Leaders of the hospital sector and other major healthcare groups have denounced the Senate Republican leadership’s Affordable Care Act repeal bill as little or no improvement over the House bill, which providers have criticized as imperiling the health of millions of patients.
Rick Pollack, president and CEO of the American Hospital Association, said of the”Better Care Reconciliation Act of 2017”:
“Unfortunately, the draft bill under discussion in the Senate moves in the opposite direction {from protecting coverage}, particularly for our most vulnerable patients. We urge the Senate to go back to the drawing board and develop legislation that continues to provide coverage to all Americans who currently have it.”
Bruce Siegel, M.D., president and CEO of America’s Essential Hospitals, said: “For the hospitals that protect millions of Americans and their communities—our essential hospitals—this bill might even accelerate decisions by some to reduce services or close their doors.”
“The Senate healthcare bill released today is just as bad as the version passed by the House of Representatives last month and is a threat to the health of America,” said George Benjamin, M.D., executive director of the American Public Health Association. He asserted that Senate Republicans had committed “legislative malpractice.”
David O. Barbe, M.D., president of the American Medical Association, chimed in with:
“The AMA is reviewing the Senate health system reform legislation, guided by our key objectives that people who are currently insured should not lose their coverage and that Medicaid, CHIP and other safety-net programs should be adequately funded. The AMA strongly opposes Medicaid spending caps, and we have grave concern with a formula that will not cover needed care for vulnerable patients.”
And Bernard J. Tyson, chairman and CEO of Kaiser Permanente, said: “First, we need to cover more people, not fewer people.” He suggested a three-part test to determine what healthcare progress ought to look like: Does it achieve wider access, affordability and better outcomes?
Centers for Medicare & Medicaid Administrator Seema Verma, a Trump appointee, not surprisingly, praised the bill.
“I appreciate the work of the Senate as they continue to make progress fixing the crisis in healthcare that has resulted from Obamacare. Skyrocketing premiums, rising costs and fewer choices have caused too many Americans to drop their insurance coverage. Today, Obamacare is in a death spiral and millions of Americans are being negatively impacted as a result. They are trapped by mandates that force them to purchase insurance they don’t want and can’t afford.” {The term “Obamacare” is usually used by Republicans as a derogatory term for the Affordable Care Act, the law’s official name.}
“The Senate proposal is built on putting patients first and in charge of their healthcare decisions, bringing down the cost of coverage and expanding choices. Congress must act now to achieve the president’s goal to make sure all Americans have access to quality, affordable coverage.”
Gerald Chinchar isn’t quite at the end of life, but the end is not far away. The 77-year-old fell twice last year, shattering his hip and femur, and now gets around his San Diego home in a wheelchair. His medications fill a dresser drawer, and congestive heart failure puts him at high risk of emergency room visits and long hospital stays.
Chinchar, a Navy veteran who loves TV Westerns, said that’s the last thing he wants. He still likes to go watch his grandchildren’s sporting events and play blackjack at the casino. “If they told me I had six months to live or go to the hospital and last two years, I’d say leave me home,” Chinchar said. “That ain’t no trade for me.”
Most aging people would choose to stay home in their last years of life. But for many, it doesn’t work out: They go in and out of hospitals, getting treated for flare-ups of various chronic illnesses. It’s a massive problem that costs the health care system billions of dollars and has galvanized health providers, hospital administrators and policymakers to search for solutions.
Sharp HealthCare, the San Diego health system where Chinchar receives care, has devised a way to fulfill his wishes and reduce costs at the same time. It’s a pre-hospice program called Transitions, designed to give elderly patients the care they want at home and keep them out of the hospital.
Social workers and nurses from Sharp regularly visit patients in their homes to explain what they can expect in their final years, help them make end-of-life plans and teach them how to better manage their diseases. Physicians track their health and scrap unnecessary medications. Unlike hospice care, patients don’t need to have a prognosis of six months or less, and they can continue getting curative treatment for their illnesses, not just for symptoms.
Before the Transitions program started, the only option for many patients in a health crisis was to call 911 and be rushed to the emergency room. Now, they have round-the-clock access to nurses, one phone call away.
