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DIRECTOR'S CORNER
What I’m Learning as I’m Teaching
Ann Hwang, MD
Director, Center for Consumer Engagement in Health Innovation
Over the past ten years, I’ve had the opportunity to teach in a health policy course for medical students. And over the course of that decade, I’ve enjoyed working with dozens of future doctors as they study the rapid changes in our health care system, from the passage and implementation of the Affordable Care Act, to the proliferation of different Accountable Care Organization (ACO) models, to today’s wide-ranging proposals, from Medicaid block grants to single-payer models.
I’ve spent the month of January teaching, and I love being able to see the world of health policy through the eyes of my students, who bring thoughtfulness, compassion and idealism to our field.
Here are a few things I’ve learned...
1. It’s complicated.
I mean, really complicated. By the time you talk about premiums, deductibles, cost-sharing, co-insurance, tiering, value-based insurance design, reference pricing, in-network and out-of-network, everyone’s eyes have glazed over. And these are super-smart, super-motivated medical students who are receiving formal education on this stuff. Good luck to an average consumer, trying to figure this out on her own.
Which brings me to the next point...
2. Nobody really knows what an ACO is.
In our class, we talk about ACOs. A lot. We define them in the usual way…“groups of doctors, hospitals and other health care providers who come together voluntarily to give coordinated high quality care.”
But that “simple” definition quickly unravels as you poke at it. A health system might be an ACO for the purposes of one payer, but accept fee-for-service payments for another. And explaining global budgets, one-sided versus two-sided risk, leakage, true-ups and incentives and withholds starts to feel like trying to explain an iPad to my grandmother: saying that it’s “a touchscreen tablet computer that communicates using cellular or wireless data” gets me absolutely nowhere. But if I can show her how she can use it to video chat with her great-grandkids or look at photos, then it’s got a chance.
It makes me realize that as a health care solution, ACOs (and many other innovative models of care) are a tough sell because no one can really explain what they are. Until people feel a tangible connection to them and see concrete benefits, we’ve got our work cut out for us.
As for the patient...
3. The patient is an afterthought in the health care system.
Students are great at asking that simple and powerful question: “why?” Why is our system so hard to navigate? Why is care so expensive? Why are some things covered and other things not? Our explanations, invoking payment arrangements, market power and financial incentives, don’t at all speak to the values and sense of purpose that brought my students to medicine in the first place. They’d always assumed that health care was, first and foremost, about caring for people. They learn – as they learn about how our existing health care system operates – that that’s not always the case.
Which leads me to the final point...
4. This is no time to be sitting on the sidelines.
Over the past ten years, there has been tremendous change in the health care system. We’ve seen our country make a big leap toward ensuring that people who are sick can get coverage and care, and then start to back away from that promise in the past year.
I’ve seen students change from viewing health policy as something they are only marginally interested in (the “easy” class when they would really rather be studying neuroanatomy) to seeing that they need to understand what is happening and be engaged. As the doctors of tomorrow, they are thinking hard about what the future will be like for them as practitioners, and for the well-being of their patients. I admire their compassion and commitment. And I see hope for a new generation – of health professionals, community leaders, advocates and consumers – that can continue the push toward a truly person-centered health care system.
FROM THE CENTER & OUR PARTNERS
The Center on Making Community Engagement a Key Part of CHNAs
Health Progress, the Journal of the Catholic Health Association of the United States, has published an article by Center staff on the Community Health Needs Assessment (CHNA) process. The CHNA is a federal requirement nonprofit hospitals must follow to assess and address community needs as part of their community benefit planning. The article provides recommendations for hospital staff who work on CHNAs about how to improve community engagement while these assessments are underway. The authors draw on the concepts for improving consumer engagement contained in the Center’s Medicaid Accountable Care Organization (ACO) checklist and tailor them for hospital staff and community members working on CHNAs.
New York State Health Foundation Focuses on Consumer Empowerment
A Health Affairs Blog post regarding a conference hosted by the New York State Health Foundation is full of resources and information about consumer empowerment initiatives supported by the Foundation and also acknowledges the work of the Center. Highlights of the conference included keynote speaker Elisabeth Rosenthal, editor-in-chief of Kaiser Health News, a panel on the role of philanthropy in empowering consumers, a panel of consumers and family members that highlighted the mismatch between the concerns of consumers and the concerns of providers, and a panel on the importance of consumer stories.
NOTEWORTHY NEWS & RESOURCES
Medicare Rolls Out New-ish Bundled Payment Model
A New York Times article highlights a Trump administration policy reversal regarding bundled Medicare payments. In 2016, CMS rolled out a new mandatory bundled payment model designed to slow the rise of health care costs and improve outcomes related to the biggest drivers of Medicare spending. In November 2017, however, CMS cancelled its cardiac model, along with other bundled payment models set to begin on Jan. 1, 2018, and rolled back its joint replacement model. On Jan. 9, CMS announced an updated payment model largely in keeping with the Obama-era bundled payments policy but with two important differences: the program is now voluntary for providers and applies only to 32 specifically delineated episodes of care. In this model, as in the previous model, providers can earn bonuses for billing below a target rate and may face penalties if Medicare spending exceeds the target.
