U.S. Healthcare – Moving Forward

Last week I gave a presentation to the leaders of some women’s health advocacy organizations about where the U.S. healthcare system is heading, i.e., where we go from the current situation with the A.C.A. We had a great discussion, and the organizer of the event emailed me afterward to say, “Amazing is all I can say. You are the first person who could speak to [the] ACA in which people listened and engaged.”Blog-2-17-Picture

Some of the key points I made included:

  • Focus on the future. Don’t relive the past.
  • Move forward from today’s strengths and weaknesses. The slide below describes health insurance coverage for 2015 showing dramatic increases in coverage in individual insurance and Medicaid, and a decrease in the uninsured. [Note: The Census data indicates any insurance status during the year, which is why the total is more than 100%.]Blog-2-17-Slide1
  • Are we more of less broken? Some “so-called” pundits have characterized the current situation as “broken.” To move forward, it is important to consider whether or not the current system is more or less “broken” than it was in 2010 when the A.C.A. was enacted, or in 2014 when most of its provisions started.Blog-2-17-Slide2

Several of the less broken aspects of the current situation are:

  • The business model for health insurance is now based more on managing risk rather than avoiding risk, which was a major focus before the A.C.A.
  • Access to insurance – particularly for individuals – is now much more reliable and dependable. The A.C.A. created a national floor for insurance practices, with state level implementation and augmentation. This was the focus for the “Patient Protection” part of the A.C.A. i.e., the original title of the law was the Patient Protection and Affordable Care Act.
  • Descriptions of insurance plans are now more standardized and easier for consumers to understand.
  • Medicare’s Hospital Trust Fund is now projected to be solvent for 11 more years than before the A.C.A., and the Medicare Part D benefit was significantly improved, with the coverage gap (a.k.a. “donut hole”) being filled.

Several of the still broken or problem areas in the current situation are:

  • Affordability is still a major problem. This is – and was – a problem for many individuals, as well as some companies that discovered in the midst of the Great Recession (2008-2010) that their healthcare costs were eating deeply into their profits. [Note – polling has long indicated affordability as a priority issue, which is why it was called the “Affordable Care Act.” However, affordability takes much longer to achieve than access, which was the case for the A.C.A.’s model in Massachusetts, where affordability is still being addressed.] Within the A.C.A., affordability for lower income people was addressed with subsidies, but overall costs are slowly being addressed with improvements in healthcare delivery – primarily through public-private alignment in new payment models that are driving greater “value” in healthcare. It is also worth noting that this concept of value is at the core of the new Medicare physician payment framework created in the MACRA law, which had large bipartisan support in Congress.
  • State-to-state implementation has been very variable, with some states doing a good job in creating more stable insurance markets, and others facing low numbers of insurers in their individual markets.
  • Requirements for coverage of certain benefits, and how risks are segmented or shared across populations, are potential areas where changes could be made to address perceived inequities, reduce government spending, and lower costs for some people – but also increase costs for other people. For example, changing the age ratings from 3:1 to 4:1 or 5:1 would expand risk stratification with younger people paying less and older people paying more. Similarly, excluding certain types of benefits from the required “Essential Health Benefits” (which are currently set at the state level within federal guidelines), would decrease costs for people who don’t ever use those benefits (such as contraception or organ transplantation), while increasing costs for people who do use those services. However, such “insurance by body part” practices could also cause insurers (and at risk providers) to build business models around avoiding risk rather than managing it.

Conclusions: The A.C.A. fixed several problems with the U.S. health insurance markets and improved access to health insurance. However, it also accentuated or created some other problems because of its innate structure (e.g., “inartful drafting”), hyper-partisan political advantage seeking, and the normal evolution of insurance business practices. For example, those three factors combined to undermine individual insurance markets in some states because of HHS’ inability to fully make risk corridor payments: The law was not explicit about HHS’ authority, Congress specifically prohibited HHS from shifting funds to make those payments, and many insurers had business plans for the A.C.A. marketplaces with losses in early years to build market share, while expecting to recoup those losses both through the risk corridor payments and higher premiums in later years. The result has been that most of the new non-profit insurance companies created under the A.C.A. (COOPs) failed, and many existing insurers pulled out of markets where they had significant losses, leaving fewer options for consumers. It should also be noted that some insurers have done well in the marketplaces using networks and benefits more similar to Medicaid than large company group health insurance plans, while at least one insurer apparently pulled out of several markets as a positioning strategy to try and bolster their merger plans.

