Scenario Planning in a Post-ACO and Post-ACA World for the Care and Population Health Management Industry



....and suppose there are 55
Republican Senators?

In a prior post, the Disease Management Care Blog provocatively suggested that providers, hospital boards and policymakers should hedge their bets and prepare for the possibility of a "post-ACO world."  If the Group Practice Demo's disappointing results are any guide, the likelihood of a happy ending for accountable care organizations is on numerical par with Congress' approval rating. While the DMCB likes the mutual "win-win" theoretical construct that underlies ACO gain sharing, it also recalls a life-lesson from the DMCB spouse: want you want and what you get are usually two different things.

So, if the Feds have to eventually retreat on the non-success of ACOs, what will be left in its wake?  More on that in future posts.

And while the uncertainty surrounding ACOs isn't bad enough, the DMCB has also been astonished by the battered Euro, the appearance of hospital-employed cardiologists and the absence of a Lady Gaga Christmas album.  Accordingly, the DMCB has learned its lesson and assumes nothing. 

That's why it's only natural that it would pay attention to this short and useful New England Journal Perspective article on the 2012 U.S. elections. Author David Blumenthal portrays the "consequences" as potentially "huge." The DMCB agrees. 

Three potential scenarios warrant health care leaders keeping their options open:

1. Obama wins, the House retains a Republican majority and the Senate retains a Democratic majority: Even if the individual "mandate" is struck down by the U.S. Supreme Court, the President will continue to implement the ACA's expansion of Medicaid, state exchanges, insurance subsidies and employer penalties.  House Republicans will continue their "defunding" attacks and may even draw some blood over the Innovation Center and comparative effectiveness research.

This makes the DMCB believe that more insured persons will increase the demand for population health and care management services. However, if your program is dependent on grants, watch out because the money is going to dry up - even if you have good outcomes.

2. Obama wins, but both the House and Senate have Republican majorities: The Republicans will reduce funding, hollowing out the ACA's ability to expand Medicaid coverage or support insurance subsidies. Mr Obama may have to compromise on enforcement of exchanges and employer penalties.  In the end, however, Presidential vetoes mean the ACA will not unravel, only slow down.

In other words, says the DMCB, because the number of persons entering the insurance market will be blunted, all those expansive population health business plans will need to be scaled back.  Relentless increases in health care costs among persons with insurance will spur interest in innovative care management programs that can do it better and cheaper.

3. The Republicans win a trifecta, taking the House, Senate and Presidency: Absent a 60 vote majority that can overcome Democratic filibusters, the Republicans will rely on the reconciliation process and the power of the purse to undo many of the ACA's provisions.  There'll be some modest programs involving bundling, care coordination and primary care, but the United States' "post-ACO" world will be eerily similar to the "pre-ACA" one.

To the DMCB, that means there is little hope that fee-for-service Medicare or Medicaid will cover care management.  As more persons become uninsured, population health companies will not only need to do it better and cheaper, success will depend on making more money off of fewer persons.  The only way out will be game-changing "killer" innovations.

The DMCB also offers up its own three scenarios:
  
1. Progressives, having the upper hand, will overreach and pronounce debate over the government's role in health care as over.  If cost-saving innovations flounder, the federal deficit grows and costs continue to gobble up more of the nation's GDP, the Dems will raise the option of a public payer.  Come to think of it, the DMCB suspects they'll bring it up anyway. Bloggers everywhere will be in hog heaven.

2. Progressives everywhere will pronounce any electoral loss as further evidence of their failure to properly educate a preoccupied and non-expert electorate on why they should let Washington run things.  Conservatives will overreach and pronounce the debate over the government's role in health care as over. They'll openly conspire to repeal Medicare.  Bloggers everywhere will be in hog heaven.

3. Conservatives, having the upper hand, will overreach and will assume Medicare beneficiaries want vouchers.  Smarter Republicans will have little appetite to repeat Mr. Obama's mistake of spending precious political capital on health care versus something far more important, like school prayer.  And...  bloggers everywhere will be in hog heaven.

