Consulo Indicium - 5/1/19

Information for your Consideration…

When The Future Is Too Close – It was rather disturbing to receive a notice in the media this past week that if Congress does not take action soon [to quote from the report]: “…tens of millions of Americans will only receive about three-quarters of their Social Security benefits when they retire.” Hmmm.  Now, if you were only three, four or five decades into life that wouldn’t be totally alarming.  But, if the future were much nearer than the past, it could you make more than pause – which is why I paused when I read the notice.  The annual report for the Medicare and Social Security Trust funds noted that Social Security will be tapped out 2035 and Medicare by 2026.  Yikes!  That’s seven years away.  Hmmm – another pause and big deep breath.  The recent media reports media reports are noting that the major problem steps from lower-than-anticipated tax revenue (income) and higher-than-anticipated (outflow) payments to the medical system.  In fact, Medicare’s costs “…are expected to continue rising sharply over the next several decades, from about 3.7% of the total U.S. economy to 5.9%, putting a strain on the federal budget that lawmakers must act to avoid.” So, it seems that Congress – that divided group of politicians who keep pointing fingers across the aisle – is not acting to solve the problem. A whole series of policy options have been outlined to close or reduce the long-term financing problem for both Social Security and Medicare.  Furthermore, earlier action by Congress would make the problem easier to solve that delayed action.  Is it any wonder that the American public is increasingly disenchanted with the ill-will and dysfunctional state of American politics? 

The entire Medicare and Social Security funding issue is a major issue.  Together, these two federal responsibilities accounted for 45% of Federal program expenditures – excluding net interest on the debt – in FY18. The unified budget reflects current trust fund operations. The impact of drawdowns on the balances for Medicare and Society Security as well as any transfers from the general fund impact directly on the overall budget of the US government. It’s time for leadership on both sides of the aisle to shut down their Twitter accounts and put aside the name calling so that they can listen to one another and solve problems.  Now is a far better time than later.  As I have said repeatedly, if we don’t solve these two problems – my generation will bankrupt the nation or, you’re going to see a lot of very old, angry folks out on the streets making lots of noise.  Perhaps you already are seeing that happen?

The other disturbing aspect of the report is the projection that the annual cost of Social Security benefits expressed as a share of workers’ taxable earnings is growing from 13.8% (2018) to about 16.6% (2040).  In other words, Social Security will be taking away dollars from our regular earnings in an era when the economy of the US is expected to continue experiencing pressure from our international friends and foes.  But, the Medicare side of the equation is where those of us in the health care community can have an impact by advocating for changes that will increase the solvency of the program.  The most worrisome portion of the report was the projected insolvency of the Hospital Insurance (HI) Trust Fund which pays for inpatient hospital services, skilled nursing facility and home health services following hospital stays, and hospice care. With depletion just around the corner in 2026 (yes, 7 years away!), it means that we (= the health care community) need to do our part toward increasing efficiency and effectiveness of the services we provide. The report does note: “It is possible that U.S. health care practices are becoming more efficient as new payment models develop and providers anticipate less rapid growth of reimbursement rates in both the public and private sectors than has occurred during the past several decades.” From my perspective, it’s time to accelerate our efforts. My generation will thank all of you who step forward but, even more importantly, the generations that follow the Boomers will thank you even more for lifting a large anchor off of their economic shoulders. If you only want an overview, the short version is available.  If you’re so inclined, I suggest the full report. 

Sustaining Primary Care – As a primary care Family Physician, I have felt for some time that the entire specialty has been throttled for the last couple of decades.  From low reimbursements to a de-emphasis on team models of care delivery, the specialty has not been able to adequately contribute to the efficiency and effectiveness equation.  And, yet, even the most recent studies are showing the critical importance of primary care as a foundational element of care delivery.  With the move toward value-based care delivery, the need for a strong primary care component will be even more important.  To that end, HHS Secretary Alex Azar – to his credit – announced an aggressive strategy for shifting primary care from fee-for-service payments to a global fee model.  Two approaches were outlined.  First, one of the approaches will be focused on small primary-care practices with bonuses and penalties tied to their ability to keep their patients "healthy and at home." Larger practices and health systems will be given even more lucrative upside models that also pose steeper risks. The various options range from 50% of risk/reward to 100%.  There’s also a "geographic option" whereby health systems or insurance plans could assume the primary care risk for a swath of communities within a particular region.  The launch date for these initiatives is January 2020. Over the next several weeks and months, these new initiatives will no doubt receive greater scrutiny. 

