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Health Care Transformation

Do You Know if You’re in an ACO?

Hello There Health Care Transformation Tribe,

There has been some recent news on the Medicare Shared Savings front that’s a pretty big deal but honestly most people have probably never heard of an ACO, don’t realize they are in an ACO, and don’t know that ACO’s were a large part of the Affordable Care Act when it was passed back in 2010. So let me start from the beginning and lay this all out for you.

How Doctors/Health Systems Were Paid in the Past: Fee-For-Service (FFS)

What does this mean? They get paid a set amount every time they do something

What impact does it have? 

  • It incentivizes doctors to do more (more surgeries, more labs, more imaging, etc.).
  • It does not pay doctors based on the quality of care the patient receives.
  • Doctors are not incentivized to provide care if they don’t get paid for it or if the FFS reimbursement is low, even if it would actually improve care for the patient (responding to messages, making calls to patients, video visits, mental health, obesity educational classes, etc.).
  • It siloes the providers of care from one another because everyone gets paid for only the service they provide, i.e. care is not patient-centric.

Enter the Accountable Care Organization (ACO). ACO’s are groups of healthcare providers that assume responsibility for the cost and quality of care for their patients. 

What does this mean? The payer sets expected financial and quality benchmarks for the ACO’s patient population.  If the ACO is below the financial target and above the quality targets the ACO gets to share in the savings with the payer. Note- there are two types of ACO’s: one-sided risk (upside only) and two-sided risk (upside and downside). Those who enter into two-sided risk will have to pay money back to the payer if the patients spend more healthcare dollars than expected but if there are savings they get a higher percentage of the savings. That is their only incentive to take on downside risk.

What impact does it have?

  • It incentivizes health systems to provide the right care at the right time in the right setting by the right person.
  • It incentivizes prevention and high-quality patient care.
  • It incentivizes health systems to invest in people and resources that otherwise wouldn’t be reimbursed under FFS but keep patients healthy, for example, remote monitoring in the home and calling/visiting patients after being discharged from the hospital.
  • It incentivizes health systems to break down siloes and provide patient-centric care to make sure all these items are achieved.

The ACO led by CMS (Centers for Medicare and Medicaid Services) is called the Medicare Shared Savings Program (MSSP). Commercial payers have also followed suit and created their own ACO’s as well.

Little known fact: It is well established in health care that the government, i.e. CMS, is more progressive when it comes to cost reduction and quality improvement for patients, which is very surprising to most folks because they would assume it would be the private sector. Not the case in health care!

So now that you better understand what defines an ACO let’s talk about what CMS is proposing to change about the Medicare Shared Savings Program (MSSP):

  1. Renaming the program “Pathways to Success”. Not sure the need or impact of a title change but ok.
  2. Reduces the different tracks ACO’s can take and they must take on downside risk within 2 years of entering the program (right now they have six years).
  3. ACO’s must alert their patients that they are in fact in an ACO.
  4. Adjustments will be made to ACO financial targets based on local markets.
  5. Allows providers to receive payment for telehealth services to patients in their homes (which is currently not reimbursed under FFS Medicare)

What is “telehealth” you ask? Well let me explain…

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I actually believe that most of these proposed items are good things. We should be doing more telehealth to reach patients where they are. We should be pushing health systems to move away from FFS incentives and take downside risk. It would be a good thing for patients to know whether they are in an ACO and what that means so they can continue to further engage with the health system in the most optimal way. Many are concerned that ACO’s will drop out of the program when forced to take downside risk but I think that will remain to be seen.

In the meantime, I hope you better understand the major development of the ACO that occurred within the Affordable Care Act and how some adjustments may be made to the program in the near future.

Cheers to Health and Happiness!

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My Health Care Transformation Handbook
The Handbook

Achieve your best health at the lowest price. Become an educated, empowered healthcare consumer.

Hello my Health Care Transformation Tribe!

Exciting news! My Health Care Transformation Handbook is officially available for purchase!!!

My Health Care Transformation Handbook

Do you want to understand how to navigate the healthcare system like a pro? Are you looking to achieve your best health at the lowest price? Do you wish you had the knowledge of a healthcare expert right at your fingertips of what to do and where to go and what to ask?

Then My Health Care Transformation Handbook may be exactly what you need!

I’ve been passionately working in healthcare improvement for almost ten years now and it’s become very clear to me that:

A) Health care is WAY too confusing! Even many folks who work in health care are confused by the beast that is health care!

B) Health care systems can be messy and unfortunately sometimes things fall through the cracks and patients may not always receive the best possible care.