Either Way, Mr. Disease Management Will Go to Washington

Plans are firming up for the annual if rescheduled DMAA confab. If you were planning on going to the cancelled star-crossed meeting, you’re in luck thanks to this do-over. If you weren’t planning on going, this is your second chance.

Either way, keep in mind that while Obama and McCain may have very divergent views on what to do about healthcare, both campaigns have repeatedly agreed on the need to promote programs for the care of populations with chronic illness aka disease management. While web sites do not policy make, the Disease Management Care Blog revisited both candidates’ dot coms to see if the bipartisan enthusiasm is still there.

It is.

From barackobama.com:

'Support disease management programs. Over seventy-five percent of total health care dollars are spent on patients with one or more chronic conditions, such as diabetes, heart disease, and high blood pressure.15 Many patients with chronic diseases benefit greatly from disease management programs, which help patients manage their condition and get the care they need.16 Barack Obama and Joe Biden will require that plans that participate in the new public plan, Medicare or the Federal Employee Health Benefits Program (FEHBP) utilize proven disease management programs. This will improve quality of care and lower costs, as well.'

From johnmccain.com:

'CHRONIC DISEASE: Providing Quality, Cheaper Care For Chronic Disease. Chronic conditions account for three-quarters of the nation's annual health care bill. By emphasizing prevention, early intervention, healthy habits, new treatment models, new public health infrastructure and the use of information technology, we can reduce health care costs. We should dedicate more federal research to caring and curing chronic disease.'

Will money fall from the sky? Come to Florida's Forum 08 and learn where to set out your baskets.

Not Only Can the Budget Sink Healthcare Reforms, So Can Toxic Levels of Expertise

The Disease Management Care Blog learned that the $700 Billion Big Bailout doesn't necessarily mean that the money's going to be 'spent.' The distressed mortgages that get purchased will be treated as an 'asset' on the government's books. Once property values bounce back, they'll be reverted back into cash.

Depressing, isn't it? Not only is the Fed's balance sheet being tasked to shore up the real estate markets, the technicality described above could give Washington DC the cover it needs to further increase spending. On the other hand, the likely downturn in the econonmy leading to fewer tax receipts may put the kibosh on the proposed $1.6 (D) or $1.3 (R) trillion ten-year health budgets.

Not that the DMCB has the answers. It also distrusts those who say they do. Yes, it's jealous of all those smart wonky experts that can navigate the arcane alleyways of health care policy, but there's more to it.

After a certain point, the correlation between the density of health care expertise and odds of adoption of a national program is decidedly negative. If a post-election downsized chastened Republican party wants President Obama to stumble, perhaps they should offer free one-way plane tickets to D.C. to anyone with a PhD in healthcare economics. Dems can do their part by forgoing a piecemeal approach, ignoring the novel reforms being championed by employers and seeing just how much ballast the experts add when the USS Obamacare gets launched.

Sound Off to the Republican Platform Committee

Want to share your good ideas on healthcare reform and chronic care improvement with the Republican National Platform Committee? Here's your chance.

The Democratic Race for President and Chronic Illness Care

The disease management care blog was trapped in airports over the weekend thanks to a vexing snow storm that snarled air traffic. The ubiquitous news monitors helped distract me from some of the misery thanks to slightly less miserable rebroadcasts of the recent Obama-Clinton debate.

So that readers of the disease management blog don’t need to subject themselves to the same drudgery, here is an efficiently recreated representative sample of what the candidates are a) saying and b) what we're hearing in this and other settings.

What they said:

Clinton: "This is a significant difference. You know, Senator Obama has said it's a philosophical difference. I think it's a substantive difference. He has a mandate for parents to be sure to ensure their children. I agree with that. I just know that if we don't go and require everyone to have health insurance, the health insurance industry will still game the system. Everyone of us with insurance will pay the hidden tax of approximately $900 a year to make up for the lack of insurance. And you know, in one of our earlier debates, John Edwards made a great point. It would be as though Social Security were voluntary. Medicare, one of the great accomplishments of President Johnson, was voluntary. I do not believe that is going to work. So it's not just a philosophical difference. You look at what will work and what will not work. If you do not have a plan that starts out attempting to achieve universal health care, you will be nibbled to death, and we will be back here with more and more people uninsured and rising costs."

