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Will GOP keep a test kitchen for healthcare reform?




For Kaiser Health News

Joint replacements. Cardiac care. Chemotherapy.

What do those things have to do with the repeal of the Affordable Care Act?

Economists and policymakers think the U.S. may be overpaying for such services, which helps drive up healthcare expenses for everyone. And the health law has a program that includes testing new ways to pay for care — including in those three areas — that might result in better quality and lower costs.

But with the ACA up for potential repeal, what happens to that testing now? One of the emerging questions is whether Congress will save all or part of that effort, known as the Center for Medicare & Medicaid Innovation.

Republican lawmakers have complained — along with some in the healthcare industry — that the law under the Obama administration gave too much authority to the head of the Department of Health and Human Services to create and expand projects. Now, however, that very same authority may look appealing as Republicans head the department and may want to use the center to test their own ideas, including those that would revamp Medicare or Medicaid.

“You can dislike that authority, until you have the opportunity to use the authority,” said Rodney Whitlock, a vice president at ML Strategies, a government consulting firm in Washington, D.C., and former Republican staff member of the Senate Finance Committee.

As they debate and discuss ways to repeal the Affordable Care Act, lawmakers will weigh the innovation center, funded through the health law with $10 billion for 2011 to 2019, and another $10 billion for each subsequent decade. The Congressional Budget Office estimates the center would increase federal spending initially, but ultimately result in lower costs and save up to $34 billion over the next 10 years.

Congressional Republicans have not yet hinted whether they will keep, modify or kill the program but they generally support the cost-saving goal of the center and many observers think they will want to preserve it.

“If healthcare providers can do a better job of delivering patient care … at the same or lower costs, that’s the kind of flexibility the system needs more of,” said Mark McClellan, a professor of health policy at Duke University who headed Medicare for two years under the George W. Bush administration.

One group that generally supports the broad cost-saving goal of the center, nonetheless warned that Congress should place limits on it. Otherwise, “there is nothing preventing [the center] from testing a model … that includes all Medicare and/or Medicaid beneficiaries in the U.S,” the Healthcare Leaders for Accountable Innovation in Medicare said in a white paper. “In effect [the center] could test a model that completely restructures the Medicare or Medicaid program.”

Billions of dollars have already been spent by the center, testing a variety of ideas, from ways to improve care for at-home dialysis to ways to foster more collaboration between doctors and hospitals to efforts to reduce unnecessary hospital visits by chronically ill Medicare patients. Many of the efforts look at ways to move from Medicare’s traditional fee-for-service payment system — that economists and policymakers say drive up costs — and instead set up reimbursement that rewards coordinated care. Few of the projects have been in place long enough for the center to determine if they truly save money and improve care.

Even if the center were eliminated, many experts say these types of payment reforms will continue because of private sector interest.

“Pay-for-value is going to be a guiding principle going forward irrespective of who is in power,” said Dan Mendelson, president and CEO of the consulting firm Avalere Health. “It would surprise me to see wholesale U-turn from that policy.”

To date, most of the programs funded by the innovation center are voluntary, but controversy has arisen over several recent initiatives that require participation by doctors or hospitals.

What may happen is that there will be fewer of these mandatory efforts. This year, one such project got underway, testing a method of “bundling” payments for joint replacements at 800 hospitals in 67 metro areas. For their Medicare patients, the project requires a single bundled payment to cover the cost of these procedures, including in-patient and post-operative care, instead of separate payments for each doctor, hospital or nursing home visit. A similar mandatory project for certain kinds of cardiac care has also been proposed.

In the end, the center’s future will be determined by whether the Republican majority believes it is one of the best ways to slow rising medical costs, said Christopher Condeluci, principal at CC Law & Policy in Washington, D.C., and the former tax and benefits counsel to the Senate Finance Committee.

“If the answer is yes, they will keep it and it might go to new heights,” Condeluci said.

But economist Joe Antos, a resident scholar at the American Enterprise Institute, does not think the new administration — or many members of Congress — will push to use the center’s authority to create broad, mandatory nationwide experiments with Medicare.

“I can’t imagine a Trump administration saying we want the bureaucrats to decide on the healthcare your grandmother is going to get,” said Antos. “Anything that is that much of a marquee issue absolutely has to go through Congress.”

