Advice and Commentary on the World of Professional Consulting


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by George Chapman, GW Chapman Consulting

Affordable Care Act.  A bill to replace the ACA, called the “American Healthcare Act”,  has just passed the Ways and Means committee in the Republican controlled House. The bill would: eliminate many of the taxes that support expanded Medicaid and the premium subsidies on the exchanges and replace them with consumer tax credits, provide block grants to the states for Medicaid, and discontinue the individual mandate requiring all to have insurance or pay a penalty. The bill would continue, however, the basic cornerstones of the ACA: allow children to remain on a parent’s plan until age 26, no life time monetary caps on illnesses, and insurers cannot deny coverage for pre-existing conditions. Rather than going through a disruptive and highly political repeal and replace process, many industry observers wonder why the changes proposed in the new bill were not simply introduced in Congress, over the last six years, as amendments to the ACA. The insurance lobby (AHIP) has expressed approval of some of the changes, but it has expressed concern about the potential decline in coverage and the negative impact on our most vulnerable populations. The American Medical Association flat out will not support the new bill. The hospital lobby says the probable increase in the uninsured will cost hospitals billions. Washington observers and healthcare policy experts believe the bill, as written, will not garner enough support in the Senate. The Congressional Budget Office still has to determine if the new bill’s numbers add up. The CBO has estimated that 15  million people could lose their insurance.

Mega merger drama.  Critics of the ACA have maintained many consumers really don’t have choices because one in three markets has only one insurance company left on the exchange. Consequently, consumers, physicians and hospitals could potentially be at the mercy of monopolistic pricing. Insurance companies maintain that mergers (resulting in less choices) will  allow them to reduce costs and increase efficiencies which would benefit the consumer. The Department of Justice isn’t buying that has blocked the mega merger of Anthem and Cigna, the second and third largest commercial insurers in the nation. Incredibly, Cigna is now suing Anthem to end the merger agreement and for damages. Anthem has countersued. The AMA has expressed its strong concern over the possibility of politically driven settlement negotiations between Anthem and the DOJ that could result in Anthem closing the deal with Cigna.

Accountable Care Organizations. ACOs were established by the ACA to cut costs and improve access and quality.  More than 850 ACOs across the country care for over 28 million people.  Hospitals, physicians and insurers have been collaborating the past six years. The majority of ACOs participate  in shared savings programs with Medicare and commercial insurers. Industry experts are confident ACOs will survive any changes in the laws of the land.

Telehealth.   More and more insurance companies are paying for telehealth. The immediate benefits are easier access, enhanced doctor/patient communication and remote monitoring of incapacitated patients. It will take more time and experience to determine whether or not the increased utilization of physician services via telehealth is eventually outweighed by cost reductions in other areas like inpatient care and drug utilization.  A study published in Health Affairs followed three years of claims for respiratory infections. The study concluded that nine of ten telehealth visits (for this condition) represented new or additional utilization versus visits that substituted for an in person encounter. The authors of the study recommended insurers or even providers might want to increase patient out of pocket costs to prevent frivolous or unnecessary telehealth utilization and that  telehealth might have more of a positive impact for those patients with traditionally undertreated conditions like diabetes and mental health.

Obesity.  In a study published in “Cell Metabolism”, researchers found that a dopamine deficit may be the major cause of physical inactivity which has often been blamed on obesity.  Lab mice were divided into two groups. The first group was fed low fat food while the second received high fat food. The mice on the high fat diet naturally gained more weight, but researchers noted all ice were inactive, due to low dopamine levels, to start. So weight gain itself did not lead to inactivity in these mice.

Dementia.  46 million people worldwide suffer from some sort of dementia. In the US, 5 million people have Alzheimer’s disease. One in three seniors will die from dementia complications. Dementia costs us about $236 billion a year. Researchers at Boston University school of medicine found that people who sleep more than nine hours on average are TWICE as likely to develop dementia than those who sleep less than nine hours on average.

Social media. Social media (SM) is having more and more of an impact on consumers and their behaviors every year. 40% say information gleaned from SM affects how they deal with their health. 19% of smartphone owners have at least one health related app. 41% of us say SM influences our choice of providers and hospitals. 30% of healthcare professionals use SM for networking. When it comes to sharing health info via SM, 43% of us are comfortable sharing with hospitals, 47% with physicians, 38% with insurers and 32% with pharmacies. 60% of physicians report SM actually improves the quality of health in their patients.

