MARK MCCLELLAN: Hello
everyone, and welcome to the Learning Action
Network’s Spring Virtual Forum. I’m Mark McClellan, I’m
the co-Chair of the LAN Guiding Committee. We are pleased that you
have joined us for this event, and we are also
pleased to bring everyone together at a midpoint
in the year between the summit that we help last
October, and the summit that we are planning to
host again in the fall. I see that there are over
900 people who have signed up to participate in this
event online from all across the country. Welcome and thank you
for being with us. If you are new to the LAN,
we are glad you are here. If you have already been
engaged with the LAN, you know that this
public/private partnership is an important
collaboration for working together to advance
effective payment reform, with the goal of
healthcare that delivers higher quality and
smarter spending. The LAN’s work is about
developing a shared understanding of how
we can be better in supporting actions that
accelerate effective payment reform. As we all know, there is
an ongoing debate right now about how to make
health insurance coverage more affordable and
available to families, companies, and people
who need extra help. But there is more
agreement that it is increasingly difficult to
make healthcare coverage affordable, unless we
can reduce the cost of healthcare. And there is broad and
bipartisan agreement that our traditional healthcare
payment systems often get in the way of more
efficient and effective ways of delivering
care, such as using more personalized approaches
or telemedicine and less costly care settings. Or, better coordinated and
team based care, or care that better integrates
medical with behavioral and social services. Payment reform is
challenging, and it needs to keep evolving,
but developing and implementing alternative
payment models remains a vital part of improving
our country’s healthcare and health. In the LAN, we are working
with clinicians and other healthcare providers,
patients and consumers, health plans, purchasers,
expert advisors, policy makers, and others, in
this challenging work. We are seeing promising
new directions, in addition to important
federal initiatives in the Medicare program. We are seeing more
innovation and leadership from states, and from
private health plans and regional collaborations,
we are seeing promising approaches to engage
patients, including those with serious chronic
diseases and high expected cost. These position new
directions are bolstered with more evidence on
what works to make payment reform better and less
burdensome for healthcare providers and patients, as
well as more evidence on how healthcare providers,
large and small, can succeed in improving care. Together, these trends
are helping to provide momentum toward higher
value, more effective care, that works for
patients and families. And you are going to have
a chance today to join with is in the discussion
about some of these challenges and about
opportunities for further progress. Now, in addition to these
developments in the LAN, and around the country, we
are looking for other ways to build on and
compliment the LAN’s work. I want to briefly mention
a couple of those. The PFPTAC, or the
Physician Focused Payment Reform Technical Advisory
Committee, is now accepting proposals for
physician focused payment reforms. It’s reviewing a range
of approaches that aim to help physicians deliver
more patient centered care in ways that do not
yet have good financial support, and it will make
recommendations to HHS. And the Payment Reform
Evidence Hub, based at Duke with a national
network of evaluation experts, is working on
identifying and filling gaps in evidence
on payment reforms, especially private
sector and state based initiatives. And there are a lot
more examples of how collaborations like these,
can help transform the payment reform landscape,
working with the LAN and all of you. We are looking forward
to making more progress together. Right now, continuing on
this topic of leadership to improve health outcomes
and reduce costs, it is my great pleasure to
introduce Miss Seema Verma, the new
administrator of the Centers for Medicare and
Medicaid Services, one of the most important leaders
in healthcare reform. Miss Verma is bringing
a new emphasis on state flexibility and local
leadership to CMS, to support innovative
approaches for improving healthcare and health
across the country. She was confirmed
by the U.S. Senate on March 14th, so
she is still very new in the job. Her experience in policy
and strategic projects goes way back though,
involving Medicaid, insurance and public
health, and spans state and federal government
and the private sector. For more than two decades,
Miss Verma has been involved in guiding
health policy. Throughout her career, she
has worked to put patients in charge of their
healthcare, working with states on the redesign of
their Medicaid programs, and supporting the
development of new ways to meet the diverse and
complex needs of the populations
that they serve. As the architect of the
historic Healthy Indiana Plan, she helped create
and implement the nation’s first Medicaid program
with a central emphasis on consumer directed care. Before becoming CMS
administrator, she was the president, CEO and founder
of SVC, Incorporated, and National Health Policy
Consulting Company. Miss Verma is committed
to empowering patients to take ownership of their
healthcare and making sure they have access to the
information and resources they need to be
effective consumers. She is working to reduce
burdensome regulations, so doctors and providers and
focus on providing high quality healthcare to
their patients, and as the CMS administrator, she
will enhance support for states to develop
innovative solutions, including new payment
models that focus on improving quality,
accessibility and outcomes, while
driving down cost. She completed her master’s
degree in public health with a concentration
in health policy and management from the Johns
Hopkins University, and a bachelor’s degree in
life sciences from the University of Maryland. Seema, we are very glad
that you are here with us, to join us in kicking
off this LAN summit. Thank you. SEEMA VERMA: Thanks, Mark. Thanks, Mark, that
was a great welcome. I think you actually had
down my whole mission, so I could probably just
stop and let Mark have the final word there. Well, it’s great to be
joining LAN and all of the organizations that are
focused on improving quality and providing
patient centered care. Today marks seven weeks
that I was confirmed by the Senate, and we have
hit the ground running and are focused on putting our
agenda of putting patients first. We are empowering patients
and doctors to make decisions about their
healthcare and ensure patients have the
information they need to make choices as
they seek care. And creating a system that
fosters innovation, market competition, while it
increases quality, access and efficiency. It is important that as
we move forward to drive efforts towards quality
and outcomes over volume, that we do not create
undue burdens on our providers. Heavy reporting
requirements and regulations can drive out
small providers and reduce access for patients and
ultimately increase costs. President Trump and
Secretary Price have made a commitment to the
American people to reduce regulations, and we will
fulfill this promise. We will continue to
support innovation at every level, especially
with our states. As we understand that a
one size fits all model does not work, communities
must figure out how to drive quality and value
at the local level. Dr. Price and I recently
sent a letter to states, promising them increased
flexibility to design programs that work
best for them and their citizens. Likewise, we will be
encouraging providers to develop new and innovative
payment models to advance quality, outcomes, value,
and ultimately market competition. The challenges that we
face in healthcare today, are far too great and
complex for individual sectors of stakeholders
to tackle on their own. We will not be able to
achieve these types of outcomes that we want to
see in our systems, unless we break down silos
and work together. I appreciate LAN’s
convening of payers, providers, patients,
states and other stakeholders. The LAN provides
a springboard for collaborative efforts to
increase adoption of value based payment and
alternative payment models, so that our system
better meets the needs of patients. You stand as a testament
to the fact that stakeholders across the
public and private sectors are deeply invested and
want to find ways to improve care. The good news is, there
are many examples of success. An estimated 30% of
Medicare payments are now tied to alternative
payment models, and we look forward to partnering
with more providers on alternative payment
models in the future. We appreciate the
opportunity to work with all of you, to work on
innovative solutions that improve quality and
outcomes in the most cost effective way. Thank you for having me
here today and I wish you the best of success. Thank you. MARK MCCLELLAN: Thanks,
Seema, thank you very much for joining us, and
clearly these issues of improving value and
care, taking advantage of innovative ideas that are
percolating and developing around the country, is
very important to the new administration and very
much connected to the work of the Learning
in Action Network. Now I would like to invite
the LAN guiding committee co-Chair along with me,
my good friend Dr. Mark Smith, to highlight some
of the ways in which the LAN is working to support
the implementation of alternative
payment models. Mark? MARK SMITH: Thank
you, other Mark. As many of you know, LAN’s
mission is to accelerate the transition to
alternative payment models or APMs. And we thank all of you
who have contributed your stories and lessons
learned, your expertise and your leadership. All of your efforts are
making a difference, in fact, today’s event
coincides shortly after the two-year milestone
of the LAN, and there are many accomplishments
to celebrate. So, I’m going to talk
about a couple of them. Through collaborative
workgroups and public comment, the LAN has
produced seven white papers outlining
recommendations for designing payment models,
and these are being tested and implemented in efforts
around the country. The LAN is currently
updating its APM framework that was first published
a year ago, and it’s been helpful in conversations
across the field, and you will hear from Sam
Nussbaum later about the details of the update,
later in this program. The LAN is also tracking
APM adoption on an annual basis, and has launched
this year’s data collection effort, where
we expect to see expanded participation by payers
across the country. We look forward to
releasing the 2017 report at the LAN summit,
later in the fall. We are currently
supporting two action collaboratives for
advancing knowledge and adoption of
solutions that work. One for changing maternity
outcomes, and one for evolving multi-payer
primary care payment. Resources from these
efforts are posted on the LAN website. I would especially like to
single out the leadership of the LAN’s 138
committed partners, whose organizations have
committed to tying payment to quality, and have set
their own goals for APM adoption. These partners represent
a kind of a hot bed of innovation and we
applaud their leadership. To highlight just one
example, Community Health Plan of Washington, which
is a Washington based not-for-profit, Medicaid
managed care plan. It has 72% of its Medicaid
payment tied to value based arrangements that
are in category 3B, according to the
LAN’s APM framework. And CHPW continues
to evolve its role in supporting providers in
capacity development, enabling them to take
on value based payment arrangements, and achieve
the best and highest quality care for
their members. And we applaud CHPW and
all of our committed partners in this work. I also want to commend and
encourage the increasing instances of regional
collaboration that are going on around
the country. This is very important
as healthcare quality is generally generated at the
local level by partners sharing data and
coordinating their care. And I will note here that
Washington Health Alliance is hosting a regional
dialogue around this question, following this
national broadcast, and we thank you for doing this,
and encourage others to continue the regional
work and look forward to hearing from your
discussion about this event. These kinds of
collaborative accomplishments have set
the stage for what we want to work on in the
next couple of years. We know that both sides
of the aisle agree on core tenants. Coordinated care is better
than uncoordinated care, and cost of care have to
be brought down, if the cost of insurance will
ever be affordable. We know this isn’t easy,
and this kind of change takes time. It also takes resources
and collaboration and often profound
culture shifts. And the evidence for the
change is not always there at the beginning or even
within a few months, but there is no question that
we are making progress, and it’s vital to keep
at this challenging work. Whether you are just
getting started or working on a more mature
initiative, we commend you for the reform work that
you’re doing, and I hope that our program today
inspires you to double down on those efforts,
by hearing from others experiences in
the trenches. In a moment, I’m going to
introduce you to a speaker who through her own
personal story, will remind us of the ultimate
impact of working towards quality care, which is the
care that patients get. Before I do that, let me
preview the rest of the program for you. After the next speaker,
at about 1:45 east coast time, I will introduce a
panel of stakeholders who will share their
stories of their own APM implementation and launch
a dialogue on successes, challenges and how we can
take the best learning from those experiences,
to keep moving forward. Toward the end of that
panel, we will also invite you to submit your
comments and questions online and here in person,
so stay tuned for that portion of the panel. And after the panel, we
will hear about how the APM framework, which was
first adopted a year and a half ago, is being revised
and updated, based on feedback and developments
in the field, before we wrap up at 3:30. So, as you can see, we
plan to cover a lot of ground, so we hope that
you’ll sit back and enjoy the conversation, and
also participate in the conversation. And we thank you for
