Not What You Wanted To Hear

Do you like being told no? Of course not. Who does? Maybe crazy people but certainly not your average run of the mill person. We all like to get our way and get what we want. That is human nature. We are needy beings that want want want. However, even Mick Jagger knew that we don’t always get what we want.


Hey now, don’t give me that look. I can see you giving me an eye roll and moving that mouse to close the browser window. Just stop for a minute. I have a point here. I promise.

Our modern culture is built on the premise that anything you do can be made faster and/or more efficient with the incredible power of (fanfare please) the internet. I would venture to say that in a lot of ways this is true and if it doesn’t make it faster than at least it’s more convenient. Shopping is easier, taxi rides are easier, education is more accessible, banking is easier, and meeting new people is as simple as a swipe right. So what about healthcare?

A few posts ago I spoke about how the data we leave behind us can be analyzed to make our healthcare easier and cheaper. As a consequence of that efficiency and cost-effectiveness, we may not get the care we are used to or even the care that we feel we want. This isn’t because we are getting subpar care. It is just that we don’t necessarily need everything that might have been done in the past. It is that efficiency and cost savings at work. That fact is that you as a patient may not have much control over your care at all. That may or may not be such a bad thing but I can think of a few situations where someone might get a little ticked that they are told no. angry-2191104_1920Sadly, in our modern world, some adults seem to turn immediately into toddlers when they don’t get their way. Just watch the customer service counter at your local big box store when someone is told they can’t return the doodad they bought 3 years ago… Epic meltdowns for sure. It’s the kind of stuff viral videos are made of.

Now back to the story. Coordinated care groups, cooperatives of providers, and even the participants within a payer network may not allow a patient access to certain procedures they deem unnecessary or superfluous or allow a patient to see anyone outside of the confines of their group. Why you ask? Because they feel that if they control what procedures are done and who a patient gets to see for a specific procedure then they can guarantee the quality and the cost of an entire episode of care. And if they cannot guarantee it then at least they would have a pathway to open communication to make sure they can adjust or understand better the care a patient receives. So that means that patients can’t really choose who they get to go to or whether or not to get the “extra” tests that somehow make them feel more trusting of the care they are receiving. Despite the fact that healthcare should be all about choices, those choices may start to dwindle and if you start an episode of care, say for a surgery, with one group then you likely won’t be able to move to another.

Now I imagine a lot of you thinking “What is this guy talking about? Of course I can choose what doctors I see and what providers I want to use.” But if you think about it, I don’t mean that you can’t choose what you want, only that you won’t be able to do so without consequences. A doctor who is being paid based on the health outcome of your care will be hesitant to let you out of their “area of influence” so to speak. Also, your insurance company will not be pleased and may force you to pay more if your choice moves you into a situation where quality can no longer be measured effectively. (This brings up the issue of how to measure quality which is not an easy question to answer.) There is a silver lining here though. Remember that things would not be as they are now. If you are in the midst of an episode of care it is likely that the group doing the treating is already pretty good since they will get paid based on the quality of care that they administer and not just by the procedures they complete.

So remember that even though value-based care may mean that you don’t get the same things that you used to, it also means that you are probably getting a better deal anyway. Everyone wins but only if we let the system work for us and try not to work against it. It is hard to lose control (if we even had it to begin with) but giving up some things means we can reap the benefits elsewhere. In this case, your bank account or in a more grandiose fashion the coffers of the whole country. Nothing is ever perfect but if we let the change take hold we can all be better off. In closing, I challenge you not to start humming the Rolling Stones after you read this. I said no. Don’t you do it!

See the theme here?

Bad Apples and Sour Grapes

Healthcare fraud is a consistent problem that is ever evolving and adapting to the regulations and restrictions put in place to hinder it. Once one avenue is stopped, those individuals that were cashing in are likely to move to another area and begin anew. So the question I wanted to address here is how Value-Based Healthcare will impact an industry that is rampant with fraud.