In a related discussion on the future of virtual primary care, mHealth Intelligence reports that the  program must be “…more nuanced, identifying specific patient populations and offering specific services, and they’re looking beyond early numbers and revenues to focus on cost savings, downstream revenue opportunities and patient engagement and satisfaction.” Key factors to note in the primary care telehealth space include the facts that telehealth adoption is increasing, there are challenges in simply measuring success by utilization and revenues; and, the focus of such programs needs to be focused on what patients want and expect. As efforts continue to develop the virtual primary care capabilities within health care organizations, it is increasingly clear that a focus on value-based care delivery models will carry the concept forward.  I look forward to following this important movement which will dramatically alter our notion of care delivery over the coming months. 

What About Telemedicine Full Time? – A recent study published in Health Affairs surveyed physicians from the 2016 American Medical Association database and identified 15.4% of the physicians reporting the use of telemedicine in their practices.  But, the trend is growing according to recent reports in Bloomberg. The report noted that a growing number of physicians are practicing telemedicine because they “…prefer to treat patients remotely, from the comfort of their own homes.” My prediction?  By 2025, more than 50% of practices will incorporate some element of virtual care into their practice settings.  Not to be outdone by private practice, the Veteran’s Administration recently submitted requests to Congress for $1 billion in additional funding for telehealth initiatives.  

And, Then, There’s The Workforce Challenge – Anyone who is on the front lines of health care knows about the gap that is becoming increasingly evident in the adequacy of professional skills among the workforce which is making it hard for the U.S. healthcare industry to fill jobs.  A recent report outlined the major factors contributing to the problem.  They include:

  • The skills gap in the healthcare sector is larger than for any other part of the overall economy. It is in large measure due to the lengthy training and licensing required to become a healthcare professional.
  • A disparity in demand is also evident. Some healthcare roles have far more job seekers than job postings.  This includes home health aides, nursing/medical assistants, direct caregivers, and dental assistants. On the other hand, those positions that require lengthy training (e.g. RNs, PTs, speech language pathologists, NPs/PAs) are in short supply.

The report goes on to note that "…healthcare faces a greater hiring challenge than do other sectors". The authors suggested that health care organizations need to invest more in training due to the “…unique role [health care plays] in society, one that will only become more critical as the population ages." 

In Case You Missed It - Did you know that 25 states are now part of the Interstate Medical Licensure Compact? And, what does that mean?  The compact provides physicians with an expedited means of applying for a license to practice telehealth in member states.  As Humayun Chaudhry, DO, President and CEO of the Federation of State Medical Boards (FSMB) noted: “The expansion of the Compact to half of all U.S. states is an incredible achievement and testament to state medical boards’ efforts to innovate and improve license portability.”  To date, the states included in the Compact include: Alabama, Arizona, Tennessee, Colorado, Idaho, Illinois, Iowa, Kansas, Maine, Maryland, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Hampshire, Oklahoma, Pennsylvania, South Dakota, Michigan, Utah, Vermont, Washington, West Virginia, Wisconsin, Wyoming, the District of Columbia and Guam. The Compact is one of those changes that brightens the future of telehealth and telecare.

 The Continuing March Of Technology – A new report in the journal Depression and Anxiety confirms work that was previously developed and supported at MITRE Corporation on behalf of the Veterans Administration.  The new study describes the use of an algorithm that identified 18 indicators from a list of 40,500 speech characteristics that were key markers for diagnosing post-traumatic stress disorder (PTSD).  The algorithm reported in the study revealed a 89% concurrence with expert diagnostic assessment.  The study marks the future direction where I’m projecting that clinicians will wear earpieces that “whisper” in their ear, “PTSD”.  But, it’s far more than PTSD.  It’s depression.  It’s Parkinson’s disease.  It’s attention deficit hyperactivity disorders (ADHD).  It’s any number of problems that present clinically with auditory cues. 

