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<DIV>And speaking of medical care: A few days ago I watched a PBS Great
Performance which featured Anne Devere Smith in a stunning production, “Let Me
Down Easy.” It’s from 2010 and includes an Idaho character, a bull
rider. But see it for yourself. You can find it by surfing
PBS. </DIV>
<DIV> </DIV>
<DIV>Sue Hovey </DIV>
<DIV> </DIV>
<DIV>-----Original Message----- </DIV>
<DIV>From: lfalen </DIV>
<DIV>Sent: Thursday, September 06, 2012 6:07 PM </DIV>
<DIV>To: Art Deco ; vision2020@moscow.com </DIV>
<DIV>Subject: Re: [Vision2020] The Arkansas Innovation </DIV>
<DIV> </DIV>
<DIV>At least they are trying something other than throwing more money at the
problem.</DIV>
<DIV>Roger</DIV>
<DIV>-----Original message-----</DIV>
<DIV>From: Art Deco art.deco.studios@gmail.com</DIV>
<DIV>Date: Thu, 06 Sep 2012 03:58:19 -0700</DIV>
<DIV>To: vision2020@moscow.com</DIV>
<DIV>Subject: [Vision2020] The Arkansas Innovation</DIV>
<DIV> </DIV>
<DIV>> [image: Opinionator - A Gathering of Opinion From Around the</DIV>
<DIV>> Web]<http://opinionator.blogs.nytimes.com/></DIV>
<DIV>> September 5, 2012, 9:17 pmThe Arkansas InnovationBy EZEKIEL J.</DIV>
<DIV>>
EMANUEL<http://opinionator.blogs.nytimes.com/author/ezekiel-j-emanuel/></DIV>
<DIV>> </DIV>
<DIV>> Philadelphia</DIV>
<DIV>> </DIV>
<DIV>> MENTION medical innovation, and you might think of the biotech
corridor</DIV>
<DIV>> around Boston, or the profusion of companies developing wireless
medical</DIV>
<DIV>> technologies in San Diego. But one of the most important hotbeds of
new</DIV>
<DIV>> approaches to medicine is ... you didn't guess it: Arkansas.</DIV>
<DIV>> </DIV>
<DIV>> The state has a vision for changing the way Arkansans pay for health
care.</DIV>
<DIV>> It is moving toward ending "fee-for-service" payments, in which
each</DIV>
<DIV>> procedure a patient undergoes for a single medical condition is
billed</DIV>
<DIV>> separately. Instead, the costs of all the hospitalizations, office
visits,</DIV>
<DIV>> tests and treatments will be rolled into one "episode-based" or
"bundled"</DIV>
<DIV>> payment. "In three to five years," John M. Selig, the head of
Arkansas's</DIV>
<DIV>> Department of Human Services, told me, "we aspire to have 90 to 95
percent</DIV>
<DIV>> of all our medical expenditures off fee-for-service."</DIV>
<DIV>> </DIV>
<DIV>> The change will encourage doctors and hospitals to work together to
provide</DIV>
<DIV>> patients with the highest quality care, while at the same time
lowering</DIV>
<DIV>> costs by eliminating unnecessary tests and treatments. It has been
done</DIV>
<DIV>> before, in small-scale experimental pilot programs. But as the
Arkansas</DIV>
<DIV>> officials make clear, this change will now be made in every corner of
the</DIV>
<DIV>> state, for every hospital, and physicians in almost every
specialty:</DIV>
<DIV>> surgeons, anesthesiologists, obstetricians, pediatricians, primary
care</DIV>
<DIV>> physicians. For policy makers and the public, the Arkansas experiment
is</DIV>
<DIV>> fascinating.</DIV>
<DIV>> </DIV>
<DIV>> This is how it will work: Medicaid and private insurers will identify
the</DIV>
<DIV>> doctor or hospital who is primarily responsible for the patient's care
-</DIV>
<DIV>> the "quarterback," as Andrew Allison, the state's Medicaid director,
put</DIV>
<DIV>> it. The quarterback will be reimbursed for the total cost of an
episode of</DIV>
<DIV>> care - a hip or knee replacement; treatment for an upper
respiratory</DIV>
<DIV>> infection or congestive heart failure; or perinatal care (the
baby's</DIV>
<DIV>> delivery, as well as some care before and after).</DIV>
<DIV>> </DIV>
<DIV>> The quarterbacks will also be responsible for the cost and quality of
the</DIV>
<DIV>> services provided to their patients, and will receive quarterly
reports on</DIV>
<DIV>> those metrics from the state (for Medicaid patients) or private
insurers.</DIV>
<DIV>> If they have delivered good care based on agreed-upon standards, and
if</DIV>
<DIV>> their billings come in lower than the agreed-upon level, they can keep
a</DIV>
<DIV>> portion of the difference. If their billings come in above an
acceptable</DIV>
<DIV>> level - usually because they have ordered too many unnecessary
tests,</DIV>
<DIV>> office visits or inappropriate treatments - they will have to pay
money</DIV>
<DIV>> back to the state or insurer.</DIV>
<DIV>> </DIV>
<DIV>> Arkansas may seem an odd place for such a bold experiment. It has
the</DIV>
<DIV>> sixth-highest poverty rate in the country, and ranks near the bottom
in</DIV>
<DIV>> everything from the percentage of pregnant women getting prenatal care
and</DIV>
<DIV>> the infant mortality rate to obesity, diabetes and life expectancy.
