Healthcare Reform in the USA - Here are Your AnswersSun, August 29, 2010 - 6:48 AM
First stage: Denial - "This will never happen, we won't let it!" (Tea party), "This shouldn't happen!" (Insurers), "It shouldn't happen this way."(Employers), "It's not really ever going to happen." (Providers), It's unconstitutional." (Politicians), "It's illegal! (Lawyers), "We don't need to change the health administration curriculum, again, do we?" (Professors) and so on.
Second state: Anger - I/We will not participate; I'll/We'll pay the fine instead.(employers); I'll file suit; I'll move to another country; We'll outsource to another country, and so on.
Third state - Bargaining: "We'll participate, but we'll cut benefits."; "We'll participate, but we'll cut staff." (employers); "I'll participate as long as I can control the capitation or the ACO." (hospitals); "I'll participate as long as I can employ the physicians." (hospitals); "I'll participate as long as I will be the medical home and control utilization." (physicians);
Fourth state - Depression: "In the long run, they won't need me anymore" (Consultants); "I'm never going to be able to pay down my student loans" (graduating physicians); "This is not the way I intended to practice medicine" (established physicians); "Profit sharing? You've got to be kidding!" (Practice managers); "Please buy my practice, again." (Primary Care Physicians); I may have coverage, but I won't be able to get an appointment." (Patients); This physician shortage is all going to fall in our laps; we'd better go back to school for more advanced skills." (Nurses)
Fifth State - Resolution: " So, tell me what I need to know about this concierge medicine stuff." (Physicians); "If I can't get an appointment in town, I'll get it someplace else, maybe even overseas." (Patients); "I wonder if we can take the market share away from the big city guys when their waiting lists are too long?" (Hospital administrators); "So what all do we have to do to convert the old IPA/PHO/MSO to a ACO and how long will it take"? (Physicians); "Eventually, they won't need as many tools for revenue cycle management. What's our next problem to develop for?" (Software vendors); "How will I compete in the global health space? (Providers)
So here are a few of my answers.
1. Something has to change. The system is broken beyond repair.
2. Stakeholders in the reform, take note: This is not all about you, your revenue, your position, your sustainability, your politics.
3. Read Section 1311, 1312 and 1324 of PPACA. If nothing else survives, these are the parts that give the reform its substance. It is the "what" of the reform. Build your strategic plans and responses around those tenets as if they will survive any hazing. Pay close attention to the transparencies surrounding guaranteed renewal, pre-existing conditions, non-discrimination, quality improvement and reporting, fraud and abuse, solvency and financial requirements, market conduct, prompt and accurate payment, appeals and grievances, privacy and confidentiality, licensure, credentialing and privileging, and transparency and readability of benefit plan materials and information. We won't be doing these things because its the law, we'll do them because ultimately the are the right things to do.
4. Hospitals: Competition for market share sourcing is no longer regional; get over it. Respond with a global strategy or perish on your little piece of ground. Some hospitals and businesses will close because they deserve to. Harsh but more realistic now than ever before. Consider for a moment, why does a little 30-bed hospital in rural Mexico have a global strategy to attract international patients and your big hospital does not? Arrogance or denial?
5. Providers and Payers: Not everyone will want to go abroad to shop for healthcare. In some cases, the travel may not be appropriate or feasible or cost effective. Or, they just won't want to. But, if not abroad, would they consider a wider search within their state, region, or nation? If so, are you prepared to capture that market share? If not the whole piece, what piece will be yours, if any?
6. Providers: Medicare are government reimbursement is the "Old reliable" for many doctors and hospitals and those ancillary services that support them. What if those rules changed too? What if global sourcing was enacted tomorrow for certain service lines or for expatriate retirees that currently return home to access Medicare benefits for big ticket services. What will your organization do to backfill that revenue hole?
7. Providers: plan on developing packaged, fully-inclusive prices that are defensible, and take into account the case management costs, logistical coordination, and provide alternatives for those who may purchase a package locally or may only purchase part of the package and have aftercare and followup elsewhere. In the USA, most surgical procedures have a global follow up period of 10- or 90-days, which assumes that the patient will access care locally. That assumption may no longer be valid. If you have poor documentation and coding statistics, you may not have good statistical data from which to extrapolate and defend your strategy.
8. Employers: Build relationships with your hospitals and healthcare supply chain. Don't wait for the insurers and TPAs to do it for you. You may not like or understand why they maintain the networks that they maintain for your employees' use. Ask questions, demand data. Consider moving from fully-insured to self-funded under ERISA to have greater autonomy in benefit design and primary source health status and cost avoidance data.
9. Individuals: Examine alternatives, think critically, demand customer service, not just coverage. Make the providers compete for your dollars and your business.
10. Universities and colleges: Get with the program. Stop teaching the three-legged stool and co-dependence on Medicare to finance healthcare. Teach creative solutions, not the same old rhetoric. Find current professors not those who are tenured and waiting for heaven to open and let them in. Teach bootstrapping, teach critical thinking, produce problem solvers, not cogs.
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