Thus, the A.C.A. transformed what was essentially becoming a two-tiered health insurance market (Medicaid and group health insurance plans) into a three-level system, with a more structured middle tier for individual insurance that looks like a hybrid between Medicaid and large employer health plans. One of the A.C.A.’s successes (although perhaps temporary) was this middle tier, which had been rapidly disappearing in most parts of the country as premiums escalated and people with non-trivial pre-existing conditions were excluded from buying insurance. In 2010, when layoffs were common and the “gig-economy” was expanding, the shrinking supply side of the market for individual insurance not only accentuated the problem of “job lock,” but it also undermined state and federal efforts to control health spending since so many people were “out” of the insurance system.

Are “we” better off than “we” were four years ago? That depends on who “you” are, and what you expect your situation to be in the future.

  • For individuals with health insurance through large groups (such as large companies), things are probably about the same as they would have been without the A.C.A. While premiums and deductibles are almost certainly higher, better information about quality of services is available, and there is more access to things like telemedicine – both of which would have occurred to a similar degree without the A.C.A.
  • For low income individuals, there are now subsidies to buy insurance, or access to Medicaid (in some states).
  • For middle-class people buying insurance on their own, they now have assured access to buying and keeping insurance, although in some cases their costs have increased more than what would have occurred without the A.C.A. in part because they have expanded benefits under the A.C.A.’s requirements. But without the A.C.A., costs for individuals and small groups could have been very dependent upon their age, costly illnesses, or injuries, which could have dramatically increased their premiums, or caused them to lose insurance coverage for specific body-parts or entirely.
  • For people with Medicare, things are better since the Part D donut hole is getting filled, and Medicare is driving new quality improvement initiatives, which are also benefiting people who are not on Medicare since many are being done in conjunction with Medicaid programs and private payers.

Bottom Line:

  • So, are “we” as a nation better off? Overall, we have a clearer picture of the problems and more tools to try and improve (if not totally solve) the problem areas like affordability and quality.
  • Will making productive changes be easy? No.
  • Can positive changes be made while extracting great savings from the health insurance and healthcare delivery systems? Not quickly – but possibly over the long term.
  • Can changes be made in 2017 so that no other changes will be necessary for many years? No. Like trauma surgery, the patient needs to be stabilized, and then multiple surgeries (targeted towards the problems of greatest urgency and long-term benefit) need to be done over time to improve the functioning and long-term capabilities and viability of the patient. Trying to do everything at once can lead to serious morbidity and mortality, and would be more traumatic and expensive, and waste more resources than a measured and planned approach.

Health, Healthcare, and Government Spending (and a Culture of Health)

Why governments care about health and healthcare, how they are connected to government spending and priorities, and why addressing social determinants of health is so important for making lasting improvements, were the subjects I covered in a presentation at George Mason’s graduate policy school in September. My goal was to provide the soon-to-be policy analysts and advisers with a framework for understanding those issues so they will be able to provide useful recommendations to their future decision making bosses. (See the slide below for the topics covered in the presentation.) Links to videos of the talk are below, along with short descriptions – I think that Part 6 is particularly good. (Embedded views of the videos are at the end.)

I’ve had discussions with policy makers and corporate executives about these issues since their organization’s value propositions increasingly require demonstrating individual and population outcomes with specific metrics. Those requirements are part of the broader rapid movement of the U.S. healthcare system towards more accountability. Consequently, the connections among health, healthcare delivery, spending, community organizations, and social determinants of health are becoming a top priority for healthcare and life science leaders in companies and government agencies as they seek to increase value for their organizations and the people they serve.

Any thoughts you have about this talk, the connections among health, healthcare, spending, and community health factors (a.k.a. social determinants of health), would be greatly appreciated. And if there are any aspects of these issues where I can be of help to you or your colleagues – or you know of organizations or audiences that would also benefit from a similar presentation – please just let me know as I’d be happy to discuss that with you.

