Peering Into 2016: Five Major Questions We’d Love to See Answered this Year

Jan. 4, 2016
U.S. healthcare faces many significant questions, as we begin a new year. Here are five worth pondering.

Being a film buff, I can’t help myself: I’ve often found myself quoting Bette Davis’s character, Margo Channing, in her classic line in the 1950 Joseph L. Mankiewiecz movie “All About Eve”: “Fasten your seatbelts, it’s going to be a bumpy night!”

Well, to be honest, it’s been a bumpy past several years for most healthcare professionals in the United States, and there’s no real reason to believe that things will get measurably easier in this new year or even in the next few years. On the other hand, things have become somewhat clarified on a policy level, and there is justification for guarded optimism in certain areas, even as there is equally good reason for concern in some others.

All that having been said, it will be interesting to see whether several questions have been answered by the end of 2016. Below are some that I know I, for one, would like to know the answers to, this year.

  1. Will CMS fix some of the measurement-related problems in the Pioneer ACO program?

Here’s a very basic question: shouldn’t officials at the Centers for Medicare & Medicaid Services (CMS) be worried about the growing number of departures from the Pioneer ACO program? One would think they should. And yet the departures continue, even as providers’ complaints about that program remain unaddressed. As I noted back in November, “When the Boston Globe reported on November 3 that two Massachusetts healthcare organizations—the Boston-based Steward Health Care System and the Brighton-based Mount Auburn Cambridge Independent Practice Association (MACIPA)—were leaving the Pioneer ACO Program, that dual development became the latest in a series of worrisome developments around what had started out as a showcase program for innovative accountable care organizations (ACOs).”

What’s more, as I stated, “Indeed, the launch of the Pioneer ACO Program, even more than the launch of the Medicare Shared Savings Program (MSSP), both sponsored by the Centers for Medicare & Medicaid Services, under terms of the Affordable Care Act (ACA), had created a frisson of excitement at its inception back in 2012. And even on August 25, 2014, CMS officials were able to crow about some of the results coming out of the Pioneer ACO Program, when they announced on CMS’s website” some impressive results.

But with the number of Pioneer ACOs now down to half, shouldn’t CMS officials be rethinking at least some elements of the program? After all, it is the most high-profile of the ACO programs being managed under Medicare; and let’s face it, should the Pioneer program collapse, it would create uncertainty in the industry, even as the Medicare Shared Savings Program for ACOs (MSSP) continues to grow in participation, and as the Next-Generation ACO Program gets off the ground.

But Pioneer is the “diamond-level” federal ACO program, and naturally, has garnered a large share of the attention, and for good reason, particularly since its participants are organizations that are all already known nationally as industry leaders in delivery organization innovation and effectiveness.

The thing is that some of the fixes that would be required to stanch the anticipation loss seem like reasonable, not-incredibly-difficult changes to make. The best example here seems to me to be around the departure of Sharp HealthCare from the Pioneer program in the summer of 2014.

As Alison Fleury, senior vice president, business development, at Sharp HealthCare, and one of the most senior executives in Sharp’s former Pioneer ACO, told me a year ago now, Sharp’s departure was based on very brass-tacks issues—primarily around how CMS calculates labor costs.

As I reported in a blog last January 7, Fleury told me this:  “Sharp is the largest provider in San Diego County, and we’ve been in risk contracts for 30 years. We had been in the commercial risk market prior to entering the Medicare risk market. And when the Pioneer model came out, we were interested in the ability to work for population-based payment. We were actually advocating for that sooner rather than later. And we have two Medi-Cal groups, friendly competitors, if you will; and neither the Sharp Rees Staley Medi-Cal Group, nor the Sharp Community Medi-Cal Group, could have done this on their own.”

But one of the core problems with Pioneer, Fleury told me, was that “the benchmark model in Pioneer, different from that in the MSSP, uses a national benchmark, so the benchmark does not reflect labor costs in your individual market. Our area wage index went up  8.3 percent, but our payments didn’t go up. And the Pioneer includes a disproportionate-share formula, but MSSP doesn’t. And disproportionate-share is based on your Medi-Cal proportion”—as the Medicaid program is known uniquely in California.