Really? And finally this. “Nobody knew that healthcare could be so complicated”. President Donald Trump. February 27, 2017.

On December 9th, we had a presentation by Troy Evans of 16th Avenue Inc talking about the concepts of co-working, co-living and One Million Cups Syracuse style, and how each could apply to consultants in a much different way than most of the people in the room had ever thought of.

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The first concept came under the name of Syracuse Coworks. In essence, it's an open working space where people who work independently can go, set up their laptops or computers, and not only do their work but be surrounded with a lot of other independent business people doing the same. What it offers is the chance to talk to other people who aren't potential customers and bounce ideas off, something that doesn't happen all that often when we work out of our homes. It also gives people a chance to have a conversation face to face and possibly even go to lunch or to grab a cup of coffee.

That's not the only reason it's unique. For only $100 a month you have access to free high speed wi-fi, there's a conference room, a space where you can put on a small event or presentation, a soundproof space if you want to do podcasting or videos, and even a few individual offices; those will cost you a little more than the $100 though. True, it's downtown Syracuse on Jefferson Street, but if you're bored or going stir crazy at home this is a great and inexpensive option to consider.

Next Troy talked about CommonSpace, which is the co-living piece. This consists of 2 floors of one bedroom apartments of only 300 square feet of space. Once outside that you have common areas such as a large kitchen, living room type areas, game rooms, movie area and a place to work out. These units are both short and long term lease and of course the wi-fi is free.

The initial expectation was that 50% of the people living there would also be working in the downstairs space, but it's turned out that only 15% of the residents work in the Coworks area. Most of the people are 3 month short term residents from out of the area, including some from other countries. The age ranges are from 26 to 55, with 4 couples living there.

The starting price is around $800 a month, and once a week there's a group dinner and once a month a group event. Troy mentioned that his hope was to create an internal neighborhood more than just another apartment complex.

The final piece of his presentation concerned One Million Cups, which was actually started in Kansas City by the Kauffman Foundation a few years ago. It's intention was to be more of a think tank for up and coming businesses that wanted an opportunity to present their business to a group of other independent business people and then ask their advice on promotion, marketing, the product itself… pretty much anything.

Presentations are between 5 and 6 minutes and then it's questions and recommendation time. It happens at the same time everywhere across the country (Wednesdays at 9AM) depending on time zone and the coffee and hot chocolate are free. One thing Syracuse Coworks offers (it might be offered elsewhere but we're not sure) is that anyone who comes on Wednesdays can use the co-working space for free that day, which is pretty cool.

The members loved this presentation because it offers something that most consultants could use. Getting out of the house every once in a while can be a good thing, and it's hard to beat the $100 a month price (other than going to the library) and the opportunity to talk to someone during the day (which the library would frown on). It's learning about things like this that makes PCA of CNY such a special group to belong to.

 

By George W. Chapman, MBA

I have worked with physicians, as an administrator or consultant, in every type of healthcare setting including: primary care, specialty care, community and regional hospitals, health centers, clinics, for profit, not for profit, urban and rural for my entire career. At no time have I been more impressed by their professionalism, fortitude, resiliency, adaptability and yes, sanity, as I am now.

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U.S. Pacific Fleet via Compfight

Unbeknownst to most people, your physician has managed to carry on and provide you with excellent care while shouldering the brunt of the most radical and comprehensive (but well intentioned) changes in their industry since Medicare. Despite the virtual healthcare war being waged in congress and all the uncertainty in the industry it creates, your physician continues to provide excellent care and remains your best advocate.      

The Patient Protection and Affordable Care Act of 2010, or ACA, set into motion dramatic, pervasive and unproven changes in how healthcare will be organized, delivered and reimbursed. It will impact all of us, regardless of age or insurance. But most consumers would never know that because the press and politicians have focused almost exclusively on the exchanges.