GMU - 9-29-16 Overview Slide

Part 1: Introduction. Why Governments care about health and healthcare. What is health. What is healthcare. https://youtu.be/KvDVcBGOePc

Part 2: Insights into healthcare spending with a particular focus on the Medicare and Medicaid programs. https://youtu.be/6Onuae2c0Xw

Part 3: Why spending on (and budgeting for) health and healthcare programs are unlike almost all other Federal programs, and why projecting spending is so challenging. https://youtu.be/lyaAjRzD0ic

Part 4: How government and private payers are seeking greater value and better clinical outcomes from their healthcare spending, and how data and analytics are increasingly important components of developing and evaluating those initiatives. https://youtu.be/7abj14xIcMw

Part 5: Examples of value based pricing initiatives and the importance of data and analytics for managing such programs, determining “success”, and sharing savings with physicians, other providers, or patients. https://youtu.be/MeLZA5wcpG8

Part 6: How health, healthcare, and spending on government health programs (and private insurance reimbursements) connect to each other, and how social determinants of health can drive clinical and economic outcomes, i.e., how a culture of health can be so important for transforming health in a community. This Part concludes with a brief discussion of the Affordable Care Act and the future of that program and the U.S. healthcare system. https://youtu.be/66zt_Rqf9hA

Enjoy. Pass along to your colleagues and friends. And as always, constructive comments are welcome!

New Direction for Health Reform Book

In 2005 I started writing a book about health reform.  As I was working on it, the structure and framework of the U.S. healthcare system kept shifting. I am now returning to work on this book, with the new working title, “Pivoting the U.S. Healthcare System: A Guide to Making Health Reform Work.” Below is a brief overview of the background about the book, which can also be found on my main website.

Comments, suggestions, and general inquiries about this project are welcome.

Overview – “Pivoting the U.S. Healthcare System: A Guide to Making Health Reform Work”

In my very first class in medical school, one of the first things the Professor said was, “Half of what we’re going to teach you is wrong. We just don’t know which half.”  That admission is not something you will hear in political or policy pronouncements, even though in the rapidly evolving U.S. healthcare systems situations change, preliminary data is corrected, projections turn out to be wrong in meaningful ways, and “solutions” fix problems but also lead to new ones.

To provide people with a framework for improving the quality of care and controlling costs for themselves and their communities in this shifting world, this book will examine important ideas, issues, and trends, and the steps individuals can take to help achieve better health, access, and affordability. To do that, I will provide my synthesis of observations and information focusing on policy, political, scientific, and medical changes that are building upon one another. Thus, the book will not be an academic treatise, nor adhere to specific ideological, philosophical or political lines. Rather, it will reflect what I have learned in in more than 25 years of clinical, scientific, and health policy work, and my vision for achieving a better, stronger, more vibrant, and healthier healthcare system.

Long Look Forward

In June 2003, I was invited to address the Presidents of the State Medical Societies about “The Future of the US Healthcare System.” To help these physician leaders see the future more clearly through murky waters, I discussed how the trajectories of the major US healthcare programs (including Medicare and employment-based insurance) were leading to greater transparency and accountability for both clinical and economic outcomes.  I then described a future where clinicians and providers would be responsible for the outcomes their care was producing, how payments would be tied to those outcomes, and how documenting those outcomes would be facilitated by electronic medical records and population-based analytical systems.

The reaction of the assembled physician leaders was one of dismissive disbelief. This was 2003. The world had come through Y2K unscathed, the dot-bomb recession was over, and the stock market was rising every week.  Their primary question was ‘who will pay us to put in electronic medical records and to provide information about quality and costs?’ They didn’t believe my answer that those who wanted the information – such as health insurance companies and government agencies – would pay them to provide data and information about quality and costs. Those reactions were not unreasonable at the time, since I suspect most of this group was planning to retire within the next 10 years. (This was before the Great Recession turned their 401k accounts into 101k amounts.)  However, while 2003 was generally a time of great uncertainty for the U.S. healthcare system, the year ended with the passage of a new law – the Medicare Modernization Act (MMA) – that included the new Medicare prescription drug benefit, and it was the first of several major laws driving fundamental transformation of the US healthcare systems.

