If repealing Obamacare is off the table, can we turn attention to improving it through cost-effective clinical protocols?

Paul Krugman recently wrote an article in the New York Times posing the question: if repealing Obamacare is off the table (for now), should people on the “progressive” end of the political spectrum push for a single-payer “Medicare for all” system or just advocate for incremental improvements to the privatized Obamacare model?  He says if we were starting with a blank slate, he would favor the single payer model.  But, he argues, the politics of moving to single payer are too difficult, and the evidence from other countries suggests that a privatized model can achieve comparable outcomes.  Therefore, he argues that progressive politicians should turn their attention to other social policy priorities like subsidized child care and pre-kindergarten education.

I generally agree with Krugman’s proposal to focus on incremental improvements to Obamacare, particularly if the objective is just to maintain and improve access to health insurance.  But that’s not our only objective.  We should also care about the quality and cost of health care.

I’ve long felt that policy to increase access to care should be linked to policy to assure the cost-effectiveness and value of care. Insurance is, by its nature, a collective, cooperative thing. In the long run, the people who are covered under the same insurance risk pool are sharing a finite resource. If they understood that, they would rationally desire for there to be protections against the pooled resource being squandered by other people for low value purposes. In health insurance, such protections primarily take the form of benefit policies. Benefit policies may define which services are not covered because they are considered experimental or cosmetic. They may define limitations based on age, gender, or medical history. They may also set quantity limits on coverage, such as defining the number of physical therapy visits or inpatient psychiatric hospital days covered. They may set lifetime maximum dollar amounts. But, such insurance benefit policies are very blunt instruments.  Insurance companies also protect against low-value uses of health care services using “utilization management” programs, including requiring pre-authorization processes, where doctors are required to submit justifications for proposed services and insurance company employees judge whether the proposed services meet “appropriateness” criteria.  Such utilization management programs create conflict, and insurance companies generally establish criteria that are very loose to minimize the conflict.  As a result, such programs are also very blunt instruments.

Clinical protocols, in contrast, can be more precise instruments, taking into consideration the details of a patient’s clinical situation. Clinical protocols are typically developed by physicians, and are ideally supported by evidence from clinical research studies.  Clinical protocols can take many different forms, and go by different names including “guidelines,” “algorithms,” “care maps,” and “standards of care.”  Whenever we have tried to design clinical protocols, especially for complex and costly care processes such as for low back pain, congestive heart failure, cancer or the care of frail elderly patients, we discovered that different protocols can have very different costs and outcomes.  Thoughtful design, rigorous implementation and continual evaluation and improvement of clinical protocols can lead to large improvements of outcomes and large reductions in cost. But, cost effective protocols do deny some people some treatments that would have helped them a little (just not enough to be “worth” the cost). The whole premise of designing cost-effective protocols depends on the recognition and acceptance of the collective nature of insurance and the finite nature of the resources being shared. Furthermore, it is essential that the people for whom such protocols are applied trust the people and the process of creating and implementing the protocols. In for-profit, commercial insurance companies, there is a fundamental conflict of interest if the owners of the insurance company get to control the design and implementation of the protocols and if they get to keep the money saved from denying services that could have helped people — even a little.

In a single payer system, the entire country (or each state) is treated as a risk pool, and the government plays the role of protocol developer. Some people are OK with that, while others are loathe to assign such authority to governments.  If  we continue to have private insurance companies or accountable care organizations bearing the risk for populations of patients (as in the current Obamacare system), then such organizations can make decisions about clinical protocols.  In either case, we absolutely need to create structures and mechanisms to ensure that the people receiving the care trust the people and process used to create and implement cost-effective protocols.  Some private organizations, such as Group Health Cooperative of Puget Sound (now part of Kaiser Permanente), created some structures and processes designed to build this trust back in the 1990s.

Although most other advanced countries already accept cost-effectiveness and pursue the development and implementation of cost-effective protocols, and although there would be a huge opportunity to reduce cost and improve outcomes by doing so in the U.S., making this policy shift in the U.S. will be very difficult. The U.S. population has been taught to be wary of “rationing” and “death panels” and U.S. doctors have been taught to reject “cookbook medicine.” Nevertheless, moving the health policy discussion in that direction may, in the long term, do some good.   Politicians asking “what’s next” after the apparent end of the quest to repeal Obamacare should consider turning attention to bringing cost-effectiveness to health care through clinical protocols.