The exchanges are a relatively small component of the entire Act. Of the 20 million people who receive their insurance because of the ACA, 7 million are on expanded Medicaid which leaves only 13 million out of 320 million of us (4%) purchasing individual insurance from a commercial insurance company on the exchange. The obsession with the premiums and carriers offering insurance on the exchanges has totally overshadowed the rest of the ACA which impacts us ALL. There is much more at stake for physicians, hospitals, payers and all 320 million of us than just the exchanges.  Some background is in order.

Prior to the ACA, there was general consensus among the “players” (physicians, hospitals, insurers, government, employers) that our fragmented and super expensive US healthcare system had to change. Healthcare costs us over $3.2 trillion annually or about $10,000 per person which is more than double the per capita costs in Germany, Sweden, Canada, France, Australia and Japan. The ACA was developed with input from all the players. But because everyone had vested interests to protect, what we got was compromise, not a perfect solution, and we all know how hard it is to keep everyone happy. So what happened?

The ACA became a political football and critics quickly dubbed it “ObamaCare”. When Medicare was passed into law in 1965, it wasn’t dubbed “JohnsonCare”. We all know the more political anything becomes, the more irrational, divisive, emotional and uncivil the discourse. Facts are twisted or spun if not totally ignored and the search for blame and the development of straw man arguments begin. There is far more to the ACA, and its impact on physicians in particular, than meets the public eye.    

Hundreds of billions have been invested by the players in preparation for the changes, agreed upon in principle, to improve affordability, access and quality. “Triple Aim” is the mantra of system reform: improve overall health, enhance the experience of receiving care and lower costs. Six years into the ACA, just about every horse is out of the barn.

Repealing and replacing the ACA would be like canceling an important experiment before the results were in. The ACA has been rolled out in phases and will continue to be rolled out until 2022. We are half way. Because of all that has been invested so far, none of the critical players in healthcare (physicians, hospitals, insurers), is actively lobbying Congress to kill the ACA. Too much money has been invested in complying with the ACA, especially by physicians and hospitals. Our healthcare system will take time to “fix” and starting over or introducing new legislation half way through the 12 year ACA experiment makes no sense.

As politicians, pundits and analysts pontificate, and government agencies regulate, and “big insurance” and “big pharma” bloviate about decreased profits, physicians have quietly scrambled to comply with the myriad of mandates and changes, all the while managing to take care of us. In order to get paid, or not be penalized, physicians have had to (for better or worse): master one or more electronic medical records systems; morph into “population managers”; transition from fee for service reimbursement to fee for quality or outcome; learn new and ever changing procedural and diagnostic coding; adhere to quality metrics and incentives that differ by third party payer; forfeit their autonomy by working with “care management teams”; affiliate with the alphabet soup of “health systems” out there such as ACOs (Accountable Care Organizations) and CINs (Clinically Integrated Networks); compete with retail clinics; incorporate telemedicine and on line access; and much more.

Factor in declining revenue and increasing expenses on top of all this and you can appreciate what physicians have had to deal with over the past few years. While physicians aren’t happy with every aspect of the ACA, most agree things had to change.

Despite all the regulations, mandates, confusion, and even uncertainty as to how they will eventually be paid, physicians do remarkably well according to their patients. A Harris poll from about a year ago revealed that 88% of those surveyed report they were “satisfied” with their most recent doctor visit. The aspects of a visit to the doctor’s office considered to be “very important” are: doctor’s training and expertise: 83%; doctor’s ability to access overall medical history: 65%; time spent with doctor: 58%; ease of making an appointment: 49%; efficient and simple billing process: 45%; ability to communicate with the doctor by phone or email: 44%; time spent waiting: 43%; convenience of office location: 40%; minimized paperwork 32%; office appearance: 31%.

To my knowledge, no other profession has had to endure more changes or more attacks on their autonomy than that of physician. Yet, they are exhibiting an uncanny ability to block all the “distractions” around them and focus on us in the exam room.

Physicians are a tough breed. They aren’t looking for our sympathy. Physicians are looking for us to be compliant and to take responsibility for our health. They want us to be active partners in our healthcare. Their success will depend on our success in the new reimbursement system.

Finally, I think a little understanding and appreciation are in order. Hopefully, you now have a little better idea of the conditions under which they are working. So… if your physician is running a bit behind or seems to rarely look up from his/her lap top, cut him/her some slack. Consider how they must carry on while shouldering the brunt of change.

