IIR's Government Programs Summit Keynote Announced!

Announcing: Chief White House Correspondent, Mike Allen

IIR's 7th Annual Government Programs Summit is the most comprehensive government programs event to date! This year, we're merging together regulatory compliance and financial calculations to help you navigate through legal, compliance, strategic and financial updates of ACA expansion!

Plus, for the first time under one roof, hear from CMS, HRSA, VA/DOD, OIG, NCPDP, GAO, NACDS, SNHPA as they join keynote Mike Allen, Chief White House Correspondent, Politico and Creator, Playbook and Morning Money at the gold-standard government programs event. In his session “Political Issues of the Day”, gain perspective on what's going on in Washington behind closed doors, as he shares insights into how healthcare reform may shift due to political changes.


Download the agenda for more details and speaker line-ups.

Join us March 23-25, 2015 in Arlington and register now to save $400. Be sure to use the code XP2051BLOG – Click here to register.

If you have any questions about the event, please contact Ryan Geswell at rgeswell@iirusa.com

Gross-to-Net Accounting Forum for Pharmaceutical Manufacturers is Moving!

Here's the good news. IIR's Gross-to-Net Accounting Forum is back and better than ever and has moved in with  IIR's 7th Annual Government Programs Summit!

Be ready for first quarter-end close and earnings announcements by joining us for a JAM-PACKED, one-day summit on March 23rd! Get a comprehensive overview of the entire pharmaceutical GTN process and minimize liability impacting your bottom line.

Plus, take a step further in understanding how government pricing and contracting functions impact your company's financials beyond Gross-to-Net by adding IIR's Government Programs Summit to your registration. Take advantage of our best savings of the year!

For additional information on this event and all it has to offer, please download the agenda.

Don't hesitate-start 2015 right by crossing off some professional goals with IIR's Gross-to-Net Accounting Forum now occurring alongside IIR's gold-standard Government Programs Summit. Register now and save up to $400! Use the code XP2051BLOG

I hope you join us in March in Arlington.

See What’s New at MMCC 2015

The Medicaid Managed Care Congress is in its 23rd year, and there is a reason why we have been around so long—we consistently provide the newest and freshest insights on the topics that matter most to you and your business. For the 2015 event taking place on May 20-22 in Baltimore.

Here is a sneak peek of what’s new:

8+ New Health Plan Case Studies
Evaluate opportunities to grow membership, increase quality and decrease costs by learning from victories (and lessons learned) from speakers who haven’t presented in the past, including representation from Humana, Community Health Choice, Molina Healthcare executives on a national and regional level, plus many more.

Dual Eligibles Summit
It’s not just a few sessions anymore; we now have an entire day focused on increasing revenue by successfully navigating the very complex but extremely lucrative duals market.

A 360º view
The popular Medicaid Managed Care 101 pre-conference summit has been reformatted to give you multiple perspectives on the areas that have the highest impact on your bottom line. A unique 360º view from health plans, government officials, solution providers and other perspectives for a well-rounded understanding of the topics that will grow your skill set, such as ACA implementation, improving quality, the long-term industry outlook and more.

Customize your Agenda (coming soon!)
Create a personal agenda to select which sessions will increase your ROI the most. Prepare your networking strategy in advance to optimize your time at the event and coordinate attendance with colleagues to ensure you get maximum expertise. Stay tuned as we will make this feature available in the coming weeks!

Download the preliminary agenda for more details.

Register now and save $400! Use code XU2026BLOG - Register here.

Medicaid Managed Care Congress is Back | Save $600 Now!

MMCC is back for the 23rd year, bigger and better than ever before, helping you grow membership, decrease expenditures and improve outcomes with advanced Medicaid Managed Care programming.

 Join us in 2015 for...

• The 411 from CMS as they provide clarity on government initiatives to better prepare you for this year and beyond

• 15+ case studies that demonstrate what's working for MCOs so you can strategically grow your business

• 10+ state government officials that share unique programming so you know how states are improving care & access in their states
    

Download the preliminary agenda for more details.