It</DIV>
<DIV>> doesn't have enough doctors; all but two of the state's counties
are</DIV>
<DIV>> designated as either entirely or partially medically underserved. And
until</DIV>
<DIV>> recently, it was way behind on the adoption of electronic health
records.</DIV>
<DIV>> </DIV>
<DIV>> Yet Arkansas also has certain advantages. It has a governor who
understands</DIV>
<DIV>> the issues very well. And it has doctors and hospitals who - faced
with a</DIV>
<DIV>> State Legislature resistant to raising taxes, an imminent shortfall
in</DIV>
<DIV>> state Medicaid funds and the threat of imposed managed care - agreed
to</DIV>
<DIV>> support the scheme. Finally, it helps that Arkansas is a small state;
when</DIV>
<DIV>> everyone knows everyone, it's easier to work out implementation
problems.</DIV>
<DIV>> </DIV>
<DIV>> Still, it will be a challenge. Bundled payments for hip and knee</DIV>
<DIV>> replacements, which have similar costs for all patients, have
been</DIV>
<DIV>> previously tested. But for other conditions, not every patient's needs
are</DIV>
<DIV>> the same. Some pregnant women are healthy while others have diabetes.
The</DIV>
<DIV>> state and insurers will have to provide "risk adjustment" payments -
in</DIV>
<DIV>> which providers are reimbursed more for treating sicker patients - and
some</DIV>
<DIV>> patients with especially complicated illnesses may need to be excluded
from</DIV>
<DIV>> the bundling system.</DIV>
<DIV>> </DIV>
<DIV>> Even some low-cost conditions, like upper respiratory infections,
are</DIV>
<DIV>> treated at widely varying costs, mainly because physicians
prescribe</DIV>
<DIV>> different tests, numbers of office visits and medications (in 14
Arkansas</DIV>
<DIV>> counties, over 50 percent of patients with upper respiratory
infections</DIV>
<DIV>> receive antibiotics, even though national guidelines say they should
rarely</DIV>
<DIV>> be prescribed because most infections are viral).</DIV>
<DIV>> </DIV>
<DIV>> But this is exactly what the new program will work to change, by
providing</DIV>
<DIV>> standards for appropriate care linked to the costs of treatment and
the</DIV>
<DIV>> quality of the doctor's performance compared with that of other
doctors.</DIV>
<DIV>> </DIV>
<DIV>> Maybe Arkansas's biggest challenge was getting the state's insurers to
work</DIV>
<DIV>> together. On that, it has succeeded. Arkansas's two biggest
private</DIV>
<DIV>> insurers, Blue Cross Blue Shield and QualChoice, are on board
with</DIV>
<DIV>> Medicaid. But there is one big player missing: Medicare. To really
make</DIV>
<DIV>> this innovation effective, the federal government should join
in.</DIV>
<DIV>> </DIV>
<DIV>> In the meantime, even as the state is working on implementing
bundled</DIV>
<DIV>> treatments for a first round of medical conditions, it is gearing up
with</DIV>
<DIV>> the second round. If Arkansas succeeds - even partly - it will show
the way</DIV>
<DIV>> for the rest of the country.</DIV>
<DIV>> </DIV>
<DIV>> -- </DIV>
<DIV>> Art Deco (Wayne A. Fox)</DIV>
<DIV>> art.deco.studios@gmail.com</DIV>
<DIV>> </DIV>
<DIV>> </DIV>
<DIV> </DIV>
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