CMS and Health Reform: More of the Same

Unmentioned.....

Whoa, with breathless media coverage like this (dramatically change! ambitious!) you'd think that the Feds had just announced something important about health reform. 

After reading the CMS press release, a CMS blog post and this article in the New England Journal, the Population Health Blog has concluded that it's more of the same. 

As the PHB understands it, Medicare's January 26 announcement is that it will build on three ongoing reforms:

1. Financial incentives to expand "alternative payment" methodologies to 30% of all reimbursement by 2016 and to 50% by 2018.  These include accountable care organization arrangements, monthly fees to Patient Centered Medical Homes and use of bundled payments.  In addition, 85% of fee-for-service payments that are still in place will be linked to quality by 2015, with an increase to 90% by 2018.

2. Promoting "provider integration." That apparently means a new forum called the Transforming Clinical Practice Initiative, with a first yet-to-be-planned meeting in March of 2015.  In addition, CMS will continue to rely on its Partnership for Patients and the Patient Centered Outcomes Research Institute.

3. Information technology (IT) including more promotion of electronic records, meaningful use, interoperability and universal information technology standards.

[Yawn]

The cynical PHB is not impressed. The Obama Administration was using, is using and will continue to use faux announcements to advance its reforms.  What's more, when it reads the CMS pabulum, it's riddled with the same top-down mainframe rhetoric on realigning care, moving from volume to value, accountability, alternative payment models, serving populations, building a better system, increasing coordination, convening meetings, promoting information technology etc. There are no new details here.

The PHB will share three insights, however:

1. CMS, Ms. Burwell and their White House handlers lost an opportunity to reach out to the Republicans about the sustainable growth rate and leveraging that to build on multiple areas of agreement to jumpstart bipartisan reform.  Doing so could have accelerated the forward momentum of value-quality-cost-based reforms beyond the 2016 elections.

2. That being said, health care providers need to increase their familiarity with the opportunities as well as perils of payment reform as well as the very real barriers to fixed payment schemes.

3. The announcements are a reminder how CMS is still fixated on the EHR, while the real innovation is occurring in handhelds and their associated applications.  The PHB figures that its not about the providers and their desktop electronic records, but about patients and their smart phones. As these devices continue to grow in speed, power and sophistication, providers who figure out how to use the iPlatform to leverage self-care, communication and decision support will thrive.....

With or without Medicare's incentives, promotion or IT policies.

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Handling HHS Secretary Nomination Questions

The Population Health Blog notes that HHS nominee Burwell has been scheduled to appear before the U.S. Senate Health, Education, Labor and Pensions Committee on May 8.  In all likelihood, the hearing will alternate between yawnfest softball and hyperparisan gotcha questions on the budget, ACA repeal, agencies and contraception.

The PHB plans on watching C-SPAN, hoping that some of the questions deal with its favorite blogging topics.

In the unlikely event that they do come up, the public-service minded PHB is pleased to prep Ms. Burwell with some "canned" and ready-to-go responses. The turnkey options below have been crafted to upend foes and friends alike.

When asked any question about "population health," respond by:

1. pointing out that you rely on the Population Health Blog's definition and, based on its author's many insights, believe that it is a promising feature of health reform, or....

2. affirming that "if you like your population health, you can keep it," or...

3. saying that HHS remains strongly committed to evaluating and further developing the future role of population health as an important option to derive high value care for Medicare beneficiaries!

When asked about the part of the Obamacare law that includes "shared decision making," respond by:

1. noting years of research on the topic have demonstrated that it is among the few interventions that can simultaneously reduce health care costs and increase beneficiary satisfaction, or...

2. reiterating that Congressional Republicans are not going to share in any decision making when it comes to any health care reform, or....

3. saying that HHS remains strongly committed to evaluating and further developing the future role of shared decision making as an important option to derive high value care for Medicare beneficiaries!

When asked about the Patient Centered Medical Home, respond by:

1. quoting extensively from the PCPCC web site, or...

2. announcing cautious support for the medical home, but confirm HHS' intention to name it something else, create alternate criteria, assess different outcomes and insist on budget neutrality, or...

3. saying that HHS remains strongly committed to evaluating and further developing the future role of the Patient Centered Medical Home as an important option to derive high value care for Medicare beneficiaries!

When asked about care management, respond by:

1. pointing out that, for the right patients, studies like this show teaming between physicians and non-physicians can result in outcomes that are the result of more than the sum of its primary care parts, or...

2. announcing your intent to regulate the carbon footprint of all Medicare-participating acute-care hospitals, or...

3. saying that HHS remains strongly committed to evaluating and further developing the future role of care management as an important option to derive high value care for Medicare beneficiaries!

When asked about primary care, respond by:

1. not saying that the 10% fee increase has resulted negligible changes in primary care physician satisfaction, or...

2. promising you're going to fix low primary care fee schedule rates faster than a Florida ophthalmologist submitting a $10,000 Medicare billing code, or...

