Subject: News from CREO Strategic Solutions
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The Fickenscher Files, Vol. 13
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Quote Of The Week

"If we want to solve the world's problems, we should put women in charge of the 
nations."

Howard Buffett, in accepting an award along with Bill Gates from the World Food 
Program USA for their work in helping farmers throughout the world bring their products
to market.

"I expect that it's going to be very difficult to get to an outcome, but I am committed
to getting to an outcome. We're into the really tough time and it is going to take
a lot more work."

House Majority Leader John Boehner (R-OH) in speaking with reporters on the seeming
impasse among members of the Supercommittee on how to come up with $1.2 trillion
 dollars in savings to reduce the federal deficit.

"That's a non-starter and, that's from our side! I don't like Democrats having an
offer out there that their own team cannot support."

Representative Henry Waxman (D-CA) on the Democrat proposal introduce by Senator
 Max Baucus (D-MT) to reduce Medicare payments by $500 billion over the next 10 
years.

Consulo Indicium

Information for your Consideration...

Considering Signs - Heathrow Airport in London is littered with interesting signs
sponsored by HSBSC, a leading international bank. One of the more interesting signs
is the fact that two-thirds of the people who have ever lived to age 65 are alive
today! And, we think we've got a problem with the growing number of elderly. But,
you should consider China [http://www.wikinvest.com/concept/China's_Aging_Population].
11% of their population will be over the age of 65 in 2020 or, about 170 million
 people - just over one-half the size of the entire United States. That's staggering!

ACOs and Health IT Investment Go Hand-in-Hand - Computer Sciences Corporation (CSC)
- where I learned how to be a consultant thanks to Deward Watts - recently released
a report suggesting that the deployment of health information technology is critical
in predicting the success of accountable care organizations (ACOs). The report -
 Preparing for Accountable Care: The Role of Health IT in Building Capacity [http://www.ihealthbeat.org/articles/2011/10/18/report-health-it-key-to-success-of-accountable-care-organizations.aspx?topic=ehrs%20and%20phrs]
- suggests that without a strong investment in IT infrastructure, process improvement,
care quality initiatives and other projects which foster coordination of care will
not be effective. For ACOs to succeed, investments in clinical information systems,
point-of-care automation, enterprise and master data management / integration; and,
health information exchange with the community are requisite functions. The report
concedes that ACOs in development are already stretched in their attempts to meet
health IT requirements related to meaningful use and other incentive programs. In
fact, I just participated in a meeting of the Chief Medical Information Officers
 of the 50 largest healthcare systems in the nation and the common theme was - "we're
getting max'd out in terms of resources and focus".

Heart Failure Admissions Decline - Congestive heart failure is the most common health
problem across the board in healthcare. The Journal of the American Medical Association
[http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108424537377&s=6409&e=001Aw6X3ceQz-nKDmDz9cAF9Msr8P07UPpMXCCDHTUUiUW8EZW_IBkFaPDYF1Z-AGqeCOkGqQVoitfqhq3jQ21_J2PsyzU5HCHMcR5NAWNaAA7pWGpCLlap7YSAXW_4LU4tdv6lvEsZTwQnCwIGrP-HiHLD9egJ-RPDMerjeY7kJsuGpqAL_Z8nxyY9rMOf0Y1V5H5Mroxhe38sltlx2zWSRE8k3Lxz3tNWSp3Bs049vvPcdXdmpLl4RrsNmRG9NRaL2fWe9yTyMF8=]
(JAMA) recently published an article which shows a decrease in the number of elderly
patients in Medicare's fee-for-service program admitted to the hospital with heart
failure. The admission rate declined nearly 30% tween 1990 and 2008. Why? The article
attributes the success to improved preventive care, earlier treatment of high blood
pressure and coronary-artery disease; and, education of the public on unhealthy 
habits (e.g. smoking). The study estimated that 229,000 fewer people were admitted
with heart failure in 2008 than in 1999 resulting in a savings of $4.1 billion for
Medicare. This suggests that our efforts at controlling the deficit may be misdirected.
Perhaps we should be focused on initiatives that reduce heart disease and obesity,
control diabetes and handle chronic pain more effectively. It's estimated that cancer
care costs $124 billion. Diabetes costs the USA about $174 billion and heart disease
another $440 billion. The real kicker is chronic pain which costs society about 
$635 billion [NOTE: These figures come from somewhat different years over the period
2007 through 2010]. Now, that means that four problems cost us about $1.373 trillion
dollars!! But, as importantly - chronic pain is totally under-estimated as a "cost"
for society and yet, it represents the largest piece of the pie on an individual
 basis. So, perhaps first things first is a good principle. Let's keep it simple
 (KISS) and focus on the low hanging fruit. But, no...that would be to easy...