Slow Turns

The 2003 passage of the MMA, the 2008 election of President Obama, the 2009 stimulus law (ARRA) that included the HITECH Act to support the implementation of electronic health records, and the 2010 passage of the Affordable Acre Act (ACA, or ObamaCare), have all promoted significant changes in the U.S. healthcare system.  But since it is a huge and extensively connected but disjointed set of enterprises, turning the U.S. healthcare system is a slow process. Even policy focused physicians and senior health managers have been slow to accept or react to those changes.  For example, in March 2009, I gave a Grand Rounds presentation at a hospital in Boston. Like my 2003 presentation to the Medical Society Presidents, I described a future with greater transparency and accountability, and the increased use of electronic health systems – particularly since the HITECH Act had become law the month before. The responses included a “rebuttal” from the Canadian-born Department Chair arguing for a single payer system, and a Resident who felt that the Geisinger model in Danville, PA wasn’t replicatable or relevant because – unlike most of the rest of the U.S. – Geisinger dominates its geographically insulated area.

But the more things change, sometimes they don’t.  For example, I recently heard about a senior manager at a large integrated health system that refused to consider planning for the implementation of the ACA’s many provisions: First, Congress would repeal it. Then, it wouldn’t be implemented because Mitt Romney would win the 2012 election.  And lastly, the Supreme Court would overturn the entire law.  Of course, none of those things happened, so this large health system is now playing catch-up with their regional competitors.  Similarly, in early 2014 I spoke with the physician leadership from a state that has not embraced improvements in their clinical care systems or changing incentives for physicians, hospitals, or patients to improve the quality of care or control spending.  Their attitudes reflected a strong desire to maintain their status quo of autonomy, and particularly to not be held accountable (or responsible) for their patients’ clinical outcomes or the health of their communities. Basically they had healthcare delivery and insurance structures that hadn’t changed much since the 1980s, and such physician-centered care is much better for physicians than patient-centered care.

Health Reform Pivots at the Local Level

While my 2003 presentation to the Medical Society Presidents was in many ways a nexus for the work I’d been doing for more than 15 years, it also led me to start writing a book that had the working title “Fixing the US Healthcare System.” The 2008 election of President Obama (and the subsequent passage of the ACA/ObamaCare) led me to change the title to “Making Health Reform Work.”

Now in mid-2014, with many of the major components of the ACA having begun to be implemented – and their effects starting to be seen – I’ve returned to the book and the pieces I’ve been writing for almost 10 years. With the dramatic shifts that have occurred in that time, I’ve pivoted the book’s focus to explore more directly the important changes occurring at the local level and within healthcare delivery. Therefore, I’ve also changed the working title to “Pivoting the U.S. Healthcare System: A Guide to Making Health Reform Work.”

Goal of the Book

The goal of the book will be to provide readers with insights and greater understanding of how to evaluate and influence the rapidly changing healthcare world that encompasses delivery, financing, public health, and information technology – particularly at the local and personal level. The book will explore how initiatives at the local level are what will primarily improve the health of people and communities in the coming years. Specifically, while ObamaCare and governmental activities are changing the framework and the contours of the playing field, how local leaders, organizations, and communities are allocating their resources, setting their priorities, and improving their practices involving health benefits, clinical services, and public health activities are what will most dramatically effect the lives of people and communities.

The book will enable and empower people to alter and accelerate those important changes based upon their personal and local perspectives by working with different groups to make improvement more meaningful for them and their communities. This local multi-stakeholder engagement and alignment is increasingly recognized as crucial for improving healthcare quality and controlling costs: Large employers, insurance companies, and government programs now appreciate that they are not large enough to drive major changes in any market or at any provider organization. Similarly, large hospitals, health systems, payers, and public health agencies increasingly understand that their work and goals are interconnected so that their actions needs to be aligned, and at times even directly coordinated.

Physicians are also an important group to include in this process since physicians (and other clinicians) are primary guides for patients in making healthcare decisions, and greatly influence healthcare spending and quality.[1] And of course patients – and their indirect advocates in the media, government, non-profits, and foundations – need to be part of these intertwined dialogues and decision-making.  The bottom, middle, top, left, and right conclusions all indicate that in the struggle against rising healthcare costs and burdens of disease and disability brought on by aging populations and other factors, united we can succeed, but divided we shall continue down the same failing path.

p.s. To see an old version of the working summary click “Making Health Reform Work.” The latest summary and outline are on my whiteboard and computer.  Please contact me if would like more information about my progress, focus areas, and conclusions.


