure a stable infrastructure that prioritizes improved health outcomes.'

The verb used in the AHIP headline ‘releases.’ Sorry, PCMHitzens, you still have some work to do before the insurers will start cutting checks.