‘We need to have as many Amer­i­cans cov­ered as pos­si­ble’

Modern Healthcare - - Q & A -

Un­able to in­flu­ence de­bate in the House of Rep­re­sen­ta­tives on the Amer­i­can Health Care Act, lob­by­ists and trade group ex­ec­u­tives are hop­ing for a more re­cep­tive ear in the Se­nate. “It re­ally is a new day,” said Chip Kahn, CEO of the Fed­er­a­tion of Amer­i­can

Hos­pi­tals, al­lud­ing to the fact that key Se­nate lead­ers have said they are writ­ing their own bill. Among the fed­er­a­tion’s top pri­or­i­ties, Kahn said, is ad­dress­ing Medi­care cuts en­acted in the Af­ford­able Care Act, es­pe­cially if a new law re­sults in dra­matic in­creases in the unin­sured. Kahn re­cently spoke with Mod­ern Health­care Man­ag­ing Edi­tor Matthew We­in­stock about the health re­form de­bate, as well as Kahn’s call to stream­line qual­ity mea­sures. The fol­low­ing is an edited tran­script.

Mod­ern Health­care: Trade groups were largely cut out as the House crafted the Amer­i­can Health Care Act. What’s your strat­egy for en­gag­ing with the Se­nate?

Chip Kahn: It re­ally is a new day. Se­nate lead­ers have made it clear that they’re go­ing to look at what the House did but ba­si­cally start from the bot­tom up. That gives hos­pi­tal groups, physi­cian groups and all stake­hold­ers an op­por­tu­nity to now visit with mem­bers of the Se­nate and their staff.

On the one hand, it’s re­peal and re­place. On the other hand, we need to have as many Amer­i­cans cov­ered as pos­si­ble. It’s best for the in­di­vid­u­als who have cov­er­age. It’s best for those who are care­givers. So, in terms of chang­ing the di­rec­tion, we hope we can come out of the Se­nate with a bill that re­ally keeps peo­ple pro­tected.

MH: Do you get the sense that they are re­cep­tive to your in­put?

Kahn: I’ve had some very pos­i­tive con­ver­sa­tions with staff, and we’ve be­gun to talk to mem­bers. I think they’re in lis­ten­ing mode. It may not last long be­cause they don’t have a long pe­riod of time to put their leg­is­la­tion to­gether, but at this point I’m work­ing hard to be op­ti­mistic about it be­cause they have been very open.

MH: What are the top is­sues for the fed­er­a­tion? Is it Med­i­caid ex­pan­sion? Is it es­sen­tial ben­e­fits? What are the top three things that your mem­bers are re­ally fo­cused on?

Kahn: I don’t want to put one as a pri­or­ity over the other, but in terms of the broad ar­eas, we are very con­cerned about sta­bil­ity be­ing main­tained in in­di­vid­ual cov­er­age, both for those who de­pend on that cov­er­age be­cause they’re not part of an em­ployer group or are not part of a pub­lic pro­gram, and par­tic­u­larly those who are lower-in­come and got cov­er­age through Oba­macare. If they’re go­ing to do it a dif­fer­ent way, that’s fine, but we need to sus­tain that cov­er­age. That’s a pri­or­ity.

On the Med­i­caid side, in our ex­pe­ri­ence the ex­pan­sions have made a ma­te­rial dif­fer­ence for mil­lions of Amer­i­cans and we need to main­tain that as best we can. If we’re go­ing to move away from it and they’re go­ing to ap­ply some kind of lim­its on Med­i­caid over time, the pol­icy has to be sen­si­tive to how the health­care needs of a Med­i­caid ben­e­fi­ciary can change.

An­other area is that, as part of the ACA, there were sig­nif­i­cant re­duc­tions in hos­pi­tal up­dates for pay­ment, which were cut to help fund health cov­er­age. It is re­ally a tax, just as there was a tax on de­vices or a tax on in­sur­ers or a tax on the phar­ma­ceu­ti­cal in­dus­try.

They couldn’t put an ac­tual tax on hos­pi­tals be­cause 80% are ei­ther gov­ern­men­tal or tax­ex­empt; for-profit hos­pi­tals are only 20%. They ap­plied these cuts to raise money from the hos­pi­tals to help fund cov­er­age.

If we’re go­ing to see in­creases in the unin­sured, and we’re also go­ing to be ex­pected to con­tinue to pro­vide care that Medi­care

“We hope we can come out of the Se­nate with a bill that re­ally keeps peo­ple pro­tected.”

ben­e­fi­cia­ries ex­pect, those cuts will be too se­vere. The Con­gres­sional Bud­get Of­fice and CMS ac­tu­ar­ies for years have said that con­tin­u­ing those pro­duc­tiv­ity re­duc­tions into the fu­ture was a big mis­take and was un­sus­tain­able.

We are re­ally fo­cused on those ar­eas: sta­bil­ity in the in­di­vid­ual mar­ket and keep­ing the low-in­come peo­ple cov­ered. What­ever we do with Med­i­caid, mak­ing sure that the ad­vances are sus­tained and, if the out­come of the poli­cies af­fect cov­er­age, mak­ing sure the pro­duc­tiv­ity re­duc­tions, which are un­sus­tain­able, are turned around.

MH: Ul­ti­mately, do you think we’re go­ing to see some­thing get through Congress and make its way to the pres­i­dent’s desk?