Is the Supercommittee Reaching an Impasse? - With the clock running down to a deadline
of November 23rd for a final report from the Supercommittee, House and Senate leaders
are re-inserting themselves into the behind-the-scenes deficit talks among members
of the Supercommittee. The leaders are intervening in the debt panel discussions
 [http://dyn.politico.com/printstory.cfm?uuid=F37CB418-7F69-4AF5-817C-5CE9DE618A41]
to avert an impasse for reducing the federal deficit by $1.2 trillion through targeted
reductions rather than a sweeping, across-the board spending cut if no agreement
 is reached. And, according to Hill insiders, the involvement of the House and Senate
leaders goes well beyond the usual delegated oversight with Senate Majority Leader
Harry Reid (D-NV), Speaker John Boehner (R-OH) and Senate Minority Leader Mitch 
McConnell (R-KY) all much more engaged on the specifics of the debate with the Supercommittee
members.

The significance relates to two considerations. First, the November 23rd deadline
is less than a month away and, the chances of failure are very real. The American
public is not in the mood for an impasse so the House and Senate leadership is doing
what it can to avoid that problem. Second, the Democrats are especially concerned
because the GOP appointees seem reluctant to make any deal without clearance from
their leaders. The potential cuts are obvious. Healthcare is the central target 
with Medicare reductions on the docket along with reductions in other entitlement
programs such as Social Security. For all of my healthcare followers this means 
that "yes" - we will see reductions in Medicare and Medicaid payments over the next
decade. The impasse; however, is over tax revenues. The Republicans are reluctant
to embrace additional tax revenues in the range of $1 trillion to $1.3 trillion.
 So, we shall see...

GOP Candidates Venture Into Healthcare Policy - I keep watching for the policy positions
on the various GOP candidates related to healthcare. Texas Governor Rick Perry (R-TX)
unveiled his economic plan where Governor Perry calls for a vaguely worded overhaul
of Medicare [http://thehill.com/blogs/healthwatch/politics-elections/189655-perry-plan-vague-on-healthcare-cuts].
It seems that his proposal is along the lines of a proposal introduced by Representative
Paul Ryan (R-WI), including a full repeal of President Obama's healthcare reform
 law. Perry would raise the eligibility age for both Social Security and Medicare
- an option Obama has endorsed in deficit-cutting negotiations. Perry also said 
that seniors should have more control over their Medicare benefits by stating that,
"Whether Medicare benefits are bundled with other payments to retirees, or simply
applied to the purchase of health insurance coverage, the value of the benefit is
transparent to the recipient." So, what does that mean?

