Health for life

ACOs and insurers discuss terms

The Disease Management Care Blog likes to think of itself as having achieved "critical mass." Now that its readership has climbed into the thousands (and Twitter is now well beyond 600), medical meeting organizers want to issue press credentials, medical journals are sending it embargoed previews and spammers are working particularly hard at getting maliciously-linked comments posted. The best upside for the DMCB, however, is its email correspondence with smart professionals who have insights that run contrary to the mainstreams confirmation bias.

Heres a gently edited email from one astute observer that the DMCB wanted to share:
 
While policymakers extoll the clinical integration virtues of ACOs and the PCMH, what goes unmentioned is that these vehicles often involve provider consolidation. While coordination of care and wasteful utilization might improve, does this mean that those entities could also amass considerable market leverage or become quasi-monopolies? Could that drive up costs?

I was at an specialty provider conference in early March where it was cited (in an admittedly unscientific member poll) that 25% of institutions surveyed had themselves been part of a consolidation or site of service change, mostly from community private practice to hospital-based setting. If physicians are not being employed outright, theyre entering into professional services agreements (PSAs).  Since this has to increase negotiating clout with insurers, the other locally competing providers are responding with an in-kind physician arms race.

Given this dynamic, what will happen when a system has a become a very efficient ACO and controls primary care with a locally dominant medical home network? Even if they fail to show any cost savings, will their ability to command favorable contracts be the key to economically surviving? Darwin would be proud of these long-beaked birds.

Are our federal and state governments prepared to reconcile the twin needs of integration and competition? I can’t help but think that regulators will be outmaneuvered by these increasingly powerful health care entities and that an unintended consequence of orm will be the increasing price points and the return of sticker-shock health care inflation.

Need an example of what is going on at the local level? Check out St. Lukes in Idaho and their ongoing battle with Trinity. St. Luke’s is a CMS designated ACO (on page 33) and is buying up assets left and right, employing physicians, and doing so in almost a direct anticompetitive way. I think that currently St. Lukes is doing a lot of forward thinking things, but if St. Luke prevails and Trinity does indeed go out of business as they state they will, it will leave a monopoly in that mostly rural state. When that happens, St. Lukes can set the price point.  Will they use that power to coordinate care or maximize revenue?

Believers in ACOs and the PCMH would do well to take a look at the Trinity perspective.

While the national mainstream media focuses on Obamacares dimming prospects, internecine Republican conflicts over the merits of a government shutdown, pugnacious Democratic debates over government price controls and who should take credit for the drop in health care cost inflation, check out this local city paper article on the One Simple Idea (that) Could Revolutionize Health Care. As the reporter pointed out, there was no press release, no touting and no awards.  Simply results.

The DMCB agrees.

Barbara Schneider and her team work with Philadelphia health insurer Keystone Firsts community outreach and care coordination programs to intervene on the "sickest of the sickest" diabetics.  These are 35 patients who are admitted on average more than twice a month.  Patients who are on a first-name basis with all the local emergency rooms nurses on all the shifts. Patients who live in run-down boarding houses on a good day.  Patients who are lucky if their blood sugar is only 600 mg%.  Were talking hundreds of thousands of dollars in health care costs.

Dr. Schneiders lay community health workers (more info on the science here) are seeing these individuals in parking lots, McDonalds, row homes and halfway houses  to cajole, coach, text, call, shuttle and haggle with patients, families, social workers, pharmacists and insurers to dismantle barriers one patient at a time.  If a patient isnt ready to stop abusing drugs, that doesnt mean he cant be taught to use a glucose meter.  While living circumstances may be chaotic, that doesnt mean she cant use a cell phone instead of just going to the emergency room.

As Dr. Gawande noted in his The New Yorker article about the super-utilizers, those kinds of interventions can add-up significant savings.

While Keystone has yet to release an analysis on the impact on claims expense for these patients, a cursory review of the data shows emergency room visits have been cut by a third, while inpatient stays declined by more than half.  Even with the DMCBs limited background in analytics, it suspects that when the return on investment is finalized, Keystone will conclude that the program was an unqualified success.

To the DMCB, this is what its all about.  Washington DC can continue its partisan scorched earth battles while, in the meantime, small regional community minded health insurers like Keystone First are figuring out how to do right by patients using novel programs like this. 

Image from Wikipedia

Do you feel like all you hear these days is "eat local"? Wondering what all the hype is about? Whats the point? Isnt that just a fad for hipsters and yuppies who dont get enough snooty karma from their NPR totes?

