do physicians and administrators see eye to eye? new york, ny ... ibm, research triangle park, nc...

Volume 7, Number 5 May, 2016

Published by Health Policy Publishing, LLC ● 209-577-4888 ● www.AccountableCareNews.com

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Putting the Collaborative in Collaborative Care By Wayne Sensor

s more organizations participate in accountable care organizations (ACOs) and other risk-based initiatives, the need for cross continuum communication grows. It is well documented that without robust care coordination between settings, the chances of care lapses, duplicative care and adverse events—such as medication errors—

increase. Since the primary tenets of accountable care are improving quality while reducing costs, organizations must work together to avoid any situations in which those goals could be compromised.

Adding to the existing push for cooperation is the introduction of reimbursement programs that give some financial backing for accountability. Medicare Shared Savings was an early entrant into this space, which has bred several other bundled payment arrangements, all of which are voluntary. However, more recently, the Centers for Medicare and Medicaid Services launched its Comprehensive Care for Joint Replacement (CJR) model, which for the first time, requires organizations to work together to maintain quality and limit costs. Although the CJR model mostly applies to hospitals, it is a bellwether for other initiatives that will require different care settings to embrace risk and either be financially rewarded or penalized for doing so. Going forward, organizations may no longer have a choice as to whether or not they participate in risk-based models, providing an even more compelling reason to collaborate.

Purchasing Care Providers Isn’t Enough

Some hospitals, health systems and larger group practices are trying to boost care coordination by entering into purchase arrangements and other financial agreements with various providers across different settings. However, just because a group of care providers is financially connected does not mean they communicate well or provide cohesive patient care. This requires an intentional alignment of priorities and a commitment to share information with one another and within partnering organizations.

To that end, there are some core elements that have to be present if a group of disparate providers is going to be successful with care coordination.

Do Physicians and Administrators See Eye to Eye? By John Gramer

he answer is yes, according to the 2016 Cejka Search Healthcare Perspectives study of 1,621 practicing physicians and healthcare administrators. In the study, respondents were asked to rank the

importance of ten healthcare delivery priorities. The results showed close alignment among physicians and administrators on both the highest and lowest priorities for care delivery in a post-reform environment. For example, both physicians and administrators rated effective patient communication as the highest priority issue and working with health plans the lowest.

Patient Experience: A Common Theme

Patient communication and collaboration with other providers rose to the top of the priority lists for both groups, indicating strong support for a team-based approach to care with the patient as the focus.

“Effective patient communication” was ranked the number one priority for both,

defined in the survey as “explaining medical information, such as care plans, medications and patient responsibilities, in a way that patients understand and improves patient compliance.” In addition, both groups ranked “collaboration with advanced practitioners and other providers” as part of the top three priorities.

(continued on page 4)

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In This Issue

1 Do Physicians and Administrators See Eye to Eye?

1 Putting the Collaborative in Collaborative Care

2 Editor’s Corner: James Edwards on Eliminating Barriers in Healthcare with Telemedicine

3 Creating Curriculum to Create Change: What is Nursing Doing to Promote Population Health?

8 Thought Leader’s Corner

9 Subscriber’s Corner

10 Industry News

12 Catching Up With … Bryan

R. Cote, MA


https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-11-16.html

2 Accountable Care News May, 2016


Accountable Care News

May, 2016 – Volume 7, Issue 5

ISSN 2166-2770 (Electronic)

ISSN 2166-2738 (Print)

National Advisory Board

Peter Boland, PhD President, Boland Healthcare, Berkeley, CA

Emily D. Brower, MBA Vice President, Population Health Atrius Health, Newton, MA

Lawrence P. Casalino, MD, PhD, MPH Livingston Farrand Associate Professor of Public Health, Weill Cornell Medical College, New York, NY

Wes Champion, Senior Vice President, Premier Consulting Solutions , Charlotte, NC

Charles A. Coleman, PhD, CMPH Worldwide Healthcare Solutions Senior Executive -- Providers/ACO/Bio- Surveillance/Clinical Research AMRC IBM, Research Triangle Park, NC

Don Crane, JD President and Chief Executive Officer, CAPG, Los Angeles, CA

Duane Davis, MD Vice President, Chief Medical Officer, Geisinger Health Plan, Danville, PA

William J. DeMarco, MA, CMC President and Chief Executive Officer, Pendulum Healthcare Development Corporation, Rockford, IL

Douglas A. Hastings, JD Chair Emeritus, Epstein Becker & Green, PC , Washington, DC

Vince Kuraitis, JD, MBA Principal, Better Health Technologies, LLC; Author, e-CareManagement Blog Boise, ID

Michael L. Millenson President, Health Quality Advisors, LLC, Highland Park, IL

Ann Robinow President, Robinow Health Care Consulting, Minneapolis, MN

_________________________________________

Publisher Clive Riddle, President, MCOL

Senior Editor Raymond Carter

Accountable Care News is published monthly by Health Policy Publishing, LLC. Newsletter publication administration is provided by MCOL.

