Howard Haft MD, MMM’s Post

Truth to Power The recent article by Bob Berenson and Kevin Hayes in Health Affairs makes a strong statement to Congressional leaders that they are perpetuating a flawed Physician Fee Schedule (PFS) and misguided if they trust that simply shifting to value-based payments (VBPs) will correct the flaws. The authors point out that the PFS is at the heart of the VBPs and without correcting the PFS the VBPs are doomed to fail. The connection between the VBPs and PFS may not be immediately obvious but it is real, with a major impact. As the authors point out, the roots of the issue go back to policy decisions made decades ago that were heavily influenced by industry lobbyists. The underpayment for primary care and the emphasis on procedural payments is hardwired into the 10,000 billing codes. With the PFS underpayment for primary care services as the foundation, most CMMI primary care VBPs are statutorily handcuffed to budget neutrality (with some flexibility if they can produce savings over the short haul). The budget neutrality issue compels the programs to create winners and losers, but does not substantially raise the overall payments to providers. For example, in the Maryland Primary Care Program and the ACO Flex Model the capitated payments to primary care are designed to reflect the historical billing of the practices which is based on the inadequate payments in the PFS, leaving the basic services perpetually underfunded. CMMI has employed thoughtful payment adjustments for Care Management Services and health equity which are still inadequate to address an aging population suffering from overwhelming racial, ethnic and geographic disparities.  Even if the CMS goal of having every beneficiary under an Accountable Care relationship by 2030 is met, it does not address the underlying primary care payment deficiency since primary care providers will still derive the majority of their income from fee for service based of the PFS. This situation is not the fault of HHS, CMS or CMMI. The smart, dedicated, hardworking folks in those administrations must adhere to the statutes they are governed by. The problem and the solutions belong to our Congressional policy makers. The authors draw two conclusions- “the Centers for Medicare and Medicaid Services should correct misvalued services and establish a hybrid payment for primary care that blends fee-for-service and population-based payment. Second, Congress should alter the thirty-five year-old statutory basis for setting Medicare fees to allow CMS to explicitly consider policy priorities such as workforce shortages in refining fee levels” and close with the statement “Value must be sought in both the fee schedule and APMs….. it is time to repudiate the judgment that fee-for-service has no link to quality and value” Truth to Power Howard https://lnkd.in/eRt_natp

Relationships, trust and better health The relationship between patients and their healthcare providers is built on trust over time. Underlying that trust is the understanding that the provider is bound by oath and duty to hold the interests of their patients first, in a confidential, skilled, and empathetic manner. The more confidence and trust the patient has in their provider, the more effectively they work as a team to meet the personal health goals of the patient. Studies have shown that the greater the trust the patient has in their provider, the higher the compliance with treatment, the better the outcomes and the greater the satisfaction with the care delivered. It takes time and meaningful empathetic interactions to build trust. Trust is also fostered by the ability of the provider to align with the cultural, language, clinical and communication preferences of the patient. This compatibility is important for sustaining patient- provider relationships. The more the provider aligns with the patient preferences’, the quicker and stronger the trusting relationship develops. CMS has acknowledged the importance of relationships in their new care models incorporating the Person-Centered Primary Care Measure as a quality measure. This tool asks patients to judge their healthcare experience with statements like; “My doctor and I have been through a lot together” or “My doctor considers all of the factors that affect my health”. In the absence of a long-term relationship the provider will not be scored highly by patients on this measure.  Optum Match (OM) is a newly developed tool that addresses this issue by facilitating the patients’ selection of a compatible provider. OM uses personal surveys completed by patients and providers that describe providers' culture, language, style of practice, communications and other features and match them against patients’ preferences. As noted in the article referenced below, better patient- provider compatibility can have important benefits beyond quality measures and outcomes: - Reducing the provider shopping by patients. Allowing the compatibility to be established before the appointment is made - Improving the likelihood that a patient will stay with a provider for the long term. In the current value-based payment system, stable patient panels are appreciated - Advancing health equity by using the tool to do the best match to meet the needs of minority and vulnerable populations where trust is often more difficult to establish My greatest professional joy and satisfaction comes from the long-term caring relationships with my patients. I believe it is very important to build these relationships and restore more joy in the practice of medicine. That is why I am supporting Optum Match as it becomes available for patients and providers. VISIT OPTUMMATCH.COM https://lnkd.in/e7b8GTGi Yours in health Howard