Register by Friday, 2/6 and save $600 when you use the code XP2026BLOG – Register here.

Patient-Centered Care: Health Literacy, HIT and Shared Decision-making

By Nalini K Pande, JD

“When we want your opinion…”

When we talk about patient engagement, a cartoon comes to mind that I often used when I was teaching at Georgetown.  The cartoon depicts a group of doctors conferring amongst themselves while they lean over a patient who is sick in a hospital bed.  The patient is trying to speak and a doctor interrupts and says, “When we want your opinion, we’ll let you know!”

That, in a nutshell, depicts how many patients feel when it comes to interacting with the healthcare system.  Ironically, on the flip side, many healthcare delivery executives are trying to determine how they can increase the value of the care they provide, and as a result, produce better outcomes for their patients.  Increasingly, organizations are recognizing that meaningfully engaging patients and families is the answer to this question. In fact, these organizations are focusing on more than engaging patients in making choices about their care. Health systems are focusing on engaging and supporting patients in self-care for chronic disease management, and asking for patient input on how healthcare organizations can better engage patients.

Payment Reform and Patient Engagement Go Hand-in-Hand

With payment reform leaving providers with increased risk-sharing and accountability, patient engagement may be seen as the Holy Grail to tap into improved patient outcomes and contain costs.  Yet, many patients lack the health literacy to effectively navigate what is now an increasingly complex and confusing health system.  Koh et al propose a Health Literate Care Model that would “weave” health literacy strategies into the widely adopted Care Model (formerly known as the Chronic Care Model).  In this way, health literacy would become an “organizational value infused into all aspects of planning and operations, including self-management support, delivery system design, shared decision-making support, clinical information systems to track and plan patient care, and helping patients access community resources.” [1] 

Further, the HIT infrastructure can help providers keep patients and caregivers informed, educated and literate about their personal health and medical conditions. It can support on-going self-care and wellness management, including coaching from healthcare providers and ongoing dialogue between those providers and patients.  Additionally, patient portals (available online and via kiosks)  can be effective tools in providing access to electronic health records, appointment scheduling as well as clinical support such as secure provider messaging, patient reminders, alerts, test result views and prescription refill requests. 

Perhaps, most importantly, taking a population health approach to patient engagement is essential.  Bending the cost curve and improving quality requires the management of patients in lower-acuity, primary care settings with diverse access points, education of treatment plans and adherence through clinical care and community partnerships as well as strong patient activation.

Policy makers, payors, providers, patients and caregivers should work together to develop strategies to implement:

 • The health literate care model
 • Provider, patient and system competencies needed for patient-centered care
 • HIT infrastructure & population health approaches to patient/family engagement.

Changing the healthcare culture and allowing for stronger shared-decision-making may not be the top agenda item for many health system executives.  However, given the costs of maintaining the current status quo, health system executives would do well to re-think their priorities.



Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, prevention, population health, patient engagement, and emerging payment models including accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  She previously taught a graduate health quality course at Georgetown University as an Adjunct Professor. Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.

Follow @nalinipande


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[1] Koh et al. “Analysis and Commentary: A Proposed ‘Health Literate Care Model’ Would Constitute A Systems Approach To Improving Patients’ Engagement In Care.” Health Aff. February 2013, 32:357-367. 

Prevention, Incentives and Medicare Costs

By Nalini K Pande, JD

A little over a year ago at my previous consulting job, I served as the project director for a very interesting prevention project.   The project was for the Bipartisan Policy Center’s (BPC) Health Care Cost Containment Initiative¹.   BPC had asked us to develop a financial model of the costs and benefits of a diabetes Type 2 prevention program.  Our report illustrated how the financial incentives for three different payors  (commercial plans, Medicare, and ACOs) vary given different assumptions of who would pay for these prevention services and the age at which individuals would first receive prevention services. We chose to model Type 2 diabetes prevention services given that Type 2 diabetes is reversible and given the tremendous amount that the US spends on Type 2 diabetes² .   What we learned was fascinating.