NASHP Details State Accountable Care Strategies
The National Academy for State Health Policy (NASHP) has released a brief describing the findings from their October 2017 convening of state health policy officials focused on improving population health through accountable care. The brief provides an analysis of 12 state accountable care structures and offers specific steps states are taking to ensure the success and sustainability of accountable care models for their residents. In particular, NASHP researchers use the brief to:
- identify policy levers to support health system transformation through accountable care frameworks;
- outline return on investment measures and accountable care evaluation models; and
- describe the resources states are using to invest in and sustain improvements in health through accountable care.
The brief includes a detailed narrative, as well as a comparative chart of each state’s leaders and strategies. A quick-guide to the findings is also available on the NASHP website.
New Resource Guides for Health Care Professionals and Family Caregivers
The CMS Medicare-Medicaid Coordination Office (MMCO), in collaboration with the Lewin Group, has released three new resource guides for health care professionals and family caregivers working with aging populations. Two of the guides are designed to provide health care professionals and family caregivers with resources related to managing behaviors associated with dementia. The third is intended for health care providers offering support to family caregivers who may be struggling with personal and economic hardships related to caring for loved ones with complex medical needs. Each resources guide offers service agency descriptions, contact info, and recommended trainings to assist in the assessment and management of dementia.
Updated Data on Dual Eligibles
The Medicare Payment Advisory Commission (MedPAC) and the Medicaid and CHIP Payment and Access Commission (MACPAC) released their joint annual data book on individuals with both Medicare and Medicaid (dual eligibles). The report contains data for calendar year 2013, including:
- There were 10.7 million dual eligibles, an increase from 10.4 million the previous year
- Combined Medicare and Medicaid spending for dual eligible was $312.4 billion, up from $305.9 billion in calendar year 2012
- As in previous years, spending on dual eligibles was disproportionately high. While they were 20 percent of the Medicare population, they accounted for 34 percent of program spending. And, while they were 15 percent of the Medicaid population, they accounted for 32 percent of program spending.
- Overall, most dual eligible were female, White and lived in an urban area. However, within the Medicare population, they were more likely to be African-American or Hispanic. These demographic characteristics are similar to calendar year 2012.
STATE HIGHLIGHTS
California
The California Department of Health Care Services (DHCS) released a Duals Plan Letter providing guidance to Medicare-Medicaid plans participating in the Cal-MediConnect program (the state’s dual eligible demonstration project) on changes in the Non-Emergency Medical Transportation (NEMT) and Non-Medical Transportation (NMT) benefits. Beneficiaries will now have access to NMT services beyond the 30 rides originally covered. Cal MediConnect plans must now ensure that members have unlimited access to NEMT services to attain medical services that are medically necessary. DHCS requests feedback on these changes by Jan. 31.
New York
The CMS Medicare-Medicaid Coordination Office posted a newly executed three-way contract for the Fully Integrated Duals Advantage (FIDA) demonstration program. A summary of changes can be found here.
In other news, the New York State Department of Health has released a statewide survey to all Community Based Organizations (CBOs). The purpose of the survey is to capture current services CBOs are providing that address Social Determinants of Health and to gauge CBO integration with the New York State Value Based Payment. program. The survey can be accessed here.
Washington
Washington state is implementing a Medicaid waiver that will help beneficiaries with significant physical or behavioral health conditions gain access to housing and employment. The waiver will support work by giving Medicaid beneficiaries more tools to secure employment. These supportive services are voluntary, and are not a condition of Medicaid eligibility.
KEY DATES
Thursday, Jan. 25 (12-1 p.m. Eastern) – Informational Webinar on the MIT Abdul Latif Jameel Poverty Action Lab North America (J-PAL North America) second Health Care Delivery Innovation Competition.
Please register for the webinar.
Thursday, Jan. 25 (12-4 p.m. Eastern) – Webinar: Expanding the Bounds of Care Delivery: Integrating Mental, Social, and Physical Health, presented by NEJM Catalyst.
Please register for the webinar.
Wednesday, Jan. 31 (10-11:30 a.m. Eastern) – Panel Discussion: A Policy Roadmap for Individuals with Complex Care Needs, hosted by the Bipartisan Policy Center.
Please register here to attend in person, and here to listen to the webcast
Friday, Feb. 16 (2:30-3:30 p.m. Eastern) – Webinar: A Conversation with Dr. Atul Gawande presented by Grantmakers In Aging, and made possible through the sponsorship of The John A. Hartford Foundation.
Please register for the webinar.