Consulo Indicium - 4/19/19

Information for your Consideration…

 In Case You Missed It – A recent article in Forbes highlighted a number of issues we are facing as a society related to the aging demographic. It’s a particular concern to some of us because of our direct involvement :-)  as well to others – like the broad swath of millennials who are inheriting the mess we’ve seemingly created in a number of areas over the last half century.  But, let’s not go there.  Instead, let’s focus on the aging issue. The article notes that there are two major considerations with an aging society.  First is the biological considerations related to our physical and mental capabilities that allow us to go about our daily lives. The second is transitions we all face as we move from being the doers, the leaders, the ones in charge, to the hang abouts, the sage advisors and the no-longer-up-to-the-taskers – as some who are younger think.  We all make the transition.  I’ve thought about “who is God” more in the last year than in the previous umpteen years of life.  Why?  Because I can feel God’s presence coming in some fashion and it’s a lot closer now than it was at the beginning of this journey! 

But, it is more than me, my aging colleagues and our personal journey.  There are also the societal considerations.  Are the changes in the environment beyond my horizon or not?  What can I do now for the sake of my children and my children’s children?  Will the Age Bubble burst the economic seams of the United States and bankrupt the nation? (NOTE:  If we don’t change course, yes it will!)  Will Social Security remain solvent?  I was with Michael Roizen, MD last week and he noted that living to an age over 100 is becoming increasingly common – and, that we should expect the average age of humans to continue climbing. Retirement as we know it came into existence in 1925 at age 65.  I’m looking at that age and responding as a total, unremitting failure.  But, when we look at it from a medical standpoint, 75 is the new 65 – today.  And tomorrow, it’s likely that 85 will be the new 75 a lot quicker than it took to make the change to 75.

Purely from a health care standpoint – there are some very serious questions we need to be asking about how much?  For what purpose?  Why? When? And, where?  And, those of us who are at the forefront of the aging issue need to lead the discussions.  I think it is time for the Boomers to step up to the plate and begin a serious societal debate on aging in America.  After all, we want to leave something better than we have or, at least that’s my philosophy.  Your thoughts appreciated.  By the way, don’t mis-interpret my comments.  I’m not saying “take away services or care” I am saying let’s have the harder discussion on what’s “appropriate” and “why”.  It’s an important debate not only for those who are aging but also for those who are just beginning their lives…

The First Line of Defense – Several weeks ago a new JAMA study reported that as the number of primary care physicians (PCPs) increased in a community there were gains in life expectancy and mortality rates improved.  Specifically, the study revealed reductions in cancer, pulmonary and cardiovascular death rates with the researchers stating that the addition of 10 primary care physicians for a population cohort of 100 000 resulting in “a 51.5-day increase in life expectancy whereas an increase in 10 specialist physicians per 100 000 population corresponded to a 19.2-day increase.”  In fact, the researchers concluded by stating: “…primary care is by far the most significant variable related to better health status.” 

Why is this important?  It’s important for three major reasons.  First, the demographics of the primary care population reveal that about 1/3 of them will either retire, become disabled or die over the next decade resulting in a shortage of between 7,300 to 43,100 over the next decade depending on how you count the numbers. Why?  Because they are Boomers.  Second, the number of young medical school graduates selecting primary care as a specialty is decreasing – an ominous trend for the US health care system.  And, third, primary care is essentially being disintermediated by the likes of CVS, Walmart, Telladoc, AmericanWell and others who are taking over the straightforward problems and leaving the more complicated primary care problems (e.g. asthma, congestive heart failure, etc.) to the face-to-face providers. At the present time, the US spends about 6% of our health care dollar on primary care which is roughly about ½ of what most other OECD countries spend.  And yet, the data is clear.  Spending more on primary care reduces the overall health care spend across the nation. 