Accountable Care News 1101 Standiford Avenue, Suite C-3 Modesto, CA 95350 Phone: 209.577.4888 Fax: 209.577.3557 [email protected] www.AccountableCareNews.com

Raymond Carter, Senior Editor, Accountable Care News

We continue with our op-eds and brief reports from the field this month with a commentary from Dr. Robert Phillips, Jr. on measures for payers.

James B. "Jamey" Edwards, MBA

Chief Executive Officer Language Access Network Santa Monica CA

Eliminating Barriers in Healthcare with Telemedicine

There is no doubt that technology is dramatically impacting the healthcare industry. Whether it’s mHealth, digital health, big data, telemedicine or EMRs, these technologies are the new medicine, and are being integrated as a regular part of our care continuum. These advances are driving an unprecedented period of industry innovation and creating new ways to increase access to safer and more reliable care.

While some of these technologies are in their infancy, telemedicine, in particular, is one whose time has come. Telemedicine provides real solutions that are improving healthcare today by breaking down countless barriers, building connections between patients and providers, reducing disparities and building a new world of on-demand healthcare.

One of the most basic barriers to equality in healthcare delivery and outcomes across diverse patient populations is communication. For many physicians, the difference between a high-quality patient encounter and a poor one hinges on whether a proper patient history can be taken and how well the patient can communicate their issues directly to their provider. Communication rightfully brings the patient into the care team, empowering them to positively impact their own care. Without it, providers must rely on diagnostic testing alone to build evidence for their care decisions.

As an exercise, spend a few hours of your workday trying to get basic things done without communication. This is the challenge that 1 in 5 patients face every day in the U.S. Being in a hospital is scary enough when you speak English but, for patients who are Limited English Proficient, Deaf or hard of hearing, the experience can be downright terrifying. Studies have shown that these patients do not receive the same standard of care as their English-speaking counterparts and are more likely to encounter harm due to lingual and cultural barriers.

An interesting case study happened last month, when more than 27,000 athletes from all over the world converged on Boston, Massachusetts for the 120th Boston Marathon. The marathon has dozens of medical stations staffed by more than a thousand professionals and volunteers who speak English. In the event that a runner needs medical care but doesn’t speak English, the situation has the potential to become increasingly complicated for the medical providers and dangerous for the race participant.

For the first time ever, the Boston Marathon selected a language services company to provide remote video interpretation before, during and after this year’s race in its main medical tent and dozens of medical stations throughout the course.

Language Access Network (LAN) deployed its Martti™ (My Accessible Real-Time Trusted Interpreter) technology to instantly connect the marathon’s medical providers with highly trained medical interpreters who speak and sign more than 250 different languages. This HIPAA-compliant video interpretation technology provides patients and providers with instant access to interpreters who can bridge the communication gap. LAN provides such services more than 60,000 times per month for hospitals nationwide.

Put simply, telemedicine solutions like Martti eliminate barriers to providing quality medical care at the push of a button for Limited English Proficient, Deaf and hard of hearing patient populations.

Editor’s Corner


mailto:[email protected]

http://www.accountablecarenews.com/

May, 2016 Accountable Care News 3

© 2016, Health Policy Publishing, LLC. All rights reserved. No reproduction or electronic forwarding without permission. page 3

Creating Curriculum to Create Change: What is Nursing Doing to Promote Population Health? By Katie Hooven, PhD, RN, MBA, CAPA, CNE; Tracy Perron PhD, RN, CNE, CSN; and Sharon K. Byrne DrNP, APN, NP-C, AOCNP, CNE

urses are considered the largest body of healthcare providers in the United States which gives them a great advantage to be involved with patient care decision making. Nurses are employed in a variety of settings including acute care, long term care, community settings, rehab, primary care, public health, school health, employee health, along with

many other roles. Nurses have always been trained to assess the whole person, family, and community that surrounds them. The goal of nursing is to promote health and wellness, while caring for and educating the ill. The overall goal of the Population Health program is to improve health and wellness in our patient populations. This is achieved by understanding health outcomes and the determinants that impact these outcomes.

Already established with the Affordable Care Act (ACA) is the notion that healthcare needs to improve overall heath, while decreasing costs.1 Nurses play a very important role in healthcare improvement, along with cost containment. Registered Nurses are currently educated at two levels, the four-year baccalaureate degree, and the two-year associates degree. Schools of nursing have been challenged with preparing nurses with the skill set they need to succeed in todays healthcare field. Understanding population health and the impact it has on accountable care is everyone’s responsibility.

The school of nursing, health, and exercise science identified the major strengths and resources already in place in the nursing curriculum to prepare nursing students to engage successfully in providing population based health care. An interprofessional advisory group was formed to identify areas that needed improvement, together with input from community

and population health practice partners. At issue is that the provision of population based health care requires additional knowledge and a set of skills not typically addressed in BSN curricula sufficient for students to develop competency. It also requires that nurses (a) understand the broader issues involved in determining health, (b) be able to approach solutions or interventions from that broader perspective as well as existing research evidence or best practices and (c) be able to mobilize existing community resources in the service of better health outcomes.

