A "HealthTweep" Pulse Check

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Posts Tagged ‘Mayo Clinic

MIA? Not Really…

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There is much happening in the whirlwind of health reform, and the granular transformation enabled by the passage of the Patient Protection and Affordable Care Act (PPACA). The theater in Washington notwithstanding and well as the growing storm of legal challenges to the insurance mandate leave much of the implementation path somewhat clouded.

Yet the ‘roll up your sleeves and make a difference’ crowd rather than whine and obstruct, are rather busy and focused on the granular transformational opportunites written into PPACA.

You will find some of the more interesting posts and updates from the proactive players at ACO Watch, and well as it’s sister podcast via ACO Watch: A Mid-Week Revew.

Three recent posts are well worth singling out, they include:

Jaan Didorov, MD, and publisher of the Disease Management Blog, on ‘No Faux ACO’s Here!’ A play witty on CMS Administrator Don Berwick’s earlier industry admonition, as well as ‘How To Get Independent Physicians Into an Accountable Care Organization‘, offers select insights and commentary of a mature IDN, absent the staff (or employed group)  model DNA typically associated with Mayo, and Kaiser Permanente ACO strains, but more of a private/voluntary medical staff model culture, over at Advocate Health Partners.

Also, check out ACOs and the Shared Savings Program; Some Common Misconceptions, by Reed Tinsley, CPA.

We welcome your comments and engagement!

Bundled Payment? Lets Start with the ‘RAPERs’!

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Some of the health reform conversation has focused on bundled payment as a ‘bite sized’ basis of implementing change in the ‘whack a mole’ resistent health care borg. In response to a question on a LinkedIn thread entitled ‘Changing the Health Care Payment System: First Step Toward Real Reform?’

Breaking the cycle of health care payments complexity and errors may be one way in which to stem the cost of moving to a consumer oriented health care system, which is one of the popular solutions discussed during the health care reform debate. This concept of consumerism in health care and payments for services may be provocative to many readers of this blog but the facts as they stand currently demonstrate clearly that we have to start reform somewhere and fast. The current legislative efforts have provided little in the way of support for what the American people have expressed they want in the way of a public option so perhaps as an industry we can begin to resolve some of the issues that will be explored in this discussion. It is a fact that when compared to other business sectors such as retail, health care revenue cycle management is difficult at best, fraught with paper and consists of very little standardization. This is clearly an area that is replete with opportunity to drive new business, create jobs, and leverage existing infrastructure investments all while creating better efficiencies and timelier payments for providers.


The purpose of starting this discussion is not to position the arguments within as the only area of focus for the health care debate just a good start, and all efforts in other areas should continue in tandem. Consider that the health care industry supports bad debt in excess of 60 billion, spends more than $7,000 per person and almost 2.3 trillion dollars by some estimates. Certainly, this would point to an area ready for innovation and change. There will not be a “quick fix” to address these challenges nor is the author suggesting that it is the universal remedy not to mention that many readers will disagree with the points offered in this post. In essence that is the real point of this effort is to start an open, honest dialogue addressing the issues surrounding the payment system in the US Health Care system lest we continue to get more of the same, less individuals insured, spiraling costs and no hope of stemming the tide and effecting change.


I opine below:

Excellent discussion! I will noodle some more after digesting the entire thread, plus comments. Yet, what comes up for me is the ‘C’ word. Underlying health reform whether from the bleeding edge of payment reform, or any other logical portal of entry, i.e., HIT, nothing succeeds absent the ‘cultural’ context to receive and embrace its adoption.

So why not start with ‘seeding’ the cultural antecedents to merge (both clinically and financially) all hospital based physicians (HBPs), less affectionately known in the health plan contracting domain as ‘RAPERs’, i.e., Radiology, Anesthesiology, Pathology, Emergency Room docs? This is a logical nexus for bundled payments and rather compelling from the patient’s perspective too.

The notion of bundled payment is potentially sexy. It encourages, if not drives, the consideration of collaboration (& the ostensible alignment of interests) to accept and administer global payment for professional medical services rendered; and theoretically is more efficient and cost effective. Yet, in 2010 there is neither the administrative capacity, nor (outside of IDNs of the Mayo variety) cultural capacity for HBPs to risk experimentation with the financial and clinical collaboration required to co-exist under a bundled payment paradigm. Yet, no where else in medicine is the argument so compelling for such integration, imj.

