The Labels that Matter Most

One of the more intriguing elements in Campaign 2016 is the positioning of the candidates in the wide, and somewhat confusing, political spectrum. In last Monday's debate, Bernie Sanders called himself a "democratic socialist" and Secretary Clinton called herself a progressive "who likes to get things done."

In the two preceding GOP debates, the tag "conservative" was prominently used by all 15 presidential aspirants to describe themselves, and the term "moderate" was assigned to some of these by journalists in their post-mortem commentaries.

Politicians know the power of labels. They allow candidates to describe their political philosophy in shorthand, and are indispensable in negatively characterizing their opponents when a label carries a negative connotation. It's not a new game: in George Smathers 1950 Florida Senate race against the incumbent Claude Pepper, Smathers accused Pepper of being a "shameless extrovert who practiced nepotism with his sister–in–law…and before his marriage habitually practiced celibacy." Smathers won the race, with many attributing that success to his "redneck speech."

In healthcare, we use labels to shape perceptions in much the same way. In the '80s, the label "community hospital" was removed from most hospitals in favor of "medical center" to convey higher specialization. In the '90s, "managed care" came to mean everything from staff model health maintenance organizations to capitated payments to independent practitioner associations (IPAs) and more. And in the last decade, the promise of large molecule–based drug discovery morphed from "personalized medicine" to "customized therapeutics" to "precision medicine" and so on.

Since the passage of the Patient Protection and Affordable Care Act (March 2010), aka Affordable Care Act (ACA), aka ObamaCare, a number of labels have been prominent in national discussion. Like most, they're used as shorthand and sometimes inaccurately. These are the seven labels used widely in health reform vernacular that are sometimes misused or often misunderstood:

1. "Alternative payments" – In January, 2015, CMS announced it intended to spend 50% of Medicare funds in alternative payment programs. That's code for three major programs: accountable care organizations, bundled payments and the hospital value–based purchasing programs. They're the tri–fecta referent for "alternative payments" and the road from "volume to value" that Medicare intends to lead. The label, "alternative payments," is primarily focused on the three, not the assortment of shared savings and other programs sometimes referenced by industry leaders.

2. "Value" – In classic economic theory, "value" reflects the relationship between quality and cost. But in healthcare, quality is not systematically defined and costs are not easily measured. If quality was narrowly associated with accuracy of diagnosis, appropriateness of treatment, and outcomes, it would be simpler but not easy. And if costs were defined within a consistent time period (two years or 90 days) for a given intervention and overhead (fixed costs) allocated consistently, value might be more easily measured in our system of payments. The "value" label is elusive in our system: more attention is needed to assure calculations are systematic and comparable.

3. "Accountable Care Organizations" – In the ACA, Section 3022 is the "Medicare Shared Savings Program" which provides incentives for "clinically–integrated networks of providers" to take financial risk for managing at least 5,000 Medicare fee–for–service enrollees for a period of three years. More than 400 organizations participate in that program. But additionally, "accountable care organizations" is now used to describe a wide range of risk sharing deals between providers and employers and commercial insurers. And accountability in these varies widely from bonuses to significant financial risk. So "accountable care organizations" is a catch–all label for a widening variety of deals between providers and payers.

4. "Integrated Health System" – A legal entity that includes a hospital, outpatient and post–acute services, and a physician organization in a tightly–organized legal structure is an integrated delivery system (IDS). By contrast, adding a health insurance plan makes the IDS an integrated health system (IHS). The label IHS is appropriate to Kaiser, Intermountain, Carle Clinic, Presbyterian and other organizations that operate health plans alongside their care delivery activities.

5. "Access" – In the context of health reform, "access" was contextualized as a synonym for insurance coverage, but being enrolled in a Medicaid program is no guarantee an individual is able to see a physician. Access in the larger context of health services research is about access to primary care services and specialty care as required. In many states, individuals enrolled in Medicare and Medicaid lack access to providers, though they're "insured." The label "access" will come to mean more than insurance coverage.

6. "Primary Care" – To the chagrin of physicians who practice in family medicine, general internal medicine and pediatrics, the label "primary care" is assumed to include advanced practice nurses who practice in a variety of retail and clinic settings, pharmacists and others. And employers and insurers are expanding it to include dentistry and mental health. "Primary care" means much more than physician–directed care.

7. "Population Health Management" – Every health insurer and health system is providing "population health management" along with a plethora of technology–enabled outsourcing companies like Evolent, Healthways and others. In its most prominent context, the label is used to describe a set of care coordination efforts targeted to those with chronic conditions. In others, it's used to describe activities that target any subset of consumers who share a common diagnosis (Crohns Disease, Hemophiliacs, et al). Populations may be defined broadly or narrowly across the range of healthiness, and management may include any set activities deemed necessary to coordinating their care for purposes of improving their health status at the lowest cost. It's a label that confuses many: defining which population is being managed is necessary to void its ambiguity.

Labels allow us to quickly describe a big idea, but in healthcare they may be contributing to the public's confusion. We call teaching hospitals that sponsor residency programs "academic medical centers" though no research and undergraduate medical education is provided. We use "quality of care" to mean whatever we wish, and we describe U.S. healthcare as a system though it's fragmented and disconnected.

Leaders in our industry must be careful in using labels. They matter.

Paul

Source: Swint, Kerwin C., Mudslingers: The Twenty–five Dirtiest Political Campaigns of All Time, Praeger Publishers, Westport, CT, 2006

The opinions expressed in this article are those of the author and do not necessarily represent the views of Navigant Consulting, Inc. The information contained in this article is a summary and reflects current impressions based on industry data and news available at the time of publication. Any predictions and expectations noted herein are inherently uncertain and actual results may differ materially from those contained in this article. Navigant undertakes no obligation to update any of the information contained in the article.

©2015 Navigant Consulting, Inc.