The curriculum change is focusing on developing both faculty and student knowledge, establishing learning objectives, and offering clinical experiences that will provide students with the learning opportunities needed to develop beginning competencies in practicing population-based health care with emphasis on the defined deficits. The initiative has three major components. These are (1) Faculty Development, (2) Content and Learning Object Development/Implementation, and (3) Laboratory (Simulation) and Clinical Experience Development and Implementation.

1. Faculty Development -- The school of nursing has committed to sending faculty members to conferences to enhance personal knowledge of population health. Faculty members have been attending conferences that include interprofessional groups of healthcare providers. Content experts in the field of population health have been invited to the school of nursing to review curriculum and inform the early adopters. The school of nursing has also utilized the train the trainer model and have been sharing success in faculty meetings,

2. Various learning activities have been developed which gives the students a broader perspective on nursing care and informs them of the changes healthcare is undergoing. The faculty have also implemented more database-based assignments which allows students to look into public databases and draw conclusions based on their findings.

3. The last part to the curriculum change is connecting what the nursing students learn in the classroom with simulation and real world experiences. The school of nursing has established community partnerships which gives students an opportunity to apply the principles learned in the classroom the simulation/community settings.

Overall, the goal of the curriculum change is to better prepare the largest body of healthcare providers by incorporating additional learning activities to inform them of the changing healthcare landscape. Improving patient health outcomes, while decreasing expenditures is everyone’s responsibility, and with nurses on the forefront of patient care, it it important to include them in these changes.

Dr. Katie Hooven is Clinical Coordinator for The College of New Jersey in Ewing Township, NJ. She may be reached at [email protected]. Dr. Tracy Perron is an assistant professor there and may be reached at [email protected]. Dr. Sharon Byrne is also an assistant professor there and may be reached at [email protected].

Reference:

1. A more secure future: what the new health law means for you and your family. The White House. Available at:

http://www.whitehouse.gov/healthreform/healthcare-overview.

The school of nursing has established

community partnerships which gives students an opportunity to apply the principles learned in the

classroom the simulation/community

settings.

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At issue is that the provision of population

based health care requires additional

knowledge and a set of skills not typically addressed in BSN

curricula sufficient for students to develop

competency.




http://www.whitehouse.gov/healthreform/healthcare-overview



Do Physicians and Administrators See Eye-to-Eye?.…continued from page 1

The only difference in the top three rankings is “being viewed as a partner in patients’ long-term well-being,” priority number three among physicians, and “customer service orientation” ranked number two among administrators.

Even where rankings differed, there was a common theme -- the patient experience. Physicians were focused on collaborating with patients to achieve long-term wellness versus episodic care, while managers appeared to take the broader view of overall patient satisfaction.





Business Acumen Traits Revealed as Lowest Priorities

While all ten traits were ranked as high priorities by at least half of respondents, when force-ranked, business acumen traits fell to the bottom of the list for both groups. These included: “working knowledge of health insurance requirements,” “the ability to negotiate and influence health plans to cover procedures believed to be in the best interest of the patient,” and the “use of technology to practice medicine more efficiently.”

The fact that these are recognized as priorities for healthcare delivery but fall outside of the most important behaviors for physicians, underscores the need for broad collaboration across functions -- not just intra-care team collaboration but also collaboration between clinical and business operations, such as finance, technology, care utilization, and case management.

Opportunities for Greater Alignment

The study also uncovered opportunities for greater alignment among the two groups related to the definition of quality metrics and patient satisfaction goals.

The Need for a More Meaningful Definition of Quality

While there is significant support among physicians for a value versus volume approach, physicians expressed the need for more meaningful definition and measurements of quality. For example, one physician stated, “Most are still quantity-based metrics disguised as value,” referring to facility outcome goals. Another physician explained, “We risk quality when we focus on desired outcomes that are not founded on medical evidence.”

As a result, there was a 20-point difference in how important administrators and physicians viewed “achieving quality metrics set by your facility.”

Achieving Quality Metrics Set by Your Facility

Patient Satisfaction Goals at Odds with Evidence-Based Medicine

The Cost of Satisfaction Study conducted by Joshua J. Fenton, MD, MPH, in 2012, established a correlation between higher patient satisfaction scores and increased utilization of healthcare services. Healthcare experts credited the link to clinicians’ increasing desire to accede to requested treatments to please public and private payers, which had increasingly tied their reimbursements to patient satisfaction.

At present, with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores publicly reported and impacting one to one-and-a-half percent of a provider’s revenues, survey respondents indicated that patient satisfaction goals, evidence-based medicine and reimbursement incentives may be at odds.

Physicians stated:

“The notion that patient satisfaction equals good patient care is flawed.”

“Trying to please patients can actually lead to additional costs and run counter to quality care.”

Meanwhile, the shift towards evidence-based, standardized care as a way to improve overall clinical outcomes while lowering costs emphasizes prudent use of services and placing patients in appropriate care settings. Both of which may be counter to the wishes of the patient and/or family members.

