The Patient Protection and Affordable Care Act, commonly known as “Obamacare” was an amazing triumph, whatever your political persuasion. Most folks have absorbed the idea that this legislation will require that most citizens of the U.S. carry health insurance. What is hidden in the crevices of this voluminous piece of legislation are a significant number of tools congress and CMS can use to move us to a new payment model. If we can’t get that done, we will not see any let up in the relentless increase in costs that is already paralyzing the nation.
Our experience suggests that connected health is an ideal strategy to achieve the goals of population health management, the patient-centered medical home, higher quality at lower costs and preventative care. We’ve seen our connected cardiac care program result in a reduction of admissions of about 50%, our diabetes connect program result in a decrease in HbA1c of about 2 points and our Smartbeat hypertension program result in significantly lower blood pressure.
With those results in mind, I surveyed the legislation and came up with the following provisions where connected health will be an important part of achieving success:
Sec. 2717 – Ensuring the quality of care — Reporting by health plans
Provides that the Secretary shall develop requirements for health plans with respect to benefits and reimbursement structures that, improve health outcomes through the implementation of activities such as quality reporting, effective case management, care coordination, chronic disease management, and medication and care compliance initiatives.
Sec. 2703 – State option to provide health homes to Medicaid enrollees with chronic condition.
Provides states the option of enrolling Medicaid beneficiaries with chronic conditions into a health home.
Sec. 2704 – Demonstration project to evaluate integrated care around hospitalization
Establishes a demonstration project, in up to eight States, to study the use of bundled payments for hospital and physicians services under Medicaid.
Sec. 3022 – Medicare shared savings program – Accountable Care Organizations
Rewards Accountable Care Organizations (ACOs) that take responsibility for the costs and quality of care received by their patient panel over time. ACOs can include groups of health care providers (including physician groups, hospitals, nurse practitioners and physician assistants, and others). ACOs that meet quality-of‐care targets and reduce the costs of their patients relative to a spending benchmark are rewarded with a share of the savings they achieve for the Medicare program.
Sec. 3023 – National pilot program on payment bundling
Direct the Secretary to develop a 5‐year national, voluntary pilot program encouraging hospitals, doctors, and post‐acute care providers to improve patient care and achieve savings for the Medicare program through bundled payment models. The Secretary is also required to submit a plan to Congress to expand the pilot program if doing so will improve patient care and reduce spending.
Sec. 3024 – Independence at home demonstration program
Creates a new demonstration program for chronically ill Medicare beneficiaries to test a payment incentive and service delivery system that utilizes physician and nurse practitioner directed home-based primary care teams aimed at reducing expenditures and improving health outcomes.
Sec. 3025 – Hospital readmissions reduction program
This provision would adjust payments for hospitals paid under the inpatient prospective payment system based on the dollar value of each hospitals percentage of potentially preventable Medicare readmissions for the three conditions with risk adjusted readmission measures that are currently endorsed by the National Quality Forum. Also, provides the Secretary authority to expand the policy to additional conditions in future years and directs the Secretary to calculate and make publicly available information on all patient hospital readmission rates for certain conditions.
Sec. 4108 – Incentives for prevention of chronic disease in Medicaid
The Secretary would award grants to States to provide incentives for Medicaid beneficiaries to participate in programs providing incentives for healthy lifestyles. These programs must be comprehensive and uniquely suited to address the needs of Medicaid eligible beneficiaries and must have demonstrated success in helping individuals lower or control cholesterol and/or blood pressure, lose weight, quit smoking and/or manage or prevent diabetes, and may address co-morbidities, such as depression, associated with these conditions.
Sec. 4306 – Funding for Childhood Obesity Demonstration Project
Appropriates $25 million for a 4‐year demonstration project on childhood obesity.
Those of us in the industry who have complained for years that our lack of progress was related to reimbursement issues had better take notice. The requirement will be for us to sell our services to providers. They will need to accept our programs as part of their expense base in order to achieve improved quality and outcomes and the financial rewards that come with them. This is no mean feat. The healthcare industry is built on the premise that one buys technologies because they will drive revenue. Rarely does a company make the case that a given technology is valuable because it creates efficiencies. That is what we’ll need to do to take our place in the exciting history that will be the redefinition of healthcare payment in the U.S.