Passing the Buck - The Republican Governors opposed the Obama plan to cut Medicaid
spending [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108424537377&s=6409&e=001Aw6X3ceQz-lkOCD6X5hpbCXAjKX1gDadsg9Pkjz41YGP9oX-vqrYTK5XN13eKCJkroADY5ITDGdV5rjF2vpovj7mXWmVlAZL0CH2a62aP1sWwAeX_gTTtIMPgtEqACKV29Yq9Bnvh-6VFc9O59TeCvE-O_vVqc9Ke5ibh4S7dbrBlFEBPevhEfi9804ahuolofB-3U-WHMEDZLIt9eYJKv5Xf-AJFrwM]
last week and while urging the Supercommittee to consider major changes in Medicaid,
they definitely expressed an opinion that a reduction in federal spending which 
President Obama has proposed is NOT the answer. The Republican Governors Association
in their letter [http://rgppc.com/gop-governors-engage-super-committee/] to the 
Supercommittee argued that the Obama plan would simply shift costs to the states.
Not to be out done - the Democratic governors also oppose Obama's plan, for the 
same reason. So, we're seeing the shell game of healthcare costs beginning to play
as it relates to Medicaid... Obama proposed combining various rates of federal Medicaid
funding into a single percentage for each state which would save the federal government
about $100 billion. As an alternative, the Republican Governor's Association (RGA)
wants the Supercommittee to give states more control over their Medicaid programs.
They presented a list of options [http://rgppc.com/rgppc-medicaid-report/] for ceding
power to the states related to their Medicaid rolls and how the states pay doctors.
The RGA also supports repealing a provision of the healthcare reform law that prevents
states from cutting Medicaid eligibility before 2014. So, we shall see...

The Supremes Will Consider Healthcare Reform - As expected, the US Supreme Court
 will consider the various challenges to the Obama Healthcare Reform initiatives,
including the individual coverage mandate. According to various reports, the court
will be consider five of the six petitions it has received related to the individual
mandate, including the suit filed by 26 states and the National Federation of Independent
Business. This means that the ultimate decision will rest with the Supreme Court
 on the status of the healthcare reform package. It is likely that the Court will
announce its decision to proceed on November 14th although it could potentially 
defer a decision until a later conference. The lawyer who is likely to argue against
the constitutionality of the Obama Healthcare Reform package is Paul D. Clement,
 a former Justice Department official. Since 2000, Clement has argued more Supreme
Court cases than any other lawyer. He's a strong advocate of state's rights and 
is also involved in defending the tough new Arizona illegal immigration law as well
as the new Congressional prohibition against interstate recognition of same-sex 
marriages. So, the chess pieces are being deployed. Everyone is getting prepared.
And, as I've said multiple times - it all comes down to Justice Kennedy. I wonder
what he's thinking about when he wakes up in the middle of the night? He is the 
"decider" to coin a George W. Bush phrase.

ACOs - A Final Regulation But An Evolving Concept

Will we ever get there?

The Center for Medicare and Medicaid Services (CMS) finally released the final rules
[http://www.ofr.gov/OFRUpload/OFRData/2011-27461_PI.pdf] which outline the approach
toward developing Accountable Care Organizations (ACOs) under the Medicare Shared
Savings Program. However, the 686 page document released by CMS arrived with less
fanfare than one might think. Due to the number of delays in publishing the final
rules, increasing skepticism among some in the healthcare industry on the future
 of ACOs, and the initial perception of extreme difficulty in meeting the requirements
to prepare for participation in the program - many simply lost interest.

When the Accountable Care Act was originally passed in March 2010, the industry 
embarked on a feverish quest to begin plans for creating ACOs as quickly as possible.
In fact, some pundits noted that ACOs were actually comparable to the enigmatic 
unicorn - everyone seemed to know what they looked like, but no one had actually
 seen one. Many experts pointed to Geisinger Clinic or Kaiser Permanente as examples
for the ACO movement. In reality most everyone agreed; however, that the likelihood
of the entire USA healthcare system moving toward a totally integrated model is 
remote at best. So, other models are needed.

Over the last 18 months, we've seen a plethora of dialogue on physician alignment
strategies; models for better care coordination; pay for performance, medical homes
and bundled payments strategies; and, approaches toward disease management protocols
and programs. These are but a few of the myriad of discussions that have swept the
nation as the industry prepares to participate in the program. And, while some think
the hype may die down, the nature of the current healthcare crisis requires us to
consider some type of alternative like ACOs. I recently attended a conference attended
by the CEOs of the 50 largest healthcare systems in the nation. One leader in an
 apt description of the situation said, "Well, I don't necessarily think we have
 a burning platform today but, it sure is getting warm and I can smell smoke." No
statement could be truer in describing the current healthcare environment in the
 USA. With the nation facing the largest federal and state deficits in the history
of the republic, the economy flattening; and, with the wide recognition that Medicare
and Medicaid represent two-third (yes, that's 2/3rds) of the fiscal problem - something
needs to be done and business-as-usual is not going to cut it.