Mutual Understanding of Roles

With physicians and administrators bearing much of the weight of the industry’s transformation, it is not surprising that some respondents expressed frustration in the way they believe their roles are being perceived.

Copyright 2016 by Health Policy Publishing, LLC. All rights reserved.

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Of interest are the common themes expressed among both groups – both feel as though they are being held accountable for things they cannot control; both desire to be treated as more of a partner; and both feel the value of their roles are somewhat underappreciated.

Creating a Culture of Collaboration

Some of the advice offered by physicians and administrators for fostering greater collaboration between the two groups includes:

1) Nurture dyad leadership by coupling clinical experts with experts in workflow engineering, information technology, metrics management and financial reporting, to accelerate transformation and innovation.

2) Provide clinically-oriented training for more administrators so they can better understand the day-to-day demands of direct patient care.

3) Provide physicians with individual performance metrics, relative to facility and national peer groups, in order to empower them to more actively contribute to organizational goals.

4) Create cross-functional teams and committees to tackle transformational initiatives, including administrators, department managers, physicians, nurses, case managers, therapists, technicians and other staff members, for improved processes and employee engagement.

5) Involve clinicians in setting the agenda and key performance indicators for new care models, such as quality outcomes, value-based incentives, evidence based medicine practices, and clinical technology requirements. Rely on these clinical ambassadors to communicate the goals and rationale behind these initiatives with peers for improved physician engagement.

There is immense potential for physician contribution to creating solutions for today’s healthcare challenges. One doctor stated, “We understand delivery of care better than anyone and can be valuable resources in cutting waste and improving processes, if we are embraced as active participants in solving these problems.”

Forward-thinking administrators also recognize the potential in harnessing the strength of various healthcare resources. As one chief executive officer commented in the survey, “The best administrators I know value and engage their physicians in

creating facility standards and policy.”

John Gramer is president of Cejka Search, a nationally recognized physician, allied health and healthcare executive search firm specializing in healthcare for more than 30 years.

Of interest are the common themes expressed among both groups – both feel as though they are being held accountable for things they

cannot control; both desire to be treated as more of a

partner; and both feel the value of their roles are

somewhat underappreciated.

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June 9 - 10, 2016 -- Grand Hyatt – Washington, DC Offered as part of National Payment and Delivery Reform Week

Eighth National Medical Home Summit – June 6-7, 2016 | • Sixth National Bundled Payment Summit – June 7-9, 2016

Pharmaceutical Summit on Business and Compliance Issues in Managed Markets – June 8-9, 2016

www.ACOsummit.com



Putting the Collaborative in Collaborative Care.…continued from page 1

Integrated care management. To effectively manage care, all those involved in a patient’s treatment must be able to see and interact with the care plan. This allows the group to stay abreast of what’s happening with and to the patient, as well as weigh in on care decisions that arise; technology is essential to enable this level of collaboration. Organizations should look for solutions that integrate with their electronic health record (EHR) and unite care team members across the continuum, including primary care physicians, care managers, home health nurses, long-term care providers, pharmacies and family members. By leveraging this kind of technology, organizations create a command center of sorts that facilitates cooperation, information sharing and care monitoring.

Evidence-based care. Protocols that guide providers in delivering comprehensive and consistent patient treatment are one of the hallmarks of accountable care. These ensure that patients with certain conditions receive timely and targeted interventions that have been proven to be effective. When used reliably, evidence-based protocols almost guarantee that every patient receives the right care at the right time. Finding ways to employ evidence-based medicine is a good strategy for ramping up quality while keeping costs in check. Once again, technology can be helpful because it prompts providers to use evidence-based protocols at the point of care. For example, if a patient comes in for a visit with elevated blood sugar, an automated solution tied to the EHR reminds the care provider to follow a series of protocols for diabetes that not only address the patient’s current condition but enable stronger chronic care management down the line.

Risk stratification. Not every patient requires the same degree of attention. For example, the 65-year-old patient with no

chronic conditions who regularly schedules his annual physical and seems committed to managing his health does not need the same level of monitoring as the 65-year-old patient with congestive heart failure and diabetes who has struggled to manage his weight and often skips appointments. Organizations can better focus their already stretched resources by leveraging data analytics to segment patients into risk categories and prioritize attention to the most at-risk individuals. These are the folks who are most likely to have an acute care episode, unnecessary hospital readmission or other negative health event.

Going one step further, risk stratification technology can send alerts to all members of a targeted patient’s care team when certain criteria are met, such as an unexpected weight change, skipped appointment or high blood pressure or blood sugar reading. After receiving the alert, the care team can regroup about the need to intervene and/or escalate care.

Engaged patients. Research shows that the more engaged patients are in their care, the better their health outcomes.