Prevention Efforts Can Yield Cost Savings

The key finding from our report was that a diabetes prevention program “can produce overall cost savings which increase over time for an individual.” Given this, why wouldn’t we roll out these prevention programs on a widespread basis?  Well, the answer may surprise you.  To delve into this, you will need to understand three key issues:

• - First, who pays for the diabetes prevention program? 
• - Second, who benefits?
• - Third, when do the savings kick in?

Our report showed that if private commercial plans bear the cost of the diabetes prevention program, they may not reap all the benefits.  This is because of two reasons.  First, if individuals switch health plans over time, another plan would reap the benefits – allowing for only small benefits for the plan that implemented the prevention program.  Second, if you’re 55 or older, there is no incentive for a private commercial plan to cover your participation in a diabetes prevention program.  Simply put, by the time the cost savings would kick in (10 years), you would be on Medicare and Medicare, not the plan, would reap the benefits. 

So, what if Medicare paid private plans to cover these diabetes prevention programs?  Perhaps, then, we would all win.  Those with private commercial plans would benefit from diabetes prevention services and Medicare would benefit from healthier beneficiaries who save the program money. Our report found that while the Government does recoup savings when it pays for the program, it only did so for those who are near 60.  In fact, the Government receives very little savings from a younger population who would stay with the private sector and continue to be with a commercial plan during the timeframe when most of the savings would be realized over a 25-year period.

Where does this leave us?

In essence, what we have is a scenario where payors are reluctant to pay for prevention services since they won’t benefit completely.  Has our patchwork system of health care created disincentives around prevention?  Not quite.  Our study found that if patients could join an ACO when they are under 65 (as a commercial ACO) and then stay in the same ACO when they are over 65 (as a Medicare ACO with shared savings between the ACO and Medicare), perhaps the ACO would get the best of both worlds.  In this scenario, an ACO could invest in its patients through prevention programs and recoup the benefits, assuming limited plan switching.

Investing in prevention appears to be a game of “what’s in it for me?” How do we change it to a “win-win” scenario? The answer is simple.  We do so by utilizing new systems like ACOs that allow payors to reap long-term savings. 

Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, prevention, population health, and emerging payment models including accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.


Follow @nalinipande

                                           

¹ Under the leadership of former Senate Majority Leaders Tom Daschle (D-SD) and Bill Frist (R-TN), former Senator Pete Domenici (R-NM), and former White House and Congressional Budget Office Director Dr. Alice Rivlin, BPC’s Health Care Cost Containment Initiative  “explored and evaluated strategies to contain health care cost growth on a system-wide basis, while enhancing health care quality and value.” 
 ² In Appendix D of our report, we noted a study by Dall and colleagues that estimated the costs associated with Type 2 diabetes as $105 billion for medical costs (along with $54 billion for non-medical costs such as lost work days).  

Population Health: Cockroaches, Health Behaviors, and Social Determinants

By Nalini K Pande, JD

I was at a conference a year ago on dual eligibles when I heard that a health plan was going to focus on pest control to help its patients. What? A health plan was going to hire exterminators for its patients? Then, I realized just how brilliant this idea was.  Cockroaches present numerous health issues, including triggering asthma attacks.  If you want to stop expensive Emergency Room (ER) asthma visits, then attacking the root cause of the problem would be a good start.  In essence, treating the asthma attack in the ER would be only one piece of the puzzle.  Focusing on how to make sure you don’t send your patient home to a cockroach infested housing complex would make much more sense.   Had the health plan stumbled upon something innovative, cutting edge and timely? Yes!  In fact, it did so by adopting a population health focus.  

What is Population Health?

Population health can be defined as  “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”  Population health shifts our concept of health away from individual, clinical health, and instead complements public health by emphasizing a more community health focus.  David Kindig’s County Health Rankings Model (below) provides a nice overview of key factors to consider beyond clinical care.  In fact, we see that health behaviors, social and economic factors and physical environment are even more critical to health outcomes.  Thus, if you want to improve the health of vulnerable, sick and poor populations, perhaps moving outside the clinical walls of the doctor’s office might be the best place to start.