In a VBH model the focus on collaboration of providers and coordinated care means one very important thing that is missing from a volume based model, communication. Currently a large portion of fraudulent claims to healthcare payers are made by solo providers that are only one part in the chain of treatment. In a VBH world the chain becomes a web and lots of people suddenly see what procedures have been done, what drugs are prescribed, what tests have been performed and treatments administered. Even my 4 year old will tell you that when someone is watching… you shouldn’t do something you know is wrong.

angry child
If I can’t see them, they can’t see me, right?

This is even more important when a group of providers can all benefit from the administration of high quality and cost-effective care to their patients. It is as simple as peer pressure. “My friends made me do it” is a pretty weak excuse except when what they made you do is not commit a crime.

Now I don’t want to make it seem that all avenues of fraud are closed by a VBH system. In fact existing schemes can still flourish it just might be a little more difficult to pass some things by your colleagues. That is unless your colleagues all want to cash in too. So now what you have is a web of providers all collaborating to coordinate care and defraud the payers. If a large portion of the group is “in” on it then there is really not much that can stop them from cashing in… except that quality is being measured by external reference frames. What I mean is that the metrics that have to be reported in order for the assessment of quality to be made are also being reported by lots and lots of other provider collaborations and groups. That assessment of quality and the subsequent payment are therefore being evaluated rather guaranteed and a group of coordinated fraudsters could in fact lose money if their quality and cost measures fall below acceptable levels.

So the system of quality review and measurement is self-correcting right? Sure, in many cases it would be. That is of course (see I told you they always find a way) unless the quality measures are being fabricated as well. What you have now is a group of providers, institutions and patients all working together to get money out of the system. The trouble is that this would be terribly complicated and probably difficult to organize. Unfortunately I am constantly surprised as how innovative and devious people that have been convicted of healthcare fraud can be. Is it out of the realm of possibility? No, certainly not. Is it likely? I would put it at a low or medium-low risk.  The ways a scheme like that could fall apart are too numerous to count so in my opinion it just wouldn’t be worth the effort to make a few extra percent on an episode of care.

So this brings me to my closing. Right now what healthcare fraud really looks like is a number of bad apples all hanging out in the barrel making it all look bad.

bad apple
Fraudster in fruit form

VBH would do a great deal to pick those out and throw them away. The only trouble then would be the groups of sour grapes that spoil the system. Fruit metaphors aside I think I have made my point. The trouble today with fighting healthcare fraud is that it’s often very difficult to weed out the bad from the good, like I said they are really good at hiding. VBH can go a long way to shining light into the dark places but I certainly don’t think it will go as far as painting red arrows that say “Fraud This Way”.


Disclaimer: This Blog is for educational purposes only as well as to provide general information and a general understanding of the topics discussed.  The Blog should not be used as a substitute for legal advice and you are advised to seek additional information from your insurance carriers, Medicare and/or Medicaid agencies for additional criteria and regulations regarding these services.

The Invention of the Minivan

Imagine, if you will, a country where everyone moves from place to place in single person combustion engine vehicles. A country where all the laws, expectations, and infrastructure is built to support only single person vehicles. In this world of singular travel, the population realizes that it is inefficient and that all of these single person vehicles are burdensome not only in terms of space but of pollution and traffic. In order to change their ways and improve the acceptable methods of travel they begin to make laws requiring change and the creation of… the minivan.

Minivan coolness may vary

This new multi-person vehicle is more efficient, produces less pollution per person, and is superior to the single person vehicles in almost every way. This leap in progress does not come without its drawbacks. For example, many roads have not been created for a vehicle as wide as a minivan and often cause traffic jams where they once never existed. Revenue from tolls suddenly begins to drop. The same amount of people are passing the tollbooth but the number of vehicles has reduced as the person per vehicle ratio has risen. This hypothetical place becomes polarized over the issue and people are suddenly either a SP (single-person) supporter or a MV (minivan) activist. Political turmoil abounds as debate and discussion stifle change and the issue only becomes more perplexing when someone invents the 4-door sedan.