Unfortunately, the patient is a key member of the healthcare team who is often overlooked. There are several ways that organizations can get patients on board. First and foremost, providers should deliver relevant education to patients about their conditions and what their roles should be in addressing their health. Patients should have a full understanding of what’s necessary to improve their health and be positively encouraged to take an active role in doing so. To further foster patient participation, providers may want to grant individuals access to their care plans and allow them to share information with other care team members. Technology solutions are available that facilitate this exchange, letting patients send messages to providers as well as enter vital information into their care plans, such as daily blood pressure readings or weight changes. Not only does this help the patient feel more involved, it also gives critical information to the care team that they would not be able to obtain elsewhere.

Data analytics. To sustain performance over time, care team members must have access to quality metrics and cost information. This will help the group identify opportunities for improvement and target interventions to raise the bar on performance. For instance, organizations that regularly review readmission rates by provider or condition can pinpoint opportunities to provide preventive care and reduce costly episodes. Similarly, providers that look at frequently missed care path items can identify interventions that need to be tweaked or individuals that require a little more attention. Referral rates are another key metric to review, so organizations can get a sense of who is seeking care inside and outside the ACO.

A Challenging But Manageable Endeavor

Although it’s easy to say that care providers must collaborate, it becomes more difficult when they actually try to do it. However, by using technology that allows seamless communication among care team members, segments risk and empowers patients, organizations can take a step closer to delivering truly accountable care.

Wayne Sensor is Healthcare Advisor to Ensocare, which provides care coordination solutions to help manage patient care transitions, reduce length of stay and reduce readmissions. He may be reached at [email protected].

Eliminating Barriers in Healthcare with Telemedicine.…continued from page 2

While most of us are familiar with the direct-to-consumer telemedicine applications like Teledoc or Doctor On Demand, telemedicine is also being used to tackle other types of healthcare disparities. In underserved rural and urban hospitals, telemedicine makes it possible to access providers in a broad variety of specialties like neurology to aid in stroke cases, intensivists for ICUs and mental health for patients in need..

All of these telemedicine applications work to save lives by removing hurdles to the effective and efficient delivery of high-quality healthcare for all patient populations. Telemedicine, and other medical technologies like it, are forging a path into the future of healthcare by increasing patients’ treatment options, driving more satisfying experiences and improving outcomes, all while reducing costs. Healthcare’s new quadruple aim.

Jamey Edwards can be reached at [email protected].

http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_86.pdf





Each month, we ask a panel of industry experts to discuss a topic of interest to the accountable care community.

Q. Your initial reaction to the CMS proposed rule for implementation of MACRA?

“Most experts will agree that the new payment system taking effect in 2019 is a significant improvement from the SGR formula. While there will be some “winners” and some “losers” under the new system, providers will be rewarded for delivery high-value care and given options for rewards for demonstrating performance improvement.

Those physicians adopting what are considered Advanced Alternative Payment Models (APMs) will have a more favorable annual payment update (5 percent) than other providers, although it is estimated that perhaps less than 5 percent of providers will meet the eligibility requirements in the early years for Advanced APMs under MACRA. All other providers required to report through the Merit-based Incentive Payment System (MIPS) will have their reimbursement increased or decreased -- ranging from -/+ 4 percent in 2019 and increasing to -/+9 percent by 2022 -- based on their performance across four domains. Providers will be benchmarked against each other to establish these payment adjustments; as a result, nearly half of physicians will see some reduction in their Medicare payments.”

S. Lawrence Kocot, JD, LLM, MPA

Principal and National Leader, Center for Healthcare Regulatory Insight, KPMG, Former Senior Advisor to the Administrator, CMS Washington, DC

“While we applaud CMS for continuing to push towards payment for value in population health, we are concerned about unintended consequences of having the opposite effect due to the complexity of MIPS and the exclusion of Track 1 MSSP from the “Advance Alternative Payment Model” definition. We continue to believe strongly that having invested far more (tens of millions of dollars) than shared savings has returned to date represents significant downside risk to our organization, which would otherwise meet all the criteria as an advanced APM. The level of downside risk required as a two-sided ACO is not surmountable for us with only one year of results under our belt, even though it was a successful first year! We were glad to see that there is still some benefit given to ACO participation under MIPS, and that the measure domains of both MIPS and Advanced APMs otherwise continue to align with the investments our DVACO providers have been making in both technology and care model transformation across the continuum. However we are concerned about the sustainability of ACO investments (the only model fully supporting population based outcomes) under the proposed rules as well as multiple competing more limited models such as CPC+ and bundled payments.”

Katherine Schneider, MD, MPhil., FAAFP

President and CEO Delaware Valley Accountable Care Organization Radnor, PA

“Two things are clear. First, the implementation of MACRA, a law passed with overwhelming bipartisan support, will determine the future of ACOs. Second, clarity of Congressional purpose -- the creation of APMs -- is anything but clear in the details of implementation. There may yet be an industry backlash over this complexity that endangers the evolution of ACOs into APMs.”