County Health Rankings Model

Aligning Forces For Quality and Population Health

Aligning Forces for Quality (AF4Q) is the Robert Wood Johnson Foundation’s “signature effort to lift the overall quality of health care in targeted communities, reduce racial and ethnic disparities and provide models for national reform.”   These targeted communities, known as Alliances, have played a unique role in improving the population health of their communities. Alliances, as neutral conveners, have, among other things, created strong partnerships to improve Health Behaviors and address Social Determinants. 

Health Behaviors: Providers and health plans need to focus on activities that help identify and assist patients in managing their own care and modifying their health behaviors.  Their ability to proactively reach out to patients who need preventive and chronic care and help them access care management will require them to transform their systems for communicating with patients.  AF4Q Alliances have stepped up to help:

• • Puget Sound  Health Alliance conducted an outreach campaign to engage consumers in their health care.  Own Your Health is a campaign to empower consumers to become active participants in their own health and health care. 
•  
• • P2 Collaborative of Western New York worked with New York eHealth Collaborative (NYeC) to gather consumer input for the design of a patient portal to help New York state residents better manage their health and health care.
•  
• • Let’s CHANGE (Commit to Healthy Activity and Nutrition Goals Every day) is a partnership with the Healthy Memphis Common Table and the Shelby County Health Department to fight childhood and family obesity.  It includes 37 organizations spanning a broad spectrum of businesses, community-based organizations, and government.

Social Determinants: “Bridging the gap” between health care and population health stakeholders, includes a recognition of the importance of social determinants of health ranging from poverty, to education, to housing.     P2 Collaborative of Western New York is working with the Mayor’s Task Group for Creating a Healthier Niagara Falls on an empowerment approach for Niagara Falls. 

Can hospitals, health plans and other providers “go it alone” to address every category of Kindig’s model?  Perhaps the more important question to ask is: “Why would they?”  By partnering with community groups such as RWJ’s AF4Q Alliances, as well as public health entities, health systems can finally treat the whole individual and truly impact health outcomes. 


Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, population health, and emerging payment models including accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.
Follow @nalinipande

Last Chance to Save $600 to Medicare Congress 2015 is Friday!

Be prepared for the toughest operational and finance environment in Medicare!

Attend the Medicare Congress, Feb 3-5 in New Orleans to:

• Increase reimbursement with stronger Star Ratings
• Drive enrollment and retention through customer centric approach
• Ensure CMS compliance and prepare for audits
• Improve quality of care with higher performing networks
• Expand your network by meeting the needs of dual eligibles

Join us in February at the only event that gives you the freshest, newest, and adrenaline-charged content as we power through the next 50 years of Medicare! Download the brochure for full details.

Don't miss out on maximum savings for IIR' s Medicare Congress. You have until this Friday, December 12th, to save $600! Be sure to use the code: XP2007BLOG | Register here.

PLUS! Dual Forum and Stars University are back by popular demand. Click here to learn more.

$840 Million opportunity for AAAs to help primary care offices improve care quality

Via Care at Hand

The Centers for Medicare and Medicaid Innovation (CMMI) recently announced the Transforming Clinical Practice Initiative (TCPI), a new $840 million effort over the 4 years to support 150,000 clinicians in sharing, adapting and further developing comprehensive quality improvement strategies.

Although the funding will go predominantly to physician groups in the outpatient setting, part of the grant consideration will be based on the physician group applicants’ ability to partner with community organizations.

The funding will depend on achieving certain quality measures, many of which are best achieved through partnering with community-based organizations. Unfortunately, there is no reference to area agencies on aging (AAAs) specifically. However, if AAA leadership can quickly curate ROI calculators for AAAs to appeal to the grant applicants, there is a good chance AAAs can see revenue through this grant mechanism similar to their success with a similar funding mechanism in Massachusetts.