[1] As an old axiom states, “the most expensive piece of medical technology is the pen in the physician’s hand.”  Today, that prescribing and referring pen is being replaced with a keyboard, a mouse, and a touchscreen, but the effect is similar, even as electronic medical records and systems are raising their own concerns about costs and quality.

Medicaid and State Level Health Transformations

I recently guest lectured on Medicaid and state level health transformation at a George Mason University public policy class.

To start, I led the class through a discussion of how states differ from each other around 14-plus factors related to healthcare delivery, financing, policy, and politics. In this discussion we talked about the importance of policy makers appreciating those factors as they consider how to improve health, and the different routes states have taken for Medicaid improvements and expansion. (See picture of white board below.)

We had a great discussion, and I emphasized the importance of both multi-stakeholder alignment, and health information systems that can provide data for transparency and accountability – which together are fundamental to health improvement and reform efforts. Later in the class we talked about how all the state and federal health reform and improvement efforts have transparency and accountability at their core, and how decision making comes down to people and relationships. Continuing that theme, we discussed how healthcare is local, and for most states the relevant geographic “unit” for transformation of healthcare delivery, public health, and the social determinants of health is the city, community, or region – depending upon how each of those terms is defined.

One of my favorite parts of this class was talking with the students about the intersection of policy and politics. We talked about how the baseline for improvement/reform efforts are the 14-plus factors discussed at the beginning of the class, and the need for policy makers and implementers – such as the students in their current and future work lives – to keep focused on what measurable objectives they are trying to accomplish, i.e., not just on processes disconnected from outcomes. (See slide below.)

Thoughts or comments?

Health Reform and Transformation in San Diego & California

I recently sat down with Kevin Hirsch, MD, President of Scripps Coastal Medical Group* to talk about health reform and transformation in the San Diego region. (See video below.)

Dr. Hirsch’s insights are interesting and timely because California often precedes the rest of the country in adopting new approaches to healthcare delivery and financing problems.  An example of this may be California’s 2006 Hospital Fair Pricing Act, which addressed very high hospital bills for the uninsured. This month’s Health Affairs includes an article that analyzes the impact of this law, and the authors’ findings contrast markedly with Steven Brill’s Time magazine article, “Bitter Pill: Why Medical Bills Are Killing Us.”

The California law is a significant step, and the Health Affairs authors describe it as a “detailed and well-structured approach.” The Act did have  limitations: it only protects uninsured people with incomes under 350% of the FPL, the state has minimal enforcement activities, and it only covers hospital bills and not those from physicians or outside services. (Note: In 2011 the law was expanded to include bills from ED physicians.)

Since the ACA will leave many people without health insurance, the Health Affairs authors conclude, “Policy makers and health planners in other states searching for options to protect the uninsured should be encouraged by our findings and should seek to learn more about California’s approach and determine how they might adapt similar laws to their own state’s health care system.”


(Disclosure: I’ve known Dr. Hirsch for many years – and aside from out obvious East Coast-West Coast attire differences, we continue to share a similar hairstyle and are both working to improve healthcare quality and efficiency.)

 

*Scripps Coastal Medical Group includes more than 140 family medicine, internal medicine, obstetrics and gynecology, pediatrics, physical medicine and rehabilitation, rheumatology and general surgery clinicians practicing throughout San Diego County, and exclusively provides medical services through Scripps Health, a nonprofit integrated health system, under the Scripps Coastal Medical Centers brand.

Health Reform and Low-Income People in Washington DC

I recently sat down with George Jones, Bread for the City’s CEO, to talk about health reform and the challenges low-income people in Washington DC have accessing healthcare. The video of our discussion is below.  A couple of notes: 1. George’s title changed from Executive Director to CEO about a year ago.  I’ve known George for more than 15 years, so my bad when I introduce him as the Executive Director. 2. Please excuse my verbal stumbles and be impressed by George’s answers – we filmed this in one take in his small, hot office at Bread for the City.  I’m confident there will be improvement in future videos – and of course, your feedback is always welcome!

Health Reform’s 7 Lively Concerns (Not the 7 Deadly Sins)

At a recent meeting about implementing the Accountable Affordable Care Act, Don Berwick, (the recent CMS Administrator, and the Founder and former CEO of the IHI), listed 7 areas that worry him about continuing with successful health reform and the implementation of the ACA. (Note – I’ve rephrased some of these into question form and added some summary comments.)