Michael L. Millenson

President Health Quality Advisors, LLC Highland Park, IL

Thought Leaders’ Corner



“AMGA appreciates that CMS has engaged with the stakeholder community and understands that implementing MACRA will be an ongoing process. AMAGA is reviewing carefully the proposed MACRA rule and is in the process of surveying its membership to determine their readiness to participate in a risk-based Medicare program. The MACRA legislation and proposed rule represents the one of the most significant and far-reaching changes to the Medicare program since its inception. AMGA members are experienced in providing the type of integrated care that the law envisions, but as proposed in the rule, it will be challenging to qualify as an Advanced Alternative Payment Model, as Track 1 Accountable Care Organizations are excluded and the Patient-Center Medical Home option only is open to those with 50 or fewer clinicians.

Risk-based payments also are a new environment for many providers and AMGA remains concerned that there is little time for our members to prepare. The MACRA proposed rule will be finalized this fall, but data collection and reporting, which will determine payment levels, will begin in January 2017. This is aggressive timeline for providers to make any necessary changes and upgrades to their Electronic Health Records system, revise their care management processes, or ensure they are appropriately staffed to not only provide care, but to analyze the data that will inform strategic decisions.”

Chester A. “Chet” Speed, J.D., LL.M.

Vice President, Public Policy American Medical Group Association Washington, DC

“As indicated by the positive response by physician associations, such as the AMA and AAFP, to the MACRA implementation proposed rule, it’s clear that it is ‘physician-friendly,’ providing a lot of flexibility with regard to performance metric selection and de-emphasizing Meaningful Use. The proposed rule clearly tilts the table toward the Merit-based Incentive Payment System and away from Alternative Payment Models. The de-emphasis of Meaningful Use for physician practices could perpetuate the divergence in EHR adoption that exists between hospitals and physician practices. In addition, the proposed rule’s more strict APM policy -- which precludes bonus payments to physicians for upside-only ACO programs such as the popular Track 1 of the Medicare Shared Savings Program -- could make it more challenging for integrated delivery networks in the MSSP to achieve hospital-physician alignment.”

Ken Perez

Vice President of Healthcare Policy Omnicell, Inc. Mountain View, CA

Thought Leaders’ Corner

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Public Files for Pioneer ACO Performance Years 1-3

On April 22 CMS released Pioneer Model ACO Public Use Files (PUF) and Research Identifiable Files (RIF) for Model Performance Years 1-3. The PUF and RIF provide basic data that will enable research and policy analysts to conduct analysis of the experience and performance of participants in the Pioneer ACO Model.

The PUF and RIF each consists of three data files for each performance year: (1) Data on Participating Providers; (2) Data on Aligned Beneficiaries; and (3) Data on ACO Financial Performance. The PUF contains summarized data on Participating Providers and Aligned Beneficiaries. The RIF contains data that identifies individual providers and beneficiaries.

Findings From Leavitt Partners ACO Report

Writing in a recent Health Affairs Blog post, Leavitt

Partners David Muhlestein and Dr. Mark McClellan, now the Robert Margolis Professor of Business, Medicine, and Policy at Duke University and the Director of the Duke Margolis Center for Health Policy, analyze the findings of the Leavitt Partners ACO report released in January.

The 838 ACOs across the country have service areas in in all 50 states and the District of Columbia and have grown by 12.6 percent over the past year, serving some 28.3 million people in 1,217 identified accountable care contracts. But growth has been uneven, e.g. more than 20% penetration in the Northeast but 0-3% in Alabama and Mississippi. That said, they predict that ACOs will continue to grow, and “providers have begun to think about population-level payments as an eventuality as opposed to just a possibility.”

Anthem Reports $14.8 Million Savings from ACOs

Anthem Blue Cross in California recently reported that four medical groups in its ACO Enhanced Personal Health Care Program (EPHC) achieved $14.8 million in savings in just one year Across a variety of metrics related to inpatient care, outpatient care, professional costs and pharmacy expenditures, through a 7.7% reduction in inpatient days/1000 and almost a 3% decline in outpatient length of stay.

Additionally, prescriptions per 1,000 decreased 6.5% while the generic pharmaceutical prescribing rate increased 6.9

Anthem continued….

The four groups were the second cycle of the program, with savings similar to the first group. Anthem has 19 ACOs offering Enhanced Personal Health Care to members across California:

These four of the 19 medical groups participating in Anthem’s ACO program produced these collective results during the Oct. 1, 2013 to Sept. 30, 2014 time period: Cedars-Sinai, Humboldt IPA, UCLA Health and Torrance Memorial. These savings are in addition to the $7.9 million saved and previously announced with UC Davis, Sharp Rees-Stealy, Sharp Community, HealthCare Partners, Santé and SeaView.

Anthem provides member-level data in a secure fashion to each medical group so they can intervene with the sickest PPO members to provide more coordinated care. In addition to the information, Anthem pays each participating group a care coordination fee, which helps fund the additional clinical coordination and care.

Cigna Collaborates with Chicago’s Rush Health

Cigna has entered into a new collaborative care relationship with Chicago’s Rush Health. The program is part of Cigna Collaborative Care, a value-based model that uses incentives to engage health care professionals and drive improved health, affordability and customer experience.

