Tom Dougherty, FACHE, Principal, has extensive expertise in risk-based coordinated health care delivery models, health plan network management and administration of hospitals, nursing homes, and home health.

COPE Health Solutions draws on Tom’s experience and knowledge for its health system clients that are developing or enhancing their risk-based care and capitation models.

Why do you enjoy working in the health care industry?

The health care industry attracts intelligent, highly educated and motivated people who care about people and their communities.

Health care is an exciting industry with incredible complexity and significant challenges that are ever changing. Health care is a team sport: whether engaged in population health, hip replacement surgery, skilled nursing care, health plan services or a doctor’s office visit, the resources, technology, coordination of services and ensuring the safety of the patients is complex and requires providers to work as a team. Health care is not boring.

What are your favorite aspects of your role at COPE Health Solutions?

Superior people produce superior results. I get to work with an incredible team that delivers excellent work and achieves exceptional results. The clients and projects afford me the opportunity to apply my experience, knowledge, business acumen and talents to make a difference through the building of risk-based coordinated care delivery models.

What are your thoughts on transforming health care?

The health care industry has plenty of opportunities for improvement. Change does not come easy to health care, and most organizations only change when left with no other choice. It was fortunate that the proposed repeal of the ACA failed, as these efforts are evident that organizations that have built their businesses on the principles of fee-for-service and volume will not change without a fight. Despite the fact that health care transformation views unnecessary volume as unnecessary and wasteful, it is the livelihood of these organizations.

People forget why the ACA originally passed. The ACA lowers overall health care costs. This has been true, despite recent years in which costs have started to escalate again. The ACA established coverage for essential health benefits, like treatment for mental health, addiction and chronic diseases. In addition, it eliminated preexisting conditions, allowed adult children to stay on their parents’ health insurance plans until age 26 and set up insurance exchanges that have benefited millions of previously uninsured people. The ACA also provides tax credits to individuals and small employers, promotes value-based payments, and will eliminate the Medicare “donut hole” gap. Most Medicare Part D prescription drug plans cover enrollees to a certain dollar threshold. Above this threshold, enrollees have to pay all costs out-of-pocket for their prescriptions up to a yearly limit. The gap between the threshold and the yearly limit is the donut hole.

Finding a compromise in health care policy will not be easy and there are no simple solutions. Here are a few examples of the choices and challenges our legislators face:

• Medical saving accounts – these work for those with decent wages, but not for lower income individuals that struggle to feed their families.
• Consumer driven health care – these are code words for “shifting costs – higher copays and deductible to the consumer.” This is a proven strategy to lower health care costs. As a rule, the more the consumer pays for health care, the less they purchase. Consumers avoid expensive procedures that eventually cause more health issues. Large deductibles also drive higher bad debt, especially for hospitals.
• While the elimination of preexisting conditions looks like it will continue, affordability remains unclear. If healthy individuals are not included in the insured pools, the pools will be unsustainable because they will be high-risk with adverse selection. It is strange that, while everybody must purchase car insurance, which helps spread the cost/risk of those that have accidents over those that do not; the principle of spreading the cost/risk of the sick over those that are healthy, is ignored for health care coverage.

Here is what we do know:

• The fee-for-service model’s quest for volume will continue to drive up health care costs. The more services provided, the more revenue one makes.
• Risk-based coordinated care provides higher quality care at a lower cost. It disrupts the business models of many health care providers, and is by no means easy to do well.

Fee-for-service care delivery models will escalate health care costs faster. Better options are coordinated care models, in which health care providers and payers are aligned.

What is your specialty in health care and what are some of your thoughts on this subject?

I specialize in building and managing risk-based coordinated care systems. In many markets, coordinated care is disruptive to the established business models, the status quo, causing some people and organizations to get upset simply because there are changes. Coordinated care changes the way we think about the delivery of medical services, and sparks thought-provoking questions, such as: where would be the best place to provide the care; when would be best time to provide the care; can the service be provided in a more economical setting?  Due to these changes, many existing organizations may no longer provide valuable services in a coordinated care model, causing additional frustration amongst those people and organizations that may have their livelihood threatened.

I remember in 1982 how many people thought the great American health care system was ending. DRGs started that year. I believe there will be many more changes, more struggles and more conflicts. Health care as an industry will continue and it will keep changing. We need to campaign to make the right changes. We need to change the health care system to focus on the health of the population and value, not fee-for-service and volume.

We need integrated health care, not dis-integrated health care.

Contact Tom Dougherty at tdougherty@copehealthsolutions.com or 909.238.9898 and read his full bio here.