How CMS Should Cope with Increased Chronic Disease Rates

Baby boomers, those born after World War II, started turning 65 a few years ago. Today, more than one in 12 Americans, or more than 37 million Americans, are 65 or older, and the ranks are increasing by 10,000 per day.

The most sobering statistic, confirmed by a recent United Health Foundation report, is that eight of 10 seniors, or nearly 30 million, have at least one chronic condition based on 34 measures of senior health.

This building crisis of acuity is nothing new and we are going to share three approaches to transforming the most expensive, and one of the least effective, healthcare systems - ours.

Doing nothing is not an option. By 2030, one in four Americans will be 65 or older and, if things don’t change, the Federal government and the American people will be bankrupt well before that crisis peaks.

Compounding it all, today’s seniors are “much more likely to live sicker for a longer period of time,” according to Rhonda Randall, MD., a senior advisor to the foundation.

The socialized medicine solution: Europe has well-established solution that goes something like this: “You have lived a good life and we will make you comfortable as nature takes its course.”

Speaking for all baby boomers, and in the immortal words of the 101^st Airborne General Anthony McAuliffe to the German Command’s demand for surrender at the Battle of the Bulge… “Nuts.”

The CMS solution: When their ACO initiatives, which are dominated by hospitals whose financial stability is undermined if they succeed, fail to deliver, they will be left with no alternative but to continue reduce rates for services. This is the unit cost solution that only increases utilization until the point of provider financial ruin or exhaustion (usually both). The probable doom of this initiative is that the private insurance sector will no longer be able to subsidize Medicare and Medicaid in 2014 because of the multiple, and hugely expensive, unfunded mandates from Obamacare. 

The innovator’s solution: Work to create a healthier population by utilizing care coordination, population management, and risk and disease stratification can do much more than simply manage chronic conditions. We can stall their progress and even reverse them, and the tools to do this are here today.

The challenge is that the triad of healthcare - providers, payers, and patients - have to work together, and invest in themselves without government largesse, and in spite of government regulation.  The creation of independent physician networks that can not only manage care, but create transparency and competition to provide higher-cost services from hospitalization to diagnostics at more realistic prices, is taking hold nationwide. Everyone has a huge, common stake in making this vision work: survival - literal and economic.

And partial solutions won’t do. One comprehensive set of capabilities can successfully impact the triple aim from a multitude of directions, and provide training to optimize them, and that is MDclick. In fair disclosure, we are both advisors to the company, but our job is not to promote it, it is to optimize its effectiveness. That means that we know what it does and how it works from the inside.

MDclick is not a single-focus software solution, but a cloud-based suite of analytic and informatics tools that draws data from multiple sources such as EHRs, payers, labs, diagnostics, and others, and aggregates this data into easily visualized and actionable information. It empowers physicians and patients to better manage their health status as a team. The suite includes both a provider and a patient portal. It allows for true patient-centric coordinated care and information access among providers, eliminates duplicated and unnecessary services, and is proven to reduce costs. It stratifies risk with tools that show the impact of multiple clinical options, stratifies disease to eliminate gaps in care, and provides enterprise level population management that can drill down from region, to practice, to patient. It also measures patient experience to improve outcomes and improve patient satisfaction scores.

The MDclick system can marry financial data from payers with clinical data from practices, and soon will provide prescription guidance, formulary, and options for specialty pharma creating substantial savings.  In the near future, it will provide quality and cost reporting to physicians and even type patients by personality to help determine the most effective approach to gain their attention and cooperation, promoting compliance and healthy life styles.

And, its performance is not speculative. Comparatively with users and non-users in an ACO setting, apples to apples, users spent 64 percent of the average Medicare expenditure while non-users spent 84 percent. It far outperformed non-users in every metric.

MDclick will not be the only solution, but it is a big step toward solving a national problem - if it is adopted. Those that do will not only survive but if they unite with other like minded, independent providers they will likely thrive.