  1. Will Care Change? (After payments change to incentive value rather than volume.)
  2. Will Costs Actually Be Reduced? (It is too early for much data, but can we get to a sustainable level of GDP spending on healthcare, e.g. 15%?)
  3. Will the Mechanics of Coverage Be Successful? (e.g. Insurance Exchanges)
  4. Will the Safety Net Be Maintained/Sustained? (i.e. Beyond Medicaid)
  5. Will there be a Continued Commitment to Science? (People want healthcare that works, e.g. evidence based medicine.)
  6. Will Prevention Efforts Continue? (It is easy to say, hard to do, but also an easy target for funding cuts.)
  7. Will Communications to the Public About the Value of Healthcare Changes Improve? (Debra Ness, the President of the National Partnership for Women and Families, noted in a later panel that “normal” people – i.e. non-healthcare wonks – don’t understand the terminology that “experts” use, but when they describe what they want from the healthcare system, it sounds very much like the basic elements of a patient-centered medical homes. This indicates that the public should like the system we are moving towards, but they don’t understand the vision because the communications hasn’t been appropriate…. Something I wrote about last year. )

Two other important facets of healthcare improvement that he noted later in his remarks are:

  1. States are moving forward as experimental fountains – and this is a good thing.
  2. There is a great need for engaging the business community as major payers – their voices have not been involved enough in local and regional discussions.

These are all important aspects of implementing healthcare reform where the decisions made by local, regional, and national entities could either accelerate or stall progress towards higher quality, lower costs, and better care experiences.  As such, they are now part of my list for determining if initiatives will likely be successful, or may be moving in a direction that won’t produce the desired results, e.g. by reinforcing or expanding local monopoly-like entities.

P.S.
Later in the conference Dr. Berwick noted that in his discussions with the leaders of healthcare organizations around the country they are consistently facing the “How” challenge.  That is, they all recognize that the healthcare world is rapidly evolving and although the payment system hasn’t yet changed significantly, they know it will, and therefore they are seeking to understand how to transform/restructure their delivery operations and supporting infrastructure, (e.g. IT systems), to be ready for this future that is rushing towards them.

Health Insurance Security Creates Jobs

People feeling secure that their health insurance will continue (or be easy to get) creates an often overlooked societal benefit, i.e., it promotes job creation – particularly for entrepreneurs. Because this value is hard to quantify, it is seldom seen in policy or political rhetoric. (It is also overshadowed by the general “job lock” phenomenon of employment-based health insurance.)

This week’s National Journal has a great article on this topic (“The Other Jobs Bill”) that examines Massachusetts’ experience with their insurance reforms and coverage requirements: The expert consensus is that these reforms have boosted Massachusetts’ economy and job growth compared to other states. Two quotes from the NJ article highlight the impact:

“Massachusetts, despite the confounding effects of the recession, can now offer aspiring entrepreneurs the freedom to leave large companies and start small ones – and give dissatisfied workers the freedom to change jobs, freelance, or scale back their hours without worrying about depriving their families of health coverage.”

“Despite some initial concern from the business community, companies have largely embraced the law as a benefit, not a burden.”

Implications for the Supreme Court’s Ruling on the ACA

Driving home how interstate commerce is affected by health insurance coverage, the article tells the story of a start-up company’s Founder recognizing the business value of guaranteed access to health insurance through the state’s exchange: It was the factor that “finally snagged her several talented staff members from bigger, established companies out of state.” [emphasis added]

Healthcare Turkey Talk

Thanksgiving is a great occasion for learning what people think about the future of the US healthcare system.*  This year, I’m going to find out what people are thinking about some of the coming health delivery system changes – particularly Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMH).

I’ve conducted this two-question informal survey with handfuls of people and found their level of knowledge and positive reactions equivalent to Congress’s approval rating, i.e. 9%.  This is worrisome, since if transforming the US healthcare system to increase value and quality will be partially based on ACOs’ and PCMHs’ superior care coordinating abilities, it will be hard to improve cost, quality, and access at the local level if the average person/patient doesn’t know what these organization are, there is inherent aversion to their names, or there is resistant to unexplained “changes.” (For example, several people I’ve talked to have thought Accountable Care Organizations seem like HMOs, and Patient-Centered Medical Homes are home care, nursing homes or hospice.)