As part of this program, registered nurse care coordinators employed by Rush Health will help individuals with chronic conditions or other health challenges navigate the health care system. Cigna will compensate Rush Health for these medical and care coordination services. In addition, Rush Health may also be rewarded by Cigna through a “pay for value” structure if it meets specified targets for improving quality and lowering medical costs.

“Cigna has seen first-hand the value our collaborative care arrangements can bring to individuals as well as to physician practices,” said Peter W. McCauley Sr., MD, regional medical executive for Cigna’s Northeast region, which includes the Midwest. “Cigna currently has 150 collaborative care relationships in 29 states, and we’re delighted that Rush Health is now one of our collaborative care arrangement partners.”

“This collaboration is consistent with our mission to improve overall patient experience and further enhance the quality of health care provided to our patients,” said Brent Estes, president and chief executive officer of Rush Health. “We are excited to participate in the Cigna Collaborative Care program.”

Industry News

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Catching Up With…continued from page 12

So-called medical homes and ACOs are emerging in creative and surprising ways: urgent care centers are being designated as primary care providers, and they are taking risk; health plans are allowing members to select urgent care as their PCP, and I would not be surprised if in 5 years members of both Medicare Advantage and commercial plans are electing very new types of organizations as their so-called PCP

Health plans are also changing reimbursement policies, paying a premium rate to in-network partial hospitalization and intensive outpatient substance abuse treatment programs for also addressing co-occurring depression. The market is responding too. In a case illustrating how primary care, behavioral health and schools need to integrate to get better outcomes, Integrated Wellness of New Haven Connecticut almost immediately made an impact in its market. Kids previously given ‘referrals’ to psychologists skipped appointments or if they went were unable to pursue further services because their school districts required specific testing. A frustrating cycle followed. But in one case the integrated wellness practice took a leap and it’s a model others should try. I covered this story in my Behavioral Health Hour blog.

I also think integration is happening in non-traditional settings, but those where the spiral of addiction and crisis first emerge. In Butte, Montana, a school district hired three case managers for its suicide prevention program and Rogers Memorial Hospital in Wisconsin appointed a medical director and operations director for behavioral health. See https://thebehavioralhealthhour.wordpress.com/ for other examples.

What will remain a challenge to payers and providers and these new types of medical homes and ACOs is how to transition patients safely and prevent a relapse. Integration is difficult without common agreement on outcomes measures. A patient with Bulimia should not be considered in remission if they are now drinking alcohol. A Medicare senior discharged from inpatient rehab due to a dehydration-induced fall should not be considered recovered if they return to addictive behavior, such as drinking, and if their PCP or home health aide isn’t focused on the root causes of the dehydration – the senior never dealt with the loss of her husband. I don’t think we get to integration from broad policy, but from local market collaboration and new models that focus on special populations who most benefit from behavioral/primary care.

Accountable Care News: If you were in charge of a research agenda on accountable care, what kinds of things would be the most important to study and understand? Bryan Cote: For starters, we need to understand what motivates those who are providing healthcare themselves and what

consequences are in place for not doing the right thing, and what rewards are in place for doing the right thing. We need to understand this of the full continuum – payers, hospitals, SNFs, doctors, and post-acute caregivers, as well as patients. I’m beginning a study of consumer, physician and payer attitudes about survival and cancer, for example, at what threshold is an additional month of quality life worth it, and who ought to be accountable for these decisions.

In the behavioral health arena, it’s most clear to me that there is a tremendous link between poor physical literacy in youth and links to costly behaviors and outcomes, from diabetes to depression to social consequences, like violence. We ought to better study the barriers and opportunities to bring more creative programs to schools and communities to reverse these costs before they occur. I did one such study in the fall that you can read here, but it only scratches the surface in my opinion.

Accountable Care News: As a student of health policy ad health reform, what’s your reaction to the latest arrows in the CMS quiver – Net Gen ACO, CPC+, and the MACRA proposed rule? Bryan Cote: It likely makes participating in the Next Gen ACO or CPC+ more attractive long term (i.e. 2020 and beyond),

particularly if you are a behavioral health type of organization. This regulation is very new and focuses on alternative payment methodologies. I believe we are already seeing tremendous activity in the commercial market around ‘alternative payment’ strategies, many of the earliest in oncology around 2009 when health plans like Regence BCBS retro-authorized preferred providers for developing and complying with evidence based protocols, or Highmark for reimbursing providers at ASP +20% for helping lower readmission rates.

Payment innovation has filtered into other services including primary care. A Medicaid MCO in Pennsylvania has offered a $400 PMPM to Care Connections, an outpatient primary care ‘home’ in the Lancaster Health System that closely works with Medicaid patients. The cost to the plan, $2400 over 6 months, is far less than a single admission. In the future, I see more innovation toward episodic based payments for substance abuse being a national policy priority, if and when we can come to consensus around outcomes measures and what constitutes recovery and a reasonable relapse rate.

