Sunday, October 4, 2015

Long but important comments by an expert - Kip Sullivan

Oct 3, 2015
Yesterday DHS staff made a Powerpoint presentation to the Delivery Design and Sustainability work group (one of three work groups within the Health Care Financing task force). This presentation made it even clearer what DHS wants from the task force: They want the task force to recommend policies that expand ACOs to all Minnesotans.

True to form, DHS spoke in a language that sounds remarkably like English but actually isn't English when you ask yourself, What did I just hear? I will do my best to translate.

The presentation included 31 slides. It was entitled "Integrated Care Models and Value-based Purchasing in Minnesota." I know you understand what "in Minnesota" means. Let me translate the rest:

* "Integrated care" means medical care delivered by large corporations that own clinics, hospitals, pharmacies, and nursing homes. You see, providers can only communicate clearly with one another if they have the same corporate logo on their doors. Otherwise, communication is impossible. Email doesn't work, phones don't work, faxes don't work. If you don't have a corporate logo on your door, you provide "fragmented care" and, worse, "uncoordinated care."

"Value-based purchasing" is something insurers (public and private) do. "Value," as you know, is a combination of cost and quality. You might fear that letting DHS or BCBS define "value" is a recipe for disaster, but you'd be wrong, according to DHS. DHS knows we're on the brink of being able to measure not just cost per patient accurately, but the quality of care given to that patient as well. Moreover, DHS knows that some IT nerds somewhere are about to invent a computer program will that will combine an accurate score for cost with an accurate score for quality into a single "value" score. And then, DHS can rank all HMOs or all ACOs with a single value score, and award contracts on the basis of this score. Ditto for BCBS. It can rank all doctors and hospitals in the state and decide which ones to include in their ACO.

The first two-thirds of the Powerpoint slides are devoted to explaining ACOs that DHS has already set up within the Medicaid program. The first few slides use the phrase "integrated care model" (ICM) but gradually that label is displaced by the phrase "accountable care organization."

DHS warns us in slide 5 that we're never going to know what an ICM or an ACO actually does. Slide 5, entitled "MN approach to Medicaid ICM," says: "Define 'what' we want, rather than the 'how,'" and "Allow for local flexibility and innovation...." Slide 5 says what we "want" is "accountability for total cost of care," "robust quality measurement," and "models that drive rapidly toward increasing levels of integration."

See what I mean? The words are all words all have an obviously Anglo-Saxon origin, but when you stop and ask, What the hell did DHS just tell me, you realize you have no idea what they said.

The problem is that DHS won't state clearly what their end game is -- to identify the corporations they have in mind that will rule our system, and the tactics these corporations will use to control physician-patient decision-making. DHS's goal is to cram all Minnesotans into a few enormous insurance companies that will be nothing more than HMOs on steroids, but will be called ACOs. The Big Three insurers and a half-dozen dominant hospital-clinic chains (Allina, Mayo, Sanford, etc) will run these ACOs.

The Big Three and the hospital-clinic chains know precisely what DHS is up to. The rest of us don't. This is dog-whistle health policy. It's profoundly undemocratic.

Slides 24-28 describe DHS's attempt to determine how widespread ACOs are already in MN. This attempt was apparently conducted around the time MN received the SIM grant. I infer that from the title of slide 24, "SIM ACO baseline: What we hoped to learn." This note appears (after the name "Karen") at the bottom of the slide: "We wanted to learn about ACO and ACO-like practices in the health care delivery system and we wanted to know the strengths, weaknesses and barriers experienced by providers and payers, with the ultimate goal engaging our stakeholders in a broader discussion around statewide goals and SIM priorities."

The phrase "our stakeholders" appears to refer to insurance companies and hospitals. According to slide 26, DHS interviewed five insurance companies, five medical groups, and two community service workers for this "SIM ACO baseline" study.

Slide 27, entitled "ACOs are spreading," informs us that 40 percent of fully insured businesses (as opposed to self-insured) are "in ACOs," although there's no indication of whether the businesses know they're in an ACO. (I've never heard of an ACO definition which defines ACOs by the businesses that are "in" them. This is a definition peculiar to DHS.) We learn that about half of all providers (individual docs, clinics and hospitals) are in "organizations" that are in ACOs (note the convoluted progression from provider to organization to ACO).

Slide 28 informs us that, regrettably, the amount of insurance risk (presumably meaning risk borne by ACOs) is "low," defined as less than 10 percent of their revenues. But, and here's the good news, "many anticipate growth in % in next five years." You see, it won't be long before insurance companies have shifted all risk over to ACOs.

Not one of the slides in this presentation presents evidence that ACOs function as claimed -- that they reduce costs or improve quality. There is a good reason for that: Existing research shows ACOs either save no money or are raising costs, and that ACOs do improve their scores and the tiny handful of quality measures that are imposed on them, which of course tells us nothing about what happened to the patients whose care was not measured.

Not one of these slides discussed the evidence that "value based purchasing" harms poor people (because cost and quality cannot be measured accurately, that is, in a manner that measures only factors under physician or hospital control). This even though the entire task force has agreed they will examine every recommendation they make for its impact on health disparities.
Despite the evidence, and despite the threat that ACO mania will rapidly increase consolidation and worsen disparities and raise costs, the last slide, slide 31, recommends that we mash the ACO button even harder and spread ACOs across the land.

I have attached the slides that I have discussed here.

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