Accountable Care

If value-based care is to take shape, it’s critical that providers actively engage with patients to help them better understand the true cost of care.

A patient survey helped a seriously ill patient with a secondary complication that would have otherwise gone undetected.

Results of two polls published in the past week, from the Kaiser Family Foundation and Pew Research Center, demonstrate growing support for the Affordable Care Act, aka Obamacare. The Kaiser Health Tracking Poll: Future Directions for the ACA and Medicaid was published February 23, 2017. The margins in February 2017 were 48 percent favorable, 42 percent  unfavorable. While the majority of Republicans continue to be solidly against the ACA, a larger share of voters who identify as Independent have shifted to a favorable position on Obamacare. Furthermore, the KFF survey found that more than one-half of Americans overall say Medicaid is important for their families, with fewer Republicans saying so. Fifty-six  percent of Americans said they had some connection to Medicaid, either currently or in the past. The KFF survey was conducted February 13-19, 2017 by telephone among 1,160 U.S. adults ages 18 and older. The Pew poll asked people if they approved or disapproved of the healthcare law passed by Barack Obama and Congress in 2010. The difference between pro- and con- in the Pew poll was wider than in the KFF survey, with 54 percent approving and 43 percent disapproving. Among people who disapprove of the law, more want to see Republican Congressional leaders modify the law versus repealing it, now with 44 percent of Republicans seeking repeal and 42 percent looking for a “repair.” There’s also a big difference in how younger Americans view the ACA compared with older people by a 2:1 ratio: 65 percent of younger adults approve of the law vs. 31 percent who disapprove. Support for Obamacare has also grown among Americans between 50 and 64 years of age. Note that the divergence in positive/negative responses in both polls reversed in 2017, lines crossing in the opposite directions as the 2017 new year set in with the eventual confirmation of Secretary Tom Price to lead the Department of Health and Human Services, and the reality of prospects for an ACA repeal. Finally, college graduates are more likely to support the Affordable Care Act than people with no college. The Pew poll was conducted among 1,503 U.S. adults the week before the KFF study, February 7-12, 2017. Health Populi’s Hot Points:  Media outlets repeated the Democratic Party leadership’s mantra that “Republicans could make America sick again.” The UK’s Financial Times reported that, “Trump warns party on speed of health reform as lawmakers push alternative visions.” The column pointed out: “The day after Republicans took a first step towards repealing the Obama reforms, the president and Mr. Pence separately met lawmakers who are pushing alternative visions for improving healthcare while trying to insulate themselves from future public ire.” The issue “spans household budgets, government spending and the profitability of the health industry,” the FT called out. Indeed: the U.S. healthcare economy is $1 in $5 of the national economy: As such, the healthcare economy is the national economy. At last week’s annual HIMSS conference, which attracted more than 40,000 healthcare information technology users and developers to Orlando, there was a growing number of vendors focused on patient payment systems – to deliver greater transparency, medical banking, and so-called “revenue cycle management.” Healthcare providers, hospitals and physicians alike, are confronted by patients who are now payers: paying first-dollar coverage out-of-pocket whether in high deductible health plans, working through health savings accounts, or paying @retail without insurance or under-insured. These patients are Democrats, Independents, and Republicans alike, all seeing $1 in every $5 bill in their pocketbook going to healthcare costs. Over one-half of respondents to the February 2017 KFF poll reported some connection Medicaid: a fact that Congress, President Trump, and Secretary Price should note. I’ll put a real-life, fine point on this: I spent last Friday morning, February 24, with the Kansas Hospital Association brainstorming the growing role of patients as consumers in U.S. healthcare. Kansas Governor Brownback had not expanded Medicaid to-date, and neither had the State House been keen to do so. The night before my speech to the Association, the State House had voted in favor of expanding Medicaid. That issue will now be considered by the Kansas State Senate. This is a state that has been very conservative about Medicaid expansion. Now, in February 2017, we see a sign that state representatives seek a change. Kansas could be a bellwether. Watch this space: “ad astra per aspera” means, “through hardship to the stars.” There are few greater hardships than a very sick person facing a choice between paying for healthcare services and life-saving drugs, and paying for food, shelter, and heat in the winter.

