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While Colorado spends $30 billion in health care every year, costs continue to increase while value decreases. Yet, Colorado is better poised than many states to take on the challenge of improving health outcomes and stabilizing and/or decreasing costs due to its examples of structured, coordinated health care delivery systems...

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As a patient, would you like to know how much a medical procedure will cost you before you get it? As a buyer of insurance, would you like to know how the providers in one health plan’s network compare on cost and quality measures with those in another? As a Colorado taxpayer, would you like to know how new initiatives from Medicaid, the Child Health Plan Plus and public health departments are affecting health outcomes and costs?

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This week, the Congressional Budget Office (CBO) released an analysis of 10 Medicare demonstration projects undertaken over the last 20 years. All were designed to save the program money, but only one succeeded in doing so. Do these findings mean we should abandon efforts to redesign our country’s health care payment and delivery systems?

Not at all. In fact, when you look below the surface of the CBO report, you reach precisely the opposite conclusion. The reason most of these pilots did not achieve their desired goals is because they were built upon our existing fragmented delivery and fee-for-service/pay-for-piecework system—a system that incents more, not better care, pays a second time for avoidable complications and provides no and incentive for care coordination and better outcomes.

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January is a time for stock-taking, for rear view mirror- and crystal ball-gazing. Often, that turns into a kind of “Look, Ma, no hands!” punditry that’s fun to write but doesn’t really advance the conversation.

So, having now set myself up for anyone to shoot down (my New Year’s gift to readers), I’d like to opine on something CIVHC learned over this last year and consider its implications for our work—and that of our partners—in the coming months.

In mid-2012, CIVHC surveyed the largest commercial insurers in Colorado to assess what proportion of expenditures in the commercial market are fee-for-service (FFS), and what proportion are not tied to volume (e.g., care coordination payments, bundled, global)...

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By Lalit Bajaj, M.D., M.P.H., and Nathan Wilkes - APCD Advisory Committee Members

Featured in Denver Post, Guest Commentary 4/27/12

We've all heard the old adage you can't manage what you don't measure. The same is true for health care. In Colorado and across the nation, costs for health care services continue spiraling out of control, gobbling up higher percentages of our wages while taking away from resources that could improve our schools and infrastructure.

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Measuring outcomes in meaningful and consistent ways; giving providers incentives to improve; holding them accountable for their results. Comparing providers against their peers as well as against their own historical trend. Rewarding low-performers who improve, without penalizing high-performers that don’t have as far to go. Making sense of a bewildering tangle of expectations and requirements.

That’s the landscape of health care accountability, right?
 

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This week, Governor Hickenlooper will sign HB 1281, setting up 2-year payment reform pilots within Colorado’s Medicaid program. Brief pilot programs might seem like baby steps – but for a program as large and challenging as Medicaid, they are essential “proofs of concept.” And these pilots will likely have a big impact on how Medicaid takes shape in the coming years. This legislation is important both for the path it lays out for Medicaid’s future, and for the broad bipartisan and multi-stakeholder consensus it reflects.

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Saturday’s New York Times carried a front-page story about negotiations between administrators and the physicians’ union at the New York Health and Hospital Authority over a new pay-for-performance arrangement. Physicians’ raises will be tied to their performance on indicators such as patients’ assessments of physicians’ communication with them, how quickly ED patients are transferred to beds and how quickly patients are discharged, as well as quality metrics such as 30-day readmission rates for certain diagnoses.

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I read with great interest the Health Affairs Article, “Focus Groups Highlight That Many Patients Object to Clinicians’ Focusing on Costs.” This study found that patients will opt for a more expensive treatment or diagnostic option even if the more expensive choice offers only a slightly improved chance for a better outcome. I am paraphrasing and simplifying the scope of the study but the general sense is that when it comes to a patient’s decision on what medical intervention they want, cost is not important. My professional experience as a physical therapist and orthopedic practice administrator has shown me that costs can play a major role in a patient’s decision to seek elective care. I would like to contrast the Health Affairs study using focus groups’ responses to a hypothetical situation with the real world experience of actual patient dollars being part of the patient’s decision.

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People often wonder why health care costs so much. Surprisingly, the answer may lie not just in the price of medical care, but also in the way we pay for it.

Our current "system" rewards inefficient, high-cost medicine and penalizes efficient, low-cost health care. Because patients and insurance companies pay for each visit, procedure, prescription and lab test separately, there are built-in incentives for more care without regard to whether it is the right care or is making a difference in patients' health. As a result of the current health care payment structure, many experts believe that 20 to 30 percent of care provided does not add value – or even potentially harms the patient.

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February 13th marked five years since Governor Ritter signed the Executive Order to develop the Center for Improving Value in Health Care. In those five years since CIVHC was merely an idea born out of the 208 Blue Ribbon Commission on Health Care Reform, much has changed for our organization and our state as a whole. The future of health care in Colorado looks bright, and I’d like to take this opportunity to introduce several new staff and highlight some new resources we made available this month in support of Colorado efforts.

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Editorial version published by Denver Business Journal 4.13.12

As the CEO of an organization deeply focused on efforts to make Colorado’s health care better and less expensive, I get a lot of questions about the Affordable Care Act (ACA, Federal Health Care Reform, aka Obamacare). Many assume that if the Supreme Court strikes the law down, the work of CIVHC and many other partner organizations somehow goes away and we hit a big re-set button for our work.  Nothing could be further from the truth. 