I imagine that you have only continued to read so far because you are curious what my point is… Well you are in luck. I will likely tell you what I am up to in the next few sentences. Or maybe not. In either case here is a picture of my cat Finnegan as a reward for getting this far.


The hypothetical circumstances I described above are an allegory for the healthcare industry in the U.S. In case you hadn’t guessed it yet, the “multi-person vehicle” is really this newfangled idea I’ve been blabbering on about for the last few months. My point was to illustrate an instance where a complex system was built to function one specific way. This situation can hamper change, and sometimes progress, because the underlying infrastructure is not equipped to adapt. Not necessarily because someone wants it to stay the same but simply because the system has never had to change.

So, if you are still with me here is the whole point (I told you it was coming). Value Based Healthcare is such a profound change from the current way of doing things that the infrastructure and legal framework for healthcare in the U.S. is not completely equipped to handle the change.  In fact, there are a few legal establishments that are barriers to adopting a value-based payment model.  Anti-fraud laws that exist today were designed for a fee-for-service model in a world where doctors often worked for themselves instead of for larger healthcare groups. The Stark Law and the Anti-Kickback law have been specifically indicated by the American Hospital Association as major blockers to the adoption of the value-based initiatives put forth by the MACRA legislation. These laws inhibit hospitals from being able to initiate collaborative and coordinated care for patients without the possibility of legal ramifications. The MACRA legislation even states that the Department of Health and Human Services must make legal exceptions and changes in order to allow for easier pathways to success for new and innovative payment models.

Legal barriers are only one part of the complex landscape that has to be tiptoed through in order for coordinated care partnerships to flourish. The connectivity of systems, equivalent health record formats, as well as organized and consistent billing for each episode of care from both institutional and outpatient providers are all necessary components for a complete VBH system.  While it is easy to put these down in words, it’s not so easy to overcome such hurdles. The reason? The minivan was just invented and not all fuel stations, mechanics or dealers are equipped to handle it.

The takeaway here? If we, as a population, want to make sure that concepts like VBH survive and take hold, we must do what we can to embrace the change. If positive sentiment from patients and legal backing from the government can support each other, more and more providers and payers will make the investment in change. I would say that VBH is already well on its way but even the best-laid plans can fall prey to unstable circumstances. I don’t think that will happen but in my experience it’s always better to be prepared and keep a watchful eye.



Watching from the Wings


Do you ever get the feeling that someone is watching you? If not then I applaud you for your ability to compartmentalize, because someone probably is watching you. No, I don’t mean that neighbor that always seems to be outside when you leave to go to work or that white panel van that sits down the street. I am talking about someone watching the digital wake that follows each of us through our lives.

Whether it is by social media posts, online shopping, internet searches or any number of other online activities, we are generating data all the time that is being harvested and analyzed by huge tech firms. The internet giants use this data to provide value to their platforms and ultimately to customize advertising to each individual user in order to make a profit.

Regardless of your stance about internet privacy and the ethics behind mining what is perceived as personal information, there is a bright spot here. This concept of monitoring and using personal data has been pivoted and transformed into something that we can all benefit from. Insurance companies can use the analytic techniques born in the online world to start driving real change in their provider networks. This can help to reduce their overall cost to operate as well as the premiums they charge for their products.

When it comes to your healthcare data all roads lead to your insurance company. Your primary care provider’s office visits, laboratory claims, prescriptions, and durable medical equipment requisitions all pass through your insurance company. These claims send signals to your insurer about the course of treatment your healthcare providers are administering but until very recently those signals were largely recorded but ignored. Traditionally doctors and other providers would often use one of two methods to prescribe treatment. One was to start with a generic treatment and progressively change that treatment until it became targeted and highly effective for each patient. The other method would be to have a patient go through a barrage of tests to see what, if any, indicators of different conditions would come back in order to then design a specific and effective course of treatment. On paper neither of these seems to be very efficient but, in the end, patients got the treatment they need despite the often times burdensome cost.

