As the new year approaches, healthcare leaders face many challenges including rising costs, persistent labor shortages and changing consumer expectations. There are policies on federal and local levels that could be enacted or amended to ease some of these concerns. In this conversation with Dr. Robert Bessler, founder and CEO of Sound Physicians and Robert Garrett, CEO of Hackensack Meridian Health, they discuss policies that could improve health outcomes for patients and will move the needle on health equity and value-based care.
Dr. Robert Bessler founded Sound Physicians in 2001. Today, he leads a multi-specialty medical practice with more than 4,000 clinicians improving outcomes in more than 400 hospitals across 45 states.
Robert Garrett is the CEO of Hackensack Meridian Health, New Jersey’s largest health network with 18 hospitals, 500 patient care locations, 35,000 team members and 7,000 physicians.
What healthcare policies are top of mind for you and your organization?
Dr. Robert Bessler: Changes to the Medicare Provider Fee Schedule, including those related to budget neutrality adjustments, will cut reimbursement by approximately 8% across all specialties on Jan. 1, 2023. Unless Congress acts, these changes will strain physician practices — and the hospitals that employ them — at a time of acute workforce shortages and compensation inflation.
Robert Garrett: We are focused on ensuring that Congress eliminates or mitigates some of the harmful cuts that, without action, will become effective Jan. 1, 2023. We would also like to see Congress extend telehealth and hospital at home flexibilities beyond the end of the federal public health emergency. We are hyper-focused on supporting our workforce and our communities’ behavioral health needs.
What still stands in the way of greater value-based care adoption and what can be done to encourage more riskbased contracting?
RB: As CMS renews its push toward population-based payment models, its biggest challenge is including and incentivizing hospitals and specialists, who account for the largest share of overall spending. As the voluntary Bundled Payments for Care Improvement Initiative struggles with participation, CMS should consider a mandatory bundled payment model that better integrates with the Medicare Shared Savings Program and broadens risk participation.
RG: Inoperability is a national hurdle to implementing value-based care and succeeding in risk-based contracting. Without standardization among electronic medical records, sharing timely data – a critical component of any valuebased agreement – remains problematic. Additionally, increasing collaboration and engagement between CMS and the organizations administering its programs could lead to greater adoption and success.
Healthcare organizations are seeing more patients with mental health needs, but provider and bed shortages persist. What are some opportunities to address the mental health crisis from a policy perspective?
RB: Patients with mental health needs continue to face challenges with access. Telemedicine is perhaps the most promising tool for mitigating provider shortages in ambulatory and inpatient settings. Based on our experience in acute and post-acute care, telemedicine would also shift more care from hospital to home-based settings. Realizing telemedicine’s potential requires new, more flexible reimbursement policies from both CMS and commercial payers.
RG: We are very concerned with the increasing number of children and adolescents with mental health needs coming to our emergency departments due to unavailability of behavioral health beds. This acute issue needs to be addressed through bed and workforce expansion. We also need to ensure mental health parity; our community members must access mental health services before it becomes a crisis. Parity is an issue of equity.
Social determinants of health are being recognized by CMS as metrics for payment. Can you share strategies for factoring SDOH into payer contracts?
RB: Ideally, contracting mechanisms would account for the highest-needs patients, with performance measures that recognize a provider’s additional investment in caring for those most socially at-risk, as well as partnering with community resources that help mitigate SDOH and create better healthcare outcomes for patients. As hospital physicians, we have a unique opportunity to assess and mitigate SDOH that may further impede a patient’s wellbeing.
RG: Our digital platform, Unite Us, has screened over 500,000 people at high risk for one or more of the social determinants, and made more than one million referrals so those people can get help. We also use community health workers to lower the total cost of care and increase the value of each contract by connecting value-based care and other targeted groups of patients to community services that address SDOH and health-related social needs.
Home health exploded during COVID-19 and more organizations are adopting hospital at home. What home health regulations do you think could help ensure quality care?
RB: This explosion was the result of capacity challenges for hospitals and post-acute facilities, particularly skilled nursing. As we move toward a new normal of more care at home, we need payment models and regulations that discourage over-utilization in low-acuity patients and allow for the safe management of higher-acuity patients. Telemedicine reimbursement policies that allow for efficient physician oversight of home-based care will be critical.
RG: We need Congress to extend or make permanent the Hospital at Home program beyond the end of the public health emergency. If it expires, our patients will be negatively impacted. Hospital at home has reduced readmissions and adverse outcomes, e.g., falls and hospital-acquired conditions. While quality measures are already in place, we need further collaboration with state and federal regulators to provide additional guardrails for continued quality as the program grows.
Can you describe what kind of telehealth policies you’d like to see adopted by state and federal governments?
RB: As it resumes some of its previous restrictions on telemedicine, CMS is rightly wary about over-utilization. We’d like policymakers to recognize different use cases. Outpatient, specialist-focused telemedicine services tend to be discretionary and may result in increased visits and costs. In our experience, however, inpatient and post-acute telemedicine has the net effect of reducing readmissions and moving patients to lower-cost settings.
RG: The policy should unify both federal and state agencies regarding reimbursement, address how telehealth is defined and regulated and tackle some of the most critical challenges regarding reimbursement. The telehealth waivers provided by CMS enabled Hackensack Meridian Health to expand these services. This is good for our patients and our providers. If Congress does not act, many of these flexibilities will go away at the end of the federal public health emergency.
If you could enact policy that would bring the most amount of good to the most amount of people, what would that be?
RB: Healthcare spending accounts for nearly 20% of the U.S. gross domestic product, but many of those costs are social in nature, relating to poverty, crime, lack of access and homelessness. People without housing who frequently visit the emergency department are just one example driving up overall cost of care. With more investment in solutions outside of traditional healthcare, we’d have greater impact on direct healthcare spending costs.
RG: We must modernize Medicaid. Providers are disincentivized to treat Medicaid patients because of meager reimbursement rates, which hurt provider recruitment and Medicaid providers’ ability to innovate. This ultimately means that Medicaid beneficiaries do not have equitable access to quality care. Modernization is especially critical now, with so many community members accessing Medicaid due to the ACA and COVID flexibilities.
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