Eight in 10 U.S. patients would welcome some aspect of virtual healthcare, but only 1 in 5 providers is meeting that need.

Large employers are taking more control over health care costs and quality by pressuring changes to how care is actually delivered, based on the results from the 2017 Health Plan Design Survey sponsored by the National Business Group on Health (NBGH). Health care cost increases will average 5% in 2017 based on planned design changes, according to the top-line of the study. The major cost drivers, illustrated in the wordle, will be specialty pharmacy (discussed in yesterday’s Health Populi), high cost patient claims, specific conditions (such as musculoskeletal/back pain), medical inflation, and inpatient care. To temper these medical trend increases, large employers are looking to change the way health care is accessed and delivered through funding telehealth (for 90% of companies), providing price transparency tools (among 85% of companies), building and referring workers to Centers of Excellence (in 85% of firms, focused most on transplants, bariatric surgery, joint surgery, heart care, and cancers), and to a lesser extent, promoting accountable care organizations (among about one-fourth of employers). Consumer-directed health plans (CDHPs) will be a universal health insurance plan design by 2020, shown in the second chart. At least 84% of large employers will offer a CDHP option in 2017, and one-third will offer only a CDHP. Most high-deductible health plans in 2017 (92%) will be accompanied by a health savings account (HSA) The median employee cost-sharing amount this year was a $1,600 deductible for employee (single) coverage in a CDHP, and in-network out-of-pocket maximum payments were $4,000. For families, the out-of-pocket max was $7,200 with a $3,200 deductible. Telehealth is expected to be a universally-sponsored service among large employers by 2019, and most companies already use virtual care. One-third of large employers directly contract with telehealth vendors, according to NBGH’s survey. While most employers are offering telehealth services, in the first half of 2016, only 3% of employees had utilized this benefit. Looking to the future, employers are bolstering investments in mental and behavioral health, and in the financial wellbeing of their workforce. Influence physical well-being is a top-three priority among 85% of employers, followed by improvement employee engagement in healthcare decision making (that is, consumerism) for 65% of companies, emotional/mental wellbeing among 59%, and financial security and wellbeing for 58% of employers. Health Populi’s Hot Points:  Large employers are emboldened to drive changes in health care delivery — especially for virtual care via telehealth channels and narrowing networks for high-cost specialty care like transplantation and bariatric surgery via Centers of Excellence. Most employers are also deploying at least one cost transparency tool to support employees’ healthcare consumerism and decision-making chops. However, only 3% of employees have used telehealth services that have been available in the first half of 2016; this is an important proxy for understanding just how “consumerist” employees are with respect to saving money in deductible spending. The consumer-patient’s cost difference  between a virtual vs. in-person visit is significant: a telehealth visit with American Well is currently priced at a low of $49 compared with a face-to-face primary care visit for $95, urgent care for $140, or emergency department admission for $750. NBGH identifies employer tools and programs more companies are offering in 2017, including nurse coaching for care condition management, disease management, lifestyle management, self-service decision support tools, price transparency tools (fast-growing in 2017), and medical decision support/second opinion services. Large employers clearly understand the importance of these tools to support their mass adoption of high-deductible health plans. There’s no consumer-direction without such programs, and less optimal ROI on employers’ significant investments in health insurance without them. This week’s announcement of Accolade receiving a $70 million investment to further scale the company’s healthcare concierge services is an example of the market’s recognition of the importance of these employer-sponsored programs. This is health reform, playing out in the private sector. This blog first appeared at Health Populi.

Learn how to deploy population health management into process, work culture and technology systems with data.

Starting in 2019, Centers for Medicare & Medicaid Services, will change how they pay physicians in a profound way. Unfortunately, the details are complicated and confusing, and many of the particulars have yet to be worked out, which has led many healthcare leaders to glaze over the details and focus on more immediate concerns.

Learn how Medical Center Health System identified patients at high risk for readmission, and how by tracking these patients' experiences, they were able to analyze the effect of transitional care on readmission rates as well as patient satisfaction and overall costs.

With most patient data now being recorded in a shareable form, we're poised to accelerate population health IT. Now it's on to the next set of major challenges, which will be front-and-center at HIMSS15: sharing data and putting it to beneficial use.