The URAC Report

The American healthcare system is in a state of uncertainty. And it is failing patients. 

At least that’s the assessment I’ve frequently come across over the past few weeks. Roiling politics and the resulting policies seem to be the root of this uncertainty. Be it the changes ushered in by the Affordable Care Act (ACA) or the looming changes brought by the election of Donald Trump and a Republican-controlled Congress, it seems that healthcare will be in a state of flux and disarray for the foreseeable future. 

By James (Larry) Holly, M.D., CEO, Southeast Texas Medical Associates

Southeast Texas Medical Associates’ (SETMA’s) pilgrimage toward Patient-Centered Medical Home (PCMH) began in 1999 as a result of our study of Peter Senge’s The Fifth Discipline. In that study, we identified ten principles which would guide our development in both our practice and in the electronic medical record (EMR) tool which we would design.  (see SETMA: May, 1999 - Four Seminal Events)  Ten years into our development, we realized that those ten principles were also the principles of PCMH.

Healthcare ranking systems intended to measure quality of care can garner mixed reviews among providers. While many critics point to flaws in how such systems are structured, organizations like URAC are focusing on approaches to quality measurement that may be more reflective of provider performance. 

 “Ranking systems are heavily weighted toward process measures,” says Marybeth Farquhar, URAC’s Vice President of Quality, Research and Measurement. “Many of the measures that contribute to a ranking are basically indicating that a task has been completed, rather than looking at patient outcomes that resulted from that task.”

By James (Larry) Holly, M.D., CEO, Southeast Texas Medical Associates

To be successful, the implementation of new policies and initiatives that will produce the future we imagine must be transformative – which comes from within. 

Transformation results in change that is not simply reflected in shape, structure, dimension or appearance, but is also part of the nature of the organization being transformed. The process itself creates a dynamic which is generative. It not only changes that which is being transformed but it also creates within the object of transformation the energy, the will and the necessity to sustain and expand that change and improvement. Transformation is not dependent upon external pressure (rules, regulations, requirements) but is sustained by an internal drive which is energized by the evolving nature of the organization.

“Only two things in life are certain – death and taxes.” I had a high school teacher who liked to pull out this famous quote from Benjamin Franklin every time he got an unanswerable question from some wisenheimer.

As I sat last week poring over hundreds of pages of health plan brochures trying to sort out the best option for my family, I’m reminded of this quote and can’t help but wonder if there is a third certainty in life that Mr. Franklin missed – health insurance is about as clear as dishwater.

Hardly a month goes by that we don’t hear about a cyber or ransomware attack on a healthcare provider, manufacturer or health plan. Though major attacks are the ones that make the news, healthcare providers across the country face the risk of an attack of any size.

The Privacy Rights Clearinghouse estimates that more than 900 million records have been breached in the United States since 2005 as a result of nearly 5,200 reported incidents. Of those, about 30 percent—more than 1,500 data breaches—occurred in the healthcare industry.

Uncertainty in the legal and regulatory landscape. Lack of HIPAA enforcement. Little interest in fraud from the OIG. State licensure statutes that were written long before the technology for telehealth existed. Risks to quality healthcare. Plus, the changing expectations from patients as consumers. 

The rapidly growing telehealth industry is replete with challenges – and opportunities, which was the focus of a URAC-sponsored webinar, Challenges and Outlook for Telehealth in the Changing Healthcare Economy, on October 26, 2016. URAC Vice President Deborah Smith moderated the discussion with Adam Romney, partner at Davis Wright Tremaine, and Robert Bernstein, MD, vice president for clinical affairs, Carena. 

They say that “states are the laboratories of democracy.” In no place is this more evident than the state of Vermont’s efforts to radically change their healthcare delivery system.

On October 26, CMS and Vermont’s Green Mountain Care Board (GMCB) jointly announced the Vermont All-Payer Accountable Care Organization (ACO) Model. This new, first of its kind initiative is aimed at accelerating healthcare delivery reform for the entire state and its population by establishing a statewide ACO that is responsible for the health outcomes of its entire population.