 “So,” Fleury told me, “we had expected our Medi-Cal business to go up 25-30 percent, and had expected our Medicare payments to go up” under the Pioneer formula. But, she said, “because the model uses a national benchmark, it doesn’t work that way. We weren’t getting enough money in the benchmark formula, so that what we were paying our providers was not reflected in the benchmark. We were decreasing our utilization significantly, but the financial model showed that we were just breaking even, and we believe that the 2014 would have shown us increasing costs, even though that wasn’t true.” The fundamental problem there, she noted, “is that there is no correlation between shared savings and utilization. The pioneer model did change on January 1,” she added, “but we were not willing to be subject to a loss in 2014 under the old model. Also, the Pioneer model was not risk-adjusted as the MSSP models were. So the benchmark didn’t reflect having sicker patients.”

What strikes me about all this is how peripheral the issue of labor costs is to the broader goals of Pioneer, and indeed, to the broader goals of all the federal ACO programs. Yes, CMS officials need to stand on principle when it comes to core clinical outcomes measurement issues; but labor market inequalities? Really?

So my hope is this: that in 2016, CMS officials get their collective act together and move forward to shore up participation in the Pioneer ACO program, because it matters. Pioneer could once again be a maximal showcase for ACO innovation—if the top people at CMS will let it. But this is an example where the devil is in the details—and the details are working against a broad overall progress that is much needed in U.S. healthcare, both practically an symbolically.

  1. What will the new physician performance measures under MACRA end up looking like? And will they make a qualitative difference?

Just last month, I wrote about the new Quality Measurement Development Plan (MDP) announced by CMS officials, around the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) legislation passed last spring by the U.S. Congress, which repealed the long-maligned sustainable growth rate (SGR) formula for Medicare physician payment, but in turn authorized the creation of a new set of clinical outcomes measures to be embedded in Medicare fee-for-service (FFS) physician payments.

As I noted, the MACRA legislation had identified five quality domains to focus on—clinical care, safety, care coordination, patient and caregiver experience, population health and prevention—for measures to be developed under the MDP, and to be aligned with the National Quality Strategy and the CMS Quality Strategy.

The Quality MDP was really quite vague and aspirational in its language, with virtually no details. But one could certainly hope that what comes out of the process of measure development will be positive and will lead to the right kinds of incentives for physicians, going forward. What’s more, this is an area in which healthcare IT will play a decisive role, as not only have physicians already been ordered to implement electronic health records (EHRs) under the HITECH (Health Information Technology for Economic and Clinical Health) Act; with the implementation of measures under this Quality Measurement Development Plan, there is simply no way they’ll be able to effectively meet the requirements of whatever set of measures is developed under the plan, without strong HIT.

What remains to be seen is whether the implementation of the measures will lead to a qualitative difference in the outcomes of patients being treated by physicians in U.S. healthcare. But one can hope that it will.

  1. Will hospital c-suites and boards of directors invest what they need to, to ensure cybersecurity?

There have been so many reports of data breaches at U.S. hospitals and health plans in the past year that such reports are literally becoming a weekly event. Then again, not all data breaches are created equal. For example, the breach that was reported by UCLA Health back in July was unprecedented for a patient care organization, with perhaps as many as 4.5 million people affected.

As I said in a blog written the day the news of the breach broke, “What’s startling is that the breach at the Indianapolis-based Anthem, revealed on Feb. 5, and which compromised the data of up to 80 million health plan members, shared two very important characteristics with the UCLA Health breach, so far as we know at this moment, hours after the UCLA breach. Both were created by hackers; and both involved unencrypted data. That’s right—according to the L.A. Times report, UCLA Health’s data was also unencrypted.” Now, the issue of whether or not to encrypt data at rest within the EHR is becoming more urgent over time. But whether or not hospital CIOs choose to encrypt data at rest within their EHRs or not, industry experts agree that two key issues must be addressed. First, as Mac McMillan, CEO of the Austin, Texas-based consulting firm CynergisTek is urging publicly, hospitals must engage in behavioral monitoring; and, as one hospital CIO told me just last month, her biggest worry is the vulnerability resting inside her organization’s own staff and clinicians, who continue to fall for phishing schemes, and continue to make other mistakes with devastating consequences.

The question is: will hospitals, medical groups, and health plans begin to turn a corner around these issues in 2016, even as the threats only continue to escalate? Only time (and news reports) will tell.

