Things I Think . . . I Think
We all have our guilty pleasures. One of mine is reading my weekly issue of Sports Illustrated cover to cover. During this time of year, every issue ends with the same column titled “Things I Think I Think” – a column dedicated to “all the latest news, buzz, and inside information”. Like all of you, I have been bombarded with buzz daily about the latest developments in healthcare reform. In an attempt to keep up, I have immersed myself in the law for the last several months, trying to make as much sense of it as I can. After taking in all of this information, and adding in a few of my own thoughts, here (so far) is what I think…I think.
- Even though I get email every day on how to be one, and the law allows for the formation of them, I don’t believe that ACOs are ready for primetime just yet. There is a lot of good that may come from them in theory, but the operational challenges of actually designing, implementing, and successfully managing an ACO are daunting at best. The complexities of actually pulling all of the moving parts together may prove too much for the majority of healthcare organizations, leaving much of what the law has set out to do a distant goal for many.
- The pilot project that CMS has underway for orthopedics, interventional cardiology, and cardiovascular surgery is already approaching the halfway mark, with preliminary performance data expected in November of 2010. These bundled payment models are likely here to stay, at least in high dollar specialties. There are several facts that lead me to this conclusion. First, these models are designed to jointly incentivize physicians and hospitals in their efforts to deliver high quality care by removing the primary reimbursement barrier facing them today; disparate payment systems that are misaligned. Secondly, the outcomes metrics in these specialties are well developed, and some of them have already been rolled out by CMS for public comment outside of the demonstration project to be used in other portions of the healthcare law. And last, but certainly not least, the enormous amount of financial savings that is likely to be gained by implementing these models will simply be too great for CMS and other payers to ignore.
- Physician payment reform may not come in the form of repealing the SGR, but will be greatly shaped by the Value Based Payment Modifier section of the new law. This section (section 3007) is designed to reward physicians who deliver high quality, low cost care with respect to their peers by changing the amount paid per work RVU. The metrics to be used are due out by January 2012, rule making is set for 2013, with full implementation scheduled for January 1, 2015. This may seem a long way out, but the advantage this modifier may have over other methodologies is that it avoids the need to overhaul the payment infrastructure currently in place. Once quality metrics are defined, you will simply be paid more (or less) per work RVU using the same systems that CMS currently has in place.
At the end of the day, I guess what I think I think is that even though we have a long way to go before all of the pieces of the puzzle fall into place for truly meaningful reform, we are soon to see the effects of several of these pieces, signaling the beginning of truly significant change to our system.
Mark,
I like this concept very much. Great post - a few comments:
ACO: I agree with your assertion that ACO may not be ready for prime time, but come at it from a different angle. Workforce. We already know of the primary care workforce shortages in this country. If the center of any good ACO is primary care (see http://bit.ly/izgk0 pdf), we are going to need to be prepared with primary care providers to fill the practices that are the center of the ACO wheel. We can get there, but there are several systemic issues that will first need to be addressed (e.g. medical school/state incentives for primary care).
I agree with your take on CMS/ACE and bundled payments. Anytime we start talking about payment reform, we can finally talk about health care system reform. Bundled and blended payments are a way to shift from fee for service to alternative ways of paying for healthcare services. We all recognize that as long as fee for service is present, high costs and low quality will rule the roost. Where this could really add value is in the area of integrating systems of care that often are disparate in payment and delivery. For example, integrating mental health into primary care (where most mental health is delivered anyway - but not paid for) could benefit from a different way of payment.
Oh and SGR...
So yes, there are many exciting pieces in reform that when combined equal the possibility for disruption of the current healthcare status quo. I for one want to see that significant change healthcare.
We must both spend too much time "think"ing about things. I agree with your assessment and cautionary comments about ACOs. From a different perspective, I pull on concepts borrowed from Peter Senge, in considering the evolution of change in moving from "ideas to invention to innovation" in which he distinguishes between what is implied by each.
Fundamentally, in his jargon, an "innovation" occurs when there has been demonstrated scalability, understanding of what would be necessary to replicate efficiently, there is an associated value equation addressed, and a business/reimbursement model which supports the efforts.
In his thinking, an "invention" is when we discover "one that works" which while perhaps imperfect, inefficient, not clearly reproducible, has been demonstrated to be possible. A useful (at least to me) parallel is considering manned flight. Orville and Wilbur Wright are credited with inventing the airplane. But unless you were interested in flying alone, taking off from a moving railroad car, and dying on impact in several hundred yards, it wasn't seen as a commercially successful venture. It wasn't until 1935 that McDonnell Douglas identified 5 components which needed to be present for many reasons, that manned flight finally became commercially possible, and eventually viable and sustainable.
If we wish to push the analogy, some consider the ACO an idea. In manned flight, Leonardo da Vinci created drawings which suggested a helicopter type of vehicle. It was a great "idea" but only took about 500 years before it even moved to the invention phase.
While perhaps it's stretching an analogy (but hey, we're just thinking here), my concern is that in many cases, not only with the ACO but also the PCMH, we may be closer to the "invention:" level of development, but are trying to jump start it to the innovation platform.
So, perhaps simplistically, are we considering how to make an Orville and Wilbur Wright level of model a commercial success, or is there need for further tinkering and inventing without some of the economic constraints or risks that are described above. After all, I'm just thinking, you know???
First, I salute you - and your optometrist, and your ophthalmologist, who I hope will give you some high-quality care for the bleeding eyeballs you've now got - for reading the full text of the bill. I've tried, and am still working my way thru it. Slowly. Thanks for the précis of several important sections.
I agree with you, and with Ben, that ACOs aren't ready for their closeup...yet. But the effort to get them online must continue at speed, since accountability tied to revenue is the only way to effect real systemic change. That, and the blended payment model Ben talks about, are two essential pieces in building a better healthcare delivery system that works for both sided of the care model: providers AND patients.
I'll keep hammering away at my central point that patients must take a place at the table for this discussion. Even if it means getting eye-strain reading thru the impenetrable bureaucrat-ese that makes up all legislation...