So, why are we on this course?  I’ve said it so many times before but I’ll say it again, “The health care system is performing exactly as the incentives of the system are asking it to perform.”  If the money is put into specialties – we will get specialty services.  If the money is directed at acute care – we will get acute care.  If the focus is on “doing” things to people, you get a system that “does” things. And, finally, if prevention is not a focus and instead all of the money goes into sickness – then a sickness-oriented system will result.  The US health care system is performing exactly as it is presently incentivized.  So, if we want to change things – we need to start with the incentives. 

Value-based care delivery is a model that forces this question to the forefront so, there is hope.  My sense is that we are moving down that track.  If we don’t want to bankrupt the nation due to the weight of health care costs, it’s actually an imperative!  Health care is the #1 issue on the minds of Americans.  Now we need leadership. Actually, not just leadership but “unified” leadership.  In other words, bipartisan leadership or perhaps better put, non-partisan leadership.  Will that be forthcoming?  Yes – over the longer term. It has to be there for the sake of the country. The short term is another story…

So, What’s Happening On The Value-Based Payment Front? – First, we are definitely learning that “incentives” do matter.  Adam Boehler, the Director for the Centers for Medicare and Medicaid Innovation (CMMI) recently gave an update on the state of value-based care at the America Hospital Association meeting in Washington, DC.  He noted several important considerations. First, trying to practice in two different incentive worlds (value-based vs. fee-for-service) is “very hard”.  Second, open transparency on the results of practice is an imperative if we want providers to respond to a change in incentives. He then went on to articulate four priorities for the office: 1) supporting the patient-as-consumer, 2) creating provider accountability, 3) pay for outcomes; and, 4) prevent disease. The office is also going to be re-evaluating the criteria for evaluation and the metrics used in conducting the evaluation of results.  There was also an undercurrent of focus on telehealth and telecare as areas in need of further support and demonstration. He also noted that there will be an increasing focus on primary care models as well (SEE above commentary).  We’ll see.  The rhetoric is good.  Now we await the reality. 

 What About Specialty Care?  There was a recent article in Health Affairs that highlighted some very interesting trends among large employers.   The big employers – like Walmart – are moving toward the use of a select group of specialists for selected services (e.g. open heart, cancer care, etc.).  By having their employees use specific providers they are able to shift services to those physicians who perform at the top of their game from a clinical, quality and cost perspective.  In return the companies pay for all travel and health care costs associated with the services.  And, the result?  As an example, Walmart, Lowe’s and McKesson reported a combined savings of more than $19B under such a model that had patients using specific spine and specialty surgeons for a set of selected services.  That’s a chunk of change by any measure. Expect to see more of this strategy in the coming year…

Better To Be Late Than Never –  A large study from the US reports that people who engage in high levels of leisure activity throughout their entire lives had a 1/3 lower in their risk of death.  Tell us something we didn’t know!  The good news for the late bloomers; however, is that people were inactive in the early part of their lives but then increased their physical activity later during middle age enjoyed the same reduction in all cause mortality as if they had been exercising their entire life!  Oh, oh!  That means there’s now a very good, documentable reason to exercise as part of your daily routine.  The data is compelling.  The experts keep arguing that 80 is the new 60. So, it seems that are no more excuses… The lucky one is Toto the Wonder Dog.     

Consulo Indicium - 3/19/19

Information for your Consideration…

The President’s Budget – As Presidential Budgets go, it is like all of the others that have been submitted in recent years.  Whether the President is Democrat or Republican, the characterization is the same: “Dead On Arrival”.  So, I wasn’t surprised when the Trump Administration recently laid out their FY2020 Budget to hear the same clarion call that Republicans gave to the Obama Administration.  A couple of key points and items of interest should be noted in the President’s Budget; however, including the following:

  • The discretionary portion for the Department of Health & Human Services funding was reduced to $87B (↓12% from FY2019).  That’s a fairly sizeable chunk of change and cuts deeply into the innovation side of DHHS spending.
  • National Institutes of Health (NIH) was proposed at $34.4B or, a reduction of $5B (↓12% from FY2019.
  • National Cancer Institute (NCI) was slotted at $5.2B, a reduction of $900M (↓15%)
  • National Institute of Arthritis & Musculoskeletal & Skin Diseases (NIAMS) – $521M, a reduction of $84M (↓20%).
  • Food and Drug Administration (FDA) – $6.1B or, a $643M Increase (↑12%) 
  • Mandatory Spending for Medicare & Medicaid is project to result in savings or reductions (depending on how you count it) of $1.25 Trillion over the next 10 years.  Now, that will be accomplished primarily through:
  • Modifying payments to hospitals for uncompensated care = $98B in savings over the next 10 years;
  • Consolidating and block granting graduate medical education payments = ($47.9B);
  • Reducing Medicare coverage of bad debts = ($38.5B);
  • Paying on-campus hospital outpatient departments at the physician office rate instead for certain services = ($131.4B); and,
  • Paying all hospital-owned physician offices located off-campus at the physician office rate = ($28.7B).
  • Not to be excluded were Prescription Drug Costs which were slotted for reductions or savings over the next decade with the following proposals:
  • Eliminating cost-sharing on generic drugs and biosimilars for low-income subsidy (LIS) enrollees = ($930M) over 10 years;
  • Excluding manufacturer discounts from calculation of out-of-pocket costs in the Medicare Part D coverage gap to correct misaligned incentive and treat brand and generic drugs the same when calculating out-of-pocket costs = ($74.7B) over 10 years;
  • Eliminating pass-through payments for drugs to lower out-of-pocket costs by making them eligible for the reduced 340B payment level= ($4.3B) over 10 years;
  • Reform exclusivity for first generics to spur competition = ($1.2B over 10 years; and,
  • Establishing a beneficiary out-of-pocket maximum in the Medicare Part D or, a cost of $14B over 10 years.
  • Other items of interest included the elimination of funding for the Agency for Healthcare Research & Quality (AHRQ) where the functions would be moved into a new National Institute for Research in Safety & Quality.

New Interoperability Rules Proposed by CMS – In a move that has been advocated by many of us for some time now, HHS finally proposed new interoperability rules requiring insurers of Medicare Advantage, Medicaid, Children's Health Insurance Program and Affordable Care Act plans to provide electronic health data in a standard format at no cost by 2020.  Kudos to the Office of the National Coordinator (ONC) for Health Information Technology who pushed the requirements forward at the various agencies including CMS. The information included in the rule stipulates that diagnoses, procedures, tests and providers that the patient has seen, and provides insights into a "beneficiary's health and healthcare utilization," according to a summary on the CMS proposed rule. The requirements would be accomplished through the use standard APIs or Application Programming Interfaces which allow disparate software products communication through standard interfaces on selected data. The new rule also stipulates that insurance providers who block the information will be publicly identified with the intent of ending the practice. It will be interesting to see if anyone objects to this portion of the rule.  Now, a final cautionary note.  With the CMS notice running at 251 pages and the ONC notice, at 724 pages – be prepared for a long week of review.  I’ve only glanced at the surface.  The new rules deserved your review, consideration and response. 

Baby Boomers Drive Higher Health Spending Costs in USA – In news that didn’t rock my day – in large measure because it is so obvious – CME came out with a new report citing that the US health spending rate is projected to grow from a current state of $3.6 trillion in 2018 to about $6 trillion by 2027 – or, within the next decade.  That represents about a 5.5% annual growth rate due to primarily Boomers getting older but also the rising costs of medical goods and services.  The growth also means that the percent of GDP devoted to health care is projected to grow from 17.9% (2018) to 19.4% (2027).  The good part – if you can say that increasing our proportion of GDP health care is good – is that the growth rate is far below the 1990-2007 period which experienced an average of annual 7.3% growth rate.  Regardless, the growth does continue and for every point of a percent that we take out of the GDP for health care, there is a reduction in expenditures someplace else.  I won’t go into the litany of reductions but my two favorites are education and infrastructure.  For a complete review of the findings, you should review the recent Health Affairs article which provides an overview of the findings from the US Office of the Actuary. It’s clear to me that a change in our nation’s payment model is moving into rapid focus along with cost management.  Without such change, I keep arguing that we – The Boomers – will bankrupt the nation.  And, I really don’t see that the Millennials and beyond are going to let that happen :-)