“Transitions is for just that point where people are starting to realize they can see the end of the road,” said San Diego physician Dan Hoefer, one of the creators of the program. “We are trying to help them through that process so it’s not filled with chaos.”
The importance of programs like Transitions is likely to grow in coming years as 10,000 Baby Boomers — many with multiple chronic diseases — turn 65 every day. Transitions was among the first of its kind, but several such programs, formally known as home-based palliative care, have since opened around the country. They are part of a broader push to improve people’s health and reduce spending through better coordination of care and more treatment outside hospital walls.
But a huge barrier stands in the way of pre-hospice programs: There is no clear way to pay for them. Health providers typically get paid for office visits and procedures, and hospitals still get reimbursed for patients in their beds. The services provided by home-based palliative care don’t fit that model.
In recent years, however, pressure has mounted to continue moving away from traditional payment systems. The Affordable Care Act has established new rules and pilot programs that reward the quality rather than the quantity of care. The health reform law, for example, set up “accountable care organizations” networks of doctors and hospitals that share responsibility for providing care to patients. They also share the savings when they rein in unnecessary spending by keeping people healthier. Those changes are helping to make home-based palliative care a more viable option.
In San Diego, Sharp’s palliative-care program has a strong incentive to reduce the cost of caring for its patients, who are all in Medicare managed care. The nonprofit health organization receives a fixed amount of money per member each month, so it can pocket what it doesn’t spend on hospital stays and other costly medical interventions.
Gerald Chinchar’s medicine is packed in a kitchen drawer for a Sharp HealthCare Transitions program nurse to check. (Heidi de Marco/KHN)
‘Something That Works’
Palliative care focuses on relieving patients’ stress, pain and other symptoms as their health declines, and it helps them maintain their quality of life. It’s for people with serious illnesses, such as cancer, dementia and heart failure. The idea is for patients to get palliative care and then move into hospice care, but they don’t always make that transition.
The 2014 report “Dying in America,” by the Institute of Medicine, recommended that all people with serious advanced illness have access to palliative care. Many hospitals now have palliative-care programs, delivered by teams of social workers, chaplains, doctors and nurses, for patients who aren’t yet ready for hospice. But until recently, few such efforts had opened beyond the confines of hospitals.
Kaiser Permanente set out to address this gap. Nearly 20 years ago, it created a home-based palliative care program, testing it in California and later in Hawaii and Colorado. Two studies by Kaiser and others found that participants were far more likely to be satisfied with their care and more likely to die at home than those not in the program. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)
One of the studies, published in 2007, found that 36 percent of people receiving palliative care at home were hospitalized in their final months, compared with 59 percent of those getting standard care. The overall cost of care for those who participated in the program was a third less than for those who didn’t.
But Enguidanos knew that Kaiser Permanente was unlike most health organizations. It was responsible for both insuring and treating its patients, so it had a clear financial motivation to improve care and control costs. Enguidanos said she talked to medical providers around the nation about this type of palliative care, but the concept didn’t take off at the time. Providers kept asking the same question: How do you pay for it without charging patients or insurers?
“I liken it to paddling out too soon for the wave,” she said. “We were out there too soon. … But we didn’t have the right environment, the right incentive.”
A Bold Idea
Dan Hoefer’s medical office is in the city of El Cajon, which sits in a valley in eastern San Diego County. Hoefer, a former hospice and home health medical director and nursing-home doctor, has spent years treating elderly patients. He learned an important lesson when seeing patients in his office: Despite the medical care they received, “they were far more likely to be admitted to the hospital than make it back to see me.”
When his patients were hospitalized, many would decline quickly. Even if their immediate symptoms were treated successfully, they would sometimes leave the hospital less able to take care of themselves. They would get infections or suffer from delirium. Some would fall.
His patients were like cars with 300,000 miles on them, he said. They had a lot of broken parts. “You can’t just fix one thing and think you have solved the problem,” he said.
And trying to do so can be very costly. About a quarter of all Medicare spending for beneficiaries 65 or older is to treat people in their last year of life, according to a report by the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)
Hoefer’s colleague, Suzi Johnson, a nurse and administrator in Sharp’s hospice program, saw the opposite side of the equation. Patients admitted into hospice care would make surprising turnarounds once they started getting medical and social support at home and stopped going to the hospital. Some lived longer than doctors had expected.