that participation. Before introducing our
next speaker, I invite my co-Chair Mark McClellan
to engage our audience, by gathering some information
through an on-line poll. Mark? MARK MCCLELLAN:
Great thanks, Mark. We thought it would
be great to use this opportunity to get a
little bit of information from you all, about where
you are and the journey toward alternative payment
models and what role you see yourselves playing in
this process of reforming payment to support
better healthcare. I’m going to ask two
questions right now. One of them, the first
one, is directed to those of you all who are
actually implementing alternative payment
models right now. After that, a question to
those who are supporting the implementation of
alternative payment models. The first question is
for providers and for healthcare payers who
we know from the forum registration, represent
a quarter or so of the audience that is
joining us online today. If you are, or represent a
provider or a health plan, please take a moment now
to respond to the poll that you see
on your screen. For those of you who are
here in person, if you represent a provider or
payer, you can access the poll on your mobile device
and again, we would like to get your
responses right now. You can follow the
instructions there with you. If you are not from one of
these two groups, hang on, the next question
is for you. So, on this first
question: Are you participating in an
alternative payment model in whole or in part,
and for how long? And you see the
range of choices. They include: Being at it
for a while, three years or longer, less lengthy
time periods, down to people who are thinking
about joining a payment reform effort, or not
participating at this time. For those of you who are
online, you will see the results appear
in just a moment. We are going to come back
and talk about these a little bit later in
our program today. Now, for all of those
who are not direct implementers right now —
that is not people who are in healthcare
organizations or health plans that are
implementing these payment reforms, please respond to
the second question that we have up on the screens
now, for those of you who are here in the audience
on your mobile devices. Look at the ways in which
you can support advancing alternative
payment models. So, these include:
Advocacy and consulting, providing education and
resources, expertise, serving as a convener,
or other roles. Again, we are looking to
get a sense from you of your interest and
background and we will come back to these results
a little bit later on in the event this afternoon. For right now, it looks
like we do have a whole diverse range of expertise
and perspectives with us. Mark, I would like to go
back to you, to introduce our next speaker. MARK SMITH: Thanks, Mark. I’m really looking forward
to hearing our next speaking, who was
planning to be here, but circumstances being what
they are, is going to be speaking to us from home,
so we really appreciate her being able to do so. Nancy Michaels has a very
compelling story to tell, which reminds us all
that the point of payment reform is not payment
reform for its own sake, but to improve both the
affordability and the quality of care that
patients actually receive on the ground every day. In 2005, she had it all
as a published author of several books, a
sought-after business speaker with Fortune 500
companies as clients, and a Tom Peters Wow Project
Personified Award, and the mother of three
small children. In what seemed like an
instant, Nancy found herself in the hospital
for an emergency liver transplant and cranial
procedure with significant medical complications that
would twice nearly end her life, and left her in a
two months’ coma in the intensive care unit at
a major Boston medical facility. She made it through
this long health crisis, miraculously, with
no residual problems. Today, she consults on
strategies, tactics and tools, to increase patient
satisfaction, engagement, and safety. She is going to share
her perspectives on what matters most to patients
and our collective efforts to move our system towards
paying for quality and value, rather than volume. From Concord,
Massachusetts, we are grateful for your being
able to be with us by audio. Welcome, Nancy. Nancy, can you hear me? The stage is yours. NANCY MICHAELS: Oka thank
you so much, and I’m sorry I couldn’t be
there physically. Today, I am doing a better
job of listening to the cues that my body gives
me and I knew heading to Washington D.C. today
wasn’t a good idea, when I got in the car. So, I turned around and
came back, but I’m so happy that I can be with
you here in this format. I want to share with you
some things that were incredibly important to me
during my hospital stay. It was now 12 years ago. I had an emergent liver
transplant that literally — it seemingly happened
almost overnight, where I went into complete
organ failure. Fortunately, by the time
I — within a few days of entering Beth Israel in
Boston, they had reversed my kidney’s functioning,
and they were functioning again, but my liver
definitely needed to receive a transplant. I’ve learned a lot about
organ donation and all of this after the fact. I never expected to be
a recipient, but I’m so grateful that modern
medicine can do the things that they can today. I wanted to share a couple
of things that still remain very memorable, in
my mind, about things that were done, and maybe some
tweaks to things that might have made my
situation a little bit more optimal in
terms of my care. I’m not taking of the care
I received for granted, in any way, because I know
that ultimately, these people at that hospital
saved my life, and I am forever grateful for them
and for all of the work that people in the
medical field do. It’s really just
overwhelming to me at times to think about the
things that they did in order to maintain my life. I just wanted to
start off with that. I think oftentimes we
absolutely pay attention to more technical
expertise. We want the best surgeon
or nurse, or medical team for our family
members or ourselves. But I think we also want
other things that are maybe more softer kind of
topics, I guess, or items that mean a lot to us,
that I don’t think would cost a lot more. I think that the biggest
issue, obviously, is time, but hopefully some of
these ideas will not be overly taxing, because I
think that a lot of it is just how we approach
certain things. I wanted to just share an
example about years ago, my son, when he was born,
I realized something was very wrong, and for a long
time, I was told that, you know, I must be crazy,
there was nothing really wrong with him. He wasn’t maybe developing
as quickly as his sister, but boys might be a little
bit slower in certain areas. And I just — my gut
instinct just confirmed all along that there
was something wrong. He was diagnosed at the
age of three with having Asperger’s Syndrome. One of the things that was
incredibly frustrating as a parent, was in the
mornings, every time I would feed my son his
breakfast, he would literally through the eggs
off the table and it would hit the wall. It was just overwhelming
to him for whatever reason, I just
couldn’t figure it out. We ended up bringing in a
behaviorist to work with us. She observed this
happening one morning, and she turned around and said
to me, Nancy, make him breakfast again, and just
tell him that you are going to give it to him,
before you put the plate down. So, I did. I made the breakfast
again, and I said, Noah, here are your eggs,
and I put them down. He picked up the fork
and he started eating. I looked at her like, this
could not have been this easy. What was I missing? That’s all I had to do,
was tell him that I was giving him his breakfast,
and he would pick up a fork and start eating it? And she explained it to
me, that this concept is called, “previewing
expectations”, and she said that because my son
had sensory integration issues, that receiving
that without being told, was very
affrontive to him. That this actually —
this theory of previewing expectations, would work
with anybody in my life. She said, you can do this
with your daughter, you can do this with your
husband, you can do this with friends. If you let people know
ahead of time what to expect, everyone wants to
be more in compliant when they know what
is happening. I have thought about that
so often, since my own experience as a
patient, because I think oftentimes, I didn’t
know what was happening. I think that when you are
patient, you are at your most vulnerable. I felt like my modesty, my
humility, everything had been stripped from me. When I woke up from a
two-month coma in ICU, I was trached, so I
remember, I really [inaudible] of that time,
I think because I couldn’t speak, as they were
dialing me down off that respirator. And I often thought
of that example. I wish that people would
talk more to me about what was going to happen. Even in that day. So, obviously, that’s not
— it doesn’t add any cost to this experience. It might cost a little bit
more in time, and I’m not sure whose role, if
not everyone’s, is to contribute, to help
alleviate a lot of the stress and anxiety
that patients and their families have in
those situations. That would have been
something that I would have loved more of. It did happen, but I
don’t think that it was incredibly consistent and
I just think it would have gone to addressing a lot
of my anxiety and fear in those situations. Especially to being in
the ICU where you have ICU psychosis and those things
are absolutely real, and I thought at different
points in my stay that my nurses and doctors were
almost trying to kill me, or taking my medication. I wasn’t thinking
clearly at all. I really felt, getting off
that respirator, I almost felt like I was going
to die of suffocation, because I just wasn’t
aware that the harder it was for me to breathe, it
was actually a good sign and they were weaning
me off of this. But it really
wasn’t communicated. It was very, very fearful
for me as a patient. Especially not being
able to speak as well. I do want to say that I
think that really what patients want, are what I
would call the four C’s. That is compassion,
communicative, consistent care. In compassion, I want to
share a story of something that a nurse of mine, who
I just reacquainted myself with, last October, who
I hadn’t seen in about 11 and a half years. His name was Frank, he was
the first nurse that I had seen when I was brought
from my local ER to ICU at Beth Israel. There was just something
about him, he just had a very kind way about him. When I woke up from a
coma, he was one of the people I actually did fear
and I thought he was not — I thought he was enemy,
when of course, he wasn’t. He did one of the kindest
things for me, and I had been asking, or mouthing
out, to my doctors and nurses, that I really
wanted to go outside. It was August. It was actually late July,
or mid-July, when I woke up from a two-month coma,
but I knew it was summer out. I was very thankful and
very much aware of what had happened. I just really wanted
to be outside. They kept tell me, and
I’m sure for all the right reasons, that I was much
too immune suppressed and probably wouldn’t
be able to do that. One day, he came in
early to his shift and he offered to take me down
for a routine CT scan. We did that, he waited
outside for me, and he took me to an area in the
hospital that was very unfamiliar to me. I had just mapped out in
my mind, where I was going based on the hallways that
I was being carted to, and this was not
very familiar. He opened these two big,
black, double doors, I will never forget it, and
he brought me outside onto the loading dock of Beth
Israel Deaconess Medical Center, and pushed
my stretcher into the sunlight, and just stayed
there for five minutes. Didn’t say anything to me. And it was just one of
the kindest things that he could have done. Now, it did take him time
to do that, obviously. He probably did something
that maybe wouldn’t have been encouraged by my
entire team, but it’s one of the best memories
I have of being in a hospital and having — and
having that experience. That really was just
a very small act of compassion that I felt
that he had for me, that again, I’m talking about
it now, 12 years later. It certainly had an impact
on me then and continues to. In terms of communication,
a lot of that ties into what I said earlier
in being proactive, or previewing expectations. I don’t think there is
ever a fear that you could overcommunicate with
a patient or a family member. I think that it’s far
better to say more than say less. One of the people that
my parents, who were in charge of my health,
unfortunately, [inaudible] my illness and they were
my healthcare proxies. They were dealing with
this doctor consistently, who was really part
of my entire team. I had infectious disease
involved, because they weren’t sure what was
causing my organ failure. I also had a transplant
team, I had a liver doctor on board. So, I had many different
people as part of my team. He was really very
familiar with everybody and everything that was
happening, and he would meet with my parents
almost daily, and tell them, you know,
what was going on. So, it was very comforting
for them to know that they could call on him and that
he would be up to speed on my case. They went in one day and
they asked to speak to him, and they were told
that, oh, gee, you know, he actually just moved
to South Carolina. He got a job there, but
somebody else will be coming by and they will
give you an update. And my parents were
really devastated. I was not conscious at
the time, but I can only imagine how that must have
been for them to suddenly have the person who they
had complete faith in, to suddenly go away and
not be told that. Or not been able to say
goodbye to him, or who might be taking over? Were they really up to
speed on everything? As it turned out, that did
happen, but there was no communication around what
was going to happen, what was about to happen,
that I think would have alleviated a lot of stress
from their perspective. Consistent care, I think,
is really about — you know, I absolutely love
my doctors and nurses. I would do
commercials for them. I am so grateful to them
and for the things that they have done. I remember one nurse in
particular, Erin, who was there at the
very beginning. She just actually switched
jobs, and it was her first week when I entered BI. She was my nurse
practitioner from that day forward, until about, I