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by George Chapman, GW Chapman Consulting

Hospital ratings. The recent five star ratings of hospitals by Medicare raised the issue of whether large teaching hospitals got a fair shake because the survey upon which the ratings were based (Hospital Consumer Assessment of Healthcare Providers and Systems) did not account for patient acuity. Large teaching hospitals treat more trauma and often care for difficult patients transferred to them by surrounding rural and suburban hospitals.   A study published in the Journal of General Internal Medicine looked at online hospital reviews by consumers on Yelp. About 25% of the almost 3,800 hospitals in the Medicare survey also had ratings on Yelp. The correlation between the Medicare rating received by a hospital and the Yelp reviews was very strong. Yelp reviewers reported on staff quality and compassion, access, convenience, bedside manner, cost, billing, scheduling, treatment of family and visitors. Researchers found that consumers are more savvy than the industry thinks. Hospitals that performed better on both outcome and processes enjoyed greater market share and growth. Word gets around and patients seek care where it’s the best.

Telemedicine.   Many argue telemedicine will never be as effective as a real face to face encounter between patient and provider. So far, the technology has proven effective in many scenarios such as: the patient is incapacitated (sick, injured, contagious); foul weather; transportation is unavailable (commercial or care giver); patient just needs remote monitoring;  patient needs encouragement or compliance pep talk; patient needs medicine checked; patient has mental issues and acts out; patient can’t leave work; on call provider can refer to video visit.

RomneyCare update.  Industry observers keep an eye on what is happening In Massachusetts because it is consider the harbinger of things to come under the Affordable Care Act. The Massachusetts Center for Health Information  reported that costs in 2015 were $8,424 per capita which is an increase of 3.9% over 2014. The benchmark or target was an aggressive 3.6%. (Everyone in Massachusetts has insurance.)  As with the rest of the nation, drug costs were responsible for most of the cost “overrun”, accounting for a third of all costs. Larger, more efficient healthcare systems are putting a lot of financial pressure on smaller community hospitals and rural systems.

2016 election.  Both candidates agree drug companies seemingly raise prices arbitrarily and something needs to be done.  Trump would allow Medicare/Medicaid and commercial payers to purchase drugs from countries like Canada. Clinton would appoint a federal watchdog to monitor price increases and limit the amount of income consumers would have to spend out of pocket on drugs. But controlling the pharmaceutical industry, let alone prices, will not be easy unless the revolving door between the FDA and the drug manufacturers is controlled. The FDA has data on how many of its former employees now work as consultants or lobbyists to the pharmaceutical industry but has not released such data.

National spending.  In 2014, we spent $9,523 per capita. Still the most by far of any developed country. At $3 trillion, healthcare was 17.5% of our GDP in 2014. (it is currently trending at 18%.) Medicare and Medicaid accounted for 36% of spending. Commercial insurance accounted for 33% and out of pocket another 11%. The remaining 20% is VA, federal employees, Public Health Service and other federal programs.

Specialty rankings.  According to a study of online physician reviews published in Becker’s Hospital Review, consumers report the highest satisfaction levels with neuromuscular specialists, thoracic surgeons, podiatrists, plastic surgeons and colorectal surgeons. The lowest ranking were with: psychiatrists, preventive medicine specialists, pain specialists, emergency physicians and neurologists.

Physicians refusing care.  A debate over how much autonomy a physician should have when he/she has a conscientious objection to providing a service like abortion, birth control, unnecessary testing and assisted suicide is published in the Journal of Bioethics.  Those who argue a physician does NOT have the right to refuse care feel access to care, especially when there are few if any alternatives, must override a physician’s personal beliefs. Those who argue a physician DOES have the right to refuse care argue they are entitled to have values like everyone else. Sweden and France bar physicians from refusing any legal service and can suspend or revoke a practitioner’s license. The US, Canada and the UK have historically allowed the refusal of services based on conscientious objection. Most physicians who will not provide certain services due to moral objections will be happy to refer their patients to another provider without disrupting the overall relationship between them.