In 2005, the pair hatched and honed a bold idea: What if they could design a home-based program for patients before they were eligible for hospice?
Thus, Transitions was born. They modeled their new program in part on the Kaiser experiment, then set out to persuade doctors, medical directors and financial officers to try it. But they met resistance from physicians and hospital administrators who were used to getting paid for seeing patients.
“We were doing something that was really revolutionary, that really went against the culture of health care at the time,” Johnson said. “We were inspired by the broken system and the opportunity we saw to fix something.”
Despite the concerns, Sharp’s foundation board gave the pair a $180,000 grant to test out Transitions. And in 2007, they started with heart failure patients and later expanded the program to those with advanced cancer, dementia, chronic obstructive pulmonary disease and other progressive illnesses. They started to win over some doctors who appreciated having additional eyes on their patients, but they still encountered “some skepticism about whether it was really going to do any good for our patients,” said Jeremy Hogan, a neurologist with Sharp. “It wasn’t really clear to the group … what the purpose of providing a service like this was.”
Nevertheless, Hogan referred some of his dementia patients to the program and quickly realized that the extra support for them and their families meant fewer panicked calls and emergency room trips.
Hoefer said doctors started realizing home-based care made sense for these patients — many of whom were too frail to get to a doctor’s office regularly. “At this point in the patient’s life, we should be bringing health care to the patient, not the other way around,” he said.
Across the country, more doctors, hospitals and insurers are starting to see the value of home-based palliative care and are figuring out how to pay for it, said Kathleen Kerr, a health care consultant who researches palliative care.
“It is picking up steam,” she said. “You know you are going to take better care of this population, and you are absolutely going to have lower health care costs.”
Providers are motivated in part by a growing body of research. A studypublished in January showed that in the last three months of life, medical care for patients in a home-based palliative care program cost $12,000 less than for patients who were getting more typical treatment. Patients in the program also were more likely to go into hospice and to die at home, according to the study.
Two studies of Transitions in 2013 and 2016 reaffirmed that such programs save money. The second study, led by outside evaluators, showed it saved more than $4,200 per month on cancer patients and nearly $3,500 on those with heart failure.
The biggest differences occurred in the final two months of life, said one of the researchers, Brian Cassel, who is palliative care research director at the Virginia Commonwealth University School of Medicine in Richmond.
One reason for the success of these programs is that the teams really get to know patients, their hopes and aspirations, said Christine Ritchie, a professor at UC San Francisco’s medical school. “There is nothing like being in someone’s home, on their turf, to really understand what their life is like,” she said.
Bernard Tyson, CEO of Kaiser Permanente, discusses why the nonprofit integrated health system, the nation’s biggest, has bought the nonprofit Group Health Cooperative, in Seattle, which has 600,000 members. It’s Kaiser’s first expansion into a new market in 20 years.
Among his remarks to Hospitals & Health Networks:
“We’re excited because we’ve had a long-term relationship with Group Health for many years. We’re two very similar organizations with similar histories, so the match just makes a lot of sense. For Kaiser Permanente, we wanted to grow in new markets in addition to what we were seeing in our current markets. This is our first new market in more than 20 years. We’re excited about this one in particular because it’s such a wonderful plan and delivery system that we’re going to build on as a part of Kaiser Permanente.’’
“We’re still working on the strategy in terms of where we’re going to put new facilities, but we’ve made a clear commitment that when we come into the market, we will be building some of our state-of-the-art medical centers in Washington state. We haven’t finalized the plans, obviously, as we’re just now taking it over. And really, now we’re beginning to look at the whole delivery strategy layout, but we’ve been very explicit about our commitment for capital in this market.’’
The simple life: A reconstruction of the inside of Henry David Thoreau’s cabin at Walden Pond.
Ian Morrison discusses the search in other sectors for lessons to create a simpler, more cost-effective healthcare system with better medical outcomes.
He writes in a Hospitals & Health Networks piece:
“Forget healthcare for a moment and think about other service experiences in your life. How much time do you spend on your phone? Is it the vehicle for your life? Is it your primary gateway to your family, friends, travel reservations, recipes, dates and data?