would say, five years ago. And suddenly I was
told I had a new nurse practitioner, who was a
lovely person, there is nothing at all wrong with
her, except that I really wanted to be seen by Erin,
because Erin knew me, she had that history with me. I know that can’t always
be done with staff changes, et cetera,
that obviously would be impossible, but I think in
this case, Erin could have remained my nurse, because
she had been with me all these years. But they had a switch in
the hospital system to take patients by the first
letter of their last name, and somehow “M” didn’t
make it onto Erin’s docket, it was given
to someone else. I think in those cases —
and I still see Erin when I go in there, but I think
that is an easy thing to shift, if somebody wants
that, or should just be maybe more aware of the
fact that you actually do — I think — get very
attached to people who have taken care of you. Erin was one of those
people, and I remember vividly going in with
my parents at one point, after being hospitalized
for six months. I had gone to Spaulding
Rehab for six weeks, and then I went back to BI
with a failure to thrive diagnosis. And after I was finally
discharged after six months, I went back in 11
more times over the next six months with
various complications. I had [inaudible] in
my lungs, I had high potassium, I had two
rejection episodes. It was a very complicated
case, obviously. But I remember going
in for a visit with my parents and
Erin was there. And I looked at her and
just said — because I really felt like I was
never going to get better. I asked her, I said, Erin,
will I ever get better? And she looked at me, and
I think she was shocked and she just looked at me,
almost like a deer in the headlights, for a
second, and said, yes. Yes, you will. And it was so powerful for
me at that moment, because she really gave me hope,
when I really didn’t have a lot. So, obviously, I’m very
attached to Erin and would still like for her to
be my nurse, and she is someone who if I can’t get
through to the person I’m assigned to, I do call her
and she gets right back to me. We have that history, that
I think is just really reaffirming in terms of
our relationship and this continuity of care that
I think we all want to receive. I think those are
really my big takeaways. I mean I think the art
of previewing actions and obviously, we want
our doctors to be very knowledgeable and capable,
but we certainly want them to be — to have some
compassion, to be very communicative, and offer
that consistency of care whenever possible. So, I would be happy to
take questions, if we have time for that, but I am
just so grateful that I could do this for
you today, virtually. And I’m so sorry, again,
that I couldn’t be here physically, but I knew it
was better to listen up and pay attention
to myself. I have been known to
ignore that in the past. So, no longer. MARK SMITH: Well, that is
terrific and we thank you very much for sharing the
story, it’s a reminder of the fact that all of us at
some point or another will be patients and at some
point, or another, the things that will be
important to us, include technical competence,
but a whole lot more, including understanding
the path that we are walking on, which is
something we are going to talk about today. So, it’s a really great
reminder and we appreciate your participation. NANCY MICHAELS:
Thank you so much. MARK SMITH: Thank you. Thank you, for being here
virtually and putting up with this. The next portion of
our program is a panel discussion encompassing
multiple stakeholder perspectives, and we
are going to launch this dialogue by hearing
from two providers and a regional payer, about what
it takes to do the nuts and bolts of changing from
a system in which people are rewarded for the
number of things they do. The number of procedures,
the number of visits, the number of hospital
admissions. As opposed to the
achievement of some pre-arranged,
pre-determined quality level, including the
things that are important to patients, that is to
say, value over volume. First, let me ask the
director to put up the results of our first poll
that was done when Mark asked. We asked, how long people
have participated in APMs, for those that
are implementers. And if we could put
that up on the screen. And the answer is, 26%,
or a little more than a quarter are three plus
years, 24%, one to two years. So, about half are
a year or more. 14% less than a year, 14%
would like to participate, but not ready at this
time, and 22% are not participating. This is probably a good
sign that we have people at different parts
of this journey. The second question was,
what is your role in advancing APMs? Here we have 11% advocacy,
28% consulting, 30% education and resources,
9% expertise, 14% convening, and 8% other. So, we are going to talk
about the need for all of these roles as we hear
from the panel, but I think it’s worth pointing
out that for anyone who is implementing APMs, there
are lots of nuts and bolts stuff to be done, and it’s
not easy, because we are changing a culture that
is deeply imbedded in both the economic model of
everybody in healthcare, and the cultural
presumption of everybody in healthcare including
patients about the way the thing works. So, let me introduce our
second poll, which is to ask this question: For
those of you who are implementing APMs, what
is it that is a problem? What are your obstacles
in instituting value-based payments? Leadership support,
organizational culture, technology and
infrastructure, legislation, financing,
access to implementation tools — that is playbooks
about how to do things — other, or none. You are off to the races,
and everything is going just swimmingly. Probably not many in that
category, but if you are in that category, by all
means, check that box. As we said, trying to do
this involves nuts and bolts, changing the way we
do things and we are very lucky to have with us a
number of people who have been on the implementation
side of this work, so let me introduce
them to you now. Brian Bourbeau is Director
of Practice Operations for Oncology, Hematology
Care in Cincinnati, Ohio. Karen Johnson, Vice
President for Healthcare insights and partnerships
in Blue Cross/ Blue Shield in Kansas City. Emily Brower, Vice
President of Population Health for Atrius Health. Each of you has about
six minutes — that’s six minutes, to share your
implementation story and then we will hear
from responders. So, Brian, let’s
start with you. Then Karen, then Emily. BRIAN BOURBEAU:
Thank you, Mark. Oncology, Hematology Care
is a community cancer practice in Cincinnati,
Ohio, with 53 providers across 13 locations. We are in Ohio, also in
Indiana and Kentucky. Four years ago —
actually, five years ago, we began a strategic
planning exercise and one of the opportunities arose
to improve our care model. We adopted a medical home
that we call the Oncology Medical Home Model, and
many of the ideas that we put on the board five
years ago, survived. Some did not. But they centered around
wanting more comprehensive care for patients, and
better navigation, working through psychosocial
support, and financial support. A second stream was
evidenced based care, really focusing on what
drugs are most effective. Best side effect profiles,
and then starting to focus on a new subject called
“financial toxicity”. Third, was access. Many of our patients were
ending up into the ED, and were admitted to hospitals
for conditions that we knew we could treat either
in extended hours or weekends, Urgent Care
visits, or maybe even triage and
education at home. We shot a couple of
supporting strategies for that. First, was accreditation. There wasn’t an
accreditation program for Oncology Medical Home five
years ago, but there is today. We are one of ten
practices that helped found the Commission
on Cancer, accredited Oncology Medical Home. That gave us an outside
perspective of whether or not we were doing
the right thing. We also sought
payment reform. We knew that the current
payment model did not support what we wanted
to do, and so we found partners with Medicare
and with private payers to help support this new care
model and change how we do oncology in the country. In 2012, we were 94%
straight fee-for-service. We had a small quality
and value program with a private payer that
represented about 6% of our business. We set goals for 2016 upon
joining the HCP LAN, to hit 63% quality and value,
ranging across different categories in the
framework, by the end of last year. We actually hit 64%. So, we met goal
number one. Goal number two is to
reach 90% by 2020, and it ranges from some simple
pay for performance programs, to more
advanced, bundled, and shared savings
and risk models. Our latest model is the
Medicare Oncology Care Model. It is a five-year project,
supported by the Center for Medicare and
Medicaid Innovation. There are 190 practices
across the country, ranging from one office
community centers, to large academic
health systems. It blends together
redesign and quality improvement, with a change
in how oncology is paid for. It involves shared savings
and risk for practices that performed well, or
made to improve their performance in the model. Each practice has its own
work stream that it knows it needs to improve upon. I may perform well in one
area, and you may perform well in another, and the
Oncology Care Model gives us the freedom to work on
what we need to improve. For us, we came down to
some of the three work streams that we
saw back in 2012. First, was
evidence-based medicine. We have applied both
treatment pathways, and what cancer care we
give you, what drugs and radiation, as well as
triage pathways and other evidence-based medicine
strategies to improve the quality of care. We are also surrounding
our patients with 20 nurse navigators and, I lose
count, I think I’m up to 11 financial navigators
today, who help patients through their journey with
all the psychosocial and financial support needs. Finally, we call it ED
avoidance, because we find out our patients
end up in the ED. But we have dedicated now
a triage unit that does great work in getting the
patience the care they need either at home or
through urgent visits and used as an evidence-based
medicine approach to accomplish that. In our first year of the
program, we have received one quarter of results
and over multiple quarters here, you see leading
up to June of 2016, even adjusted for inflation,
we see a rise in Medicare expenditures per
beneficiary for cancer care. In our first quarter, July
through September of last year, we saw the
first downward tick. I’m not here to claim
success yet, but we liked those early results. One of the benefits of
being a part of this program is quarterly
feedback to let you know how you are doing as a
practice, and how the model is doing overall. So, we hope to see another
quarter of great results here soon. Thank you. MARK SMITH:
Great, thank you. KAREN JOHNSON: Thank you. I am delighted to be here
to share with you the story of CPC Plus
in Kansas City. We are one little region,
made up of five counties in two states. Lots of great clinicians
and one payer. Fingers crossed for
round two announcements. So, to understand our
story, you really have to go back to 2009, when the
medical director at that time started looking at
the early results coming out of the national
demonstration project and other patient centered
medical home pilots and said, this is a good
idea, we should do this. So, in 2010, we launched
a pilot with about 161 physicians, caring for
about 40,000 of our members, and it went well. By 2012, we decided to
go from pilot to program. At that point, we had
a substantial number of physicians involved and
then in 2012, you may recall, there was
something else going on, called the Comprehensive
Primary Care Initiative, which we were quite
excited about. We enthusiastically
submitted our application, which was not to be. So, undeterred, we
soldiered on, we continued to grow momentum for our
program and our little market. In 2016, we had over 800
physicians, caring for over 200,000 members in
our 32-county service area. We were getting really,
very good results and very encouraged. But, it is not without
its challenges. So, here to talk to you
about a few that we see as important in addressing
head on, because we think that if you do, they will
lead to successes, no matter how small or
incremental those successes might be. I think the first is
really, as a health plan, we really have to
reimagine what our role is in member health. As an industry, we have
invested substantially in direct to member programs
like wellness and disease management. We also know that members
prefer to get their healthcare from
their providers. I think that with the
right financial incentives in place, with the
alternative payment models, we have to
reimagine our role in supporting providers
differently. And you will hear me often
say, it’s not just about the payment. It’s about how we support
them with other resources and information. One of the things that
we did at Blue KC, is we redeployed a number of our
disease management nurses, as primary care nurse
coordinators, and they are working actively with the
care coordinators and our medical home practices,
learning and growing with each other. Another important piece
of this is talking to employers. They shoulder a
substantial burden of the cost in our healthcare
system today, and we have to bring them on
the journey with us. It’s hard conversation,
employers want to know how their dollars are
being spent for their population. Unfortunately, it’s
hard to tie results of alternative payment model
pilots and programs to specific employer groups. So, what we are left with
sometimes, is health plans making the decision
to leave self-funded employers out of
the conversation. At Blue PC, we took a
very different approach. We had everybody at the
table and we choose to be very transparent about the
costs that we were paying. The new payments to
medical home providers, which were actually on
top of fee-for-service. So, we know — I spent
actually 20 years as a broker before I joined on
the health plan side, and we know don’t like to talk
about added cost on the employer’s side. I think the fact that we
brought everyone to the table, and we are very
transparent about the conversation, we actually
even came up with a name for all of these payments
that we report with claims costs each month, quarter,
however frequently the employers are reported. Medical Value Payments,
