Health Care Happenings

This past Friday, I had the opportunity to attend the official dedication and opening of the National Intrepid Center of Excellence (NICoE) on the campus of the current National Naval Medical Center in Bethesda MD.
And what a truly fantastic facility this is!

This new facility is now the nation’s foremost facility for research, diagnosis and treatment of traumatic brain injury (TBI) and post traumatic stress (PTS), conditions which afflict thousands of our nation’s military personnel and veterans. This center joins the existing Center for the Intrepid, which is also a world class state-of-the-art center located at Brooke Army Medical Center in San Antonio Texas.

The NICoE is a model of public-private partnership and was completed on time (actually a bit early..) and on-budget. It cost nearly $60 million to design, build and equip and every cent came from gifts from the general public. It’s progress and development was overseen by the Board of Trustee’s of the Intrepid Fallen Heroes Fund.

This center is architecturally unique and promotes a wellness and healing environment due to its use of windows which incorporates an indoor-outdoor atmosphere. Most importantly, NICoE has been specifically designed to meet the needs of our injured heroes. Its rooms, labs and open spaces are warm and inviting. The diagnosis and treatment equipment represents the latest advances in care, and the progress made in this Center will lead to further improvements in diagnosis and treatment. In addition, NICoE will incorporate families into the treatment process, which is key to the care that will be provided.

The location of the Center plays an important role. The proximity of it will foster partnerships with the National Institues of Health, the Uniformed Services University of the Health Sciences and the Department of Veterans Affairs. Employing a “center of centers” concept, NICoE will further leverage the distinguished expertise of four established centers within the Department of Defense: the Defense Veterans Brain Injury Center; the Center for the Study of Traumatic Stress; the Deployment Health Clinical Center; and the Center for Deployment Psychology.

We at MOAA look forward to the progress and the outcomes research which will be generated by this outstanding Center ~ The National Intrepid Center of Excellence for Psychological Health and Traumatic Brain Injury, which will address the needs of the men and women who have recieved these injuries serving our nation.

As I continue to digest, read, and talk to people regarding the new healthcare reform law, the Patient Protection and Affordable Care Act (PPACA) it is evident that there exists several intended over-arching themes.

The first is that the Department of Health and Human Services (HHS) will play a very large role in both the administration and the oversight of the law. A couple of things are starting to crystallize on this front. The Office of Consumer Information and Insurance Oversight just became operational. The office is responsible for ensuring compliance with the new insurance market rules, such as the prohibitions on recissions and on pre-existing condition exclusions for children that will take effect this year. Also HHS will be key in the management of pilot programs, insurance premiums, insurance exchanges, Medicare premiums, etc. It will also play a very large role in coordinating work across key federal agencies critical to the reform eg. the CDC, NIH, FDA, and CMS to name a few.

Payment for performance will take a front seat. Throughout the new law an emphasis on “transparancy” is present. PPACA sets new standards regarding reporting about quality, patient and consumer safety, efficiency, and ties to profitability in almost every sector. Also, in implementing PPACA, there will be an increased focus and scruitiny of business practices and compliance with the new regulations.

Another central theme is that of connectivity and coordination of care and services. Some have called this the “new normal” for the healthcare delivery system. This new normal will require the connection of doctors, hospitals and ancillaries with community health centers, mental health programs, school clinics etc. to bridge gaps. Information-technologies will be the glue; and new structures and newly integrated systems of care will probably result. The linking of primary care with specialty care has long been a desired goal of our system.

Changes in insurance and access. The bill’s most immediate impact is insurance reforms intended to expand coverage while standardizing benefits to assure quality is not compromised. Regulations around risk-ratings, premiums, pre-existing conditions, and health exchanges will create this new landscape. Also the fact that the individual mandate included in the bill, will increase the ranks of the newly insured by 32 million will surely result in change and challenges.

One of the largest changes that will occur will be in the collaboration between the state and federal governments. The PPACA creates numerous responsibilities with respect to implementation and administration for the individual states. This comes at a tough time for most state governments in that many of them are coping with high unemployment, over run state budgets and declining revenues, and growing obligations. As the state and federal governments share responsibility and accountability this will be a recurrent theme in coming years.

By this coming September, many of the initial mandates will be clear and implementation underway. We here at MOAA will continue to closely watch and monitor any amended changes, the effects of implementation and other initiatives associated with this new law.

That’s the message I heard on the radio driving to work this morning.

The program guest said, “Are you having a hard time falling to sleep at night? Waking in the morning not feeling refreshed?”

The individual went on to talk about how Americans are living on adrenalin. We are constantly connected, engaged and it is becoming more and more difficult to unwind at the end of the day.

Yup, that’s me I thought.

We’ve all heard the physical and emotional consequences of not a doing good job managing stress in our lives.