C) Because no one is taking ownership over educating people on what to do and where to go, many people actually don’t make the best decisions for their health or their wallet!

So I decided to change all that with My Health Care Transformation Handbook. This first edition handbook is your ticket to having healthcare expertise at your fingertips! Now you don’t have to worry that you don’t know what you’re doing or that you might be getting taken advantage of or that you might be making a bad decision. I’ve helped hundreds of people navigate the health insurance and provider system and now I’ve written my expertise down within My Health Care Transformation Handbook to guide and support you along your healthcare journey!

My Health Care Transformation Handbook has six sections to support you:

  1. My Prevention– to support your health and happiness. It even includes the recommended guidelines for preventive screenings and vaccinations based on age and gender.
  2. My Health Care Status– to manage and document your current health state, provider care team information, medications, urgent issues, etc.
  3. My Clinical Encounters– to manage your clinic visits, emergent issues, hospitalizations, surgeries, and more. It even includes key questions to ask your doctor!
  4. My Advance Care Planning– to support you or loved ones in decision-making around your goals of care in an unforeseen event.
  5. My Health Insurance and Billing– to educate you on how to understand and select your insurance. It even includes tools to support you in budgeting and estimating healthcare costs.
  6. Extras– including my key recommendations on how to reduce your healthcare costs!

I wrote this book just for you for when you’re ready to delve in and learn what you need to know about managing your health and taking control of navigating this crazy, confusing healthcare system. This is for people who want peace of mind and confidence. Who want to care for themselves and their loved ones.

Here are a few of the results you can expect from My Health Care Transformation Handbook: 

  • Clarity on how best to navigate the healthcare system in order to achieve your best health at the lowest price
  • Confidence to ask the right questions and get the care you deserve
  • Freedom from the fear that may be holding you back from really engaging with the healthcare system
  • Support and expertise to guide you along your healthcare journey
  • Tools and resources to move your health in the right direction towards a long and healthful life for you and your family
  • Comfort in knowing you have my healthcare expertise to support you as well as a community of like-minded individuals who also want to live a happy, healthy life

Who My Health Care Transformation Handbook Is For: 

  • You select your health insurance by picking the cheapest health plan available.
  • You don’t know the difference between a copayment and coinsurance. Or is there one?
  • You have never heard of the USPSTF and you have zero clue which cancer screenings you should get and when.
  • You think a “Patient Portal” might have been how they provided health care in a Star Wars movie…
  • You have walked into an Emergency Room to receive medical care (BTW if you can walk and talk, it’s most likely not an emergency…unless you have chest pain, loss of breath, etc. but read the book!)
  • You’ve never heard of Advance Care Planning.
  • You would have NO idea what to expect and what to do if you were hospitalized.
  • You know you need to learn about health care and you want to learn about health care so you can better protect yourself and your loved ones.
  • You love big pretty books.

Who My Health Care Transformation Handbook is NOT For:

  • You hate books.
  • You already know everything there is to know about health care.
  • You get excited about risking your health and who cares how much money you waste on health insurance!
  • You are ok with waiting until you get sick and feel crappy and are actually seeing doctors to start caring about all this healthcare junk.

If you are ready to feel knowledgeable, confident, and empowered, purchase My Health Care Transformation Handbook today for $49.95 + shipping. The first shipment of books is limited so be sure to order yours soon! There is no better time than today to take control of your health and start utilizing my healthcare expertise. Especially with open enrollment season right around the corner!

Have any additional questions about My Handbook?? Be sure to contact me today with any questions! 

I’m so happy and excited to support you on your healthcare journey and, as always, Cheers to Health and Happiness!

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Prevention

Prevention is Key- Part 1

Hello Health Care Transformation Tribe!

Today I’d like to chat about one of the most important things you can do for yourself in order to have the best health at the lowest price and that is PREVENTION! Prevention means stopping something from happening in the first place.

Many expensive and painful diseases are actually caused by ourselves, not our genetics. For example, obesity due to overeating and lack of exercise causes us to have diabetes and heart disease. Smoking causes lung cancer. Excessive alcohol drinking causes a myriad of body problems including liver disease, GI problems, and osteoporosis.

So as you can see, it is actually very much in our control to keep ourselves healthy now so that in the future we don’t have to deal with a crappy, painful, expensive disease.

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So what are my key tips for staying healthy and preventing disease?