or MVPs, is what we call them. And happy to report that
at this stage employers are for the most part
on the journey with us. It’s going to continue
to be a challenge to have these conversations,
but they are important conversations to have. I think we all know that
engaging providers as partners is very different
than contracting. And what is really
challenging, is we are still contracting with
them, because we are still built on a fee-for-service
infrastructure, but we are also engaged with them
as partners in very many different ways, and I
think that it’s just really important that
we understand what the provider
experience is like. In CBC Plus, we talk a lot
about how we have to align quality measures or
exchange data and methods that don’t burden
the providers. I think it’s important to
step back and look at even the nuts and bolts. Some of the administration
that was in place long before alternative payment
models, which gives us opportunities to better
serve providers, and we know that that’s really
where we get what we all want out of this. So, we kind of know
how the story ends. We, in 2016, when CBC Plus
was announced, Blue KC was once again at the table
saying, we really want to do this. We think this is important
for our community, we think this is important
for providers. We also knew that we
might be the only payer to apply, but we worked
closely with our providers, we rallied
as — we tried to rally support for other payer
applications, but at the end of the day, we knew
that we might be the only ones applying. So, we also looked at the
numbers and that’s how we ended up with a little
five county region. We knew that market
density could be achieved with just Blue KC and
CMS if we focused on that market. And it has been
significant. One of things I hope
we talk about is the community collaboration
that is required, and CBC Plus has given us a
platform for that, whether we have other payers
officially at the table or not. Oh yes, of course,
we were in. One of the things that we
were asked to do as part of this panel today, is be
inspiring, which is kind of a tall order. But I have found that as
we have engaged with the LAN and others on a
national and regional basis, that I’m often
inspired by others. So, I want to share
with you something that inspired me, and this came
from Dr. Cunningham, who is the Chief Medical
Officer for the Blue Cross/Blue Shield of
Oklahoma plan, and it was in the LANPAC webinar
— and that’s the Payer Action Collaborative, if
you are not familiar with the acronym. They were asked, to what
do you attribute your success in what is now
known as CPC Classic, and he started this with
something like, you know — it sounds much better
with his charming Southern drawl, but it’s really
pretty simple, pretty straight forward. “We always put the patient
first and don’t let our organizational baggage
get in the way.” With that, I will close
and look forward to the conversation. MARK SMITH:
Thank you, Karen. Emily? EMILY BROWER: Thank you,
so pleased to be here. I’m going to talk a little
bit about Atrius Health’s participation in
alternative payment models, a model that we
believe is best suited for providing those strong
relationships, supporting strong relationships with
providers and patients, and hopefully delivering
that compassionate consistent communicative
care that Nancy was talking about earlier. Because I’m going to talk
about our experience and our Medicare ACO model, I
have my disclaimer here, so you know the views and
information are my own. So, Atrius Health provides
care and coordinates care for 675,000 patients in
Eastern Massachusetts. We have been in that
market for a good long time. We embrace value
based payment models, alternative payment
models, really focused around, as I said, that
meaningful relationship between the patient
and the provider in our patient centered medical
homes, and we have 29 practice sites
in Eastern Mas. Then going out from there,
coordinating care across the community. We will always raise our
hand to participate in those kind of payment
models, and so as a result, about 80% of our
revenue is in total cost of care or value
based models. So, we have a lot of the
tools and infrastructure that gave us a strong
foundation to participate in the Medicare
ACO models. It also enables us to
perform very well on delivering quality
outcomes that patients deserve. To speak a little bit
about why participating in the Pioneering ACO in 2012
was important to us, it was really about getting
all of our Medicare patients into one
model of care. So, we had about 50% of
our Medicare patients in the Medicare Advantage
model and 50% still in Medicare fee-for-service. So being able to wrap our
arms around the other 50% meant that our delivery,
the way that we take care of patients could be
consistent across the entire population. It also gave us some
experience getting into risk — financial risk,
for PPO models — Medicare being the largest
PPO in the country. Then, furthering our
mission to work with others in a very
collaborative manner, to transform care nationally,
hence our participation in the LAN, the Healthcare
Transformation Task Force, and as a Pioneer ACO and
now a next generation ECO. So, our Population Health
Approach is one, I think that will not be
unfamiliar to most, which is really bringing
a comprehensive patient-centered approach
to patients who have the most advanced illness and
really need us to wrap around the patient,
the family, and their community resources,
to make sure we are delivering exquisite care
for them in the manner that they have
communicated to us they would like to
be cared for. And then, going down the
pyramid, those patients with multiple co-morbid
diseases, very much focused on preventing
acute exacerbation of those diseases, and then
preventing the development of chronic disease
in the first place. We focus, we say, on our
highest risk patients and those highest cost events. That’s our biggest
opportunity that then translates success down
the pyramid for other populations. Many Medicare ACOs, we
would start that process, or a process with
any population really understanding the
population and what their gaps of care are. Then bringing the folks
in our organization and in our community, focused
on improving care. So, those are the
clinicians and others to redesign the system
to deliver that care. We have seen some
great results. Atrius Health, because
of that long history, providing care in these
kinds of models, was both a foundation for success,
but also a challenge, because we started out
the model as a low-cost provider. Those patients, even
though they were in fee-for-service in
Medicare, often had been our patients within HMO
and POS models, where we had been caring for them,
for generations, for decades. So, for us, really had
to work hard to deliver savings coming out of a
historical low cost for efficient provider, but we
have been able to do that year over year. Haven’t quite gotten our
results yet for 2016, but looks to be even better. So, continuing to drive
value for that population as part of delivering
results as a whole. Again, within payment
models that at their essence are about
supporting the relationship between the
primary care provider and the patient, starting from
there and then going out in our concentric circles
to manage the total cost and total care. MARK SMITH: Thank you. So, we have now heard
three examples of people who have been implementing
different advance payment models, alternative
payment models, and you will note that in each
case, they decided the kind of partners that they
needed to get this done. It might have been
employers, it might have been state or federal
government, and certainly patients. We now have four
responders who will speak to their own perspectives
on their alternative payment models. We’ve got Phillip
Bergquist, who is Manager of Policy and Strategy
Initiatives from the Michigan Department of
Health and Human Services. Linda Brady, who leads
Healthcare Strategy and Policy for the
Boeing Company. Debra Ness is President of
the National Partnership for Women and Families and
a member of the Guiding Committee of the LAN, and
Patrick Conway, another Guiding Committee member,
is Deputy Administrator for Innovation and Quality
for the Centers for Medicare and
Medicaid Services. So, love to hear from each
of you in terms of your perspectives on this work
and the work that you yourself are doing around
alternative payment models. Phil, let’s
start with you. PHILLIP BERQUIST:
Great, thanks, Mark. It’s interesting to hear
the sort of stories of the three of you as we all
work forward in this payment reform journey. I’m somewhat new to
state government, and I’m learning that lens in
that perspective each day. One of the things that I
have come to appreciate about our role as a
state government and in particular our role as an
insurer in the Medicaid program, are the layers of
integration and the layers of partnership. So, as a state Medicaid
program, as a state Health and Human Services
Department, we come together with providers,
we come together with payers, we come together
with patients and community members and
advocates, and really pulling the pieces
together to lead a strategy and also
to have some vision. I think one of the things
that we are most excited about right now in our
work as a state, and in particular as a
Medicaid program, is the alternative payment
methodology partnerships that we are working
on right now with our Medicaid Managed Care
organizations in the state of Michigan. Using the LAN APM
framework as a guide and as a way to have started
that conversation, partnering with each
of these managed care organizations, who are
then partnering with their provider networks, and the
patients that are served by those providers to
figure out not a one size meets all strategy for our
entire state, but a menu of options and really
a shared framework in talking about goals. So, setting a structure
forward where each of our Medicaid health plan
partners becomes accountable for a goal,
has the opportunity to look at multiple payment
methodologies to meet that goal, to work with payment
approaches that support providers at different
stages of readiness, and different abilities to
engage in a pretty complex — as you guys said, a
pretty complex system of things that are being
undertaken right now. In looking at those goals
develop, we are still early on in our process,
but at looking at those goals develop, it’s really
exciting to see payers coming together in
thinking about proactively engaging providers and
providers thinking about proactivity in engaging
their patients and the communities that they
serve to think about how we can do it better and
how those goals can shape the work that we do
together over the course of the next three years. With that lens in
place and that sort of collaboration happening at
multiple levels, it can be a complicated thing to
take on, and a complicated opportunity to realize
— and I think one of the strengths that we have
going into it, is the opportunity to work with
lots of different experts and lots of different
folks that are doing this work across the country. We have adopted that LAN
framework as a way of not only to help us set goals,
but as a way to talk about payment. That’s been helpful, but
we also are able to use things that we learn, to
use expertise from people that we meet, to tap into
things that we may not have directly, or to share
things that we do have directly, to help others. And that’s been a really
wonderful thing thus far. I think one of the pieces
that is most interesting to see evolve today, and
you guys all hinted at it in your comments as well,
is that we are never done. Everybody has taken
a step and a journey. Michigan has taken many
steps over time as a large commercial program that
have been really wonderful for our provider base
in participating in the multi-payer advanced
primary care demonstration and in advancing health
information exchange, and we have had the beginnings
of payment reforms, much participation in Medicare
shared savings programs. Our next step as a
Medicaid program, is coming through this
alternative payment methodology strategy, but
there will be a step after that. That’s interesting to see
that component evolve, and it was interesting to hear
it from the three of you as well, and see that
evolving in different ways. Each of you taking a
different step, we are taking many steps in
Michigan and many steps at the same time. But to see all of those
pieces come together and play out with a supportive
environment around each other, is really
rewarding. I think we have a lot
of work ahead of us. It’s great to hear
different organizations taking different
perspectives and accomplishing this work. I think that we have a lot
to learn from one another in doing that, and to
see which one works for different populations. That’s my favorite thing
to remind myself of, is that as we try different
things, and as we test different things,
especially when it comes to payment, and how
payment impacts the way that we deliver care and
best serve our patients, that we have many answers
for many populations and many needs. It’s exciting to see those
things come together and looking forward to
the conversation. MARK SMITH: Thanks. Linda? LINDA BRADY: I’m
delighted to be here. I’m with the Boeing
Company and for the last several years, we have
been direct contracting with multiple health
systems in four markets. So, we have two health
systems in Puget Sound. It wasn’t our original
intent to go with two systems, but it seemed
to fit the need of our population, which is where
our largest employee base is. Then in 2016, we launched
in St. Louis with Mercy Health Care Alliance, and
then in Charleston with Roper St. Francis. Then this year, we just
launched with Memorial Care Health Alliance. With each one of these
arrangements, it’s been a direct contract. Directly with the health
system and with the providers. It’s not a situation
where we have the contract settled in and
then we walk away. We are actually talking to
every single one of these systems multiple
times in a month. Not just quarterly or
annually, it is every month. We gather together to
talk about the challenges. You asked a question
earlier about what are some of the obstacles
that our systems or our initiates face? And there was no option
to say, all of the above. I did note that to myself,
thinking, well, we could classify it. We are challenged, and are