Though it won’t cure the common cold or reverse the mortgage meltdown, local food is pretty darn great, and not just because it’s traveled a shorter distance in a gas-guzzling truck or plane. Food from nearby is healthier and tastier, not to mention good for the planet, good for your community, and good for your spirit.

Here’s why.

LOCAL FOOD IS GOOD FOR THE ENVIRONMENT

Local food has a smaller carbon footprint. Flying bananas in from South America uses fuel for the plane ride AND power for cooling and storing mechanisms. Food from your ‘hood (or nearby) puts much less CO2 into the air with its transport.

Keep in mind, not all local food is carbon-light. Wintertime greenhouse tomatoes may come from the farm down the street, but the power to heat their environments is not negligible. Still, if you stick to local and seasonal food, you’re golden.

Patronizing nearby farms also supports green, open spaces in your area. Farms are susceptible to commercial development and exurb spread. If you help keep them solvent, you ensure your region hangs on to those lovely spreads of farmland and pasture.

Local farms tend to be smaller farms, as well. Big, national suppliers will farm massive tracts of monoculture: acres of soybeans or corn, which isn’t particularly good for the environment or the national waistline. They often use heavy pesticides and genetically-modified seeds. Smaller farms, on the other hand, tend to be much more diverse, and the best ones integrate their production in a symbiosis of fertilization and need, keeping the soil super-healthy and producing awesomer produce and animals. When animals are involved, it means a better life for them before they become dinner, too.

LOCAL FOOD IS GOOD FOR YOUR COMMUNITY

Buying your food from local producers also supports your local economy. Greenmarket farmers take home about 90 cents of each dollar. With supermarket produce, after the marketing, transport, and distributors, the farmer’s getting more like 21 cents. Part of the reason: government farm subsidies are heavily weighted towards grain and meat production.

Buying local also gives you a personal connection to your food. I know that my eggs come from near Ithaca, and my apples a few towns over upstate, and I get to hand my money right to the farmers that raised them. I guess at the supermarket I’m shopping alongside my neighbors, too, but it feels more personal, and features more smiles, when we’re doing it outside, in the sun.

LOCAL FOOD IS GOOD FOR YOU!

Local food is better for you. Its way fresher than what’s transported across the globe to your mega mart. Supermarket produce is often picked a week before it’s ripe, and has to do its final ripening in transport. Local produce is often picked the day you take it home. Nutrients are preserved, and the flavor is often more prominent. Like, amazingly so.

Local food is often, hothouse tomatoes aside, seasonal. Anyone who’s sampled a strawberry in January knows that food in its prime season just tastes better. And, bonus: seasonal food is super-cheap! Right now my supermarket’s red peppers are $4.99 a pound. In August the greenmarket has that down to $1.99. The seasonal price drop happens in grocery stores, too, but it’s way more dramatic at the farmers market. Plus, the apples taste more like apples, and the greens are bright and still have a little dirt on them from when they were picked that morning.

Eating local and seasonal also supports variety in your diet and the food that farmers grow. This happens in two ways: first, when you commit to eating local, you get pushed, deliciously, outside your veggie comfort zone. If you’re used to string beans and zucchini year-round, a local meal in October can broaden your tastes to Brussels sprouts, kale, and cauliflower. (I think this connection with the seasons is good for your soul, too. Especially in the city, its good to keep in touch with how nature goes.)

The second kind of variety: Local farms, because they’re not beholden to corporate supermarket beauty standards, are also able to sustain uglier, weirder breeds of plants. My supermarket usually has three or four varieties of apples; the greenmarket has at least twelve. Those heirloom tomatoes may be super-unattractive, but they’re also super delicious.

The farmer’s presence at the greenmarket bolsters your sense of community, but also gives you a valuable resource that’s absent from all but the awesomest supermarkets. You can ask, “Hey, what’s the best way to store these carrots so they keep as long as possible?” and also, “What do the eggs who laid these eggs eat? “How much to they get to frolick outside?” Sure, I could share my enthusiasm with the supermarket stock clerk, but I’d rather gush to the person who grew it himself.

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There are ways beyond the farmers market to eat well and cheaply while being good to the planet, and I’ll get into some of those next time. But what do you think, readers? Do you shop at a farmers market or subscribe to a CSA? Do you get local food another way? Why or why not?

Resources:
“If buying locally isn’t the answer, what is?” Grist.org
“10 Reasons to Eat Local” Eat Local Challenge
“Why Eat Locally?” Treahugger
Foodroutes.org
Local Harvest

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If you like this post, you may also like:

• The Argument for Spending More on Food
• Dr. Veg-love, or: How I Learned to Stop Worrying and Love Seasonal Produce
• When to Splurge on Organic