Healthcare spending and insurance coverage - Colliding trend projections In the past few weeks, the nonpartisan Congressional Budget Office (CBO) released their projections for insurance coverage trends from 2024-2034 and CMS released their projections on healthcare spending through 2032. The insurance coverage projections show an increase in the uninsured from the recent low point of 7.7% to 8.9% by 2034, representing an additional 4 million uninsured persons.  The increased number is based on current laws unwinding the Covid-19 Medicaid stabilization rules, the rollback of expanded advanced premium tax credit (APTC) subsidies for Health Benefit exchange plans and an increase in undocumented immigrants unable to access health insurance.  CMS projects that healthcare spending will increase to over $7 trillion by 2032 taking up 19.7% of the total gross domestic product. The increases are driven predominantly by price increases and an ageing population with Medicare spending rising from $14,226 in 2021 to $24,921 per enrollee per year by 2032.    There are some additional issues and impacts created by the collision of higher healthcare costs per person and more uninsured people, that may not have been taken into consideration: As healthcare costs increase there may be a tipping point where some employers, employees and independent purchasers may find that commercial insurance premiums are not affordable. For the past decade insurers have been mitigating the premium costs by adding high deductibles, copays and coinsurances which lower premium costs while shifting these costs to families. Without significant wage growth, the increased healthcare insurance expenses can exceed many families’ financial capabilities. This impact could lead to a higher rate of uninsured persons 1. CMS has planned to have all beneficiaries under accountable care relationships by 2030 in hopes that these programs will reduce spending. The largest incentives for providers to engage in these programs is the ability to generate financial savings that come back to them. In the near future all of the reasonable savings might be wrung out of the system and their will be little incentive for providers to participate 2. As the number of uninsured patients grows, this group will likely defer early preventive interventions, become sicker, develop more costly end stage complications of chronic diseases, and result in increases in uncompensated care. This will ultimately pass the costs of that care onto other payers. This is the trajectory based on current policies. Who we elect to lead our states and the nation will influence the future policy direction. If our leaders preserve the APTCs, expand Medicaid, and invest wisely and sufficiently in prevention, primary care and public health; we may have a better long-term result. What do you think will happen with healthcare spending over the next decade? What do you think will happen to insurance coverage? Yours in health Howard

Wealth Determinants of Health (WDoH) A recent article In JAMA Internal Medicine that measured the prevalence of Federally Qualified Health Centers (FQHCs) screening for the Social Determinants of Health (SDoH) was an eye opener in several ways. The study determined that among the 1338 FQHCs there were 887 that were identified as “screening” for SdoH factors. Information was collected from patients on four factors, food security, housing stability, transportation adequacy, and financial strain. They found that only 25% of the 21 million patients served by the FQHCs had been screened for these factors. The data should not be used to criticize the FQHCs that have just begun this important work and will get better with improved technology and more support. The real story here is the results of SDoH screening of over 5 million patients. Among patients at FQHCs who were screened, the mean positive screening rates were 16.3% for food insecurity, 15.4% for housing insecurity, 14.1% for lack of transportation, and 27.6% for financial strain. Financial strain is nearly twice as frequent as the other SDoH items. It is not hard to see how financial strain also underpins the lack of housing, food and transportation.  The poorer you are, the more obstacles are put in the way of achieving your full measure of desired health. Being poor in the world’s most expensive healthcare system makes the obstacles to achieving good health outcomes harder to surmount. Even moving up the wealth scale into the middle-class ecosystem of commercial insurance and Medicare does not remove the economic barriers of high deductibles, co-insurance and copayments on top of high monthly insurance premiums. The inescapable truth is that according to the most recent Medicare financial data, the average healthcare spending in the US in 2024 is projected to be over $15,000 per person per year compared to the average for other economically developed countries of $5,000 per year. We have an unacceptably expensive healthcare system. The message to policy makers is that it is not too late to take control of the high prices. The costs already exceed most Americans' budgets and disproportionately harm the most vulnerable patients.  Targeting the highest cost, noncompetitive healthcare items with price controls (drugs and hospitals), investing in prevention and early interventions (public health and primary care), and reducing administrative expenses can restore healthcare affordability and save lives. Without addressing the Wealth Determinants of Health, increasing numbers of us will only be window shoppers on 5th Avenue, dreaming about the best healthcare that only the very wealthy can afford. Yours in health Howard  https://lnkd.in/echKuaRk