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Hospital Value-based Purchasing program 1% incentive is like homeopathic medicine — too diluted to actually work

In the June 15, 2017 issue of the New England Journal of Medicine, Andrew Ryan and colleagues from the University of Michigan published an evaluation of the Medicare Hospital Value-Based Purchasing Program (HVBP).

To summarize, if you offer a 1% incentive, and then dilute it by offering it only for the 40% of hospital patients covered by Medicare, and then dilute it further by spreading it across three domains (clinical process quality, patient experience and mortality), and then dilute each of these by basing them on multiple component metrics, and then dilute it more by choosing metrics that have already been reported for a number of years (and therefore the “low hanging fruit” improvement opportunities may already have been picked), and then further dilute it by offering the incentive mixed in with many other incentives for such things as meaningful use of EMRs…..

Wait for it….
You don’t see impact, even after 4 years.
The thinking behind HVBP is like homeopathy, where the practitioners assert that the more they dilute the homeopathic remedy ingredient, the more powerful the remedy becomes.
Imagine if a company hired a CEO and wanted to incentivize her to achieve growth and profitability. Would they consider a 1% incentive to be meaningful (even without further dilution).  No, the board would choose a number 50 to 75 times higher.
How about an equipment manufacturer choosing an incentive percentage for its sales team?  One percent sound like enough?
I’ve been exasperated for years that our value-based reimbursement designs – for both government and commercial payers – include an incentive that is far too small to motivate the types of changes they are intended to cause.  I fear we are just setting ourselves up for eventually someone saying “well, we tried incentives, and they don’t work.”
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First take on new CMS Comprehensive Primary Care Plus model

CMS CPC IconThis morning, I read about the recently announced next generation version of the CMS Comprehensive Primary Care model, which will require multi-payer participation and will involve up to 5K practices in 20 regions.

Sounds interesting.  I need to study it in more detail.  But based on my initial assessment:
  • I agree with the idea of pursuing payment and delivery system changes on a multi-payer basis to make it more compelling to providers.
  • I also agree with the idea of prepaying some E&M and then paying reduced FFS for E&M to cover only marginal cost of E&M office visits to make providers incentive-neutral on encounter modes.
  • But I disagree with move away from shared savings and implicit abandonment of the idea of non-governmental primary care-based organized systems of care pursuing care process innovation in favor of CMS taking over responsibility for defining a nationally-standardized multi-payer “care delivery model” and injecting it into individual primary care practices using a CMS-developed  “learning system.”
  • I also disagree with the Track 2 idea of partnering with “CMS-convened” IT vendors and contractual commitment to specific IT capabilities.  That approach basically takes MU, which was a huge distraction from real improvement, to even more obnoxious levels of micro-management.
Overall, I share the Fed’s frustration with the limited impact of previous efforts to transform primary care payment and delivery models, but I think the solution should be to define incentives which are more timely, coherent and consequential, enabled by more meaningful transparency requirements, clearer care relationships and some empowerment of primary care delivery organizations to define their own referral networks.
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Physician-led ACOs now outnumber Hospital-based ACOs: Why this makes sense, and where our terminology breaks down.

At a recent meeting of the American College of Physicians covered in MedPage Today, Neil Kirschner, PhD reported on the growth of ACOs. Dr. Kirschner is the ACP’s senior associate of regulatory and insurer affairs. He reported that in March, 2012, there were only 136 ACOs  that had ACO-style gain-sharing contracts with Medicare, a commercial payer or both. Those ACOs included 91 “hospital-based ACOs” and 45 that were described as “physician-led ACOs.” In the last year, the number of ACOs has almost tripled from 136 to 391.  And, significantly, the 202 physician-led ACOs now outnumbers the 189 hospital-based ACOs.

ACOs by doctor vs hospital sponsorship 2012-2013

Why are physician-led ACOs growing faster?