Clearly, the nature of the exclusive ‘franchise’ often afforded to HBPs in my view augurs in favor of such integration even absent the ‘quid pro quo’ group culture typically required for its successful implementation.

Health Care ‘Texas Style’: A Model for the Nation?

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In the aftermath of Atul Gawande’s landmark piece ‘The  Cost Conundrum‘ and the selective emergence of the ‘Mayo v. Mc Allen‘ mantra, I’ve been tweeting of late on the ‘irony’ of certain Texas health markets, particularly given the concentration of hospital assets in non profit health systems, and the timely question of whether such consolidations produce the ‘community benefits’ proffered by their leadership. The recently published Commonwealth Fund study ‘Aiming Higher: Results from a State Scorecard on Health System Performance, 2009‘ has supplied certain metrics to further contextualize the conversation.

First some background: I spent 13 years in the Lone Star state, initially advising a major national proprietary hospital management company’s implementation of its managed care strategy in the Houston market, followed by implementation physician networks for a 140,000 member global risk Medical Group, and finally managing payor and provider contracts for a joint venture ‘Super PHO’ affiliated with a dominant faith based hospital system in Dallas/Fort Worth.

Now mind you, everything in Texas is big – especially its delivery system players who have literally architected quite beautiful (and very expensive)  ’cathedrals of medicine’. Examples include: the Texas Medical Center (an NIH like cluster of some 12+ competing institutions), Memorial Hermann Health SystemBaylor Health Care System and Texas Health Resources to name a few of the trophy properties. Yet, years after the roll out of the strategic plans of these health systems, and the fulfillment of their market share objectives, certain of the state’s health care indicators look quite grim when contrasted to other parts of the country.

One might wonder why? Afterall, the typical pre-merger or alliance argument in favor of consolidation, acquisition or market expansion, was typically framed as follows, it will:

· Improve quality

· Improve access

· Increase operating efficiencies; and

· Lower costs

Yet according to the Commonwealth Fund study, and now years after these consolidations, here’s how Texas ranks on key metrics of health status compared to all 50 states, and the District of Columbia.

· Overall: 46

· Access to care: 51

· Prevention & Treatment: 43

· Avoidable Hospital Use & Costs: 42

· Equality between rich and poor: 50

· Equality between non-Hispanic white and minority: 48

· Healthy lives: 21

· Children with medical and dental check-ups in past year: 40

· Adults with a regular doctor: 49

· Medicare reimbursements: 46

· Infant mortality: 19

· Breast-cancer deaths: 18

· Colorectal cancer deaths: 15

· Adults who smoke: 17

· Overweight or obese children: 32

Not exactly ‘best in class’. So why not ask, where is the ostensible and promised ‘community benefits’ and not just those codified in IRS code, to justify the tax exempt status for most of the entities above? How is this ‘return’ (to the community) being measured; (is it via Medicare or Medicaid ‘shortfalls‘, or charity and bad debt write-offs; or some tangible real world contribution); or is it even accurately measured? The IRS 990 filings are somewhat ‘fluid’ on the specific reporting of activities that count towards community benefit.

Most, if not all, of these institutions are primarily ‘non profit’ (with some affiliate JV exceptions) yet they are aggressively managed to generate a surplus of revenue over expenses; after all ‘no margin, no mission’. While they do not have stock holders or investors per se, they do have bonds that require adequate debt service coverage in order to maintain favorable credit ratings and competitive access to capital.

This is where the ’story’ for the consolidations and, for some, the unspoken truth of the matter emerge, IMO. While perhaps stated in the vision for some, most of the benefits of consolidation are to be found in the pricing leverage that comes from asset concentration. Hospitals want higher rates, and payors (health plans and insurance companies) can tell you how difficult it was, and likely remains today, to extract material discounts from these massive institutions given their scale and market dominance.

So the question remains open: have they delivered, or are they just plain ‘doin’ it wrong’? Is the promised value proposition a reality today for the Texas residents they purport to serve? Based on these, and other metrics, many would say no. Rather than more of these Texas sized giants, why not refocus the Lone Star state on their one home grown version of a ‘Mayo Clinic’ model domiciled in Temple, Texas aka ‘Scott and White‘.