While this funding does not explicitly cater to AAAs like other CMMI initiatives such as the Community Based Care Transitions Program (CCTP), the TCPI may be a productive way for AAAs to diversify their revenue streams over the next four years.

Care at Hand is a 2014 FDA/CMS Summit for Payers event supporter. The FDA/CMS Summit for Payers is taking place next week, December 11-12 in Washington DC and it is not too late to register. Save $100 when you register with the code XP1917BLOG – Register now!

The Medicare Trajectory: Take the Healthcare Quiz

By Nalini K Pande, JD

Want to reduce the nation’s spending on healthcare?  How about your own healthcare spending? This quiz could help do just that.  “How” you ask?  It’s quite simple.  When we think about Medicare spending, we don’t often think about kids, young adults or even adults under 65.  But, we should.  The major driver of Medicare costs is spending on chronic disease.  How do we reduce this spending?  We get people like you and me to take care of their health, focus on prevention, and become an active player in the health system before we become Medicare-eligible.  In doing so, you could end up saving money.  And, we also engage those already on Medicare to better manage their care.  Certainly, this is easier said than done.  

Why is America so alienated from their own health care? Could it be that the health system has become so complex that you would have to be a health care expert to figure out what’s going on?  And, who has the time?  This holiday season as you dine with your loved ones and catch up on some good books, you might consider sharing this fun Healthcare Quiz.  This “take” on the 12 days of Christmas will teach you everything you need to know - well, at least 12 important health topics. 

Quiz Directions: Read the Healthcare Quiz and see how many of these terms you know.  Use the red short answer key to see what these terms mean.  You get 1 point for each numbered phrase/term you know for a total of 12 points. Want to earn extra points?  Then, read the “Detailed Answers” section below to learn why these 12 issues are critical to the health policy landscape and earn extra points.

Detailed Answers
(Give yourself an extra point for every detailed answer you know)

12 States Expanding: The Supreme Court has indicated that states can determine whether they will expand Medicaid to cover some of the uninsured under the Affordable Care Act.  Thus far, 28 states and DC have expanded Medicaid.  You get a bonus point if you know whether your state has expanded.  Click the link to see if you are right.

11 Measures Measuring: Health quality measurement is critical to improving the quality of health care services and identifying areas in need of improvement. Measures also inform consumers.  Check out the following consumer health quality sites: for hospitals (Hospital Compare), health plans (HEDIS), and doctors (HealthGrades), as well as an overview of all consumer sites.  Measures can be controversial given operational challenges, and concerns that incorrect inferences have been made from measures. All of this leads many to question how useful some measures are for determining true health quality. Now that I have you completely confused, let’s move on to the Exchanges.

10 Exchanges enrolling:  Also known as Health Insurance Marketplaces, the Exchanges are where both individuals and small businesses can go to shop for health insurance coverage.  Federal subsidies (premium tax credits) are available to consumers if they meet certain incomes requirements. Some states established their own Exchanges. Other states relied on the federal government to do so.  Open enrollment for 2015 coverage started Nov 15 2014 and ends Feb 15, 2015.

9 Duals pending: Dual eligibles are given this name because they are covered under both the Medicare and Medicaid programs.  They are generally the sickest and most costly beneficiaries of the Medicare and Medicaid programs.  Currently, 9 states are in the process of implementing a capitated (managed care) model with goals of improving quality and cutting costs for duals.  What’s pending is the evaluation.  It has yet to be seen how successful these initiatives will be.  Additional states are implementing other models as well.  What’s important is that HHS is focusing on ways to address this vulnerable and high-cost population that maintains strong quality standards while also reducing costs. 

8 Curves a bending: Bending the cost curve in the policy arena really means reducing costs over time.  If someone is acting like a know-it-all about some policy, just throw out the phrase, “but will it bend the cost curve?” and watch them quickly back away.  You get a bonus point if you use this phrase at work or with friends today.