The rapid growth of physician-led ACOs makes sense because ACO-style gain-sharing reimbursement arrangements are more favorable to physician organizations than hospitals. When a hospital-based health system enters into an ACO contract, it basically says “if you succeed in reducing the total cost of care (primarily by reducing your own hospital revenue), we’ll give you back a portion of your lost revenue.” That’s reminiscent of the old business joke “we lose money on each unit sold, but we’ll make up for it in volume.” But, from the point of view of a physician organization, particularly a physician organization that emphasizes primary care, the ACO contract basically says “if you do more primary care work to avoid the need for hospitalizations and emergency department visits, we’ll pay you for that extra work and we’ll give you a portion of the money we no longer have to pay to the hospitals.”

So, why would hospital-based organizations ever enter into an ACO-style gain-sharing agreement?  Two main reasons.

  • First, as a defensive measure. By forming an ACO in which they are involved, they can avoid or delay the formation of a physician-led ACO. It is better to be “doing” than to have it done to you.
  • Second, as a way to prepare for a potential future state where providers are bearing far more risk, such as in capitated reimbursement arrangements. It takes a very long time to develop effective population management capabilities, including establishing effective governance, building trust, deploying the right health information technologies and analytic systems, and, most importantly, recruiting and developing human resources that can effectively use data and improve care processes.

Ambiguous ACO Terminology

Finally, a note about the use of the term “ACO” and ACO growth statistics.

Many people get confused about the definition of ACO.   Some argue that an ACO is, by definition a specific type of Medicare reimbursement arrangement, the Medicare Shared Savings Program (MSSP), created by the Affordable Care Act (ACA).  But, I don’t agree that the term “ACO” defines a type of contract, and that the term ACO only refers to Medicare.  The “O” is for organization. On its face, the term refers to a type of organization, not to a type of contract.  When people generate statistics about ACOs, they should be counting organizations, not gain-sharing contracts.

I consider a provider organization to be an ACO if:

  1. It includes primary care physicians, and
  2. It has or plans to enter into at least one contractual arrangement where the provider organization takes responsibility for an attributed population of patients, and bears at least some risk for quality and economic performance

In common use, people are most likely to refer to a provider organization as an ACO if at least one such contractual arrangement includes a fee for service component with some risk sharing that includes at least some up-side opportunity to share in savings. The Medicare MSSP and Pioneer ACO contractual arrangements are just prominent examples of such contracts, not limiting to the definition of ACO. Because of that fee-for-service connotation, people don’t tend to describe a staff-model HMO as an ACO, even though they meet the definition I proposed above.

Furthermore, when categorizing ACOs, it is important that the categories are mutually exclusive.  The term “physician-led” seems to refer to an attribute of the governance of the ACO, such as whether the person serving as the CEO is a physician or whether the majority of the shares or votes on the board of directors are controlled by physicians or by people that are employed by physician organizations.  The term “hospital-based” seems to refer to whether the provider organizations that own the ACO include at least one hospital or hospital-based health system.  An ACO can include a hospital as a co-owner and still be “physician-led.”  Therefore, there is inherent ambiguity in the statistics comparing the number of physician-led to hospital-based ACOs.

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Beautiful video from Cleveland Clinic advocating empathy

We focus on optimizing care processes, analyzing data, implementing technology, and the other technical and scientific aspects of our work to improve health care.  But, this video created by the Cleveland Clinic is a touching reminder of the human element, advocating for empathy in our work.

http://www.youtube.com/watch?v=cDDWvj_q-o8&feature=youtu.be

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New HIT ROI lit review is a methodologic tour de force, but misses the point

JAMIA logoRecently, Jesdeep Bassi and Francis Lau of the University of Victoria (British Columbia) published in the Journal of the American Medical Informatics Association (JAMIA) another in a series of review articles that have been written in recent years to summarize the literature regarding the economic outcomes of investments in health information technology (HIT).  Such articles answer the questions

  • “How much do various HIT technologies cost?”
  • “How much do they save?”
  • “Are they worth the investment?”

They reviewed 5,348 citations found through a mix of automated and manual search methods, and selected a set of 42 “high quality” studies to be summarized.  The studies were quite diverse, including a mix of types of systems evaluated, methods of evaluation, and measures included.  The studies included retrospective data analyses and some analyses based on simulation models.  The studies included 7 papers on primary care electronic health record (EHR) systems, 6 on computer-based physician order entry (CPOE) systems, 5 on medication management systems, 5 on immunization information systems, 4 on institutional information systems, 3 on disease management systems, 2 on clinical documentation systems, and 1 on health information exchange (HIE) networks.