But, It’s Not Just The Boomers – One of the more disturbing news items in recent weeks has been the number of outbreaks from measles and other very controllable infectious diseases.  Facts matter here.  The fact is that immunizations save lives.  If there are real, documentable reasons why children (or adults) should not receive immunizations, it should be considered.  But, simply because you read junk information on the web and come to the conclusion that it’s true when it is not – is NOT a good reason to allow parents or others to simply skip out on required immunizations.  Perhaps we should let people forget about stop signs because someone wants to get to their destination quicker or how about just ignoring solid lines on the highway when we are going over a hill.  Perhaps we should do away with hand washing in public restaurants for those that don’t feel it is necessary.  There is a litany of half-baked ideas out there that could support any one of these ideas.  And, they are not facts.  They are not true.  Let’s get serious.  

Reconfiguring Primary Care – The leader of Medicare's innovation center, Adam Boehler, recently unveiled his thinking for a new model for primary care physician payments where he intends to "blow up" how primary care is reimbursed. One of the primary objectives is to adopt telehealth and online consultations.  You can check out the full report at STAT.

The Continuing Disintermediation –While I am an ardent supporter of technology, I’m increasingly concerned with the ongoing disintermediation of health care services.  The splintering is becoming a problem as more and more organizations enter the market by offering up solutions that provide “immediate” care.  The problem is not the solutions.  It is; however, the fact that the solutions are most often totally disconnected from the ongoing “care” of an individual.  It is not only the call-from-anywhere health clinics (e.g. AmericanWell, MDLive, etc.).  The newest one on the block is OnMed which are standalone kiosks where you can get immediate care 24x7 from online physicians.  In addition, you can also get your prescriptions filled right in the kiosk.  Does this mean that CVS and Rite Aid are next in the disintermediation play or will they simply deploy these devices?  While it is absolutely true that about ¾ of primary care can be provided on a virtual basis, the remaining 25% is crucial and requires face-to-face time.  The problem on the horizon is the dropped information, the disconnected virtual care, the miscommunication and other problems that will no doubt arise as more and more players enter the 75% without considering the 25%.  We may be creating more problems than we are solving. What are your thoughts?

In Case You Have Not Heard About Xcertia – On the possibility that you may not have heard about Xcertia, I thought I might include a short piece on it for the blog.  Xcertia is a joint initiative sponsored by the American Medical Association (AMA), American Heart Association (AHA), DHX Group and, the Healthcare Information and Management Systems Society (HIMSS) to focus on mHealth App standards and guidelines. The collaboration is bringing together the independent efforts of each organization to foster safe, effective, and reputable health technologies. Late last year, the organization released its Privacy and Security Guidelines as part of a multi-staged, annual approach toward defining guidelines for mHealth Apps.  The organization has tapped the expertise of members from the AMA, AHA, Partners HealthCare, PCHAlliance, HIMSS, Consumer Technology Association and others.  Check it out.  They are providing a very valuable service to the public and the health care community.  Here are some other issues that have been highlighted of late that need to be considered:


Consulo Indicium - 1/24/19

Information for your Consideration…

The State of International Medical Graduate Education – According to the National Resident Matching Program (NRMP), international medical graduates (IMGs) who sought residency positions in the US applied in smaller numbers than in prior years but had greater success in actually finding a postgraduate year 1 position in 2018.  57% of US citizen IMGs matched versus 56% for non-US citizen IMGs.  Both of those rates are the highest since 1993.  In addition, the most IMG-friendly specialties for the 2018 match were Pathology (45%), Internal Medicine (43%), Neurology (35%); and, Family Medicine (30%). 