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Changing how we pay for health care – the process of moving from the current fee-for-service, pay-for-volume method to paying instead for quality and value – takes time and effort. It won’t be an easy proposition to shift to models that support care coordination, that bundle payments for chronic diseases or that reward providers for meeting cost and quality measures.

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Recently I spoke about Obamacare to two different community groups. My expectations of each group were different given their locale – one was in well-to-do neighborhood that trends quite red at the voting booth (I was braced for anything up to and including a death panel discussion) and the other was in central Denver which I guessed would be more progressive in tenor. It turns out that the conversations were nearly identical and characterized by a striking polarity in which nearly everyone simultaneously viewed Obamacare with hope and fear.

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Rarely does a day go by that I don’t run into another article arguing the efficacy of health care reform tactics such as medical homes, Medicare payment reform, and Electronic Health Records (EHR). A recent example is “Do Electronic Medical Records Save Money?” by the New York Times. The piece reveals the results of a 2008 federal survey showing that physicians using electronic records actually ordered more high cost tests than their peers who were still using paper medical records. This is contrary to the belief that EHR systems have the potential to save costs by reducing the number of tests being ordered.

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The spirit of innovation is alive and well in Colorado health care. And, even as providers, patient advocates and health plans respond to local needs, they’re identifying many of the same problems. Even more striking: they agree that the changes they need to make to improve health, improve care and control costs can’t be done without radically transforming the way we pay for health care.

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In grad school, our cigar chomping chairman of the department would explode with a resounding Horse Sh#@t whenever somebody gave an answer that wasn’t well thought out, supported by facts or was just plain wrong. Get it wrong on all three counts and his cigar would fly across the room at about the same speed as his expletive. It got your attention.

As I held my breath waiting for the Supreme Court decision, and fearing the Accountable Care Act (ACA) would be overturned, I reflected on the times when I could have responded with my professor’s epithet when facts were being ignored or willfully misconstrued. It wouldn’t have changed a thing but would have felt good for the moment.
 

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As one looks at the efforts to transform health care delivery and payment in Colorado, two overwhelming impressions emerge. The first is the sheer quantity of innovation underway in our state. To see what I mean, look at CIVHC’s Inventory of Payment Reform and Delivery Redesign Strategies and the graphic that accompanies it . While we’ve done our best to be comprehensive, we know we’ve left important initiatives off these documents (and please contact us if yours is missing). But even our non-exhaustive list requires nearly two dozen pages to describe.

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With the President’s re-election, the concepts embodied in the Affordable Care Act will pick up steam. One of those is the Accountable Care Organization (ACO) model. ACOs are voluntary organizations that focus on coordination for patients across care settings, including doctors’ offices, hospitals, and long-term care; the coordination is made “accountable” through payment models that reward quality and share (potentially) both up-side and down-side risk. While the ACA enabled ACOs specifically for Medicare, this vision of coordinated, accountable care is being used for all populations and a variety of payers. So this seems like an opportune time to share some information and observations about ACOs—both nationally and within our state.

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I’ve been in health care for over 30 years and as I think about most of the problems with healthcare… access, quality, cost, safety, etc., many of the solutions to these issues were obvious even back in those early days of my career. We knew then that fee for service reimbursement created perverse incentives and that outcome based payments aligned incentives for better care and lower costs. In general, care was siloed, inefficient and demanded vertical and horizontal coordination along with tools such as electronic health records (EHR). The problem was that there was no pressure to change unless it was self-generated. Today, many of the same problems exist, but the impetus and external pressures to improve are upon us.

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Three national experts in bundled payment design and implementation spoke to a packed auditorium of more than 150 health care executives in Denver last week at CIVHC’s Bundled Payment Seminar to make the case that bundled payments are changing the face of health care across the country and illustrate how Colorado providers, payers and purchasers can—must—embark on this path. The consistent message from all presenters was that bundling is not just, or even first, about controlling costs. It is a critical technique for improving quality and creating a more patient-centric health care system.

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This time of year is sports fan’s heaven but unfortunately I seem to have been born without the “sports fan gene”. Family, friends and colleagues exchange sad, knowing glances at my pathetic mixed sports metaphors and attempts to engage in post-weekend sports banter.  Despite that, as I write this first health care blog of 2013, all I have are sports metaphors floating in my head.  I apologize ahead of time to all sports fans out there.

Having crossed into 2013, the trigger date of 2014 for implementing the biggest elements of the health care law seems imminent...

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Originally posted on www.wanthealthcarellc.com.

I do a fair amount of work in payment and delivery system reform, in various communities around the country.  I have been speaking to physicians about change coming for over a decade. If you have done any of this work, you may have had this common experience: that change is hard, and people have to have a really good reason to change the status quo. I admit it sometimes seemed to me that change would never come. 

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For several months, a very broad group of stakeholders has met as part of CIVHC’s Delivery System Redesign and Payment Reform Advisory Groups.  Both groups have concluded that Colorado cannot move forward without simultaneously transforming payment systems and the delivery of care.

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