learning so much, the fact that we’ve got two systems
in the same market in their third year. They also take care of two
cohorts, so it isn’t just cohorts that actually
enroll and decide that they want to be part of
the ACO model, but it’s also for employees that
use these systems, but didn’t enroll. They stayed with a more
traditional healthcare plan. So, that has posed some
interesting challenges to our systems. I would say a key theme
for us right now, we’ve got a number of them: One
is, one size does not fit all. One of the advantages of
being in multiple markets and working with very
different systems, is we are learning a lot,
but it’s very unique. Each market has its own
personality, its own needs. The culture in the market
of our employees and how you want to engage them. What their health risks
are, are very, very different. And, the reputation of
each of the markets, of the different systems. So, that’s been a
fascinating journey. We have been able to
take forward some lessons learned in Puget Sound. They are kind of our
leaders out there with no blueprint. Sort of making the
blueprint as they go forward. But we have learned from
some of our newer players, some of whom are
differently shaped. In Puget Sound, our two
systems are made up of multiple partners, not
just one primary health system, it’s
multiple partners. In St. Louis, for example,
it’s a primary partner. A partner that had
experience at one point as a health plan, and
that has brought in an interesting perspective to
what we are trying to do. Universally, all of them
are challenges with data. Data, data, data. I was listening to you
talk about what something is inspirational, and
for us, it’s always about family first, patient
first, member first. That and it’s hard — it’s
not supposed to be easy. That’s a famous line in
some movie about that. But it is about the
patients first and I think we are still trying to
crack that — what we call the $64 million question:
How do you engage our members in a very powerful
way, an important way, to get them invested in
their own healthcare? As employers, we are
coming behind our health plan partners, often the
community, to try and fill in the gaps. By doing that, we’ve added
sort of one off or some might describe it as
boutique solutions, both in wellness as well
as in healthcare. And in working with our
ACO partners, what we are learning is, all of these
solutions — two things, our employees get confused
and aren’t always sure about what’s available. The second thing, our
other theme is, are these solutions taking member’s
eyes away from the PCP? So, we have a very
heavy emphasis, without exception, across our
markets, about the importance of the primary
care physician and the role they play in the
member’s engagement and care. So, we are looking at how
do they differentiate in their market? How do they make the
experience for the members so unique and so helpful,
that the member wouldn’t want to go anywhere
else but there? And that is a big problem
that we are trying to — “problem” isn’t the word,
it’s “challenge”, that we are trying to address. We see each of our systems
taking the steps to do something unique and new
and it’s a very exciting time to be in healthcare. Every day I pinch myself,
thinking, how lucky I am to be part of this, to be
working with people who care so deeply and
intensely, about changing the way care is delivered. MARK SMITH: Thanks. Debra? DEBRA NESS: Thank you. I’m Debra Ness and I’m
with an organization called The National
Partnership for Women and Families, which for four
and a half decades, has been working to improve
health, equity and economic security for
women and families. I, as an advocate, view
this work to move toward alternative payment and
to move us away from fee-for-service, as
being in the service of achieving that mission. Of improving the
well-being and the economic security of
women and families. I think it’s why, at the
end of day, I ask myself always, “Are these models
that we are building, really providing better
care for the patients and families that use them?” So, I would like to touch
on three things that are particularly important
to me, as I answer that question for myself and as
I advocate and as I listen to the panelists here. The first is, this idea of
co-creating the outcomes that we want. We all want better
outcomes, we all want people to have better care
experiences, we all want to lower costs. I think we all — at least
intellectually, agree that we can only get there
if we do it together. That getting to that ideal
state is something that we have to co-create. I think we do that —
I think we say that intellectually. I think payers and
providers and other stakeholders try to do
that, but we often fall short when it comes
to engaging really collaboratively with two
of the key players — the clinicians and
the patients. I think a lot about
the conversations that physicians are having
today about the amount of change that is coming
at them, the burden, and there is lots of
talk about burnout. Then I was very encouraged
by listening to some of your stories about what is
going on in Kansas City, the fact that Karen
talked about the fact that collaborating with
clinicians is not the same as contracting with them,
really resonated with me, because of course you
are going to have a very different kind of
engagement if folks are there at the table helping
to create the system they think will work the best. I want to encourage us to
remember that that is also true with patients. At the end of the day, we
all talk about the fact that we want a system
that’s patient-centered. And in fact, administrator
Seema Verma started us out, saying, we want to
be patient-centered in our healthcare. Well, how can we get there
if we don’t have patients with us at the table, from
the very beginning, in the design and the development
and the implementation and eventually in the
evaluation of these new models of care. One of my questions for
everybody here is, how are you involving patients and
gauging them to make sure that the new models you
are designing are really going to meet their needs? My second point is really
going to echo what Linda was saying about the
importance of primary care and how important it
is that we build these alternative payment models
on a strong foundation of primary care. And I say that for
really two reasons. One sort of, quite
plainly, the primary care clinician is your
gateway to other care. And in some estimates, I
have seen, 90% of other use of the healthcare
system is determined in some way, shape
or form, by PCPs. For patients, there is an
enormous opportunity for good relationship with
their primary care clinicians to really guide
them in the way that they use and engage with the
rest of the healthcare system. We talk a lot about the
need to change culture, the need to engage
patients differently. We need to understand that
the role of the primary care clinician — and
that relationship between clinician and patient, are
really at the heart of how we will probably most
engage patients and most change the way that they
interact with healthcare system. Finally, I want to urge
us to think about the ways that we are assessing the
value of these new payment models. Yes, we are looking at
whether they lower cost. Yes, we are looking
at clinical outcomes. But are we really looking
at whether or not, at the end of the day, the
patient had a better experience in this model,
then they did in that model? Or in the old way? I think we haven’t quite
figured out how to get at that yet. Is the care better today
than it was yesterday? That is the question that
I hope we all can work together to figure out. Thank you. MARK SMITH: Thanks, Debra. Patrick? PATRICK CONWAY: Yeah, so
it’s an honor to be here today with the panel, and
I was reflecting back on the panel and my over
six years on this tour of government service, which
feels like 42 in CMS. I had the honor to serve
now three different presidents and four
secretaries of health. I think importantly, an
honor to partner with people like we heard here. I will reflect on
five things briefly. One, I do think the
federal government has a role in partnership. You heard about it in
Pioneer ACO and CPC Plus, and the Oncology
Care model. All of the examples here,
the federal government had a role to play. The Innovation Center in
particular at CMS, we now indirectly affect over two
thirds of Americans, over 200 million, directly have
over 18 million people in various payment models
like we heard about today. Over 200,000 providers,
and over 30% of payments in alternative
payment models. So, I think a partnership
that we need to continue to develop, but I think
can be a catalyst for change. Two, I think we heard
about public/private partnership, and their
critical nature of public/private
partnership. You heard about the
Primary Care Plus initiative, I would also
say, some of the work that LAN is doing now, on
alignment of these payment models. So, ACO’s or bundled
payment or primary care, things like quality
measures, risk adjustment, attribution, et cetera,
as aligned as possible. So, if you are a provider,
you are getting a common signal, much easier to be
successful, I think, when we have alignment across
public and private sector, including with
states as well. Third, and related, I
think we still need to tap into ideas and innovation
from across the country, and tap into what I will
call state and local innovations. So, certainly in our state
innovation models, but also broadly. You know, how are we going
to innovate in various states? What models make sense
for those states and communities? How are we going to do
catalytic investments like state innovation models
or accountable health communities that really
focus on a given geography and really tap into
the resources, the partnerships, the
potential collaborations of that state
and local level. Four, and Debra said most
of this, so I won’t resay it all — but, patients
and consumers first. I do think co-production. We are doing some work in
co-production, but I think we have opportunities
to improve. How do you really
co-produce with patients, with consumers, with
providers as well? How do you really have
true co-production mentality? I still practice as a
physician who mainly takes care of children
with multiple chronic conditions. In my clinical practice,
I’m able to talk about goals of care, not just
for that hospitalization, but long term
goals of care. We still don’t have a
reliable system to measure that, to achieve that at
a real patient centered level, in my opinion. Then lastly, how do we
have a true continuous learning system? So, I think we made
progress here based on data and evidence, but at
a macro level, how do we learn what works
and scale that? I think we are doing
better today than we were three or five years ago,
but we still are not as rapid cycle in our
learning, as I might want. And then also, at the more
micro level, you know, I used to have to manage
within a delivery system, you know, how do you
get the data and the information and the
evidence at the point of care to that primary care
clinician or that patient and family making a
decision about surgery — whether to have it or not. How do we really get the
data and evidence at the point of care as much as
possible, to drive care change? So, I will just close with
thanking the panelists and really look forward to
the discussion today. MARK SMITH: Thanks. So, what we are
going to do now. First, I am going to
report on results of our second poll, and then I
have a question for each of our presenters, and
then we will have a conversation. So, if we could put up
the results of the second poll, that would
be terrific. What are your obstacles
in instituting value-based payments or APMs? Leadership support — I
think all of the above probably most people
would say that. But leadership support,
organizational culture, technology infrastructure,
which I will include, data. Legislation, financing,
access to implementation tools and actually fairly
small numbers for both other, and none. So, it sounds like we got
the main obstacles and it sounds like most people
have some version of all of them. Let me say first to our
audience that is online, here is an opportunity for
you to submit questions to the question box on your
online engagement tool. We will get to some of
them, as many of them as we can. I think for those of you
who are in the audience, you have ways to
do that as well. Write them on a card, give
them to the other Mark, and we will get to as many
of them as we can also. I have a question
for you, Phil. We heard our patient
talk about previewing expectations. Jemma Internal Medicine
has this long-standing feature called “less is
more”, which kind of gets at the point that many of
us, not just providers, but patients, often start
with the presumption that, the more the better. More tests, more
procedures, more drugs, more everything. I said Phil, I apologize
— Brian, sorry. You’ve laid out this very
impressive re-organization of care for patients
with cancer. Where one might pressure
that they would presume that more is better. It turns out, I suspect,
that less of somethings — perhaps chemotherapy,
perhaps other things it’s better — how is it that
you’ve talked to patience to preview the
expectations for this journey that you’ve
now reorganized? As opposed to the old
days, where people would page us to do stuff, you
have thought through what their pathway is for a
certain kind of cancer. You should be in a positon
to preview expectations, but also in some ways,
change their expectations, because you have changed
the model of care. So, how do you talk to
patients at the beginning of this process, about
both what they should expect and how do you
involve patients in this co-production that you
have heard Debra and Patrick talk about? BRIAN BOURBEAU: Well, I
think a great example is end of life care. It’s the realization
that you are treating a patient, not a tumor. Not a disease. And you and I, as patients
— if we were patients of the same physician, let’s
say of Dr. Conway’s, we have different life
impacting us, we may have different desires
for end of life care. I may want an
aggressive approach. You may decide that you
don’t want to have your last days spent in the
hospital receiving more therapy. So, we need to have
conversations with our patients and really
explore, you know, what their values are, what
their desires and goals of therapy are. And we do that up front. So, as part of the
oncology care model, advanced care planning