In the next blog post, i’ll touch on the physician role in the Texas market, and the historical rise and fall of physician driven integrated delivery systems in particular.

Here’s how Texas ranked in key areas compared to all 50 states and the District of Columbia.
• Overall: 46
• Access to care: 51
• Prevention & Treatment: 43
• Avoidable Hospital Use & Costs: 42
• Equality between rich and poor: 50
• Equality between non-Hispanic white and minority: 48
• Healthy lives: 21
• Children with medical and dental check-ups in past year: 40
• Adults with a regular doctor: 49
• Medicare reimbursements: 46
• Infant mortality: 19
• Breast-cancer deaths: 18
• Colorectal cancer deaths: 15
• Adults who smoke: 17
• Overweight or obese children: 32

Written by 2healthguru

October 22, 2009 at 8:43 AM

Mayo Clinic ‘Transform’ Healthcare Symposium

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The visionaries at Mayo Clinic are at it again.

On September 13-15th, 2009, the Mayo Clinic Center for Innovation is hosting a collaborative symposium entitled ‘Transform‘. This event intends to engage ‘stakeholders’ in the timely yet complex conversation of how to reform the health care experience, including its over-engineered, under performing and unsustainable panoply of failed business models.

The net is cast wide to include and crowdsource the entire spectrum of interested parties from physicians, hospitals and health plans to bloggers, ‘twitterers’, scientists, designers, health policy wonks and artists.

The goal is to transform both how health care is experienced, delivered, and lest we forget, financed. The symposium intends to be ‘organic’ and ignite both real time (at conference and via the ‘twittersphere’) and a post event, after market continued engagement in this very timely conversation.

Why Attend?

  • To be part of the solution.
  • To connect with thoughtful colleagues from inside and outside the health care industry.
  • To discover new models of care that will transform the experience and delivery of health care in the 21st century.

Lots of talented and forward thinking tweeple speaking and likley to participate in this event.

So who’s going to be the anchor model in medicine? Will it be Mayo or McAllen? The stakes are high, so why not be the change you want to see Tweeple…. lets get ‘er done!

Written by 2healthguru

September 7, 2009 at 11:08 AM

Mayo v. McAllen – The Battle for the Soul of American Medicine?

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In a June article in the NewYorker, surgeon and writer, Atul Gawande brought life to the landmark ‘small area analysis’ work of team Darmouth, i.e., Wennberg, Fisher, et al. The Darmouth crew has been studying and documenting the widespread and unjustifiable variations of medical practice patterns by US geographic regions for quite some time.

Gawande’s genius insight was to put a timely face on this ‘value proposition inequity’, by comparing Medicare’s practice patterns and cost profiles from two demographically comparable Texas communities – El Paso and McAllen.

For historical context, this inexplicable and unjustifiable range of practice variance including cost profiles, is not news. I recall circa the 1986 timeframe when Deak Wooten, the then Director of Blue Cross of California’s ‘Prudent Buyer’ plan (an innovative PPO), under the stewardship of Leonard Schaeffer (pre Wellpoint roll-up, or better yet ‘Mashup’ of healthplans), presented the concept of ‘small area analysis’, stressing the need to minimize variation both as a quality enhancing as well as cost savings ‘management initiative’. Yet, here we are today, some 20 plus years later, and the concept is only making its way into the American psyche as a result of the intense national debate we are witnessing relative to US health reform initiatives.

While Gawande brings the issue to main street, the bigger and perhaps more strategic question is nested in his narrative on ‘who will ascend to “anchor model” status in US medicine’, Mayo or McAllen? Few in the popular press or even healthcare sector seem to focus on the profound implications of even calling the question!

Worse yet, Gawande cautions:

Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing.”

This strikes me as an urgent call to action. Especially when considering, when Gawande refers to “Mayo”, he’s referring to that class of medicine as represented by Geisinger, Kaiser, Cleveland Clinic, Intermountain Health, and other group practice cultures that have spawned progressive integrated delivery system (IDS) network models; where ‘integrated’ means merging both direct care & financing platforms.

If the “Mayo’s” of the world fail, then there is no hope for a public/private market solution to the chronic ‘whack a mole’ phenomenon of US health care. The government will step in and put the private sector out of it’s collective misery – not a picture I favor!

Written by 2healthguru

July 13, 2009 at 1:59 PM