I want to be clear that there is nothing implicitly wrong with either of these treatment methods as they can both provide effective care in the long run. That does not mean that there isn’t room for improvement. A bicycle can take me to work every day but a bicycle with a motor can get me there faster and with less effort. Enter modern high-performance and cloud computing services, and a completely new way of administering care comes to light. This would not come without some sacrifice on your part. You would have to let your insurance company keep records of your health information, the care you have received, and the outcomes of your treatment. Would you be comfortable with that?

Imagine, however, you are diagnosed with a relatively common condition. It is nothing overtly serious mind you but will require significant treatment to control. Now, what if your insurance provider has information on thousands of people that have similar symptoms, health history, and are undergoing treatment now? What if your providers could leverage that information to tailor a treatment to you that could not only provide the most effective care, but that ended up saving you and your insurer a lot of money? Are you still uncomfortable? What if you knew that building and using systems like this could dramatically increase the overall health of the public and at the same time reduce healthcare costs overall? Is it worth it?

  • Disclaimer: This Blog is for educational purposes only as well as to provide general information and a general understanding of the topics discussed.  The Blog should not be used as a substitute for legal advice and you are advised to seek additional information from your insurance carriers, Medicare and/or Medicaid agencies for additional criteria and regulations regarding these services.

If You Bundle… They Will Save

Bundled payments aren’t just a way to save on auto and home insurance but are potentially an effective method to save on healthcare costs… unless they aren’t.

Under the MACRA legislation, CMS’s Center for Medicare and Medicaid Innovation (CMMI) created a number of rules in an effort to move Medicare providers into a more quality-centered payment model. One part of this endeavor was the creation of Episode Payment Models (EPM) and the Cardiac Rehabilitation (CR) Incentive Payment Model. These episodic models were intended to reduce the overall cost of some procedures that required significant time in a hospital to complete treatment. For example, surgery to treat a hip fracture and all of the care following that surgery would be paid by Medicare at the same rate regardless of the volume or types of procedures necessary to complete treatment. The CR incentive program was designed to provide incentive payments based on the Medicare beneficiary use of cardiac services in the first few months following a heart attack or coronary bypass surgery.

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The idea is to fix the cost of all procedures and tests together in one convenient bundle in order standardize the cost and encourage hospitals to increase coordination of care. The result would be an increase in quality of care and a reduction in overall cost.

The final rules for Medicare bundled payment programs were published in the Federal Register on December 20, 2016 and mandatory participation in the programs was slated to begin on July 1, 2017.  The models were held from starting on July 1st and placed on hold while the Department of Health and Human Services could reevaluate the program. Fast forward to 3 weeks ago on August 15, 2017 and CMS published a proposed rule that cancels the EPM and CR programs completely. Citing a hope to increase future voluntary participation, CMS was stopping the bundled payment programs as they were required to be mandatory.

I wanted to bring this up not only because it is relevant to VBH but more so because this is a change occurring right now. The world surrounding VBH is fluid and dynamic. There are ebbs and flows in policy however, VBH has made steady progress toward full realization over the past couple decades. While it doesn’t matter what stance you take with regard to policy changes of this kind it is important to remember that it will take significant investment from providers, hospitals and payers for VBH to take hold as the predominant model for healthcare payment. Resistance to change is usually a given and the more stakeholders that are satisfied and open to a change now, the less likely there will be resistance in the future.

This turn of events might be considered a step backward but, bundled payments are only a small part of the larger whole. In fact not all of CMS’s bundled models were cancelled. The Comprehensive Care for Joint Replacement (CCJR) model was left mostly intact. The geographic regions required to participate in the program were decreased and only about half of the total overall hospitals intended to participate remain in the program.  I also don’t believe that bundled payments will go away anytime soon. They are a relatively straightforward way to drive change when it comes to major hospital-centric procedures

Needs of the Many

The shift to Value Based Healthcare is not as simple as changing the way that healthcare providers get paid. Healthcare organizations across the spectrum are not equipped to handle a landscape where long-term quality and outcomes are the driving force behind the success or failure. The implementation of the MACRA legislature for Medicare is driving change in the private insurance world and those providers that do not embrace and adapt to the changes will find it difficult to survive.