Lau HIT ROI results

Key results:

  • Overall, 70% of the studies showed positive economic results, 24% were inconclusive, and 6% were negative.
  • Of 15 papers on primary care EHR, medication management, and disease management systems, 87% showed net savings.
  • CPOE, immunization, and documentation systems showed mixed results.
  • The single paper on HIE suggested net savings, but the authors expressed doubts about the optimistic assumptions made in that analysis about a national roll-out in only ten years.

My take:

Bassi and Lau have made an important contribution to the field by establishing and documenting a very good literature review methodology – including a useful list of economic measures, a nice taxonomy of types of HIT, and many other tools which they graciously shared online for free in a series of appendices that accompany the article.  They also made a contribution by doing some tedious work to sort through lots of papers and sorting and classifying the HIT economics literature.

But, I think they missed the point.

Like many others, Bassi and Lau have implicitly accepted the mental model that health information technology is, itself, a thing that produces outcomes.  They evaluate it the way one would evaluate a drug or a cancer treatment protocol or a disease management protocol.  Such a conceptualization of HIT as an “intervention” is, unfortunately, aligned with the way many healthcare leaders conceptualize their investment decision as “should I buy this software?”  I admit to contributing to this conceptualization over the years, having published the results of retrospective studies and prospective analytic models of the outcomes resulting from investments in various types of health information technologies.

Process PuckBut, I think it would be far better for health care leaders to first focus on improvement to care processes — little things like how they can consistently track orders to completion to assure none fall through the cracks, bigger things like care transitions protocols to coordinate inpatient and ambulatory care team members to reduce the likelihood that the patient will end up being re-hospitalized shortly after a hospital discharge, and really big things like an overall “care model” that covers processes, organizational structures, incentives and other design features of a clinically integrated network.  Once health care leaders have a particular care process innovation clearly in sight, then they can turn their attention to the health information technology capabilities required to enable and support the target state care process.  If the technology is conceptualized as an enabler of a care process, then the evaluation studies are more naturally conceptualized as evaluations of the outcomes of that process.  The technology investment is just a one of a number of types of investments needed to support the new care process.  The evaluation “camera” zooms out to include the bigger picture, not just the computers.

I know this is stating the obvious.  But, if it is so obvious, why does it seem so rare?

This inappropriate conceptualization of HIT as an intervention is not limited to our field’s approach to economic evaluation studies.  It is also baked into our approach to HIT funding and incentives, such as the “Meaningful Use” incentives for investments in EHR technology, and the incentives created by HIT-related “points” in accreditation evaluations and designations for patient-centered medical home (PCMH), accountable care organizations (ACOs), organized systems of care (OSC), etc.  The designers of such point systems seem conscious of this issue.  The term “meaningful use” was intended to emphasize the process being supported, rather than the technology itself.  But, that intention runs only about one millimeter deep.  As soon as the point system designers put any level of detail on the specifications, as demanded by folks being evaluated, the emphasis on technology becomes instantly clear to all involved.  As a result, the intended focus on enabling care process improvement with technology slides back down to a  requirement to buy and install software.  The people being evaluated and incentivized lament that they are being micromanaged and subject to big burdens.  But they nevertheless expend their energies to score the points by installing the software.

So, my plea to Bassi and Lau, and to future publishers of HIT evaluation studies, is to stop evaluating HIT.  Rather, evaluate care processes, and require that care process evaluations include details on the HIT capabilities (and associated one time and ongoing costs) that were required to support the care processes.

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The race in on between triple-aimers and hospital defenders

This week, Julie Creswell and Reed Abelson published an interesting piece in the New York Times about how the war between hospital chains puts doctors in a bind.  I think the article includes many relevant facts about the consolidation of the health care market.  But, I conceptualize the conflict a little differently.

Here’s my take…

For a number of years, there has been an internal battle within the federal government.  The CMS has been promoting the idea of formation of ACOs to achieve clinical integration of physician and hospital services.  But, as I described in an earlier post, the FTC and the Justice Department have been concerned that hospitals would use ACO safe harbor provisions as cover for consolidation to increase market power and drive up prices.