The guest on the radio show suggested meditation as a way to relax at the end of the day. Unplug from TV, video games, reading, or other activities that stimulate your body and brain.

Maybe it’s worth a try. I found some great suggestions at the Mayo Clinic web site and even a relaxation exercise video you might want to check out too.

How about you—do you have any mediation exercises or tried and true activities to help you unwind at the end of the day you’d like to tell us about?

As I have followed the healthcare bills that have gone through Congress, and having analyzed (and still analyzing and sifting…) the many provisions contained therein, I have found that there really are some good “nuggets” which will begin to lay the groundwork for health system change in our country. Besides a focus on the healthcare “insurance” industry, there are provisions which aim to tackle the issue of rising costs and increasing the quality of care.

Tucked into the health care bill which was recently signed into law is a relatively little-known provision that could lead to one of the most significant health care reforms in decades, reducing costs while simultaneously increasing access and quality.

Section 10104 of H.R. 3590, the Patient Protection and Affordable Care Act of 2010, states that the secretary of the Department of Health and Human Services “shall permit coverage in the exchange to be offered through a qualified direct primary care medical home plan.”

The upshot is that this provision essentially enables individuals who shop in the insurance exchanges to elect an alternative to traditional insurance plans in which patients and / or employers pay a flat monthly fee directly to a primary care provider for all primary and preventive care, chronic disease management and care coordination throughout the entire health care system. Under the new law, a flat-fee direct primary care medical home membership, which may start out as low as say $49 per month, and acts much like a gym membership, can be bundled with a new, lower-cost “wraparound” insurance plan that covers unpredictable (and catestrophic) services. Thus, under this type of model for primary care service delivery, the need for an insurance carrier to act as a third party intermediary is eliminated, and the primary care provider is paid directly. The result would serve to simplify burdensome administrative processes and to lower costs in this venue of care. About a third of all states have this in some shape or form as a viable model.

Prior to the Healthcare Reform Bill passage and earlier this year, the Military Health System (MHS) on the direct care side, instituted a policy which requires the implementation of the ‘Patient-Centered Medical Home’ model of primary care in its Military Treatment Facilities (MTF’s). While, the provider reimbursement issue is obviously not a factor, the model’s concept of care delivery is a quality and access improvement.

According to the policy, it’s implemetation is intended to provide for a comprehensive primary care model which will improve patient satisfaction and outcomes. The MTF’s are therefore encouraged to utilize innovative approaches that are patient-centered and access focused. Open access scheduling, online appointing and online provider/patient communication, 24 hour nurse advice and triage lines, and provider/patient telephonic consults are examples of some of the innovative approaches that will hopefully be used to enhance patient-provider communications.

So if we look into the future, this single short provision, may indeed be one of the best-kept secrets of the new law. It may not only ensure that health care will be available to people of modest means, employed by small businesses and currently the uninsured individuals, but it has the potential to completely change the way primary care - and insurance- is delivered and paid for. This is something to look for in the next round of TRICARE contracts!

There has been quite a bit of discussion, research studies, and of course proposed legislative language with respect to reforming health-care in this country. In this regard, I thought this recent Commission report deserved a closer look as TRICARE reimbursement rates are tied to Medicare’s. As required by the Congress, each March the Medicare Payment Advisory Commission (commonly referred to as MedPAC, and is non-partisan independent agency), reviews and makes recommendations for Medicare payment systems. These are the fee for service systems (FFS) and the Medicare Advantage (MA) program. This report is widely anticipated as its principal purpose is to make recommendations for annual rate increases and updates under Medicare’s various FFS payment systems.

The goal of Medicare payment policy is to get good value for the program’s expenditures, which means maintaining beneficiaries’ access to high-quality services while encouraging efficient use of resources. This is good, in that as a taxpayer, anything less would not serve either those that rely on this system, or those of us who finance this system through our taxes.

The report gives great consideration to the current national environment for context in setting its payment policy. The report makes very clear that the Medicare program and other U.S. health care payers are on an “un-sustainable financial path”. For most of the post-World War II period, health care costs have risen faster than the economy. The Centers for Medicare Services (CMS) reports that health cares total share of the economy rose from 7% in 1970 to an estimated 17% in 2009. This high rate of growth is projected to continue, absent meaningful financing and delivery reforms. Hence, the drive for some degree and level of health care reform. This is at least a start.

A number of factors are responsible for the sustained high rates of growth in health care costs for public and private programs. The Congressional Budget Office (CBO) cites advances in medical technology, national wealth, and the consumption-increasing effects of insurance as major contributors to historic and projected growth. Other factors include changes in demographics and disease burden, rising personal incomes, and increases in prices charged by providers.

Rising spending places an increased burden on those who fund it. For example, higher premiums for health care benefits have resulted in increased costs for employees (which are starting to surpass any increase in their wages), and for Medicare beneficaries a growing share of their income must be used to pay Medicare premiums and cost sharing, and higher taxes.