It would seem that a large number of providers, payers, and industry experts believe that the only way for those smaller practices and organizations to survive is to band together. Many VBH payment models that have already been implemented center on the concept of coordinated care. Coordinated care relies on the concept that providers can come together to provide a comprehensive care regimen. The different providers would collaborate in order to reduce duplicate or unnecessary procedures and tests as well as ensure that a more complete picture of health is driving the treatment rather than the separate opinions of different specialists.

Accountable care organizations (ACOs) from CMS and patient-centered medical homes (PCMH) are two such examples of coordinated care models intended to drive a more collaborative and customized approach to health. alphabet.jpgThere are other models out there right now, but if I mention too many others this post would start to look more like alphabet soup than I am comfortable with. More and more VBH models appear all the time and each has its distinct pros and cons. To my earlier point, this hangs some smaller providers out to dry because they simply aren’t equipped to meet the requirements of the new collaborative models.

That isn’t to say that they can’t provide high quality care or collaborate with other providers. It’s more likely a matter of the VBH world moving faster than many thought it would. Innovative and advanced payment models that rely on new health care trends like electronic health records, telemedicine, data collection, and predictive analysis are out of reach for many providers because they weren’t prepared to need them any time soon. You may be asking yourself “But Kevin couldn’t those providers just get some new technology and everything would be ok?” and to that I would say “Probably not”.

Let me paint a picture to help explain. A smaller provider wants to get into this VBH stuff and so decides to invest in updated software and a whole lot of fancy computers to help move into the new age. He can’t afford them himself so he gets some help, say from his friendly neighborhood bank. He is convinced that this new coordinated care concept is going to help him improve his margins and build a stronger business. He has even found a coordinated care group to join. All is well. Shortly after working in the coordinated care system, a series of troubling events occurs. A number of patients didn’t take their medication when they were supposed to and have become even more ill. He didn’t prescribe the meds but he performs the procedures that help treat the problem the meds were supposed to have prevented. Now he or his partners can’t force their patients to take their medicine and, in fact, have no control at all but to the payer it seems like they are falling well short of the expected cost and quality measures they are expected to adhere to. That means they don’t get paid as much as they could have. Things get better for a while but then it happens again and again and again. sad docNow our provider friend can’t pay the friendly neighborhood bank and is left holding his hat in an office filled with fancy computers that are now nothing more than expensive door stops. His partners in the coordinated care group however, are fine because they are large enough to take a few hits and keep on moving. Unfortunately, for our friend he is out of luck and out of business.

Now that example is somewhat exaggerated but it does fall close to reality. There is a shared risk when it comes to coordinated care and as such, it may be difficult to get some providers to fall into such a model. I have noticed that a lot of smaller practices and providers have started forming “alliances” and other more local networks where they share a patient base and certain standards. That shift is likely due to other financial reasons but it may have an added benefit. This kind of networked provider group is probably going to be much more commonplace as time goes on. As the needs of VBH standards grow more and more complex it will be necessary for your local doctor’s office to no longer stand alone unless they want to get swallowed up by other larger and more corporate healthcare groups.

Can you Quantify your Quality, please?


The word quality is probably one of the most subjectively defined words in the English language. A Google search for its definition returns that quality is “the standard of something as measured against other things of a similar kind; the degree of excellence of something.” Quality is also a word that is used every day especially in the context of well-being. Expressions like “quality of life”, “quality of care” and (almost redundantly) “quality of health”. This begs the million (or more aptly billion) dollar question, who gets to decide what quality means?

In my first post I mentioned that value-based healthcare (to which I will affectionately refer to as VBH from now on) is intended to provide the highest quality and most efficient care to patients by incentivizing providers. So, in general, if a doctor is providing high-quality care with minimal associated time and cost, they would be paid more for their services than a similar doctor providing similar care that is either not of the same quality or as efficient.