CMS was confident that, if ACOs faced enough risk, the savings from clinical integration and care process transformation would outweigh cost increases from higher prices.  But, when CMS proposed ACO regulations that had the audacity to include a modest amount of downside risk for providers, they faced a huge provider backlash.  CMS buckled under the pressure, and approved final ACOs regs that allowed providers to choose only upside rewards, with no downside risk.  As I’ve noted before, the vast majority of providers that ended up forming ACOs have very little skin in the game.

Within hospital organizations that formed ACOs, there are a mix of leaders.  Some leaders are enthusiastic promoters of the CMS vision of clinical integration, a resurgence of primary care, and achieving the “triple aim” of improving quality, increasing satisfaction and reducing per capita cost.  Other ACO leaders are more focused on the financial health of the hospital portion of the delivery system.  Such leaders are concerned that the per capita cost take out will come out of the hides of hospitals, some of which will be forced to close when their revenue cannot cover their substantial fixed costs.  These two types of leaders have been unable to agree on the need to make substantial investments in clinical process transformation and the associated clinical information systems designed to achieve the cost take-out.  So, the federal government came to the rescue with HITECH funding for EMR technology.  The Feds were able to justify this funding based on the need to stimulate the economy, rather than the need to reduce health care cost.  As a result, the HITECH “meaningful use” regulations are focused more on quality than cost take-out.  Though well meaning, the HITECH funding and the associated meaningful use regs actually created a huge distraction for IT professionals within provider organizations.  Many ACO leaders have directed their IT professionals to focus on meeting externally-defined meaningful use requirements — studying for the test — rather than doing the far more challenging work of actually figuring out how to support the triple aim through clinical process transformation.

The one thing that the two types of ACO leaders could agree upon was physician practice acquisition.  The triple-aim-oriented leaders were in favor of acquiring practices as a means to get sufficient control to achieve clinical integration.  The hospital-oriented leaders were in favor of acquiring practices as a means of controlling the hospital’s inbound referral pipeline to keep the beds filled and to increase market share to gain bargaining power against health plans.  So, practice acquisition has proceeded vigorously.  Now, the race is on to see which group of ACO leaders is going to dominate.  To this point, the triple-aim-oriented leaders remain hampered by longstanding weakness in physician leadership and governance structures (the problem of “herding cats”), the traditional dominance of specialty leaders over primary care leaders, the lack of available analytic talent, and lame clinical information systems.

Right now, the hospital-market-power-oriented leaders are out in front. There is a great risk that they will be too successful, making it too obvious that the FTC and the Justice Department were right about market consolidation. That outcome would lead the health care policy community and the public to conclude that “accountable care” is a failure, as happened with “managed care” in the 1990s, sending the idealistic triple-aimers back into exile for another decade.  But, that outcome is not yet certain. There remains a chance for some provider organizations to figure out ways to achieve the triple aim, including per capita cost take-out, and still accomplish profitability and growth, thereby disrupting the long-standing hospital-centric order. I would estimate the probability of that outcome to be less than 50%, but still likely enough to be worth fighting for.

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We’re up to 154 Medicare ACOs

Today, the CMS announced that it added another 89 ACOs to the Medicare Shared Savings Program (MSSP).  Including the original 6 Physician Group Practice Transition Demonstration participants, the 32 Pioneer ACO, and the 27 MSSP participants announced in April, that brings the total number to 154, serving more than 2.4 million Medicare beneficiaries.  Beginning this year, new applicants will be accepted only annually.

The new ACOs includes some that serve Michigan:

  • Oakwood Accountable Care Organization, LLC, located in Dearborn, Michigan (with 1,546 physicians and partner hospitals), and
  • Southeast Michigan Accountable Care, Inc., also located in Dearborn, Michigan (comprised of 333 physicians, including group practices and a network of individual practices), and
  • ProMedica  Physician Group (250 physicians in Michigan and Ohio)

Other new Medicare ACOs that are particularly large include:

  • Advocate Health Partners (2,237 physicians in Illinois)
  • Wellstar Health Network, LLC (1,203 physicians in Georgia)
  • Indiana University Health ACO (1,837 physicians)
  • Iowa Health Accountable Care (1,551 physicians),
  • University of Iowa Affiliated Health Providers (1,791 physicians)
  • Maine ACO (1,595 physicians)
  • Essential Health (1,404 physicians in Minnesota, North Dakota and Wisconsin)
  • Balance Accountable Care Network (1,069 physicians in New York City)
  • Mount Sinai Care (2,249 physicians in New York City)
  • University Hospitals Coordinated Care (1,770 physicians in Ohio)

The full list of new ACOs is available here.