When the initial proposed rules were made public, providers and hospitals responded
with a litany of concerns. CMS received 1,320 comments, all of which criticized 
the proposed rules as doing little to encourage participation. Onerous reporting
 requirements, lack of appropriate incentives, and the perception that the programs
created unacceptable financial risk quickly thwarted any enthusiasm to "get on board"
with the voluntary program. As a result, CMS went back to the drawing board. "We
 listened very carefully...," CMS Administrator Dr. Don Berwick said, "and this 
final rule includes a number of improvements suggested by those comments that will
strengthen the program."

After reviewing the final rules, I must applaud the efforts of CMS. Clearly, Dr.
 Berwick did hear our concerns and followed up with a much more palatable program
that offers greater reward, lower financial risk, a simplified approach; and, fewer
quality requirements. The new rules also decrease some of the barriers to entry 
for participation in the program. To begin, CMS removed the two sided risk from 
track one of the three available levels of participation. To illustrate the differences
in the one and two sided risk models, I have included a table prepared by The Advisory
Board which is exemplary.

Design Element

One-Sided Model

Two-Sided Model

Sharing Rate

Up to 50% based on quality performance

Up to 60% based on quality performance

Minimum Savings Rate (MSR)

Varies by number of assigned beneficiaries

2%

Shared Savings Method

First dollar sharing once MSR is met or exceeded

First dollar sharing once MSR is met or exceeded

Maximum Sharing Cap

Total shared savings payments cannot exceed 10% of benchmark

Total shared savings payments cannot exceed 15% of benchmark

Minimum Loss Rate

None

2%

Shared Loss Rate

None

One minus final sharing rate applied as minimum loss rate is met; loss rate capped
at 60%

Maximum Loss Cap

None

Losses capped at 5%, 7.5%, 10% in years 1, 2, 3; respectively

Other changes include reducing the number of proposed quality measures [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108424537377&s=6409&e=001Aw6X3ceQz-nDdGGKfQSsZlwfrcDI2scKYKXvMTsNcfuGoM2sYmTm45zoQoRzb68THvbXi5lwYgXoprTh18vPJCzEl-eBgdB3KqGrqayGoiQ7B-AvGKkhrpHMDqDcOdhR2RXmSja-myr7wT2etuu7Qxo3DZ13s6RM]
from 65 in 5 domains, to 33 measures in 4 domains. The proposed requirement that
 50% of primary care providers use electronic medical records has also been removed
as a condition of participation. Other notable changes include the following:

* The anti-trust provisions were temporized to eliminate Department of Justice review
for ACOs that hold a market dominant position,
* Altered the assignment date for Medicare enrollees for the end of the year to 
the beginning of the year which makes it easier for an ACO to adjust for the potential
cost of care and allowed for adjustments in primary care payments if the condition
of the patient changes during the course of the year,
* To further encourage provider participation and assist physician-owned and rural
providers with start-up costs, CMS through the Advanced Payment Model [http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/advance-payment/],
is offering early access to some of the $170M expected savings - although the money
must be paid back once any level of savings is achieved,
* Allows rural health organizations and community health centers to develop ACOs
 which was not included in the original proposal,
* Created the Comprehensive Primary Care Initiative [http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/cpci/]
that will test new service delivery and payment models along with monthly care management
payments for fee-for-service Medicare beneficiaries. The initiative was included
 to incentivize the development of programs that can serve as building blocks for
assisting programs to achieve ACO preparedness.

Whether or not the revised rules will be sufficient to encourage participation remains
to be seen but, my prediction is yes - over time, with a tremendous amount of hard
work and some cooperation - ACOs will gain momentum. As one of my favorite colleagues
likes to say, "The way to eat an elephant is simply, one bite at a time." We clearly
have a large meal in front of us in terms of preparing for a move toward an alternative
approach in paying for healthcare but, the time is now.