  1. Will the Medicare mandatory readmissions reduction program finally force hospital executives to rethink readmissions?

As news reports noted last summer, “Once again, the majority of the nation's hospitals are being penalized by Medicare for having patients frequently return within a month of discharge – this time losing a combined $420 million, government records show. In the fourth year of federal readmission penalties,” a U.S. News Aug. 5 report noted, “2,592 hospitals will receive lower payments for every Medicare patient that stays in the hospital – readmitted or not – starting in October. The Hospital Readmissions Reduction Program, created by the Affordable Care Act, was designed to make hospitals pay closer attention to what happens to their patients after they get discharged. Since the fines began, national readmission rates have dropped, but roughly one of every five Medicare patients sent to the hospital ends up returning within a month.”

The program, created under the Affordable Care Act, initially looked at 30-day readmissions for heart attack, heart failure, and pneumonia, with fiscal 2013 penalties set at up to 1 percent of Medicare revenues, and then raised to up to a 2-percent reduction in 2014. For fiscal 2015, CMS, added COPD (chronic obstructive pulmonary disease) and total hip and knee replacements, with a ceiling of 3 percent reduction, and with the majority of hospitals being fined. By fiscal 2016, penalties increased to encompass 2,665 facilities.

So here’s the core question: how many hospital organizations will learn how to master the mandatory readmissions program? Doing so will require applying very strong analytics solutions and processes to figure out and improve on their current readmissions track records. The thing is, none of this is exactly new: the ACA was passed by Congress and signed into law by President Obama in March 2009; we are now in calendar year 2016. The good news? CIOs, CMIOs, and other informaticists can really establish themselves as heroes here, as they help to lead their colleagues forward to analyze and improve on their 30-day readmissions records. The bad news: this program is not going away. And the penalties are likely to grow larger still, over time.

  1. Will vendors, providers, and everyone, begin to really leverage the FHIR standard to push interoperability forward?

There are so many questions in everyone’s minds these days about interoperability. It is indeed an area of concern in U.S. healthcare, as the lack of true interoperability remains a stumbling block to future progress in so many areas, including the effectiveness of analytics work for population health, accountable care, and readmissions reduction work; true clinical transformation; and further progress on health information exchange—among numerous other areas.

HCI Managing Editor (then Senior Editor) Rajiv Leventhal, reporting from the Health IT Summit in Atlanta on December 2, reported on an important exchange about interoperability at that event. In his coverage of a panel on progress towards interoperability, he quoted Jeff Gartland, vice president at RelayHealth (the Alpharetta, Ga.-based McKesson business unit which focused on clinical connectivity), as saying that, “When we succeed in this space, conversations won’t be about the bits and bytes of interoperability, but about outcomes. You look at the World Wide Web as an example—that wasn’t an overnight success. You don’t think about standards, protocols, or other things going on behind the scenes when you call Uber, look at a website, or send an email. We will get there.”

Further, Gartland said in December, “When you talk about FHIR [Fast Healthcare Interoperability Resources], it’s a model past the one of sending around meaningful use-era type documents. It actually gets into granular detail. Using CommonWell as an example since they leverage FHIR: you don’t have to leave your EHR [electronic health record] or RIS [radiology information system]—it’s within the workflow. The complication is that the package in between those workflows is a meaningful use-level document, which most people don't want to hunt and peck through. If you want a medication list only, you don’t want to hunt through all that other stuff. FHIR lets you grab the information that’s important. We had Cerner, athenahealth, and McKesson working together to demonstrate the ability to pass those granular FHIR resources. This way, you can send just the problem or medication, for example, from one system to another.”

And, as I reported from the Health IT Summit in Houston, also last month, during a panel discussion on interoperability at that conference, Chris Ingersoll, vice president of solution architecture at RelayHealth, noted that “Right now, there’s not maturity on the standards side,” Ingersoll acknowledged. “It's custom work to connect your system to another system Smart on FHIR has the potential, but it’s not available right now. It’s one of the reasons they went from Stage 1, sharing pieces of a health record, to Stage 2, the requirement to share the CDA.”

The deeper underlying set of questions here has to do with the extent to which healthcare IT vendors will really begin to deliver on the promise of standards-based interoperability, and how quickly providers, payers, vendors, and policymakers can come together to accelerate progress in this key area. Will 2016 be a breakthrough year for interoperability? One could guess either way about that.

There are certainly many more questions out there in the healthcare Zeitgeist, too; but these are five to which it would be great to get this answers this year. Stay tuned and find out—we’ll know 12 months from now whether these questions indeed were answered in any clear way during this calendar year. In the meantime, I think, my quoting Bette Davis as Margo Channing still makes as much sense as anything.

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