“The complexity of health care is being judged against other industries that seem to effortlessly deliver services in ways that are simple and easy to use. And not just with mobile apps.
“Think Southwest Airlines. It flies the same planes on all routes so crews are interchangeable. Southwest keeps it simple: no bag fees, no tricks. And it still gives you peanuts.
“Or think Netflix. It knows what you like and makes it easy to binge watch House of Cards without leaving your couch.
“Or Amazon. It will get you absolutely anything on your front doorstep within a day or two. Maybe an hour or two when it gets the drone thing down.
“Or Uber. You press a button, and a Stanford graduate student picks you up in his Prius in three minutes, and you don’t have to tip him or fumble for cash.
“These businesses are backed by enormously complex technology and logistics. They use sophisticated algorithms to customize the user experience. It is immensely difficult to design and execute these services, but to the customer it appears simple.
“We need to learn from them. And we can find signs of simplicity in health care.”
He then gives some hopeful examples from healthcare:
Jon Kingsdale argues in Health Affairs that news coverage of Aetna’s plan to exit from 11 of the 15 states where it now offers insurance on Affordable Care Act insurance exchanges, and similar actions by some other big insurers, such as Humana and United Healthcare, has contained much hyperbole and that in fact the exits are no big deal.
He writes:
Critics of the ACA are citing these departures as evidence of the law’s fatally flawed design. Even supporters worry about how to staunch the outflow. And the news reverberated in presidential politics, on both sides. What’s really going on here? Are these big insurers bailing because Obamacare is just too risky? Will more such desertions cripple the marketplaces?”
He answers himself: “Not all health insurance companies are the same, nor do they necessarily serve the same customer segments. In fact, most medical insurance companies, unlike Aetna and United, are regional non-profits, such as the state (or smaller) Blue Cross Blue Shield plans, Kaiser Permanente and HIP. These ‘regional’ plans and Medicaid managed care organizations (MCOs) are generally better positioned to compete on the new marketplaces than ‘national’ insurers.”
“By contrast, national firms such as Aetna, United and CIGNA are far better positioned to serve national employers and other large, self-insured groups than to compete for individual households.”
“The vast majority of purchasers on the ACA marketplace are low-to-moderate income households, who are searching for low-priced health plans. As extremely ‘price-sensitive’ buyers, most seem willing to trade access to a broader network in return for lower premiums. Regional health plans and Medicaid MCOs are generally more successful than national ones in negotiating the lowest payment rates with local doctors and hospitals. As a result, the Blue Cross Blue Shield and other regional plans generally—not always—enjoy a cost and premium advantage over national plans and tend to dominate their marketplaces.”
“In fact, United and Aetna, despite their deep penetration of the large-group insurance market, together serve only 15 percent of marketplace enrollees, and their retrenchment will impact only about 10 percent.
“They are leaving many marketplaces, but staying in those where they think they can compete. This is clearly not the same as rejecting ACA marketplaces wholesale because of some fundamental flaw in the law. Presumably, they are being selective about their participation as they see how price-disciplined the marketplaces are and where they enjoy a competitive advantage.”
Kaiser Permanente’s second-quarter net operating income plunged 35.4 percent from a year earlier even as operating revenue for its nonprofit hospital and health plan units increased in 2016’s second quarter.
Kaiser ended the second quarter with operating income of $491 million, down 35.4 percent from $760 million in the same period of 2015. Its net income fell about 30 percent, to $708 million, from net income of $1 billion in the like period of 2015.
Meanwhile, revenue rose 3.27 percent, to $15.8 billion.
Walnut Creek, Calif.-based John Muir Health and UCSF Medical Center, in San Francisco, have expanded their Accountable Care Organization to let it better compete with huge Sacramento-based Sutter Health and Oakland-based Kaiser Permanente.
John Muir and UCSF’s Bay Area Accountable Care Network started with five hospitals but has since been expanded to add seven more hospitals and three medical groups. The newly expanded ACO has been renamed Canopy Health.
The following California hospitals recently joined Canopy Health: San Ramon (Calif.) Regional Medical Center; Washington Hospital, in Fremont; Marin General Hospital, in Greenbrae; Sonoma (Calif.) Valley Hospital; San Leandro (Calif.) Hospital; Alameda (Calif.) Hospital, and Highland Hospital, in Oakland.