Watch your scale.   The good news, according to a study by a Cornell professor published in the New England Journal of Medicine, is your weight might be at an annual low…. right now. The bad news is that, thanks to the upcoming holidays, you will gain weight and a lot of the gain will be permanent if you don’t pay attention. Weight gain typically starts 10 days before the holiday season and peaks around New Year. Because the study participants were aware they were in a weight study, the professor believes the weight gains were probably artificially low to moderate and that weight gain in the general public is worse. Other studies have found that after 30, most of us gain two pounds of permanent weight every holiday season.

CNY Smokeout.  3K fun run to promote giving up tobacco products and creating healthy lifestyles. Sunday November 6, 2016. Onondaga Lake park. 8 am registration.  $20 entry fee. 727-3074 for more information.

Something that the Professional Consultants Association of Central New York does that you don't see a lot of other organizations doing it allowing time for a member to do what we call a 5 to 10 minute spotlight on their business and accomplishments. We tend to believe that it's important not only for the rest of our members to know that we have such accomplished participants in the organization, but it gives the members themselves a chance to get up in front of a friendly group of cohorts and present themselves live.

DannyChawan002What most organizations don't pay attention to is that there are a lot of members who like to stay in the background and just come to watch, but never to participate. As consultants, our belief is that everybody needs to be practiced in the art of presenting to others. We also understand some people are a bit more shy than others, but if you can't talk in front of people you're familiar with you're not going to be a very good consultant long term.

At our first meeting of the season, Danny Chawan of  Srim Enterprises talked about his career as a PhD food scientist; at least that's what I call him. Danny has multiple patents for his discoveries and creations, and has worked with multiple companies across the world in helping them to figure out how to mass produce their products. He is also kind of a local celebrity, having them and both the local regular and business newspaper many times because a lot of the work he does is in the basement of his house, which is a veritable laboratory.

Danny is also a longtime member of the PCA board, butt it's probably been a long time since we got to talk about himself in front of a lot of people. That's why we were happy that he spoke to us, and I know that with the questions a few people asked all of us were illuminated and fascinated by some of his adventures. Below is a small sample of a blog post he once wrote that helps illuminate what he does:

The Things That Affect Taste And Quality

I am a food scientist, a term that may be misunderstood by a lot of people. What I do is figure out how companies can mass produce their food items based on original formulas and recipes so that those products will taste like expected later on.

One might not know how hard it is to get something like this right, but all you have to do is think about making something as simple as cornbread and mixing together two boxes of ingredients at once instead of just one. You might initially believe that if you’re going to do this that all you have to do is double everything. However, you find that when you bake the cornbread, it’s not coming out quite as you thought it might. Maybe the middle doesn’t cook all that well or the outside gets burned, or maybe it doesn’t spread the way you expected it to in the pan.

In that small experiment, you realize that you have to change many things, from how long you bake to what temperature to even how much of the other ingredients you should put into your cornbread mix. Do you put more or less milk in? What about the eggs?

If things can go wrong with something that simple, imagine what it’s like when you’re looking to make thousands, if not millions, of a product at one time in a factory. The chemistry alone can be daunting. It’s not just ingredients or temperature at a certain point. It’s the type of oven or vat you’re cooking in, how you’re putting your product into its packaging, how long it should cook or cool, the order of ingredients, the power of spices… so many things. Many times the corrections are minor, but it could take weeks of testing to figure it out. Other times the corrections are major and costly; there are a lot of great products that never make it to market because it would cost too much to create them.

This is one reason why homemade products, or products made locally, cost so much more than products from large companies. Local products are made in smaller quantities to retain their quality, while larger companies might end up cutting some corners to get out what they do. Don’t take my word for it; make some rice krispie treats, then go out and buy a box of them, and taste them yourself. I believe you’ll understand where I’m coming from.

I tend to believe that more organizations should think about having some of their members present themselves to the group, whether it's a sort of Trade Organization or Professional Organization. After all, when groups of people get together with some clarity, not only will they have good things but sometimes they can ask questions that would benefit everybody. It's also nice to know that there are a number of Professionals in the room who are ready to celebrate as well as assist whenever possible.

This is one of the major benefits of being a member of PCA; it's open to every one of our consultants; all they have to do is ask or wait to be asked. :-)