Accountable Care News: Finally, tell us something about yourself that few people would know. Bryan Cote: I’m a writer by trade and am penning a novel called Losing Beats Winning, which will be published in another

year. You can read a snippet here from my essay on the Top 10 Movies About Losing: https://thelostcolumn.wordpress.com/2014/04/08/top-10-all-time-sports-movies-about-losing/

Check out the sister publications to Accountable Care News:

Health Innovation News and Health Insurance Marketplace News (semi-monthly)

Medical Home News, Population Health News, Predictive Modeling News,

and Readmissions News (monthly)

Go to healthpolicypublishing.com and have a look.

Multiple publication subscription discounts are available.

https://thebehavioralhealthhour.wordpress.com/2015/03/24/integrated-wellness-group-takes-case-to-schools/

https://thebehavioralhealthhour.wordpress.com/

https://thelostcolumn.wordpress.com/2014/04/08/top-10-all-time-sports-movies-about-losing/

http://www.healthpolicypublishing.com/

12


Accountable Care News: Berkeley Research Group has a pretty broad reach, both nationally and internationally. What kinds of research or consulting work are you currently engaged in? Bryan Cote: Our group is part of a broader healthcare consulting organization that helps payers and health systems and

states with clinical, compliance and operational performance improvement, and implementing new methods to link payment, reimbursement and compensation to quality. Many of our 300 some healthcare consultants are serving in interim roles inside hospitals or health plans, implementing change. Our group is focused, as we have largely been since the early 2000s, on helping healthcare companies handicap regulatory, reimbursement and market risk, through original studies and surveys of clinical, operations and policy decision-makers at the state, federal, managed care and local market provider level. With BRG’s expertise, we are also able to conduct compliance assessments. We like to think about risk and opportunity based on what we have learned from the past, like how payers responded to a Medicare policy or how physicians responded to a health plan policy change, and put this in context in assessing the likely scenarios over the next 5 years. Our team includes the former chief counsel of the U.S House of Representatives Ways & Means Committee, which has oversight of Medicare, a former principal at the Medicaid Payment & Access Commission, a former senior care and post-acute operations director, and myself, an investigative journalist, with experience as a publisher turned researcher.

Accountable Care News: You are the founder of a very different kind of accountable care organization. Tell us a bit about the Migrant Family Health Network. Bryan Cote: A little-known but large refugee population migrated from war-torn camps in Burma in 2007 to 6 U.S. states—

Texas, Arizona, Michigan, Delaware, Minnesota, and here in Hartford Connecticut where I live. These 1st generation families are, like the Irish immigrants who came to the US years ago, hard-working but have struggled mightily, facing economic challenges and cultural barriers. Most families here in Hartford did not for years have primary care or understand how to use it, mostly using the local hospital ED if anything. Many, with help from Catholic Charities, gained insurance through the Medicaid program, but in the years since migrating here, many of the young girls became young teens—going to school, learning the language, and in many ways, serving as de facto heads of household for their mom or dad or aunt who bravely brought them here. These kids have struggled with this balance, many facing mental stresses including post-traumatic stress disorder, eating disorders, clinical depression, and anxiety. In 2010, my family began volunteer teaching and coaching at a new middle school for underprivileged girls in Hartford that enrolled many students from this population. To complement the school’s mission, we developed an after-school sports, social and health support program for the girls that in three short years has helped reduce absences, ER visits and medical costs, elevated health literacy, and increased GPA and athletic achievements. This social-health network is led only by volunteers, roughly 200 in all, thus it represents a new kind of local healthcare delivery model focused on accountability and social outcomes.

Accountable Care News: Behavioral health is one of your specialties. How well are ACOs and medical homes doing these days in integrating behavioral health and primary care? Bryan Cote: There is tremendous progress on this front, but much more to be done because the system is still very

fragmented and because recognizing and responding to a behavioral crisis is difficult, for hospitals, doctors, schools and families.

Catching Up with … Bryan R. Cote is a Managing Director with the Berkeley Research Group, a 1,000-person

global consulting firm. He cut his teeth as an investigative journalist for 15 years and has 20 years of experience as a healthcare and sociology researcher, teacher, and consultant. He regularly speaks, writes, and conducts surveys about accountability, behavioral health, managed care, and healthcare disparities. In 2013, he co-founded a behavioral health accountable care organization (ACO) for migrant refugee adolescents in Connecticut, and he regularly advises companies on managed care reimbursement and ACO development. We asked Bryan to talk here about his current work, the Migrant Family Health Network ACO, integrating behavioral health and primary care, a research agenda for ACOs, the new CMS payment reform initiatives, and himself.

Bryan R. Cote

Managing Director, Berkeley Research Group (2014–present)

Co-Founder, Migrant Family Health Network (2013-present)

Senior Vice President, Marwood Group ( 2009-2014)

Executive Editor and Publisher, HCPro ( 2001-2009)

Correspondent, Oncology Business Review ( 2004-2012)

Staff Reporter, Herald Publishing (2000-2002)

Volunteer Faculty/Coach, Grace Academy (2010-present)

BS Bryant College; MA Gotham Writers Workshop


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