An independent audit has found more than two dozen problems in Kaiser Permanente’s home-care programs in Oregon, including issues tracking patient medication, reports The (Portland) Oregonian.
The paper reported that “The programs serve 750 patients who need hospice or other care at home. Three-quarters of them are on Medicare, a program that Kaiser touts as the best in the Northwest.
{T}he Joint Commission, which did the audit and which is the main healthcare accrediting organization, told Kaiser to follow up with an intensive series of additional audits. “The commission will watch providers care for patients again this month or next.”
Lacee Badgley, the mother of a 7-year-old, works full time as an insurance adjuster. Like most working parents, she finds making time for doctor’s appointments a challenge.
“I don’t have the time or energy to drive around town and then wait,” she said.
That’s why Badgley, 36, switched from her previous doctors to Zoom+, a medical provider and health insurer that aims to give patients more control and transparency. She can make same-day appointments through a mobile app, and she’s usually in and out within 30 minutes.
“It’s one-stop shopping,” she said. “I am a big fan of getting everything quickly … I get my medication, my tests, everything in one visit.”
Zoom, which serves patients in Portland, Seattle and Vancouver, Wash., is trying to buck the traditional healthcare system by offering what it bills as convenient, affordable care in a hip and user-friendly environment. The retail clinics, painted a vibrant turquoise, are stylish and simple. The prices are posted on the walls.
Zoom was created by physicians Dave Sanders and Albert DiPiero to address problems that have plagued medical care for decades: rising costs, poor service and low quality, Sanders said. “We fundamentally wanted to change the system,” he said.
The company targets Millennials, who have been at the forefront of change in other industries. Zoom is designed for an imaginary patient named Sarah, who is in her early thirties and wants to get her health care the same way she gets other services in her life — quickly and efficiently.
The waiting rooms clearly illustrate that dynamic: There are no magazines because patients don’t typically wait long enough to read.
Zoom started as a single clinic in Portland 10 years ago and now has more than 30 locations. Last year, the company expanded in Portland and now offers dental care, mental-health services and chronic-disease management, as well as appointments with cardiologists, dermatologists and other specialists.
It also opened a “performance studio” to help people reach their fitness goals and a clinic that treats emergencies such as broken bones and concussions.
This year, Zoom began selling insurance through the Oregon health exchange. Sanders said that by having insurance members of its own, Zoom will be able to better assess its success at controlling expenses and improving care.
Only about 2,500 have signed up for Zoom’s insurance, Sanders said. He hopes to expand the insurance arm over time and believes the overall model could be replicated in other cities.
In some ways, Zoom is similar to Kaiser Permanente, which also provides medical care and insurance.
But Kaiser is a closed system: It only accepts Kaiser members. Zoom is more of a hybrid, treating not only Zoom insurance members but people with other health plans and self-paying patients as well. As a result, the company is both a partner and a competitor to some other insurers.
Of course, Kaiser is also a healthcare giant {not connected with Kaiser Health News} that operates in multiple states, while Zoom is much smaller and regionally contained.
People covered by Zoom insurance can get care at Zoom medical facilities or with Zoom partners, including Oregon Health & Science University hospitals.
In recent years, more health care providers have been offering insurance, but the vast majority of them are hospital systems, said Katherine Hempstead, director of coverage for the Robert Wood Johnson Foundation.
It’s unique for a network of retail clinics to add an insurance arm, and Zoom’s model is distinct because it is selling a branded experience to a specific population, Hempstead said. One Zoom poster says the complete health system is “designed to make you happier, healthier, smarter, faster, sexier, creativer.”
Hempstead said Zoom seems to be betting on the idea that young people are brand-loyal and view health much more broadly. As a result, they may be coming to Zoom not only to see a doctor but also to work with a fitness coach, get therapy or take cooking classes.
“It’s a totally new-school approach,” she said. “A company like this is saying, ‘We will be the destination of everything you think of when you want to stay healthy.’ The question is: Will the economics work out?”
That could be a challenge given how saturated the Portland insurance market is, said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. And some insurers on the exchange are much more established.