What’s the HEC? Following a long period of advocacy and supported by a trust fund of $1 billion, the Agency for Healthcare Quality and Research (AHRQ) has signaled they will soon release a Notice of Funding  Opportunities (NOFO) for state-based Health Extension Cooperatives. The intention of this NOFO is to demonstrate the effectiveness of state-based healthcare practice transformation support systems. This is similar to the way in which the Dept. of Agriculture has shown decades of success in the Regional Extension Cooperatives (RECs) to support rural farmers. This program comes at a very opportune time as 20+ states are actively engaged in transforming the payments and delivery to primary care. CMMI is promoting state-based payment and primary care delivery reform in their Making Care Primary Program, the AHEAD state-based model, and the recent ACO Flex model. All of these programs require providers to undergo major changes in the way they deliver care, expanding their focus to population health while delivering patient centered comprehensive care. The programs also compel states to look carefully at how the health of their diverse, rural and underserved communities can be maintained and improved over time. Change does not occur spontaneously and none of the hopeful changes in these programs are easy to accomplish. The introduction of HEC resources, regionally distributed within a state, is a powerful way to meet the educational and resource needs of the states and providers as they begin the journey of transformation to high value, whole person equity focused care.  There are a few good examples of the effectiveness of "HEC-like" programs in Vermont’s Blueprint for Health and New Mexico’s Health Extension Regional Organizations. My experience in the Maryland Primary Care Program also demonstrated the essential role of the State Health Department's Program Management Office and regional Care Transformation Organizations providing technical assistance and resources to primary care practices to successfully integrate behavioral health, care management and advanced health information technology in primary care practices across the state. Please take a moment to read the AHRQ notice below: https://lnkd.in/eSTqRpN5 Yours in health- Howard

The Seven Truths about US Healthcare 1. The nation has never declared Health to be a right under the constitution, healthcare and therefore good health, remains a privilege and not a guaranteed right. 2. The high costs of care are a result of high prices, not overutilization. The high price conundrum has resulted from a long series of short sighted and profit influenced policy decisions that have made the "health system" a "wealth system" with attractive opportunities for equity investors 3. The US ranking for healthcare quality is near the bottom on the list of economically developed nations. This poor performance is a reflection of disparities in quality outcomes with the poor outcomes from underprivileged while the quality for the privileged is much better, although still less than other countries. 4. As a nation our perception of value in healthcare is influenced heavily by the media and marketing that emphasize the newest and most dramatic interventions and disregard the greater value of prevention. 5. The US healthcare delivery system is centered around hospitals rather than communities and primary care.  6. The US does not have an actual healthcare delivery system, nor is there a current workable plan to create a system. Without a cohesive plan we are committed to perpetuating a fragmented group of unrelated delivery elements. 7. The true foundations of health, primary care and public health, remain underfunded, poorly appreciated and tottering on the brink of collapse. A post-apocalyptic nation without support of this foundation, would be sicker, much more costly and at great peril when the next pandemic occurs. On the bright side, these are all issues that our leaders and policy makers can address with the support of their voting constituencies. Our policies and priorities led us to where we are and with thoughtful leadership, they can take us to a healthier, safer place.  https://lnkd.in/euZE8XCW Yours in health; Howard