is one of the redesign activities that we are
pushing in organizations across the country, to
make sure we are having conversations early,
understand the patient’s values and then apply
them to their care. MARK SMITH: So, I have a
question for you, Karen — LINDA BRADY: Are providers
having that conversation or are other care leaders
having that conversation with patients? BRIAN BOURBEAU: It’s
a team based approach. So, it starts with our
physicians, and then we also compliment that with
more specialty trained care team members. So we sent all of
our advanced practice providers, our nurse
practitioners, clinical nurse specialists, the
course of many years ago, on that subject, and so
they are available to really help with care
planning and a team based approach. MARK SMITH: I want to
speak up for doctors for a minute. There are a lot of things
that drive doctors crazy. In a lot of ways, doctors
drive other people crazy. But one of the things that
drives doctors crazy is getting different signals,
different metrics, different instructions
from different payers, and nobody seems to think
it’s either ethical or particularly efficient to
have doctors practicing to different standards for
patients based on who’s paying for them. And, yet, a lot of people
from the left and to the political spectrum to the
right seem to think that competition between
health plans is the key to reducing costs, so you
talked a lot about how you’re engaging with
providers, but most of those providers have
patients who are paid for by other payers and
apparently, the other payers haven’t yet
drunk this Kool-Aid. So, help me understand
where you think the role is for competition between
versus collaboration between providers, between
health plans, in trying to engage providers to
provide one standard of care for all their
patients, no matter who’s paying. KAREN JOHNSON: How
much time do I have? [Laughter] So, I think
this is a huge challenge to us, as health plans,
is to figure out where we compete and where we
collaborate, and I do think that’s one of the
great outcomes of this whole movement toward
a new form of payment. It’s really causing us to
have a conversation that we should have been
having a long time ago. So, like CPC Plus, for
example, we are in regions collaborating, and I
always, in the regional meetings where we come
together with – who am I collaborating with in my
region because I’m one payer? Of course, CMS, you know,
and our folks there, but we, in Kansas City,
decided that we didn’t need to wait for a formal
program, so a couple of years ago we launched
something we called at the time the Blue Ribbon
Advisory Panel, which was intended to be a
conversation in the community about the best
interests of the community and how do we move
forward knowing times are changing, and what does
that mean for all of us? So, it started with 22
healthcare leaders that were asked to come to
the table for their perspectives and their
experience, and that program has evolved, or
I shouldn’t call it a program, that group, that
community conversation has evolved to the point today
where we have probably 100 people in the community
involved in this conversation. We’ve had work groups
started, one around community infrastructure
and technology, one and all-payer work group. So even though we don’t
really have an official convening of CPC Plus in
our market, we’re saying let’s just come together
and talk about what we can do together. So, in a CPC Plus
platform, we talk a lot about focus on quality
measures and the new things that we need: data
exchange, clinical data exchange, and
quantum measures. I’m saying let’s
back it up. Let’s talk about all the
payer-specific stuff that we ask of providers that
we could collaborate on. Something as benign as
provider demographic data, and we know physicians
move and change practices and when they do that,
they have to submit forms or use logins on different
portals for every 7 to 10 payers that they have, and
if the doctor is moving within one system, from
one location to another, they do that twice. So, we’re just not making
it easier on providers and I think it is up to us, as
payers, to start looking at each other and having
those conversations and let’s start with
the easy stuff. SPEAKER: Mark, could I
jump in for a second? MARK SMITH: Absolutely. DEBRA NESS: Because this
comes right back to the first point that you
raised, and this whole idea of co-creating. If you are beginning to
take some of that burden off the doc’s, then the
doc’s also have time that they didn’t have to spend
with their patients, which, if you talk to most
doc’s that’s what they feel like they least have
and they feel like all this other stuff is
getting in the way of patient care. When the doc’s and the
patients are able to form a relationship, the
problem of more is better goes away because, when a
patient has a relationship with someone they trust, a
trusted clinician, they’re much more likely to feel
like they’re getting good recommendations in
their best interest. They’re not going to want
the more and the more. The kinds of conversations
that we’re talking about are conversations where
you can talk about why maybe you don’t want to go
that extra round of chemo, or you don’t need that
extra diagnostic test, or whatever. But I think we’re
underscoring the importance of coordinating
across the board to reduce burden, but also that also
creates more time with patients, and more time
for that relationship and what you can change the
way patients, then, engage with healthcare. BRIAN SMITH: Great. PHILLIP BERGQUIST: I think
Karen made one other point that’s really worth
stating explicitly, which is it’s not just the
“what” it’s the “how”, so you know, it’s easy, the
first thing that comes to mind for me, when I think
administrative version is quality measures, right? Different payers,
different measures, I’m measuring 60 different
things, or I’m being graded on 60
different things. It’s 60 different things,
but it’s also 60 different things reported
eight different ways. And the how in all of this
conversation is really important. So it’s, you know, is it a
different portal, is it a different format, is it a
different file, and that the details of that, they
seem to matter a lot, just as much as the
conversation around what and what that burden is,
itself, it’s how do we go about doing those things
and is there a way for us to not only, you know,
center in on the things that can be made the
same across expectations, whether that’s a
regulatory expectation or a payer expectation, but
also how do we go about getting those things
because the space between the two, you know, the 50
things measured eight ways and the 50 things measured
one way, that’s a big space that gets at
exactly, you know, Debra’s point, as well. MARK SMITH: That’s
terrific and we’ll come back to that
point, I’m sure. So, I want to ask you
about culture because you saw from the results, and
I think from most of our experience, the way in
which providers are paid doesn’t go back a month or
a year or even 10 years, it goes back decades. It’s deeply embedded
in everybody’s business model, it’s deeply
embedded in everybody’s way of operating-staffing
levels, capital commitments, etcetera. So how did you deal with
the culture question as you’ve been trying to
transform the organization from one that has done
well in a volume-based world, to one that can
do well in a value-based world? How do you tackle
that culture question? EMILY BROWER: So started
out with, I think, some advantages, some of the
precursor organizations to Atrius Health were staff
model HMO’s and they were groups of clinicians
who came together very deliberately to try and
deliver a better model that matched what they
believed was the right care. So, payment and care
coming together, so, so much a part of our DNA. We were able to hold onto
that when the market moved away from managed care
in the ’90s and back into fee-for-service, hold onto
some of that culture, that commitment to delivering
care that best supported the patient, and then when
the payers and CMS were ready to kind of get back
into that game, we were right there and trying
to advance that in our community. So I think, really
starting out with understanding from the
clinicians what they believed the right way to
take care of patients is and building around that,
because all of us in healthcare, we’re all
working for a purpose, and that’s a very strong
sort of core piece of the solution that everyone
can gather around. We’re all trying to
improve the experience of care, the outcomes and
transform people’s lives. So starting there and
saying, okay, so what’s the system, the delivery
model that is going to advance that, and then
working with the payers to say what’s the payment
model that’s going to support that
delivery model. MARK SMITH: Terrific. Anybody else have any
comments on culture? SPEAKER: Well, I do
think that it starts with leadership, too, and the
willingness for a system to be bold and be
disruptive, because that’s often a good way of
changing the culture. I would also say, back to
an original question, an original point, the last
thing any of us wants is a provider saying, okay,
you’re with this plan with this employer so I’m going
to treat you this way because this is
my check list. That will never
get changed. We’re wasting our time and
we’re in a hamster wheel. The sooner we get to all
patients are treated the same when they walk in the
door, the better chance for us to really show that
we’re making progress, and that’s real success. MARK SMITH: So I note
we don’t really have any hospital people
on the panel. [Laughter] Hospitals
are a big part of care. They’re a big part of
the economics of care and moving from volume
to value based care inevitably involves
changing the role of the hospital, the centrality
of the hospital in care, and kind of
reevaluating that. I wonder if people have
lessons they’d like to share, since we don’t have
someone who actually comes from a hospital-based
system, but they’re very much a part of this issue. Do you have some lessons
you’d like to share about what it means to be
working with hospitals in a value-based environment? Emily. EMILY BROWER: Sure, I
could certainly speak to that. Atrius Health, to do the
work that we do and get the kind of results that
we get we have to partner really well with
the hospitals in our community. And one of the great
things about all the focus on readmissions as being a
real failure mode, is that we can approach that from
all sides, so engaging our hospital partners in
improving the discharge, really creating a tight
discharge plan, and experience for the
patient, and having those hand-offs work really
effectively and smoothly and not confusing patients
with too many messages and too many people. So that’s a place where
the physician group and the hospital can partner
really well together and we both benefit. The hospitals want to
improve those measures, that’s part of their
value-based payment, and that reduces the total
cost and improves the experience. In those moments of
transition is where there’s just tremendous
opportunity for the whole community to
come together. MARK SMITH: Okay. Patrick, and then Debra. PATRICK CONWAY: A
couple quick comments. I think we’re working with
hospitals in a number of ways and sort of meeting
with them where they are on some level, so one
is state-based, we’re in Maryland, Vermont, and
now Pennsylvania for rural hospitals, we have
population-based payments for hospitals, and the
other is, you know, just before this, with the next
generation ACO with about 20 hospitals, and
their CEO spoke very eloquently-and this goes
back to culture-that they knew it was the
right thing to do. They had been in this
a while, in fairness, working with physicians
in their community but they’re in a full
population-based model in making that shift, and
she knew it was the right thing to do for their
community, and their hospitals had a focus on
serving their community. So I do think you need
more leadership in culture like that. I think the last thing
is, we also have hospitals that may not be ready for
population-based payment models but are willing to
partner with us and bundle payment in an arena, or
think about admissions and readmissions. So we’re trying to meet –
our health system needs to move through this
trajectory, including hospitals, and so we’re
trying to meet with hospitals at different
stages of change, if you will, and help them make
that shift in a way that’s financially viable but
also delivers the care we would all want for our
loved ones going through that hospital. MARK SMITH: Debra. DEBRA NESS: So I was
just going to note the connection to the earlier
conversation about culture change, as well. I mean, we’re asking
hospitals, and actually everybody, to really
rethink their role and go through a lot of change
and one of the major pieces of culture change
is making it instinctive to actually talk with
patients and communities about what you’re
trying to accomplish. So the number of hospitals
I’ve engaged with who’ve tried to change the
discharge process or reduce readmissions based
on what they know, but without ever really
engaging with patients who’ve been discharged
from their facilities, or talking to folks in their
communities, you know, they’re not going
to be as successful. Nobody can probably tell
them better what’s needed than the patients and
the community folks themselves. And so, again, I think
part of hospitals making this transition is being
willing to make that same kind of culture change to
involving patients in the design of – in the
redesign of what they’re doing. MARK SMITH: Terrific. Yes. KAREN JOHNSON: I agree
with all this leadership rests in a belief system
that you start with and, you know, it’s just that
when you see a market with stark contrasts in that
and in our own community I’ve seen hospital leaders
say things like, “I want to be a part of this
community conversation,” that I was describing
which is now known as the KC Health Collaborative, I
don’t know if I added that or not, but they ask why
they came to the table, one of the hospital CEO’s
said because there are so many win-win, win-win-win
opportunities out there that we all have to
be a part of this. For that, I’ve also heard,
when we were talking about advancing alternative
payment models in a different form, a hospital
leader also said, “What’s wrong with what’s
going on today? I don’t think
it’s broken.” So it’s interesting when
you have that in a given community, but you really
