Managed Care, HIT & ARRA

by | Mar 30, 2010

Yesterday, had the privilege to attend and present to a packed audience in New York City for CRG’s conference: IT & the Future of Managed Care: The Next Wave. Unlike most conferences I attend that are predominately focused on either the provider consumer sector of the healthcare market (tomorrow its the local New England HIMSS Chapter’s Annual Event), this event was for payers.  In light of the recent passage of the Healthcare Reform Act, ARRA and the move to digitize providers, they had a lot on their minds, particularly with regards to their future role in the digitization of medical records.

Following is my presentation. Brief as it is (was part of a panel and had about 7 minutes to fly through it), it does have a few nuggets worthy of a looksie.

[slideshare id=3596753&doc=moorecrgnycmar10fnl-100330144448-phpapp01]

Key Event Take-Aways:

Payers are struggling to develop new cost control models.  The Patient Centered Medical Home (PCMH) is attracting a lot of attention, lots of pilot studies currently underway or will be launched this year.  Remains to be seen as to true efficacy of this care model.

Telehealth is definitely ramping up, or at least some of the more innovative payers are looking to use telehealth in rural settings. (Of course, we have heard this so many times before and it remains to be seen if this time it is for real, but Cisco among others is making a big push, and with payers behind it, it may actually take hold).

Payers want to introduce best practices (comparative effectiveness) into the clinician’s workflow to insure that clinicians are complying to well-regarded and uniform standards of care.  Again, objective is to lower costs of care and improve outcomes.  Challenge, however is that clinicians are trained to deal with variability, they thrive on it.  Best practices, standards of care, etc., run counter to clinician training/culture.

Providing cost transparency/comparisons to consumers to allow them to consider costs as a variable in their healthcare decision making is difficult in many regions of the country as providers do not wish to be compared on costs and are reluctant to share such information.

Payers, as they have been for a number of years, are promoting collaborative care but are still running into significant challenges in making this happen.  The usual obstacles stand in their way, primary among them is data ownership and trust.  Payers are hopeful that HIE initiatives via ARRA and in the future CMS penalties will finally break this log-jam.

Significant interest in what Google Health and HealthVault are doing and where are they headed.  Few that I talked to are ready to commit (allow their members to export their claims data) to either platform, but they are having some pretty serious discussions internally as to what they should do. Surprisingly, (then again maybe not) no one at his event ever mentioned Dossia.

This was a well-run event with some excellent presentations.  Certainly plenty of hand-wringing in the audience as this sector grapples with both healthcare reform and the digitization of the provider sector.  What role payers will play in the future is fairly well-spelled out in the Healthcare Reform Act. Lesser known is what role payers will play within the context of healthcare IT.  Payers believe that they can play an important role in facilitating care (via telehealth, care coordination or clinical decision support tools) but as I told the audience in one of my closing comments:

Clinicians do respect the role that payers can play to a point, but there is still a level of distrust and do not expect a clinician to allow you to enter the exam room.  Keeping that in mind and respecting it will instill a level of good will that can lead to more fruitful interactions/collaborations in the future.

1 Comment

  1. e-Patient Dave

    Good write-up as always, John.

    Re “remains to be seen the efficacy” of the patient-centered medical home model – yesterday I attended the big stakeholders’ shindig in DC for PCPCC, who’s been advocating MH for 5 years now, and I was quite surprised at the depth and breadth of what they’ve been doing, attacking the issue along numerous dimensions. Many pilot programs and demonstration projects, as you say.

    Fwiw, regarding evidence, a new page on their site (3/10/10) says [see site for links]

    According to the Center for Evaluative Clinical Sciences at Dartmouth, states in the U.S. that relied more on primary care have:

    * Lower Medicare spending (inpatient reimbursements and Part B payments);
    * Lower resource inputs (hospital beds, ICU beds, total physician labor, primary care labor and medical specialist labor);
    * Lower utilization rates (physician visits, days in ICUs, days in the hospital,and fewer patients seeing 10 or more physicians); and
    * Better quality of care (fewer ICU deaths and a higher composite quality score).1

    Barbara Starfield of Johns Hopkins University reviewed dozens of studies, comparing healthcare in the U.S. with other countries as well within the U.S., and found that:

    * Within the U.S., adults with a primary care physician rather than a specialist had 33 percent lower costs of care and were 19 percent less likely to die, after adjusting for demographic and health characteristics;
    * Primary care physician supply is consistently associated with improved health outcomes for conditions like cancer, heart disease, stroke, infant mortality, low birth weight, life expectancy, and self-rated care;
    * In both England and the U.S., each additional primary care physician per 10,000 persons is associated with a decrease in mortality rate of 3 to 10 percent;
    * In the U.S., an increase of just one primary care physician is associated with 1.44 fewer deaths per 10,000 persons; and
    * An orientation to primary care reduces socio-demographic and socio-economic disparities. African-Americans who have a primary care physician in particular are less likely to die prematurely.2

    I can’t vouch for it – just passing along the link. To me it seems incredibly, intuitively obvious that having a consistent physician – someone who KNOWS YOU – is a good idea, but yeah, I guess we need evidence.

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