Consulo Indicium - 12/31/18

Information for your Consideration…

The Disintermediation Is ComingDisintermediation is the process of taking apart and putting back together in new, more consumer-centric ways.  It is the process of giving the user or the consumer direct access to information that otherwise would require a mediator, such as a salesperson, a librarian, a lawyer – or, even a doctor. Whereas in the past “intermediaries” were required for interpreting the information – like priests reading the Bible - through the use of technology users hold direct access to medical, legal information, travel, or comparative data and information directly.  The “disintermediation” comes by way of removing the doctor, lawyer, salesperson or other individual from the process.  Before the coming together there is the tearing apart.  Some examples include:

  • Walgreens (LabCorp) and CVS (Aetna) are building clinics and mobile apps to provide immediate, 24x7 access to their services – and, that does not include the efforts by Walmart and others.  Sears should have listened to me 30 years ago when I suggested that they tear out the carpet section and install clinics instead.
  • At last count over 900 Direct Primary Care or Concierge Medicine practices have been established or, a 230+% increase from 2015.
  • Amazon, Berkshire Hathaway & JPMorgan Chase have teamed up to form an independent healthcare company and hired Atul Gwande, MD – an innovator and thought leader of the first order – as their new CEO.
  • And, not to be left behind – Google, Apple, Microsoft, Express Scripts Holding or, GAME, among others – are eyeing the healthcare industry for opportunities to participate in the disintermediation party.  Their insights and analysis into how and where “health” happens and is delivered will change the way we think about “health care” on into the future. 

Actually, the disintermediation is not coming – it has arrived!

Trump Administration Recommends More Consumer Responsibility – The Congressional Quarterly recently noted that the Trump Administration in a report on how to increase competition in health care recommended that Congress and the states could take steps to decrease health care spending by lowering “…spending is to expose consumers to more costs and allow them to ‘pay directly’ for health care.” The posit that consumers are in a better position to avoid unnecessary and expensive care rather than the insurance companies which they argue are incentivized to prioritize more expensive services. Hmmm.  One of the ways to foster such consumer attentiveness is through expansion of health savings accounts.  With more than 50 other recommendations, the Administration’s plan entitled “Reforming America’s Healthcare System Through Choice and Competition” provides a lens on the thinking of the leaders currently occupying the HHS offices.  At 120 pages, the full report is worthy of a download if you’re into the nits and nats of where US health policy might be headed.  No doubt, implementation of the recommendations will be yet another story.

But, on the telehealth front, we have not seen the type of adoption that could truly reduce costs and drive efficiency (my perspective).  According to the Centers for Medicare and Medicaid Services (CMS), only one quarter of one percent (0.0025%) of the Medicare beneficiaries took advantage of telehealth services in 2016.  To bring it back full circle to the Trump Administration’s report; however, their recommendations were woefully weak.  Of the entire 120 pages, only four short recommendations were noted and they are mini-steps forward.  They include

  1. States should consider adopting licensure compacts or model laws that improve license portability by allowing healthcare providers to more easily practice in multiple states, thereby creating additional opportunities for telehealth practice. Interstate licensure compacts and model laws should foster the harmonization of state licensure standards and approaches to telehealth.
  2. States and the federal government should explore legislative and administrative proposals modifying reimbursement policies that prohibit or impede alternatives to in-person services, including covering telehealth services when they are an appropriate form of care delivery [emphasis added]. In particular, Congress should consider proposals modifying geographic location and originating site requirements in Medicare fee-for-service that restrict the availability of telehealth services to Medicare beneficiaries in their homes and in most geographic areas.
  3. States generally should consider allowing individual healthcare providers and payers to mutually determine whether and when it is safe and appropriate to provide telehealth services, including when there has not been a prior in-person visit.
  4. Congress and other policymakers should increase opportunities for license portability through policies that maintain accountability and disciplinary mechanisms, including permitting.

These are obvious minor steps.  To solve the problem requires a much more aggressive – if not assertive – approach toward solving the problem.  The technology is available.  The resources can be mobilized.  The impediments remain.  Relatively empty recommendations won’t get us there although hope is on the horizon.  The Bipartisan Budget Act of 2018 will allow MA plans, starting in 2020, to provide additional telehealth benefits. The proposed rule would allow for telehealth services from a patient's home for Medicare Advantage patients only.  So, at least we are moving in the right direction – if ever so slowly…

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