Most importantly, numerous studies have shown that much of the increase in health care spending is not explained by improvements in health status, clinical outcomes, or quality of life. These findings, combined with the projected increases in health spending, represent the core challenges for policy makers. That is: how to increase quality, improve the efficiency of the delivery system, and find the resources to finance care.

To begin to address these issues, the Commission has recommended a number of changes, such as rewarding providers for improving quality and holding providers accountable for the quality of care beneficiaries recieve and the resources expended to provide it. Many of these recommended changes aim to improve the quality of care and health outcomes by creating incentives for providers to work together to coordinate care, to decrease fragmation in the system and promote true patient centered care models.
Some selected findings:

• Hospital Inpatient and Outpatient Services. In aggregate, most indicators of payment adequacy are positive, but profit margins on Medicare patients remain negative for most of the 3500 hospitals participating in the Medicare payment systems. In other words, most hospitals have to balance their payor mix to achieve an overall positive rate of retern.
• Physician Services. Most indicators of payment adequacy for physician services are positive and stable, suggesting that most beneficiaries can obtain physician care on a timely basis. A 2008 survey found that most physicians (74%) accepted all or most new Medicare patients in their practice and more than 95% had participation agreements which require them to accept Medicare’s fee schedule.

Overall though, the Commission remains concerned about the access issue and the direction in which it might be heading. There are reiterations of recommendations to increase payments for selected primary care services and there are plans for future work on those issues in particurlar.

One issue that will certainly remain in the spotlight is that spending due to health cost growth, if it remains on its present trajectory, will surpass growth in GDP in a matter of a few years. This is a dialogue in which we all will need to participate in.

Recently, I had the opportunity to attend the annual Military Health System (MHS) Conference held here in Washington DC. This occurred only a few days before the “Blizzard of 2010″, and as I have reflected on what I saw and heard there, I wanted to offer some observations from that excellent and informative conference.

As I listened to some of the plenary speakers, which were principally the service Surgeon Generals, senior Health Affairs officials, and guests such as the Chairman of the Joint Chiefs of Staff and other healthcare industry notables, I was struck with the sheer vastness, mission complexitiy, and the actual impact that the MHS is charged with performing. For contextual purposes, it is worthy to note a few statistics of this system which is composed of over 9.5 million beneficiaries.
Consider that in one week the following occurs:

• There are 21,800 hospital admissions and 1.6 million outpatient visits
• There are 25,800 behavorial health outpatient visits
• 2.48 million prescriptions filled
• and 2,380 babies are birthed

Not to mention that simultaneously the deployed medical staff support our wounded servicemembers in theatre resulting in a 54% return to duty within 72 hours and the lowest disease and nonbattle injury rates ever reported. This, along with a battlefield survival rate that now stands at 97% which is the highest in history. I could not imagine any other “health system” responsible for and able to, achieve so much. How does it remain focused to achieve these complex objectives which seem to be at odds with each other?

We learned that in order to get an arm around all of the vast array of needs in the military medical community and to remain on target, TRICARE and the MHS have adopted the concept of the “Quadruple Aim”. This is an adaptation to a frequently discussed phrase in the healthcare community known as the “Triple Aim”. It is an idea that refers to the three integral factors that determine the overall quality of healthcare: population health, positive patient experience, and per capita cost. The MHS has taken this paradigm and added a necessary fourth determinant - readiness. Thus, to remain “on target” it is imperative that the MHS achieve objectives within these four foundational goals.

During the course of the Conference we had ample opportunities to hear how these goals were being achieved. For instance, it is well known that readiness has steadily grown in the total force for four consecutive quarters. There was initially a great deal of concern beginning in 2007, with an increase in mental health diagnoses. The MHS responded with a 20% surge in mental health providers, the establishment of behavioral health locator lines and tele-health initiatives also added capacity.

The MHS is making significant progress in the preventative health realm. The Enrollee Preventive Health Quality Index which tracks population health shows that MHS health outcomes have been on a steady rise since 2007. Notable areas where the military is ahead of target are in colo-rectal and breast cancer screenings, as well as a reduction in smoking.

There were perspectives offered on the many medical advances that have made a difference both on the battlefield and off. Since 2001, there has been remarkable progress in prosthetics, implants, hand and limb transplantation, skin therapies and in many other areas of regenerative medicine. Other advancements have been made in bandages to stop bleeding, drugs to treat or prevent chronic pain, robotic support for tele-surgery, cranial reconstructions, and the detection and treatment of traumatic stress and traumatic brain injuries. The majority of these advances have improved the lives of service men and women and ultimately can be translated to all Americans.

After attending this for a week, I came away gratified that the MHS, with all of its moving parts, people and missions, can continue to evolve and meet the healthcare needs of the active force, their families, and retirees - day in and day out. No easy feat.