Primary Care should be Funded as a Common Good The recent publication in the NEJM by Dr Mandy Cohen, Director of the CDC, describes the underused and much needed synergistic power of integrating Primary healthcare and Public Health. This synergy is underpinned by the reality that Primary Care and Public Health are the “Twins Separated at Birth” with both having the common DNA that allows them to be recognized as “Common Goods”, that both benefit society as a whole.  Public Health has long been accepted and funded as a Common Good but Primary Care recognition has lagged behind until recently.  The CDC Director makes the important point that both Public Health and Primary Care need to be sufficiently funded if they are to serve the “Common Good” adequately.  Public Health has been underfunded by states and the federal government. Primary Care has been underfunded by insurers (Commercial and Federal). The clear path to increasing Public Health funding is through government budgeting. The path to increasing Primary Care funding is more complicated and must pass through the hands of many insurers and intermediaries with diverse priorities (including profit and power) that may or may not be directed at using Primary Care to bring better health to people and communities. The 2021 NASEM report “Implementing High Quality Primary Care” suggests that Primary Care is a common good and should be provided with government funding in the same manner as public health. The report offers a governmental policy framework to support, fund, define required elements and hold primary care accountable. As we navigate this framework there are a number of important issues to address, including but not limited to: What does funding primary care as a common good mean? How should the “common good” be funded; capitation, or an enhancement to current funding models? Is moving forward to fund PC as a public good a state-by-state decision process, federal decision or hybrid? Must states and/or the federal government establish non-exhausting funding mechanisms? Must funding be linked to new or existing tax revenues and how will sufficiency of current and future funding be established? Will the current insurance providers remain as intermediaries and how will the Public Good funds be paid? How will primary care accountability be established and enforced? How will PH/PC integration be assured? What definition of primary care will be used to the inclusion or exclusion of OB/GYN and Behavioral Health? https://lnkd.in/eFAazCx9 Yours in Common Goods Howard

                          Assuring Equity in Quality Measures Value based payments are inexorably moving toward the predominant form of payments in healthcare. The equation that measures value is quality divided by cost (V=Q/C), the greater the quality the larger the value. Perhaps the most challenging element in that equation is assurance that the way we measures quality is fair and rooted in equity.  I was privileged to co-author a review article addressing the issues associated with the measurement of quality with an amazing group of physicians and healthcare professionals from across the country who are dedicated to ensuring equitable outcomes from our measurement of quality. Here is an abstract from that article in the Journal Circulation: The US health care industry has broadly adopted performance and quality measures that are extracted from electronic health records and connected to payment incentives that hope to improve declining life expectancy and health status and reduce costs. While the development of a quality measurement infrastructure based on electronic health record data was an important first step in addressing US health outcomes, these metrics, reflecting the average performance across diverse populations, do not adequately adjust for population demographic differences, social determinants of health, or ecosystem vulnerability. Like society as a whole, health care must confront the powerful impact that social determinants of health, race, ethnicity, and other demographic variations have on key health care performance indicators and quality metrics. Tools that are currently available to capture and report the health status of Americans lack the granularity, complexity, and standardization needed to improve health and address disparities at the local level. In this article, we discuss the current and future state of electronic clinical quality measures through a lens of equity. The full article is available at: Sustainable Approach to Justice, Equity, Diversity, and Inclusion Through Better Quality Measurement Nkem Okeke, Kerrilynn C. Hennessey, Amy M. Sitapati, Dana Weisshaar, Nishant P. Shah, Rebecca Alicki and Howard Haft https://lnkd.in/eQZ4BG2J I encourage you to share this article with others in your networks All the best Howard

