I hope that you enjoyed the fireworks last night. Someone on our lake put on a big show. This will not be a typical New Year’s Day. The big college football games leading up to the national championship were played on Saturday night and the NFL playoffs will not begin until Saturday. I hope that you will have a little time today to reflect on the year that has just passed and the one that will get started tomorrow. It will be a different year. There is much to ponder as we stand on the threshold of yet another cycle from the depths of Winter’s darkness through the renewal of life in Spring and all the joys of Summer which will give way to the flaming colors of Fall before the days grow dark again during the descent into Winter again and the beginning of the next cycle.
What lies ahead in 2019? Will Trump and the Chinese settle our trade disputes that are a new kind of conflict that contains unknown threats for all of us? Of less importance, will Belichick, Brady and bunch find a way to bounce back from last year’s Super Bowl disappointments? Will Alex Cora continue as the genius of Red Sox nation by out managing the New York Yankees to guarantee that he will never ever again need to buy a beer in New England? Will Elizabeth Warren’s early announcement that she is forming a committee to consider running for president turn out to be a wise move or another example of a politician whose ambitions blurred their ability to clearly see and access the possibilities of the future? Will Robert Mueller ever let us know what he found out, and will it make a difference? Will Mike Pence be president by Labor Day, and if so, will he pardon President Trump like Ford pardoned Nixon forty four years ago? What will happen to Judge O’Connor’s ruling that the ACA is unconstitutional? Will the Fifth Circuit Court of Appeals say it is hogwash, or will they pass it up to the Supreme Court with the idea that the questions it raises are beyond their paygrade? I could go on and on as I sit by my fire and gaze out over a frozen lake and ice fishing huts in the distance. Perhaps later today I will see a few brave men out there huddled together. Ice fishermen seem to find solace and some joy in gathering with friends to drink beer while they stare at the holes they bored through twenty inches of ice. I imagine that they are having bonding conversations about politics, sports, and all the domestic challenges, worries, and joys that are on hold as long as they are out on the ice. Will they be making resolutions and promises to themselves for the new year?
This last week the catchy title of an article in the online healthcare publication, MedPage Today hooked my attention. The title boldly proclaimed “Healthcare in Congress for 2019: All Hat, No Cattle, Experts Say-Most of the action expected to come from the Trump administration.” “All hat, no cattle” was a phrase I first heard from Jack Dutzer when he was CEO of Reliant health and we were trying to work together to build a million member multi specialty group practice that stretched west from Boston past Worcester toward Springfield. Jack was the most competent physician executive that I ever met. Jack grew up in Montana and did not suffer fools. When he decided that someone was insincere, did not know much about what they were talking about, could not to be trusted, or was basically all talk but no action he would say, “That guy has a big hat but no cattle.” I was motivated by the fear that at some time he might apply that judgment to me.
Joyce Frieden, the News Editor of MedPage Today has given us the opinions of several experts who believe that “The work Congress does on healthcare next year — and even the year after — will be mostly for show without a lot of concrete results..”
She quotes one consultant, Chris Sloan from Avalere, a healthcare consulting firm, as saying:
“Probably nothing is going to happen legislatively in the next 2 years around healthcare.” I think the Democrats in the House are going to use this as an opportunity to showcase their policy priorities for 2020 — things like ‘Medicare for All’ or a Medicare buy-in, taking votes on those and nailing down some specifics. You will also see Democrats in the House use their oversight power over [the Department of] Health and Human Services (HHS) — to hold hearings, and give pushback around things the administration is doing around the Affordable Care Act (ACA) like the expansion of association health plans and cuts in funding for marketing and outreach in the [health insurance] exchanges…”
I think the consultant has it right, but would also add that one by one as candidates enter the race for the nomination of the Democratic Party for the presidency they will be trying to distinguish themselves from the rest of the field by presenting their own ideas about how to get to universal coverage at a lower cost, while reducing the out of pocket spending of patients on procedures and drugs that are overpriced. I doubt that any will use a term like “The Triple Aim” but I will be listening closely to each presentation while asking myself whether their ideas add up to changes that move us toward the vision of the Triple Aim.
Sloan is further quoted on drug pricing which he sees as a an issue where some bipartisan cooperation may evolve now that the Democrats control the House.
There’s always a chance that the Democratic House and the Republican president will come together on some piece of drug pricing — like transparency reporting — but I think it’s unlikely. So the next 2 years won’t be stagnant for healthcare; there will be a lot of policy development but no major bills.”
Sloan’s opinion is expanded by Julius Hobson, Jr., JD, senior policy advisor at Polsinelli, a consulting firm. He advises that progress on drugs and nothing else is possible if there is a consensus to take small steps forward.