do start to understand where your collaborators
are, pretty quickly. EMILY BROWER: And that’s
really where that voice of the patient comes
in so strongly. I think that the last time
we decided we’ve got to do even better on
re-admissions, and I said we’re partnering with the
hospital center community, we went to talk to our
patients and we were looking for the patients
that had been readmitted 4 or 5 times in a year. So those are not patients
who are likely to be able to easily come work with
our model where we do pull patients into the care
model redesign, so we went to them. I sat at kitchen tables
talking to patients about what was their experience,
what happened, so that they could tell me in
their words what does it mean to have, what we
call, a readmission. What was that? Why did that happen? And having both us and
our hospital partners hear about some of those, what
we would call failures, definitely failures, that
is where, when the patient You can’t say, oh, this is
working great for us now, fee for service, when you
have the people that are experiencing the care
tell you otherwise. BRIAN BOURBEAU: A few
years ago we saw patient feedback on how educated
they felt they were, how supported they felt
they were in their care. And what we found was a
surprisingly high number of patients who believe,
or who expressed that we did not educate them on
side effects and symptom management. And we looked around and
thought, well, we did really great at that. You know? Obviously, you know, they
must have misunderstood the question. [Laughter] So it happened
that they didn’t and they expressed that feedback
a year later, too, and so last year we completely
redesigned how we did patient education, did
more team based care, spent more time with
patient, rewrote our patient education
materials and so on, because we certainly have
our perspective and our background and we may
understand certainly the vernacular of healthcare,
but we need to speak to the patient where they are
and find the best way to get through to them. area, but it starts with
seeking that patient feedback. MARK SMITH: Alright,
so I’m beginning to get actually a number of
questions from our far flung Internet-based
audience, and I’m going to start to kind of throw
them at you, one by one, if that’s alright. So this one’s for Brian. Can you say a little
more about that financial toxicity domain that
you talked about? BRIAN BOURBEAU: Oh, yes. So we were actually
discussing this over lunch. We have been discussing
a contrast between two different treatments that
we have for a particular symptom of cancer care,
one of which costs $1,000, the other costs $40. Now the $1,000 does
show marginal benefit on effectiveness, but it’s
also $1,000, and so we must consider that whole
financial toxicity, and what does that mean
to the patient. A study published in
Journal of Clinical Oncology last year, showed
that patients who declare bankruptcy have far higher
risk of mortality than patients who do not
declare bankruptcy. All the social
detriments of health. And so when you consider
do I treat with $1,000 drug that may be
marginally more effective, or the $40 drug, also have
to consider what impact that has on the patient
financially, and therefore, bankrupting our
patients, certainly that impacts their health just
as much as any disease. MARK SMITH: And I think
it’s probably fair to say that in the old world, a
lot of physicians wouldn’t have had the slightest
idea how much a patient actually costs and it’s
not that they don’t care, but it’s not one of the
things that people have available to them
typically, and right. BRIAN BOURBEAU: Well, I
have to thank, actually, Patrick’s team for sending
us millions of lines of data, and saying, well,
here you go figure it out. You know, thankfully, we
do have some smart people who have been crunching
those numbers, and then our physicians have
been very receptive. You know, after that
education, you know, we spent five minutes on the
subject and physicians began raising their hands
saying, “Well, we need to talk to every single
patient,” and, you know, and that’s just
a great response. That’s what we wanted, but
it starts with that data. LINDA BRADY: You shared
with us, too, that statistic where before
the providers were having financial toxicity
conversations, particularly with this
one element, it was about 50-50, the use of these
two drugs, and after they were educated and started
talking to patients it went from 90 to 10, where
90% were using the most cost effective
treatment plan. BRIAN BOURBEAU: Yes, we’re
fairly conservative in what we’re trying
to tackle, right? You know, we have hundreds
of treatments out there, but we’re focusing on
about a dozen and we’ve seen great shifts just
through educating our providers in the use,
and it goes far beyond anything you could attempt
to accomplish with prior authorization, for normal
techniques of trying to change practice, education
has been the key here. DEBRA NESS: Brian, have
you provided any training for your clinicians in
shared care planning, because you mentioned
shared care planning being part of what you do, and
that’s when you would be sharing all of this
information with patients. Because that’s part of
the culture change, too. How do you actually engage
collaboratively like that in a conversation
with your patients? BRIAN BOURBEAU: What we
found is that our nurse practitioner and clinical
nurse specialist programs do great preparation for
those providers, and so we tap into them as part
of that care planning process. So, you know, the
physician, of course, is starting that care plan
and then the psychosocial assessment, and that type
of work, is done by our nurse practitioners,
clinical nurse specialists, and RN’s,
working with the patient. And we do it in a team
based care where, as a patient, you would come to
our office and after the physician and you have
decided kind of goals of care and what you’re going
to be receiving, you also, then, go through a series
of consultations with an advanced practice
provider, with the nurse navigator, and with the
financial navigator, and often we uncover things
that maybe weren’t originally considered. You know, I had a patient,
one of the first ones I shadowed, lived in a hotel
and had to get rides from friends. And here, we had the
patient in for 36 fractions of radiation
therapy and had to consider how she was going
to travel to the office. So that, then, makes you
rethink the care plan. Is there any way we can
do a hyper fractionation? Is there anything that
we can do with their chemotherapy treatment to
address this travel issue that we felt was a more
detriment to her health than the actual
treatment selection. MARK SMITH: So let
me channel one of our Internet viewers and press
down on that, because one of the concerns that’s
been addressed in some quarters about moving from
volume to value is whether some patients, who already
face disparities, will actually be harmed by
this, whether providers who take care of patients
who are less affluent, who may be less likely to
speak English, who are physically isolated,
either in urban or rural areas, if they’re held to
the same outcome standards as other providers will
actually wind up making those disparities worse
rather than better. I wonder if anybody on the
panel would like to speak to both how you feel about
that question and what steps you’ve taken to
monitor whether not just for a given patient, but
systematically, whether or not the payment reform
that you’re adopting may have the unintended
consequence of making things worse for some
patients rather than better. PHILLIP BERGQUIST: Mark,
I think one of the things that we really try to
embrace about value-based payment, especially for
populations experiencing health disparities, is
that, to be frank, our system today isn’t working
and that’s part of why the health disparity exists
in the first place. What we know, and I think
what probably everybody watching knows, is that
there are ways that we need to provide care
differently, and that care may mean something
else in the future. You know, we’ve talked
about team-based care, and I think everybody has
referenced a team member who isn’t a physician
at some point in today’s conversation, and you
know, one population that experiences significant
health disparity is our low income populations;
near to be because of a large enrollment in
the Medicaid program. We also know about that
population, that their health is significantly
influenced by social and economic factors and that
while a physician is a really important part
of their care and their health outcomes, it’s also
really important that they have help in ensuring
stable housing, that there’s nutritious food
to eat, that there’s transportation not just to
a doctor’s appointment but to other places, that
there’s child care for somebody to work. There are many
other factors. I think what we can have
the opportunity to embrace through value-based
payment is payment that’s flexible enough to adapt
when the primary health challenge isn’t healthcare
or isn’t something that we can prescribe to, or isn’t
something that we can treat in a
traditional sense. That value-based pay has
the real opportunity to give us flexibility,
to give communities flexibility, and care
teams working together to say, what’s the right
way for us to serve this population, and that
it’s okay that it looks different than it does
today because different might get us a better
outcome than what we have right now. KAREN JOHNSON: This is a
perfect example of how CPC Plus has become a catalyst
for community conversation and potential action
in Kansas City. So the track 2 practices
have a requirement to do a psychosocial needs
assessment of their patients and connect them
to community resources. Sounds like a good idea,
but when you are a small primary care practice,
which we are fundamentally a nation of small primary
care practices, unless you’re a safety net or a
Medicare only population focused practice, you
don’t have the need in your practice panel to
build out that level of resource at the
practice level. So one of the
conversations we’re having at the KC Health
Collaborative is: could we build at the community
level some kind of a shared services model
that really leverages what already exists in the form
of things like United Way 211, and, you know,
information that the practices should be
engaging their patients in the dialog about what
are your non-medical healthcare needs. But to put that burden
of addressing all of that directly on them without
any additional support or resource is probably
unrealistic. So I just think there’s
a lot of opportunity in these models to really
engage differently. PHILLIP BERGQUIST: Ver
similar approach happening in Michigan. We have the community
level infrastructure through our state
innovation model work, not only looking at can we
help support community infrastructure for
adjusting social need and providing additional
resource to practices and resolving those needs
and creating deeper connections, so
partnerships in the way that, you know, you’ve
become partners with your providers. Those providers having
partnerships that deep with community
institutions, but also to look and see if there are
ways for large provider organizations to support
one another, too, and be on, you know, a journey
that is similar in social and economic factors to
the journey that they’re on when it comes to their
day to day business in quality improvement
and payment reform. MARK SMITH: Debra. DEBRA NESS: I think the
one other point I want to add, because what I’m
hearing is we need to move toward these payment
models that allow this kind of whole person,
whole community care, I think the other thing is
we have to be able to look at the impact of care
through measures that allow us to stratify and
see where the disparities exist, and without getting
into a debate about risk adjustment, I think there
is definitely a role for the right kind of risk
adjustment at the right times, but we also need to
be collecting the data and ensuring that, at the end
of the day, when we’re looking at outcomes, we
can assess whether or not we are eliminating or
perpetuating disparities. MARK SMITH: Agreed. So I have a question
addressed to the Michigan representative. One writer says: Well, a
lot of people in Michigan spend much of the year in
Michigan but part of the year in Florida. [Laughter] And I suppose
some people spend some of the year in Kansas City,
Kansas and others in Kansas City, Missouri. [Laughter] PHILLIP BERGQUIST:
Or the day. [Laughter] MARK SMITH: So we’ve spent
a lot of time talking about kind of focusing on
integrating work within a community, but there are
lots of people who either go back and forth for the
time of year, or work in one community, live in
another community, have family. Do people have examples
of kind of collaborations across state lines, or
perhaps, across county lines or beyond the usual
regional things that might serve the needs of not
only wealthy people from Michigan who live in
Florida, but workers who migrate from one part of
the country to another. People have some
comments on that? PHILLIP BERGQUIST:
Michigan is home to a very large migrant farm worker
population, in addition to folks that go to Florida. When it gets cold in
Michigan state, I think that there are quite a
few good opportunities. One of my favorites is
actually more related to that migrant and seasonal
farm worker population in Michigan where safety net
providers in Michigan, Texas, Florida, and a few
other places, have come together to say, is there
something that we can do to coordinate the care for
that person or for that family when that
person is with us? So to make sure
something like care isn’t interrupted when the
change across state lines happens, or if it’s a
person who’s enrolled in the Medicaid program to
see is there a way to very quickly recognize when a
state resident’s change has happened and re-enroll
that person in the Medicaid program in the
new state so that there isn’t a gap in coverage. I think that really
successful examples of that can be seen,
but through strong collaboration
between providers. I think it’s equally true,
and maybe you can think of an example for this, that
large payer organizations, particularly payers at
the regional level and, in some cases, even
Accountable Care Organizations at a
regional level have started to look at
community in this broader sense and maybe, you know,
another word that I hear kind of substituted,