                       Primary Care Investment “Virga” The rain that forms in the clouds, that you can see falling, but never wets the ground, is called “virga”. The renowned healthcare economist, David Cutler, published a recent article in JAMA, where he describes a broad economic problem in healthcare where the principle that you can “do well by doing good” has been cast aside too often in favor of “doing well without doing good”. He cites examples of private equity purchasing hospitals, broad based consolidation leading to price increases without increasing quality, and the common practice of “upcoding “patient diagnoses in order to gain shared savings.  These are all important issues that dilute the effectiveness of investments made in healthcare but equally important is the growing impact of corporations that siphon away investments that are intended to go directly to primary care practices.  Many articles and reports have noted the precarious financial position of primary care and the worsening workforce shortages. As primary care has been weakened it has also become vulnerable to schemes and programs that promise some interim financial relief in exchange for sharing large amounts of primary care intended investments. It is easy to understand how a practice that is barely surviving will be enticed to accept a deal that offers a marginally better income, even at the expense of giving away a major portion of current and future shared savings or other new revenues.   As CMS is developing more models designed to increase investments in primary care, as the physician fee schedule is leaning more toward increased primary care payments, and as many states are setting aggressive targets for primary care investments, it will become even more attractive to profit driven corporate entities to find ways to attach to those investment dollars before they actually reach the intended primary care providers.  It is critically important that policy makers and regulators enact guardrails, regulations and policies that monitor the flow of the primary care investments to assure that the majority of that “rain” reaches ground level and does not evaporate, like virga, into corporate profit without “doing the public good” as intended.  Primary care providers and practices can only do good for their patients with what actually reaches them. Policy suggestions- 1.      States and Feds to seek and enforce antitrust statutes and regulations 2.      Corporate practice of Medicine laws should be vigorously enforced and loopholes eliminated 3.      Pure upcoding schemes where corporate entities derive significant profit at the expense of providers efforts should have aggressive limitations on the percent of profit allowed by the corp. 4.      Noncompetition clauses should be eliminated 5.      Contracts between providers and controlling entities should allow for termination of the contracts while preserving the provider’s revenue stream Yours in health Howard

What is the sweet spot for the number of quality measures to use in Value Based Programs?                                                 (The answer may surprise you) There has been an ongoing controversy over what the correct number of quality measures providers should be accountable to in value-based payment programs. Clearly, too many quality measures attached to financial incentives can dilute the focus of providers. Conversely, too small a number of quality measures may distract the providers attention away from important measures that do not have incentives. This seems like an untenable dilemma. Recently CMS made a bold statement regarding their intent to revisit the issue and work toward limiting the number of measures. In fact, the answer may not be found in the number of measures, but how the measures are used.   The quality measurement world has roots in Peter Drucker’s dictum regarding business processes, “You can’t manage what you cannot measure”. This was applied with great success to a broad array of factory and other business processes.  However, it has been noted that the rule does not apply universally since not everything that matters can be easily measured, the context of the measurement is important and defining specific goals can be challenging.  In healthcare, we have developed a myriad of process and outcome measures that relate to the steps required to deliver high quality care. These steps are carried out in the modern context by teams of health professionals and their supporting staff. If healthcare was a factory each of the workers in that factory would be responsible for, in whole or in part, some of the quality steps or measures to deliver the care at their work station. In a factory setting they would be provided with data driven feedback that allows them to continually improve their work and create more high-quality products in an efficient manner. The workers receive promotions or other rewards for their success. The finished products would be judged by the consumers by how well the finished product meets their needs; not by how each worker performed each activity. So perhaps the answer to the question of how many measures to use is that healthcare providers should use all of the relevant quality measures, like in a factory, to manage and optimize the delivery of care without the distraction of placing external insurance driven financial incentives on these activities.    The value based financial incentives would be more appropriately placed on the final product of all of those processes and activities as judged by the patient.   To achieve that goal will require much more engagement of knowledgeable consumers with a better understanding of what to reasonably expect from healthcare, including convenience, clarity, and unwavering dedication to providing the best level of health the patient desires. Yours in health and quality Howard