Physician sees good things in a Trump health program


Anish Koka, M.D., a pro-Trump cardiologist in Philadelphia, thinks that the next president may well be good for physicians and patients. Among his observations in a Medical Economics essay:

“Millions of patients currently with insurance would suddenly lose their health plans {if the Affordable Care Act-created insurance marketplaces were abolished, as Mr. Trump has called for}. No one wants this, and Trump and the Republican Party now face intense pressure to come up with a replacement. As a result, I find it very unlikely that physicians or patients will suddenly have to deal with a large number of patients without insurance. There are also encouraging signs that the replacement plans being discussed will more than likely include health savings accounts—a Trump/GOP favorite—that will be allowed to directly pay primary care physicians in a subscription model similar to direct primary care. This capitated model puts physicians, rather than insurance companies, in the driver’s seat and would be music to the ears of primary care physicians in desperate need of a lifeline.”

“The biggest immediate headache is the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which physicians will have to face in less than two months, but it only slightly overlaps with the ACA. The overlap relates to the Center for Medicare & Medicaid Innovation (CMMI) that was funded by the ACA, and created some of the important value-based payment models physicians were going to have to comply with to avoid reimbursement penalties. The wide latitude given CMMI to propose and deploy Advanced Alternative Payment Models (APMs) under Medicare payment reform has already come under scrutiny by Republican legislators prior to a Trump victory. One would expect that in the Trump era, CMMI is unlikely to survive in its current form. This would provide significant relief to physician practices enrolled in APMs struggling to cope with the time and cost of the seeming barrage of regulatory hoops to jump through.”

The most alluring ACO model

In this HealthAffairs post, the authors argue that today’s most attractive national Accountable Care Organization model is offered by CMS.

They write:

“Fortunately, CMS heard the complaints about early MSSP  {Medicare Shared Savings Program} models and addressed the majority of them through the progressive structure of the Next Gen {of ACOs} model. In fact, the core difference between MSSP Track 1 and the current Next Gen model is that the latter is based upon extensive feedback from health systems regarding their concerns about MSSP Track 1.

“Next Gen is therefore a program that health systems have directly asked for. The model still has room for further improvement — for example, Next Gen ACOs should have access to the full toolkit of benefit- and network-design strategies found in Medicare Advantage and other provider-led offerings. But the CMMI {Center for Medicare & Medicaid Innovation} leadership has pledged to pursue additional features that could take effect in the later years of the Next Gen model, and will continue the virtuous cycle of improvements.”

Hospitals trying to revamp care via community health workers



For Kaiser Health News


Donnie Missouri, 58, doesn’t have medical training. He started his health career in the linens department in Johns Hopkins Hospital. Now, he works on the front lines — one of the hospital’s non-medical workers who reaches out to patients who doctors think are at risk of suffering setbacks that will force them to return.

One recent day at the end of March, he visited Vincent Berry, a 28-year-old man who’s paralyzed from the waist down, a condition resulting from a years-ago gunshot wound after a drug deal went sour. Berry’s doing well medically, but he lives with his aging grandmother, in the upstairs bedroom of a narrow apartment where he relies on help from friends and family to be able to leave. Missouri has been trying to help him secure independent, wheelchair-accessible housing that will make it possible for him go to school or pursue other activities that might move his life forward.

Right now, “I can’t get out and go to school every day,” Berry said, adding that he just tries to make the best of everything. “I just — I know I want to be in a house. It doesn’t have to be the best house.”

Missouri’s goal is to connect people like Berry with resources like housing, transportation and other government benefits — factors that influence health but aren’t the doctor’s focus.

What’s Missouri’s secret? It’s a combination, he says, of building rapport, meeting patients at home and, most importantly, understanding the challenges — medical and not — his neighbors face.  “You have to know your community,” he said of the East Baltimore neighborhood where he lives and works. “If you don’t … it ain’t going to work.”

What Missouri does is hardly a novel concept. For decades, community health workers have tried to fill the system’s gaps. Often hired by the local health department, they take on diverse public health initiatives — running diabetes or nutrition education programs, counseling patients to stick to their medication regimens or teaching new mothers about vaccinations.

But now, hospitals across the country are turning to them in a bid to revamp patient care. They are using these aides to strengthen their relationships with patients and surrounding neighborhoods — improving the community’s health and, along the way, their own finances.

Part of it is spurred by the 2010 federal health reform, which introduced a number of changes in how Medicare pays hospitals.

Similar efforts are underway on the state level, through Medicaid payments and health insurance regulations. Health insurers, too, are starting to show interest in figuring out how they might pay for these services.