What’s that you say? You just heard a loud noise? Don’t worry… that is just the elephant that walked into the room. You see if providers are being judged in some manner about the quality of the care they administer then that means that quality is being measured. How exactly is it that something that is, by its definition, subjective able to be quantified in order to adjust payment for a provider’s services?

There isn’t a more critical question when it comes to VBH and how to implement it. In general, the school of thought is that only other providers practicing similarly can assess the quality of a provider’s care. The thresholds and rules associated with quality care cannot be hard and fast and determined in a draconian way. In order to best get the buy-in of medical providers everywhere, determinations of quality must be allowed to change. In fact, they should probably be organically chosen to ensure that the largest possible cross-section of providers accepts the new guidelines.

That doesn’t mean that all the country’s providers are going to be sitting together and singing “Kumbaya” either. There will always be disagreements when one person or group tells another person or group they aren’t doing a good enough job. The key to developing a system where quality is evaluated and used to take action or install change is to do it gradually. The Centers for Medicare and Medicaid Services implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA for those that don’t recognize the full name) is a great example of a gradual roll out of a new payment methodology. Slowly over years the new concepts are developed, debated and implemented with an intentional allowance for adjustment and revision over time.

VBH is a somewhat utopic concept and therefore is not easy to attain. It will require significant buy-in from not only providers but patients as well. Change is never easy, but hopefully with enough time and purposeful adjustments we can make the change to a VBH centered healthcare model painless enough that no one will remember how it “used” to be.

A Question Worth Answering

If you ask any recently graduated medical professional what they think about “value-based healthcare” two things will likely happen. First, you will be greeted with a contentious look of disdain. You are probably not the first person to ask them that question, they did just finish school after all, so it’s a good idea to give them a little slack. After the look you will likely be given a brief lecture that usually boils down to one simple statement. Value-based healthcare simply makes sense.

Despite the fact that the concept started taking hold over a decade ago, value-based care hasn’t really made its way into the mainstream vernacular. You could argue that the reason is that the concept is somewhat complicated and not well defined but I am not sure that is the case. It seems much more likely that most people assumed that value-based care was what they were already receiving from their healthcare providers.

If you aren’t in the healthcare realm (providers, payers, insurance, compliance, etc.) then I’ve probably lost you. You’re probably asking “What is this value-based stuff?” and “Who is this guy anyway?” I’ll answer the second question first mostly because it is easier to answer, but also because doing things backwards is fun. I’m Dr. Kevin McCash and this is my new blog. In the interest of full disclosure, I am not a medical doctor, but in fact, a physicist that now works in health related data analysis. If you want more details about me, for whatever reason, you can take a gander at my bio. Go ahead. It’s short. I promise.

Now the first question, in case you hadn’t guessed, is the point and purpose of what I am writing now. This blog is my attempt to bring some of the finer details of value-based care and what it means to the public at large.  Hopefully through discussion of how it’s being applied and explored I can let a few more people into the “secret” that is changing the healthcare world. That being said I still haven’t answered the question.

So, what is value-based healthcare? In the most straightforward terms it’s a concept that would reward healthcare providers for providing the most effective and high-quality course of care for each patient. In contrast a fee-for-service model would pay a provider for what services they provided or procedures they performed regardless of the outcome. In a value-based environment, a patient would only receive the tests, services and procedures that are necessary to provide effective care and promote general well-being. Value-based care is such a profound paradigm shift that it makes you wonder why it has taken so long to come about. It’s a method that is driven by an age where information is a commodity that everyone can afford and by a public that is more connected than ever before. It is an attempt to stop the ever increasing cost of healthcare in this country but also provide the best overall benefit to patients everywhere. As those recent med school grads will say, the concept makes sense.

Remember though just because it is now possible does not mean that it is easy to implement. It is the challenges, innovations, and emerging realizations of value-based care that I want to explore, discuss and debate. I hope you will join me and maybe with a little luck we can all learn something new.

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