3. saying that HHS remains strongly committed to evaluating and further developing the future role of primary care as an important option to derive high value care for Medicare beneficiaries!

When asked about the sustainable growth rate, respond by:

1. Denying any White House responsibility, or....

2. Denying any White House responsibility, or...

3. Denying any White House responsibility

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Questions That Should Be Asked in the Upcoming HHS Secretary Nomination Process

As a public service, the Population Health Blog is pleased to offer up some questions that may or should arise in the course of Senate confirmation process for HHS nominee Ms. Burwell. 

If she can address the inquiries in these key categories, the PHB suggests she'll be more than prepared for the job:

The Clinton years: Supporters of the Affordable Care Act say "it is now the law of the land."  Based on your extensive experience in the Clinton White House, how would you define "is?"

Signing up young people: Do you credit the last-minute surge in sign-ups on the individual exchanges to Mr. Obama, Mr. Galifianakis or to the Two Ferns?  How will you use that insight to increase individual enrollments in 2015?

Use of social media: Since the Population Health Blog began on-line publication more than 5 years ago, health care cost inflation has moderated significantly. Please explain how Medicare's actuaries will factor this into their future projections.

Doing your part for the 2014 mid-term elections: Will you advocate that the "essential health benefit" be broadened to include coverage for global warming?

To test your awareness of the employer mandate: If Peter Baelish hires 47 part-time seasonal service employees in KIng's Landing for more than 120 continuous days in the first quarter of 2014 without a profit sharing provision, what is the number of FTEs and what would the "4980H penalty" be if it were calculated in Gold Dragons?

And finally, tort reform:  Suppose Iva Pannus buys taxpayer subsidized insurance but also participates in a workplace weight reduction program. If Iva's girth paradoxically increases and she develops sore knees, should she sue in state court to recover her out-of-pocket "bronze" plan expenses and should HHS assert a lien if there is a jury award?

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Say Hello to Sylvia Mathews Burwell, the Nominee for HHS

The Population Health Blog is naturally intrigued by the announcement that Kathleen Sebelius is resigning from her position as HHS Secretary, and that the White House will nominate Sylvia Mathews Burwell to replace her.

So, who is she? 

After reviewing a number of reports that are summarized below, it seems Ms. Burwell is a widely-liked and experienced Washington insider. She has a Clinton-Lew-Rubin pedigree and possesses considerable economic/budgetary credentials. Most of all, has the best chance of anyone of getting confirmed by a fractious US Senate.

The bad news is that she doesn't appear to have any significant experience in health care or with health insurance.  Whether her past with McKinsey or as a Met-Life Board member will help her collaborate with the state-regulated commercial health insurance business is an open question.

Onto the summary.....

Ms. Burwell is the current Director of the White House Office of Management and Budget (OMB), where she has served since April of 2013. She's described as genial, a liberal who favors social programs, is willing to take on spending-wary Republicans (with government shut-downs, if necessary) but isn't especially ideological when it comes to managing the budget.  Her nomination to OMB also helped quell criticism that the White House was dominated by males.  She was confirmed by the U.S. Senate 96-0.

Her 96-0 vote getting track record makes it far more likely that Mr. Obama's nominee will survive what will likely be an intensely partisan process.

Here's Ms. Burwell sticking to her Obamacare talking points, even if it means glancing at some notes to make sure she's got it right:

Prior to serving in the Obama Administration, she was President of the Walmart Foundation (dedicated to ending hunger). During her OMB confirmation hearings, she was criticized for not distancing herself from the company's anti-union activities. During this time, she also served on the Board of MetLife, which, during her tenure, was criticized for mishandling mortgage loan foreclosures.

Prior to Walmart, she was at the Bill & Melinda Gates Foundation for about 10 years, where she was President of the Global Development Program; she may have been more willing to leave for WalMart when she was passed over to lead the entire Foundation.

And before Walmart, she was in the Clinton White House, where she served in a variety of roles for all eight years of the Presidency. After leading the economic transition team immediately following the election, she then went on to serve in a variety of roles, including Deputy Director of OMB under Jack Lew, Deputy Chief of Staff to President Clinton and Staff Director of the National Economic Council.  When Robert Rubin left the Council to become Treasury Secretary, she followed him as Chief of Staff. 

It's unusual for anyone to last two terms with any President in modern day Washington.

She also worked as governor's aide to Massachusetts Governor Michael Dukakis.

She has experience in retail politics, having worked in the Dukakis/Bentson and Clinton/Gore campaigns.

She's also former McKinsey Company employee, where she worked for two years after her college graduation.

She's been criticized for using consultant management jargon in White House meetings.

She received an A.B. Government from Harvard University and a B.A. Philosophy, Politics and Economics from Oxford University, where she was a Rhodes Scholar and a rower. 

She's married to an attorney and has two children. Her family is originally from West Virginia. Her dad is a retired optometrist and her mom was a small town mayor who first ran for the office at age 65.

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