In addition, Millennials aren’t typically heavy users of the healthcare system, though many come for regular checkups, she said. Zoom’s success as an insurer depends in part on convincing young people that insurance “is a valuable thing for them to get and maintain,” Corlette said. Attracting young, healthy consumers also helps balance out any older, sicker members.
Other health care companies are marketing to millennials also, including New York-based insurer Oscar, which attracts younger consumers with its user-friendly technology. Oscar started selling coverage through Covered California this year. Harken Health, a subsidiary of UnitedHealthcare, assigns members in Chicago and Atlanta to a personal health coach, and — like Zoom — it also offers classes in cooking and yoga.
Darcy Hoyt, a veterinarian, said she signed up for Zoom insurance after regularly using the clinics for the past few years. The monthly premiums to cover her and her two children are lower than what her previous insurer charged, and she appreciates knowing in advance how much everything will cost.
“So far, so good,” Hoyt said. “For the relatively young, healthy families with kids falling off bikes and getting common colds, it’s very streamlined.”
The model appeals to people who want a different approach to medicine that doesn’t have the “vestigial appendices of a health care system that has been around for 50 years,” said John McConnell, director of Oregon Health & Science University’s Center for Health Systems Effectiveness.
“It’s like the iPhone,” McConnell said. “Zoom changed the paradigm … The whole way of delivering care is very different.”
Zoom is selective about its patient population. While it sees privately insured patients and uninsured ones with the ability to pay, it doesn’t accept people who are on Medicaid or Medicare.
By limiting whom they serve, McConnell said, the company’s providers may be cherry-picking the least costly patients and leaving other medical groups and hospitals to deal with medically needier people.
Sanders countered that one company can’t be all things to all people and Zoom has decided to invest its resources in serving a population that was ignored by the health system before the Affordable Care Act came along.
Zoom keeps costs low by providing care in neighborhood clinics and avoiding unnecessary tests and procedures. It relies heavily on nurse practitioners and physician assistants, and maintains small staffs. It also has its own electronic health record system.
“The whole process has been stripped,” Sanders said. “We took out a lot of the people, we took out all the paper, we took out the whole Taj Mahal.”
To advance its mission, Zoom has taken on regulators and state policymakers. It successfully lobbied for laws in Oregon allowing nurse practitioners to dispense medication and insurers to reimburse for more telemedicine.
The emergency clinic is one place where doctors said they are able to avoid overhead and pass savings along to patients. For patients paying out of pocket, a visit costs under $300.
Badgley, who has private insurance, came in to the clinic recently because she had been in bed for days with what she thought was the flu but still felt horrible after returning to work. She only had to explain once why she was there.
In the exam room, Dr. Aviva Zigman pulled out a pen and wrote Badgley’s symptoms on an oversized white board, along with the tests she might need and how long the appointment would take. Soon afterward, Zigman quickly determined that Badgley had an ear infection and gave her some antibiotics.
Zigman said that as a provider, the Zoom model is much more efficient than a typical emergency room for routine ailments and her patients can get what they need quickly.
Another Zoom patient, Amy Cannon, 45, goes to the company’s new primary care clinic for management of her high cholesterol, prediabetes and high blood pressure. The clinic, which has a kitchen in the lobby, offers cooking and yoga classes on site. Cannon said it feels more like a private club than a doctor’s office, and the assistant greets her with a hug.
“It’s ‘Cheers’ for health care,” Cannon said. “Everybody knows your name.”
A bipartisan group of U.S. senators are introducing a bill to expand telemedicine service through Medicare benefits.
Modern Healthcare reports that the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act (PDF), “would expand the use of remote patient-monitoring for some patients with chronic conditions, increase telemedicine services in community health centers and rural health clinics, and provide basic telemedicine benefits through Medicare Advantage.”
Backers also tout the measure as having the added benefit of helping providers meet the goals of the Medicare Access and CHIP Reauthorization Act and the Merit-based Incentive Payment System.
The CONNECT Act is supported by several industry groups, including America’s Health Insurance Plans, the American Heart Association and Kaiser Permanente.
“This bill would ensure that patients and their physicians are able to use new technologies that remove barriers to timely quality care. Importantly, the bill would maintain high standards whether a patient is seeing a physician in an office or via telemedicine,” said Dr. Steven J. Stack, president of the American Medical Association.