Early estimates for ACO program participation are quite moderate. Regulators estimate
that only 50 to 270 ACOs will be formed in the next three years. Nationally, there
are just over 5,700 hospitals nationwide [http://www.aha.org/research/rc/stat-studies/fast-facts.shtml]
and there are just over 660,000 physicians [http://www.numberof.net/number-of-doctors-in-usa/].
My prediction is that we are going to see very significant (actually, I predict 
"massive") consolidation among healthcare providers. With the growing realization
that we are facing dramatic fiscal changes as a result of probably redirection in
federal policy, I anticipate that the 270 number is low. Regardless, given the time
it takes to establish shared governance, care coordination models, shared responsibility
for meeting quality targets, and probably the most difficult - establishing distribution
of shared savings criteria, it seems to me that healthcare leaders need to be redirecting
their energies from "if" toward "how".

While it may take some time to realize all that ACOs aim to accomplish, I applaud
the early efforts among many of my colleagues who have embraced the ideas of reform
and created some great programs - despite initial disappointment in the proposed
 rules. Moreover, I look forward to watching ACOs take shape and remind everyone
 to keep your eyes on the elephant!

A Personal Perspective...

Considerations for your consideration...

Last week, I participated in an event hosted by the World Food Program USA [http://usa.wfp.org/]
(WFP USA) which honored Bill Gates and Howard Buffet (Warren's son) for their work
in helping to relieve world hunger. WFP USA is a not-for-profit organization that
educates Members of Congress, the Administration and other government officials 
about international hunger issues and policy issues which can improve our nation's
efforts in addressing global hunger. Secretary of State Hillary Clinton spoke to
 us saying, "Ending hunger is both a moral and strategicly imperative" for the United
States.

So, why am I mentioned world hunger when I always talk about healthcare. The reason
is the impact of hunger on health. Here's a few statistics that caused me to pause.
First, one seventh of the world's population or, about 935 million people, are suffering
from hunger and malnutrition. Of the children who go to bed hungry every night, 
30% will end up stunted in their growth and when they grow up have markedly lowered
IQs and productivity along with a decrease in life expectancy. 40% of the world's
hungry people live in China and India. Food production will need to increase by 
70% over the next 25 years to meet the needs of population growth.

There were two other kicker statistics that really got to me. About 70% of the workers
in the fields where all of the world's grains and other consumables are grown - 
are women! And, the issue of crop storage is one of the world's biggest problems.
40% of the crop in India is lost after it is harvested due to poor storage conditions.
Even though Nigeria can grow rice - probably enough to feed its entire population
- no one wants to buy their rice because of poor storage conditions which make it
nearly impossible and very expensive to process.

These are the reasons that Gates and Buffet were being honored. Their joint foundation
developed the Purchase for Progress (P4P) program [http://www.wfp.org/purchase-progress]
which has brought technical expertise to the world's farmers to that increase their
capacity for growing quality goods, increase production, and deliver a higher quality
product to market. By linking farmers around the world, they have trained more than
100,000 farmers in 21 countries related to agricultural production, post-harvest
 handling, quality assurance, finance and contracting. And, in supporting their 
program, they insisted that 50% of the farmers who are helped be women!

I think that too often we as passive, satisfied Americans think of supporting hunger
issues as simply passing out food. That's clearly not the case. Food support programs
represent less than 1% of the federal budget and under these austere times are under
attach. So, all of this information got me thinking... We need to do more, not less
as a nation of resources. And, the solution is in helping the world's farmers do
 a better job. Just as the Green Food Revolution swept across the world in the 1960's
we now need a Technical Food Revolution for the coming decade. By replicating the
Gates-Buffet program and spreading it worldwide, we could do more for the world's
population over the long term than just about anything else. So, I encourage you
 to check out WFP USA. It's a good organization, a good cause and the contributions
are clearly well spent.