7 COBRAs extending: The Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions require group health plans to continue your employer health coverage (18 months) if you have a qualifying event such as being laid off.  However, you will now pay 100% of the premium costs (not just a portion).  If you’re feeling really adventurous, you can also investigate whether the Exchanges give a better deal given their subsidies or check out your local health plan’s website (except in DC and VT) and shop around accordingly.

6 Health apps trending: Health apps are specialized programs/software often used on mobile devices that focus on health, nutrition or exercise programs.  What’s exciting is that a new app focusing on managing chronic conditions is out.  No longer do the healthy get to have all the apps.  Venture capitalists have been challenged to do more in the chronic condition app arena and it will be interesting to see this field develop further.  You get a bonus point if you have a health app on your mobile device and you use it.

5 Bundled payments!!! Bundled payments is a new payment model that transforms multiple claims into a single payment for one “episode” of care based on predetermined lump sum amount. Why is this important?  This new payment model may lead to higher quality and more coordinated care at a lower cost.  It essentially incentivizes providers to coordinate care and prevent costly and avoidable hospital readmissions. The jury is out as to whether this model will be a strong cost-saver. What is most critical is the cost transparency that the new reform represents.

4 EHRs: Electronic Health Records (EHRs) are seen as the wave of the future (and are currently being used in some health systems). EHRs allow doctors and hospitals to access your medical history, lab tests, allergies, immunizations, and radiology images all in one digital format.  EHRs improve quality, efficiency and care coordination across your care while reducing waste such as duplicative tests.  However, adoption has been slow, and transitioning from paper to digital has been challenging. Further, not everyone believes it is improving efficiency given additional burdens and high costs.  Addressing privacy and security issues are critical for successful implementation.  You get a bonus point if you already have access to your health records online (and another bonus point if you actually use it!)

3 Co-pays: A copay is a fixed amount that you pay when you visit the doctor’s office or when you buy prescription drugs. Why is it important?  As you probably have seen recently, your premium (how much you pay monthly for your health insurance), co-insurance (a percentage you pay of your medical bill) and your deductible (how much you must pay before your insurance will kick in) has been increasing over the years.  How can you effectively select a plan that will best meet your budgetary needs?  Hint: The lowest premium plans aren’t always the best.  They can have high deductibles and out-of-pocket maximums that might make a different plan a more financially appropriate choice.

2 ACOs:  An Accountable Care Organization (ACO) is a group of coordinated providers (doctors, hospitals) in which provider reimbursements are linked to improving quality and reducing costs for a  population of patients. Doctors get more money if their patients stay healthy and if they save money.  (This is unlike previous systems, where doctors are incentivized to reduce costs without always focusing on improving quality). ACOs are seen as cutting edge.  Whether they are the “next big thing” has yet to be seen.  Pioneer ACOs have seen some real success.

And a PCP in a Pear Tree! No, this is not the drug, PCP, but rather what we call in the health field, a Primary Care Provider.  Why is your PCP important?  Having a PCP leads to better health outcomes and reduced costs (through lower hospitalizations), including improved prevention and better coordination of care for those with chronic diseases. You get a bonus point if you have a PCP. 


What’s your Number? How many did you get right? 
• You get 1 point for each numbered phrase/term you knew based on the red answer key for a total of 12 points
• You get an extra point for every detailed answer you knew based on the detailed answers section above for a total of 12 additional points.  
• You get additional bonus points as indicated above for a total of 6 bonus points.

28+: Congratulations! You are a Health Guru. We need more experts like you!

21-27: Great job! You are a Health Professor.  Everyone in the office comes to you for help with their health questions.  Keep up the great work!

11-20: Nice work!  You are a Health Enthusiast. You are on your way to becoming an active player in the health system.  Keep learning and sharing what you know with others!

1-10: Hang in there!  You are a Health Rookie. Healthcare is a very complex topic. It's hard to understand health reform, health delivery system changes and payment reform when the existing system is so confusing. Keep learning!



Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, and emerging payment models including accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  She previously taught a graduate health quality course at Georgetown University as an Adjunct Professor.  Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.
Follow @nalinipande