So fair readers of this blog, let me know what you hear at your Turkey dinners and associated holiday events – and I’ll post back next week what I heard from my disparate and decidedly unrestrained friends and relatives.

 

*Unlike most meals and gathering of family and friends, Thanksgiving dinner goes on for a long time, there are no ceremonial interludes, and it is generally a sit-down affair so you can’t move on to someone else – or out the door. This means “Aunt Sally” can pull your ear or kick your leg (either figuratively or literally) for upwards of 2 hours about what’s wrong with the US healthcare system and what how to fix it.  My advice is to ask questions to find out root concerns and to gauge people’s understanding of the coming ACA changes in both healthcare delivery and insurance coverage.  Also, if you find yourself referring to a recent study from Commonwealth or Kaiser Family Foundation, (or a similar organization or government group), STOP, put food in your mouth and nod encouragement for them to keep talking, because quoting the best studies to someone impassioned about their healthcare will be about as successful as convincing your 7-year-old cousin that 3.14159 is a great dessert.

Implementing Health Reform – The Long, Hard and Twisting Maze

Health reform is now the “law of the land,” and “written in law.”  However, as people are quickly realizing, after a year of campaigning and more than a year of legislative action, implementing the new law will require navigating a long, difficult, and twisting path – even before any amendments are considered in this or subsequent Congresses.

Navigating the fast and slippery route to successfully implementing all the provisions of the PPACA will be daunting.  Three relatively recent laws are examples of the time and steps required for such implementation – and each of these was much simpler than the PPACA:

  • The Medicare Part D law was signed in December 2003 and the new benefit started in January 2006. This gave the Federal government about 2 years to develop the rules, sign up providing plans and facilitate enrollment by creating an exchange-like website and other resources, while the plans conducted the actual enrollment.
  • The Massachusetts health reform/insurance expansion law was enacted in April 2006. This was followed by a long series of staggered implementation steps. For example, insurance reforms, (on top of the state’s pre-existing significant insurance regulations), became effective in January 2007, and the new individual mandate started in July 2007.
  • The Federal stimulus law was signed in February 2009, and the HITECH Act part of the law included significant provisions and funding to boost the development and adoption of information technology by healthcare providers.  At the end of December 2009 a key draft rule on “meaningful use” was released, and it is expected to be finalized soon.  In the meantime, the Department of Health and Human Services has distributed funding to start the adoption of specific types of health IT.  (The April 2010 Issue of Health Affairs has a series of articles focusing on the implementation of the HITECH provisions of the stimulus bill.)

Written in Law – Not Written in Stone
The  implementation of these laws illustrates how it takes months and years after a law is signed to create the implementing rules and regulations, and to contract with organizations to actually carry out significant parts of the new law – and this is before any modifications are made by subsequent laws.

In the coming weeks and months, many entities will continue combing through the final law – which because of the circuitous path it took to Congressional passage is much more difficult to read and understand than most other new laws.  Some of the most challenging aspects of implementation will be in the states, where government agencies will have many new responsibilities and/or will need to be created. Federal and state governments, and many private organizations, will also probably need to hire people to carry out this implementation – and hiring government employees can be a lengthy process.

In addition healthcare companies – particularly health plans and insurers – will be working to determine how their business operations will be affected by new state and Federal regulations, despite the fact that those regulations haven’t been written yet.  And all but the smallest businesses will be seeking to understand how they will comply with – and possibly benefit from – the new insurance rules and financial incentives.

Overall, it is clear that the implementation will be the hardest part in taking health reform from a concept and a campaign position, to reality for individuals and society.  I know that many people in Washington DC – particularly Congressional, HHS and related health reform staff – worked very hard for many, many months in an exhausting process to get the law passed.  For Congressional staff at least, the implementation will be the responsibility of others, while Congress’ work will be to ensure that this implementation is consistent with their intent, and to work with HHS to adjust provisions according to the real-world bumps and detours in the road from here to there.

Conclusion
The cartoon below summarizes the expanding and complicated challenge of implementing health reform through the inevitably twisting and complicated path better than any combination of words could… I’ll have more about specific provisions and implementation in the coming days, weeks, and months….

MAZE-Man