“We need to do things differently than what we had been before,” said Ken Fawcett, a physician and the vice president of the community health worker initiative at Spectrum Health in Grand Rapids, Mich. “People are starting to recognize there are non-health care related variables that have a profound impact.”

Challenges persist, though, in figuring out how to finance community health worker programs and regulate the growing workforce.

How It’s Done

Preliminary research suggests health systems are seeing returns on these investments. Patients stay healthier. Fewer are readmitted. That reduces how much expensive, often-not-profitable care hospitals need to give, yielding a financial payoff.

“Because of this new policy environment, health care systems are going to be held accountable” for people’s health, said Shreya Kangovi, an assistant professor at the University of Pennsylvania’s Perelman School of Medicine, who directs its center for community health workers.

The American Hospital Association doesn’t systematically track how many health systems have launched community health worker programs. It’s becoming “much more common,” said Ken Anderson, chief operating officer of the hospital trade group’s Health Research and Education Trust. “This area of interest seems to be very much front and center for hospitals.”

Community health workers are often uniquely positioned to help their clients — the hospital patients.

Frequently, workers have had similar life experiences — maybe addiction, navigating the criminal justice system or simply facing difficulties gaining access to care or other neighborhood’s challenges — so they can connect with patients in ways doctors and nurses don’t, said Scott Berkowitz, Johns Hopkins’ senior medical director for accountable care.

For Missouri, that’s invaluable. When visiting patients, he avoids business clothes that might render him unapproachable, opting for a shirt and lanyard showing he’s from Hopkins, but also jeans and brown walking shoes. He jokes with Berry’s grandmother, and recognizes his dog. After fist-bumping Berry goodbye — they’ll check in later by phone, they confirm — he can cross the street to his next client, a woman with substance abuse problems. He’s a recovering addict himself.

How do programs work? Take the University of Pennsylvania’s Perelman School. Community health workers — who are full-time hospital employees — are assigned patients. They assess patients’ needs and develop relationships spanning months. An early study of the program found patients who participate are less likely to keep returning to the hospital and have better outcomes.

Penn is betting these efforts will ultimately mean savings, so it’s investing upfront: funding the program through its own operating expenses. Some health systems are using grants from private foundations or the federal Centers for Medicare & Medicaid Services to get started. New York Presbyterian Hospital, affiliated with Columbia University, started its community health worker pilot a decade ago, using grant funding. Since then, program leaders have convinced the hospital not only to pay for the program but to expand it, citing healthier, more satisfied patients.

Hopkins got a federal grant from the Center for Medicare & Medicaid Innovation to launch its program in 2012. The funding is ending this year, but it is planning to continue anyway.

In Maryland, the state has taken steps to reform hospital payments — rewarding health systems for keeping patients healthy enough that they don’t need hospital treatment. That adds financial incentives for Hopkins and other hospitals, encouraging them to use strategies such as outreach by community health workers.

Federal policies also add appeal. The University of Maryland Medical Center, in West Baltimore, for instance, started its community health worker project last year after it was penalized by Medicare for failing to meet national standards regarding how many patients it readmitted within 30 days of discharge.

The hospital’s seen readmissions drop by about half, said Zina Kendell, the program’s manager, but the program doesn’t save enough to offset the cost of running it. Still, the hospital is looking into expanding it, said Charles Callahan, vice president for  population health. “We have a model we believe in,” Kendell said.

Meanwhile, state and federal regulators are grappling with how to set standards for community health workers’ training and certification.

More than 20 states have instituted regulations or created oversight committees, according to Sharon Moffatt, interim executive director of the Association of State and Territorial Health Officials.

But there’s no consensus on the best level of scrutiny for community health workers.

Take background checks, an idea that “comes up all the time,” said Carl Rush, who heads the Project on Community Health Worker Policy & Practice at the Institute for Health Policy at the University of Texas Health Science Center at Houston.

Though well-intentioned, that standard can be counterproductive, he said. “There is a legitimate argument to be made that people who have exposure with the corrections system or criminal justice generally are better-equipped to work with people” coming through community programs.

Institutions like Penn and Hopkins train workers before sending them into the field. But Missouri, the Hopkins community health worker, said knowing the city, its resources and residents matters most.

“A lot of people sit in their office and talk about how they’re all about community,” he said. “[But] when’s the last time you got into it and found out how your community works?”

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