Let’s start with healthy eating. Some of my key recommendations that I practice are below and you can find more in My Health Care Transformation Handbook:

  • Grocery shop on the periphery of the grocery store. I steer clear of aisles as much as possible! (But also be sure to steer clear of the bakery…)
  • Eat foods that are found in nature, not made in a factory. Carrots are found in nature. Cheetos came from a factory.
  • Go to your local farmers market or utilize a market delivery service. My favorite fresh local delivery service is Grubmarket in LA but I love to head over to the Brentwood Farmer’s Market any Sunday that I can.
  • Don’t store foods from the “avoid list” in your home. For example, I don’t store any desserts in my home. If I want a dessert then I need to walk out of the house and get it. And then guess what. I hardly ever eat desserts 😉

Now second to healthy eating is exercising. Here are some of my key recommendations that I practice and, again, you can find more in My Health Care Transformation Handbook:

  • Incorporate exercise into your day as much as possible. For me, I make sure to walk or bike anywhere that is within a few miles. I bike to the office. I take the stairs up and down whenever it’s less than six flights. Stay active!
  • Sign up for a workout class at the beginning of the week – then you can’t bail out that day when you are feeling tired! For me, I plan all my workouts, whether that is running, dancing, yoga, HIIT class, at the beginning of the week so that it is already scheduled and I make my plans around working out.

Also of extreme importance is taking care of your mental health. Having a happy, healthy mental state will help you achieve balance in your nutrition and exercise and vice versa. My key recommendations on how to achieve your best mental health, with more being available in My Handbook:

  • Document what brings you joy and then manage your time to ensure you are making room for these things. For example, I know that the top things that bring me joy are building relationships and friendships, exercising, being outdoors, and, of course, educating people on health care. So I make a concerted effort to make plans with friends as much as possible, exercise and be outdoors daily, and work on Health Care Transformation as much as possible.
  • I highly recommend setting some goals and then thinking through any mental barriers you are creating to achieving those goals of living your happiest best life.

And finally, practice healthy habits. Limit your alcohol intake and I don’t think I need to tell you that smoking is bad for you… But I will… Smoking is bad for you.

Now that we have talked through the basics of prevention, take some of these recommendations, set some goals for achieving your best health, and we will chat more about prevention soon!

Cheers to Health and Happiness!

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Health Care Navigation

It’s National Healthcare Decisions Day!

Happy National Healthcare Decisions Day!!!

Wait… you didn’t know it was today?? And you don’t even know what that means??

Well then let me explain because this is really important and this is an area of health care I’m very passionate about!

The goal of National Healthcare Decisions Day is to educate and empower all individuals and doctors to complete their advance care planning.

So what is advance care planning?

Advance Care Planning means planning in advance for medical decisions just in case you are so sick that someone else has to make the decisions for you. These are your decisions to make based on your values, preferences, and conversations with loved ones.

Advance care planning is really important for the following reasons:

  • We are all mortal but prior to our time on this earth ending, we have incredible feelings, goals, and preferences on how we want our final time to play out. Some people would be happy never being able to taste food or walk again as long as they are alive. Other people would rather die than be stuck in a home in front of a TV with tubes for eating and going to the bathroom. Since you are an individual human you have your own desires and we need to make sure your family and doctors are aware of these.
  • The default of our medical society, unfortunately, is NOT to proactively have these conversations with you and your loved ones (although this is slowly changing). And then when the time comes when there is an urgent issue and no medical professional is aware of your wishes, they provide really aggressive medical care. Think surgeries and rib-breaking chest compressions and electrical shocks and tubes down throats. Now sometimes that saves a life but sometimes it actually can hurt an individual who is elderly or can be quite a shock and disappointment for those who want to die peacefully at home at the end of their life.

This Frontline episode “Being Mortal” will give you an inside look into the health care system and will really help you understand the importance of advance care planning.

So what should you do? Follow the checklist below that’s taken directly from My Health Care Transformation Handbook (available for purchase soon!) You might be the individual who needs to complete these steps or you might need to support your parents and grandparents in completing these steps. Either way, we can’t predict the future so we want to be sure that the family is as prepared as possible for whatever may come our way.

Advance Care Planning Medical Checklist:

  • Self-reflect on My Goals of Care
  • Discuss My Goals of Care with my family and friends
  • Discuss My Goals of Care with my Primary Care Provider (PCP)
  • Discuss My Goals of Care with the rest of my Care Team
  • Complete my Non-Temporary Advance Directive
  • Complete my Physician Order for Life-Sustaining Treatment (POLST) Form
  • Have my doctor scan copies of my documentation into my medical record

To learn more about Advance Care Planning, the Navigating the U.S. Health Care System 101 course has two lessons on this topic! And like I mentioned, My Health Care Transformation Handbook will be coming soon with an entire chapter to support you and your loved ones with advance care planning so stay tuned for more info!