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A Happy Day: Supreme Court upholds health care reform law granting broad access through mostly free-market mechanisms, and I am $1 richer

 

This morning, the United States Supreme Court made its landmark decision to uphold the health care reform law.  I am very happy about it for a number of reasons:

  1. I won a $1 bet.  As I described in a previous post, I bet my brother-in-law, an attorney from Chicago, that the law will be upheld.  I will be driving to Chicago this weekend to attend my father’s 75th birthday.  I’ll see my brother in law there.  He’s a trustworthy guy, so I’m confident he’ll pay up.
  2. I was right about the majority argument.  Like my brother-in-law and most of the pundits, I was originally focused on the question of whether the individual mandate provisions of the reform law represented an unconstitutional expansion of the federal government’s power to regulate interstate commerce.  My first blog post on the subject explored that issue.  But, then I read an interesting piece in the Atlantic by Jack Balkin, a constitutional law professor from Yale.  As I explained in my second blog post on the subject, Balkin argued that the penalties associated with the controversial individual mandate should be considered a tax, and are therefore a constitutional exercise of the federal government’s taxing powers.  I found the argument convincing. But I never heard anything more about that line of reasoning until this morning, when we learned that this argument is exactly the one that Chief Justice Roberts made in his majority opinion.
  3. The law was upheld with a minimum of expansion of federal power.  I shared my brother-in-law’s concern that if the law was upheld based on an expansive view of the interstate commerce clause, it would have the effect of dramatically expanding the power of Congress to dictate how we all live our lives, without being constrained by the political unpopularity of raising taxes to pay for it.  But Chief Justice Roberts called a spade a spade. Despite the terminology of the law itself, and despite the repeated assertion by President Obama that the law does not raise taxes, Roberts declared at least the individual mandate penalty to be a tax.  I do still think that the reform bill has the effect of expanding expectations about the role of the federal government in our lives, and so I still have some concern about that.  But, of all the arguments that could be made to uphold the reform law, I think the one Roberts selected is the least bad in terms of expanding government powers.
  4. We can continue the journey toward a more civilized and compassionate health care system.  Almost nobody is asserting that the health care reform law is perfect.  But, in my opinion, it is a step in the right direction.  It is better than creating a government-run monopoly.  It is better than waiting forever for each of 50 states to exercise their authority to compel people to buy health insurance.  It helps millions of Americans have a sense of security. And, it underscores that our strong tradition of individualism is balanced against our sense of duty to one another as Americans and humans.
  5. I am energized to continue health care improvement.  Over the last few years, our field has built up some momentum in transforming health care.  Health care leaders were feeling a sense of urgency to increase their capabilities in population management, analytics, lean process improvement, clinical integration and health information technology.  I feared that if the health care reform law was struck down, it could lead those leaders to relax for a few years to wait and see what comes next.  I am excited by the prospect that our field can continue to build momentum that spills beyond the limited confines of the reform law itself to allow us to make more fundamental progress in the care delivery system itself.
  6. Oh, and did I mention I won a $1 bet?
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Trinity Health and BCBSM sign contract to invest in infrastructure for clinical integration and population management

Trinity Health – Michigan and Blue Cross Blue Shield of Michigan (BCBSM) recently announced that they signed a three and a half year agreement under which BCBSM will provide some funding to support a collaborative effort of Trinity Health and its affiliated physician organizations to make improvements in infrastructure designed to improve clinical integration and support population management, with the goal of improving the quality of care, enhancing patient experience and outcomes, and reducing health care costs.  BCBSM and Trinity Health will also collaborate to implement performance measures on patient satisfaction and quality.  These infrastructure improvements and measures will prepare Trinity Health and its affiliated physician organizations for a transition from a fee-for-service reimbursement from BCBSM to a “performance-based reimbursement” or “gain sharing” arrangement, to be implemented sometime before 2016.

Trinity Health is the third health system to sign similar agreements with BCBSM, after St. John Providence Health System and Beaumont Health System.    By the end of 2012, BCBSM intends to reach agreements with additional hospitals so that 50% of its hospital spending will be subject to value-based reimbursement agreements.

More details are available in Crain’s Detroit Business.

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