“The first thing on my list is prescription drug pricing. If there is an opportunity for Republicans and Democrats to work out something together — provided neither side tries to overreach — that will be the one thing that has the possibility of being enacted…After that, I can’t find a health issue at the moment that I think the two sides could work on. But I think we’ll see more hearings on the oversight of the ACA, especially in the House, as administration officials get dragged in to see what they’re doing…A House floor vote on a ‘Medicare for All’ bill is also a possibility — although it won’t pass — along with more oversight on veterans’ healthcare…”
Frieden’s Rolodex of healthcare consultants to interview were all people that I did not know, and that includes Bob Laszewski, president of Health Policy and Strategy Associates, a consulting firm in Alexandria, Virginia who concurred that both parties will be focused on drug prices. Laszewski went a little further discussing push back from drug companies and consensus about eliminating the “Cadillac Tax” which has never been implemented from the ACA. He did see the ruling by Judge O’Connor as an issue to follow.
“Democrats will have as their top priority rubbing salt into the Republican wounds on pre-existing conditions and the recent Texas court case,” Laszewski said. “I don’t see any opportunity for bipartisan fixes. With the Supreme Court more than a year away in terms of any final decision, this will be a very dark cloud in 2019.”
Frieden’s forecast never moved away from Washington and into the broad delivery system, but I was delighted to discover that the Mass Medical Society did try to look at the issues that challenge practice in 2019 in an article in their Vital Signs newsletter. The article is entitled “What’s Coming in 2019? Seven Key Practice Trends for Massachusetts.”
The trends they see evolving are:
- Shifting toward Population-Based Care:
Population-based care systems use data derived from large patient populations to guide the care of individuals. They aim to help practices provide proactive, evidence-based interventions and coordinated care, ultimately improving clinical outcomes at lower cost… Data from two Massachusetts state agencies, the Center for Health Information and Analysis and the Health Policy Commission (HPC), show physician-led organizations performing well on population-based measures. The new MassHealth accountable care organizations (ACOs), which provide care for 800,000 patients, are designed to coordinate medical care and social services…
- Considering the Social Determinants of Health:
The MassHealth ACOs now consider the social determinants of health (SDOH) — nonmedical factors influencing disease risk — in their care management systems. A related federal waiver has secured substantial funding for programming addressing the SDOH, which include education, socioeconomic status, neighborhood, food security, racial segregation, housing, public safety, transportation, and more. Addressing these factors is essential to improving outcomes and reducing disparities…
- Prioritizing Physician Wellness:
Health systems and provider organizations are increasingly surveying their providers for burnout and seeking solutions. These may include, for example, the use of scribes and templates to ease EHR use, social gatherings to help reduce isolation, increased mentoring, improved practice workflow and on-call coverage, and expanded provider wellness programs…
- Tackling Prescription Drug Costs:
Spending on specialty pharmaceuticals, gene therapies, and orphan disease drugs continues to rise rapidly. The HPC, which monitors cost drivers, is recommending an increase in transparency and accountability in drug pricing, and an effort to enhance state negotiations of drug prices — priorities for which the Society is advocating at the state and federal levels…
- Incorporating Artificial Intelligence
Advances in AI, robotics, and machine learning can potentially improve the quality of health care services and reduce costs… AI applications have been used to schedule patient visits, refill prescriptions, supply laboratory results, and more. AI offers additional opportunities — from diagnostic algorithms to advanced treatment queries. That said, some aspects of AI raise regulatory questions and challenges.
- Ongoing Mergers and Acquisitions:
Health systems, hospitals, and payers are continuing their consolidation activities… Merging healthcare organizations are aiming to expand care services, control costs, and gain market share and negotiating power. Consolidation continues to pressurize smaller practices. Providers are encouraged to improve care coordination across their networks and reassess compensation, benefits, practice software, payer contracts, and staffing.
- Tightening Cybersecurity:
With the increasing number of ransomware and malware attacks and other security breaches, we expect to see growth in cybersecurity methods in 2019 and beyond. Digital health technology requires medical cybersecurity to manage and protect patients’ health care records from viruses, hackers, and other cyberattacks.
The list touches many of the issues that have appeared in these notes over the last few years. I expect that 2019 will be a year of laying the foundation for future incremental progress toward the Triple Aim. It is my hope that 2018 was the low point of the retreat from the Triple Aim that was precipitated by Donald Trump’s election and the two years of abuse of the ACA which that enabled. The Democrats have a lot of work ahead of them. The real work of healthcare improvement can be enabled or encumbered by what happens in Washington, but it is only in our offices, clinics, and hospitals that those laws and regulations can be turned into better care. It is my hope that each of you will align your efforts in 2019 with what is best for patients. Stephen Pinker’s book, Enlightenment Now: The Case For Reason, Science, Humanism, and Progress, contains the formula for an even better future in its title. It is up to you to blend your reasoning powers, science, and humanism- the concern you feel for others, to make progress toward the Triple Aim. It’s a long road but I am confident that we will cover a few more miles in 2019.