In the meantime, check out this comprehensive list of more resources on advance care planning.

I hope today you take this opportunity to have open honest conversations with your family and other loved ones about your goals, wishes, and preferences in the face of an unforeseen event.

Cheers to your every health and happiness.

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Prevention

Warning: This Drug May Kill You

Hello Health Care Transformation Tribe,

Last week, the Surgeon General Dr. Jerome Adams made an official announcement with recommendations to address the opioid epidemic in the U.S. He recommends more individuals keep the opioid antagonist, Naxolone, on hand in order to save someone from dying who is currently overdosing as well as provides recommendations to the general public and health providers about Naxolone and how to identify an overdose.

Let me give a quick recap on the epidemic and then I’ll give you my two-cents on the announcement along with some recommendations for you to follow in order to protect yourself and your loved ones.

Opioid Epidemic: Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, etc. Opioids have killed more than 250,000 people in the last decade, including more than 42,000 people in 2016 alone. That equates to one person dying every 12.5 minutes due to opioid overdose. Opioids kill an individual by depressing their respiratory function so the individual literally chokes to death because they cannot get enough oxygen to their brain and other organs.

Sadly enough, this problem is very unique to the U.S. in comparison to other countries:

us_global_opioid_consumption_chart_vox

Now you might notice a really interesting fact: many opioids, which lead to addiction and death, are actually prescribed to a patient by a doctor. The data show that most physicians lack confidence in their ability to prescribe opioids safely and to predict and discuss potential future drug abuse with their patients. And, in fact, large proportions of doctors are actually very concerned about opioid addiction and death.

My disappointment with the announcement is that there is such a focus on Naxolone, which is an expensive and often not readily available solution that doesn’t actually get at the root cause of the problem. The root cause of the problem is that doctors are prescribing high dosage and frequency of opioids to patients who unknowingly will get addicted and could have otherwise received a different pain intervention such as exercise, massage, acupuncture, physical therapy, etc. Unfortunately, once addicted patients turn to pill-seeking amongst different doctors to game the system and ultimately turn to getting heroin off the streets.

Therefore, it’s important that we stress the importance of educating physicians and patients on how to navigate this drug altogether to gain any potential benefit without wreaking havoc on an individual and their family.

For more background, I highly recommend the HBO documentary “Warning: This Drug May Kill You”.

The documentary will shake you to your bones but it will visualize for you how opioids can kill anyone from good kids to good mothers. 

Doctors can prescribe opioids on anything from knee surgery to a c-section. So how can you protect yourself and your loved ones?

When prescribed a pain-relieving medication, ask the following questions:

  1. Is this medication an opioid?
  2. Is there another option instead of taking a drug?
  3. Is there a non-opioid pain-relieving drug I can take instead?
  4. Is this the lowest possible dose I can take?
  5. Can I have fewer pills?
  6. How is it best to taper off the drug?

Be sure to discuss your health history, family history, and risk of addiction.

For the healthcare professionals, I recommend the following:

  • Pull your analytics on prescribing patterns of doctors so you can intervene on high prescribers.
  • Pull your data on dosage by patient so you know which patients are at risk of addiction and overdose.
  • Use these guidelines to establish protocols and procedures for your institution in order to intervene where possible.

Yes, Naxolone has the potential to save an individual who is overdosing and going into respiratory failure, but we need to start addressing the root of the problem, which begins with developing clear guidelines and operational support to physician prescribers and patients.

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Health Insurance

It’s Time for Taxes!

Hi All,

Now I know you must be so pumped about tax season so I thought I would provide you with some basics about the health insurance side of things so you don’t feel too overwhelmed!

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Here are the details on the three different types of tax forms (and you can click the link for more info):

1095-A: comes from the INSURANCE MARKETPLACE, otherwise known as the online health insurance exchanges. If you purchased your insurance on the exchange, then make sure you wait for this form before you file your taxes.

1095-B: comes from your INSURANCE COMPANY to prove you had the necessary health insurance coverage for the year.

1095-C: comes from your EMPLOYER if you worked full-time for a large applicable employer last year.

If you are going to be receiving a 1095-B or 1095-C it’s ok to move forward with filing your taxes, even if you haven’t received them yet.

For more details, feel free to play around on the IRS website and Happy Taxes!!

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