Obama: Number one, understand that when Senator Clinton says a mandate, it's not a mandate on government to provide health insurance, it's a mandate on individuals to purchase it. And Senator Clinton is right; we have to find out what works. Now, Massachusetts has a mandate right now. They have exempted 20 percent of the uninsured because they have concluded that that 20 percent can't afford it. In some cases, there are people who are paying fines and still can't afford it, so now they're worse off than they were. They don't have health insurance and they're paying a fine. In order for you to force people to get health insurance, you've got to have a very harsh penalty, and Senator Clinton has said that we won't go after their wages. Now, this is a substantive difference. But understand that both of us seek to get universal health care. I have a substantive difference with Senator Clinton on how to get there.

What I heard:

Clinton: Obama you ignorant upstart blah blah Blah blah blah blah Blah Blah BLAH blah blah Blah blah mandated coverage blah Blah blah blah blah Blah Blah BLAH blah blah Blah I’ll print money if that’s what it takes to cover the chronic condition management programs blah Blah blah blah blah Blah Blah BLAH blah blah Blah blah blah blah Blah blah blah blah Blah Blah BLAH blah blah Blah blah blah blah Blah blah blah blah.

Obama: Hillary you slanderous has-been blah Blah blah blah blah Blah Blah BLAH blah blah Blah blah blah blah Blah blah I’ll print money if that’s what it takes to cover the chronic condition management programs blah Blah blah blah blah Blah Blah BLAH blah blah Blah blah blah blah Blah blah blah blah Blah Blah BLAH blah blah Blah no mandated coverage blah blah.

The Prospects for Health Reform and Disease Management

Fed up with the media primary frenzy, my wife has temporarily banished TV election coverage from our house. So, in response, the Disease Management Blog retreated to the office and nosed around some of the candidates' web sites, press releases and press reports and copied some telling quotes:

…will require that providers that participating in the new public plan, Medicare or the Federal Employee Health Benefits Program use proven disease management programs.
.

…will ensure higher quality and better coordination of care by using state of the art chronic care coordination models with federally funded programs to provid care for Americans afflicted with the costly multi-faceted illnesses.

...infuse incentives in insurance markets that promote wellness and better outcomes for chronic diseases. Health insurance must be redefined to cover wellness and well as sickness.

...give states more flexibility in how to use federal Medicaid dollars, making it easier for states to develop innovative programs - such as one in Utah that helps people managed chronic illness, keeping them healthier and reducing costs.

...any health care proposal must first focus on containing spending. To accomplish that, the emphasis should be on better treating chronic disease, like diabetes and heart disease....

('nuff said)

Issues of election rhetoric aside, it's remarkable how much apparent agreement there is across the political spectrum on the need to develop "programs" for persons with chronic illness. While the details have yet to be worked out and then there is the matter of Congressional buy-in, it seems that no health care reform proposal will be complete without some type of "disease management" in it. That's the good news.

Want some bad news? Check out Victor Fuch's Perspective piece in Health Affairs, where he points out that the coming Congress and administration will be hobbled by an inability to marshal enough of a reform-minded coalition, fear of change outweighing its attractiveness and the disproportionate political power of special interests. Then there is the distraction of some very important foreign policy issues, including withdrawal from Iraq & Afghanistan and dealing with the nuclear ambitions of North Korea and Iran. While the long term prospects are ultimately good, the chances of something happening in the next 5-10 years is "50-50" and "the executive and legislative branch will have little time or political capital to spend on major health care reform for the rest of this decade."

(Sigh).

The Disease Management Blog will be on the road for the next 3 days. I hope to stay in a cheap hotel which means free internet access but doesn't mean a lot of time to post material. We'll see.