Kahn: Each stage here of this process is very com­plex from a pol­icy per­spec­tive and po­lit­i­cally. It has a lot to do with the ide­o­log­i­cal con­struct of the Repub­li­can Party, as well as their vi­sion of health­care. I just find it very dif­fi­cult to prog­nos­ti­cate as to what will hap­pen in the next stage. Maybe they will put to­gether a pack­age and then we get to the third stage, which is what hap­pens be­tween the House and Se­nate. In the cur­rent world, I am just ret­i­cent to make a pre­dic­tion.

MH: Let’s shift a lit­tle bit and look at your mem­bers. How are they po­si­tion­ing them­selves for the move to­ward value-based re­im­burse­ment and what are the un­der­ly­ing strug­gles they con­tinue to face to get to that point?

Kahn: The in­vestor-owned sec­tor has al­ways been very strong at man­ag­ing their hos­pi­tals to best serve their com­mu­ni­ties and pa­tients. And, be­cause by na­ture, they have been sys­tems, and some­times na­tional sys­tems, they can bring a lot of ex­per­tise to bear to help make sure that their hos­pi­tals are ef­fi­cient and cost-ef­fec­tive.

Over the past 15 to 20 years, there’s been a fo­cus on per­for­mance—clin­i­cal per­for­mance and cost per­for­mance—and the in­vestor-owned sec­tor has been very good at con­tin­u­ous im­prove­ment and fo­cus­ing on per­for­mance. You can take our per­for­mance num­bers on the met­rics and com­pare them to any other group of hos­pi­tals and we are gen­er­ally at the top end. Over the past 15 years, we got the memo and we have the struc­ture that helps us move health­care very rapidly.

MH: How much of that is con­tin­u­ous im­prove­ment and how much of that is cut­ting costs?

Kahn: Man­age­ri­ally, we are more ef­fi­cient, and I think the num­bers bear that out. It’s a fo­cus on per­for­mance both in terms of mak­ing hos­pi­tals safer for pa­tients as well as help­ing pa­tients have bet­ter out­comes. There’s been a sea change in all hos­pi­tals over the past 15 or 20 years and we are at the top of that.

Now, we may not nec­es­sar­ily have the brand name that Johns Hop­kins or the Mayo Clinic or some of those places have, but in terms of the met­rics that the CMS does or that pri­vate pay­ers do, I’d put our num­bers up against any of those in­sti­tu­tions. And some­times we have bet­ter met­rics than they do.

MH: As we talk about met­rics, you’ve also been some­what crit­i­cal of where we are with qual­ity mea­sures. In a re­cent blog on the fed­er­a­tion’s web­site, you wrote about the Balka­niza­tion of qual­ity mea­sures. What con­cerns you?

Kahn: We need pro­grams that al­low for us to fo­cus on mea­sures that mat­ter, and it’s more than rhetoric. There are out­comes mea­sures that are mean­ing­ful, that are the true in­di­ca­tors of what’s hap­pen­ing in a hos­pi­tal or what’s hap­pen­ing in pa­tient care. We need to re­ally fo­cus on those mea­sures. Then go­ing for­ward, we need a pro­gram that con­stantly eval­u­ates where there are gaps and what mea­sures are rel­e­vant, con­tin­u­ously rel­e­vant. Then, fi­nally, and it could take dif­fer­ent forms, we need some agree­ment across all of the pay­ers, pur­chasers and con­sumer groups that want to have re­port­ing of met­rics.

We want con­sis­tency across those mea­sures. It’s not to say that we wouldn’t have some dif­fer­ent mea­sures from set­ting to set­ting, cer­tain as­pects of out­pa­tient ver­sus in­pa­tient, but what­ever mea­sures we have in each of those set­tings, they ought to be con­sis­tent. Whether it’s Aetna, Cigna, Kaiser Per­ma­nente or Medi­care, we ought to be re­spond­ing to the same mea­sures. I don’t think it’s al­ways well-un­der­stood, but you can have a mea­sure for out­comes in di­a­betes, for in­stance, and it could lit­er­ally be the same mea­sure, but if dif­fer­ent peo­ple are ask­ing for it, the spec­i­fi­ca­tions and all the work that goes into build­ing the re­sults of that mea­sure may be dif­fer­ent.

In­sur­ers, pur­chasers, the CMS, physi­cians and hos­pi­tals need to come to­gether and find com­mon­al­ity, whether we do it un­der the Na­tional Qual­ity Fo­rum or some other means. It will serve the pa­tients well be­cause it will mean that across this plat­form we know that, whether it’s a pri­vate pa­tient or a Medi­care pa­tient or a Med­i­caid pa­tient, that we’re look­ing at the same re­sults from how­ever they’re be­ing mea­sured for per­for­mance and qual­ity.

MH: What are the im­pli­ca­tions if we don’t get to that point? We’ve been talk­ing about it for a long time.

Kahn: If we don’t re­ally fo­cus on mea­sures that mat­ter and we con­tinue with sys­tems that have some mea­sures that mat­ter but then have a lot that are re­quired for var­i­ous rea­sons, we’re go­ing to end up with clin­i­cians and the providers view­ing many of the mea­sures sim­ply as com­pli­ance. Not that you won’t try to meet the mea­sures, but what do the mea­sures re­ally mean for the pa­tient?

That would be a pity be­cause it would mean we’re spend­ing pre­cious health­care dol­lars and the pre­cious time of care­givers on com­pli­ance that isn’t nec­es­sar­ily help­ful to the pa­tient. At the end of the day, we want pa­tient­cen­tered care, which means that what we’re mea­sur­ing what re­ally helps the pa­tient get well.

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