The Weekly Whisk

Musings from a foodie...

Boston is a great city but, I've never thought of it as a foodie place. To my surprise;
however, I recently discovered Oleana's, [****] a veritable plethora of sensuous
 tastes. Ana Sorturi (Executive Chef), Cassie Piuma (Chef de Cuisine) and Cara Chigazola
(Sous Chef) have pulled together tastes that I consider to be on the of the finer
gourmet experiences I've had in the last year. First, if you go, request the garden
view. It's more intimate.

The first thing to know about Oleana's is that it is a "sharing" place. The meza
 (small) plates are absolutely wonderful. We shared a number of outstanding dishes.
The Spicey Fideos was vermicelli imbued with Swiss chard and orange aioli with an
infusion of garlic. Next came the "Sultan's Delight" which was a braised beef dish
in a wonderful sauce that I could never replicate. This is number one on my repeat
tasting when I go next time. The octopus was to die for... In America, the only 
other place where I've had comparable Octopus was in Atlanta which was hosted by
 a Portuguese immigrant who started a restaurant. This octopus was drizzled with
 a tomato sauce which included brussels sprouts, beans, garlic and an assortment
 of other spices. Finally, the Burratta cheese (similar to mozzarella) was absolutely
incredible. A spicy yoghurt sauce was injected into the middle of the cheese and
 it was served on a bed of miniature, spicy beets along with an olive hummus.

And, at the point of being incredibly full - they brought the lamb sausage. It was
over the top. The lamb was served on a bed of greens over yoghurt with cucumbers
 and topped with pickled red onion. If that was not enough, we decided to go for
 the pumpkin kunefe and cider poached apple. This is probably the MOST OUTSTANDING
DESERT I've had in a couple of years. Whew! It makes me sweaty just re-thinking 
how wonderful the meal was which was accompanied by a very friendly ambiance with
a gracious, casual flair. I would go there again in a micro-second. In fact, on 
my next trip to Boston, I'm headed there. I already made the reservation. Now, if
you want to go all the way, Ana does culinary tours of Turkey and the Middle East.
You can check them out at www.oldwayspt.org [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108424537377&s=6409&e=001Aw6X3ceQz-mSvky7vTUuljRZZad6UbLtm1ptqYBgwakNL5orHEAdL4HdAy1l0aewqsGyb4105DDVvP1O7S7lGlxMVqMt3atzAEPLxcpttJObXJtVHP_t5A==].

The Good, The Bad, And The Ugly

The ongoing saga...

The Good - The leaders of the 17 Euro countries reached an agreement that will expand
the scope of the European bail-out fund and boost the capital buffers of European
banks so that about 50% of the Greek debt will be placed private-sector bond holders.
For the interim, the European debt crisis has been averted. Wall Street responded
with the largest gain in 25 years.

The Really Good - The growth in the USA Gross Domestic Product (GDP) held its own
at 2.5% growth despite surges in gasoline prices and Wall Street turmoil.

The Bad - Now that Greece is resolved (sort of), all attention is turning to Italy
which is running 120% of debt-to-GDP ratio. Because of the black mood related to
 Italy, the market reversed course late last week. Furthermore, while the 2.5% growth
in the USA GDP is good news, it falls short of helping to cut in the unemployment
rate which holds steady at around 9.1%. To make a dent in USA unemployment, the 
nation needs a growth rate of about 3.0% in GDP. Most economists don't think that
will happen until at least late 2012 or early 2013.

The Ugly - The regime of Bashar al-Assad continued its downward spiral (perhaps 
this could "The Good") but over 40 were killed over the weekend in the deadliest
 demonstrations since May. When will dictators realize that the new world will not
allow the type of control over societies that worked in the past? The Arab Spring
is the result of information democracy. The control of information theocracies is
no longer viable.

The Fantastic - Those Green Bay Packers are doing incredibly well. I don't want 
to jinx it but, I've already started looking at Super Bowl tickets!! Wouldn't that
be grand!!
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