it may be even more appropriate, is population
and sort of taking ownership of a population,
regardless of how that population moves. It’s very common for folks
that, you know, transition back and forth between
Florida and Michigan to maintain that relationship
with providers in whichever state is their
most prominent state which, for many people, is
Michigan [Laughter] – and to maintain that
relationship so that provider sees the
patient as part of their population, regardless
of whether or not they’re physically located there
right now or maybe, you know, consulting through
an e-visit, or e-mailing, or using telemedicine, or,
you know, many other ways, e-consults, different
ways to maintain that relationship as well. But it all starts with the
willingness to have that collaboration and also
kind of a look at this concept of I’ve taken
responsibility for a population, regardless of
how they’re moving around. I don’t want to make
it seem like it’s not challenging, though,
because that physicality and the moving and, you
know, migration patterns really do pose
that challenge. We’ve come a long way but
have a long way to go. LINDA BRADY: And this is
where technology, I think, can also come in and play
a big, big role in being very creative in how you
can kind of take your doctor with you. EMILY BROWER: I was going
to say the same thing. So one of the wonderful
things that is happening because we are embracing
this shift as a nation, is that we’re starting to
share the same tools. So one of the things that
enables us as really a practice based delivery
system to coordinate the care all across our
community is event notification, admission,
discharge, and transfer notifications, so
historically, we’ve built that sort of in a point
to point technology, so Atrius Health, hospital 1,
Atrius Health, hospital 2. Well there is a piece of
technology on the market now that is national that
we just sort of all point – we kind of all point
there, I mean, it’s building out, and because
in multiple communities it’s worth it for multiple
systems to pay a small amount for each
transaction, but then we all see it. So all of a sudden we’re
participating, and this is called the Patient Paying;
I’m sure there are others. We participate in this now
and our case managers now see when a patient is
admitted to a skilled nursing facility in
Florida so that we can use that other really
effective piece of technology and call
the nursing home. [Laughter] Seriously! I mean, that’s, I know
we get – there’s a lot of blocking and tackling in
just the day to day care, but when we all do
this together through collaborations and broader
national models, that’s where you get the payoff. MARK SMITH: So we have
about five minutes left. I want to ask a couple
of more provocative questions. It’s all very well to say
we want to adopt value based care that will save
money kind of over the course of a year, or
maybe two; the course of a pregnancy, the course of
a cancer diagnosis, but so many of the interventions
we’re talking about may have their economic and
clinical payoff a decade or more from now and the
chances are that a patient who’s your patient now
will be Patrick’s patient 10 years from now, or
will be somebody else’s patient. So I guess, do people have
thoughts about how we even keep track of, let alone,
reconcile the issue of value based payment in a
truly longitudinal way, given the volatility of
people’s eligibility for different government
programs and the fact that, to the extent that
health insurance is still largely employment based,
people cycle on and off a given insurer. What implications
does this have for collaboration among
payers, public and private; collaboration
among payers, private, even though that are
competing with each other at the same time. What are your thoughts
about this kind of more longitudinal sense of
value as it relates to patients’ clinical and
financial outcomes? Patrick. PATRICK CONWAY: Maybe
I’ll start on this one. In 2013 or ’14, I wrote a
New England Journal paper on this on sort of
health trajectories and modifiable and
compoundable over time, it’s called a life-long
health system, but so Medicare, the average
Medicare beneficiary we now insure for more than
15 years, at the age of 65, so the longer
time frame than a few. I’ll let my colleague talk
about Medicaid, but you have people insured for
very long periods of time on Medicaid. I do think this gets
to the public-private partnership point at the
state and community and certainly there’s going
to be people that exit and move around payers, but
if you have a common framework around health
and health trajectories over time and you execute
on that across the public and private sector,
whether it’s at a national level, state level, or a
community level, there’s strong evidence you’re
going to have a population that not only has better
health and health outcomes and lower cost, you
know, better educational outcomes, lower justice
payments, etcetera, and I think this, as a nation,
is one of the big opportunities for us. How do you collaborate
to really impact health trajectories that we
know are modifiable and compoundable over time and
reap those benefits as a nation? And it is a classic
problem with the comments. There’s a reality that,
because of some of the insurers, and other
issues, people have trouble sort of managing
and wrapping their head around it, but I think you
can – we’ve seen this in some states and
communities and other places where it’s done
well, so I think it’s how do you learn from that
and scale it more broadly. KAREN JOHNSON: This is one
of those places where I think health plans really
have to start wrapping their minds around
what their competitive advantage is and, in my
mind, that’s fairly clear and that’s really they’re
our members, so what’s the member experience? It’s enrolling easy. It’s making benefits
understandable. It’s helping you tie your
benefits to how I get care. It’s all of the things
that happen outside of the direct care delivery
environment and, then, I think, then it becomes
that, what you are talking about, Patrick, which is
really creating a common care delivery framework
that benefits everyone. And I do think, though, is
payers – one of the things that Linda said earlier
that I think is really important is that patient
experience, which you don’t see in outcomes
as much, and I do think payers have a role in
sort of incenting that. I don’t think we can
create that because I think each provider’s
going to create their own unique experience of that,
but I do think there’s a way for payers to
really support that. But I think we have to
get really clear about the member versus the patient
and what’s our role in each of those strategies. MARK SMITH: And it does, I
think, go, as you said, to one of the core things
that the LAN has been about since its inception
which is kind of typified by this panel-the need
for public-private collaboration, the
need for state-federal collaboration, the need
for collaboration between, frankly, different parts
of the same agencies, of federal and state
government, to the extent that the system has
longitudinal rationality, to the extent that
providers need a common set of quality metrics,
targets, patient experience measures that
can’t be achieved by any given agency, any level of
government, or any payer. It has to be the kind of
collaboration that we’ve been trying to do. I’m afraid that
our time is up. Thank you very much for a
very thoughtful panel of both your experiences,
your reactions, your insights, and your wisdom,
and I’ll now turn this back over to Mark. MARK McCLELLAN: Mark,
thank you, and my thanks, as well, for everybody who
joined us on the panel and contributed to this
discussion, also, all of you who sent in
questions and comments. I’d now like to
introduce Sam Nussbaum. Sam has been leading
efforts on the LAN’s alternate payment model
framework for over two years now. Back in 2015, when we were
just starting up, he led the LAN’s first work group
which was tasked with developing the framework
that was published in January of 2016, and we
know that the framework has been very helpful in
discussions all across the country for shaping how
organizations move along a continuum, the
value-based care. And you heard about some
of that earlier today. Since that time, of
course, there have been evolving ideas of what
constitutes an alternative payment model, and
how they best can work together. Sam is currently leading
the Framework Refresh Advisory Group for the
LAN that’s taking these developments into
consideration for an update on the framework,
and Sam, thanks for joining us this afternoon,
to talk about the framework update. SAM NUSSBAUM: Goo
afternoon, everyone, and thank you, Mark. It is so important that
we’re here together today to learn and see the
progress that we’ve made. I think this panel has
been spectacular in both identifying the areas of
achievement, whether it’s in oncology or primary
care, but also in giving us that inspiration
for how we build to the future. In fact, there’s nothing
more important that we can do as individuals
in healthcare, as communities, and as a
nation, as providing a foundation for truly
healthier people, for better care, and for
smarter spending. And, as you’ve just heard,
it’s that smarter spending part of it that will
enable us to invest very much in the future of
social determinants of health, of education, and
infrastructure, and all that we need to
do for our nation. So why are we working
through a common framework? What is our focus? What is the
framework about? And I think it is so
important to recognize that the common framework
is to have a language that we can all speak. We talked about
measurements having their common ground, but this
framework that we’re all adopting today
enables that. It’s a system for
classifying value-based models of care, but as
equally important, a set of principles, principles
that outline the goals for better care, for payment
reform, and for innovation that we all need to invest
into our health delivery system. So it’s a rationale that
says: how can payment be an underpinning? How can an undergird
be a foundation for the fundamental changes we
need, and you’ve heard about, in the delivery
of healthcare? It really is, in so many
ways, our path forward. Now, let’s see
where we are. And the framework that
we’re using today is one that includes a
trajectory of categories. Category 1, where most
payment lives today, is really fee for service. And while we’ve seen
increasing links to quality, and that is good,
it is not going to get us to this promised land that
we all seek in patients getting coordinated care
and communities being involved in care. But we see, across
this continuum, these categories, a progression
to Category 4, which are population-based
payment models. Now, each category
includes important subcategories. So, for example, if we
look in Category 2, we have 2A, which were
payments to help physician practices, to help care
management organizations build infrastructure,
so payments for infrastructure. In addition, Category 2
had pay for value, pay for performance, so
quality payments. As we move to Categories
3 and 4, population-based models, we were seeing
different approaches taken to bearing financial
accountability; financial accountability that
allowed for better patient care. What’s important that we
discuss this framework is to understand also
what it’s not. The framework is a model
for categorizing payments, but it is not a tool for
establishing delivery systems because delivery
systems can exist within each of these
four categories. Some are better prepared
to move to advanced payment models-Categories
3 and 4-but a patient-centered medical
home can give superlative care within each of these
categories, but it’s our goal to move along
this continuum, to have providers be where they
can most effectively deliver care. So it wasn’t really our
work group’s intention to determine which model
is the best to follow. Each organization and each
community will determine that best model to follow,
but it’s to allow for evolution, for innovation
in a field while driving payment reform. So why would we, a
year after the payment categories were
articulated, we published this in January, why would
we, a year and a half later, come back and want
to refresh the framework? We believe it’s vital
because this framework enables us to see where
we are as a nation. And independent of this
debate that we’re now having about the future of
healthcare in the country, delivery system reform and
changes are essential, no matter who the payer is
and who the patients are and who the
individuals are. So to remain relevant, we
believe it must reflect the passage of new
legislation and the issuance of new
regulations, so MACRA is very relevant here, and
we’ll talk about that in a moment. But equally important, the
learning that took place on this stage moments ago,
and for the thousand of you watching this event,
it’s about learning from best practices
in the field. In that way, we can make a
more profound difference. So what topics
did we address? When we first established
the Framework we believe the principles were
enduring, but have they changed? Are they still
foundational? We wanted to clarify the
relationships between advanced alternative
payment models under MACRA and the categories of
the LAN APM Framework. We do not want 60
different categories, each one identified by
individual financing organizations. Very much to the point
that Mark Smith was raising, we wanted to
identify where safety net providers can participate
in APM adoption and also where small rural
providers can also find their common ground
in their home. In addition, with the
growth of integrated financing and delivery
systems, we said should there be a new category,
or a new subcategory where this velvet revolution
that has gone on of providers having insurance
models, and insurance companies aligning and,
in some cases, building provider capabilities, we
wanted to make sure there was a way of identifying
these advanced approaches. And we wanted to both
expedite the measurement and understand how we
can simplify the entire tracking progress while
reducing burdens for all of us. So, most importantly,
to start, we said let’s convene a representative
group and it was not only this group that made
significant input into the process, in fact, meeting
for much of the last several months weekly,
but they also reached out beyond to gain
additional information. So I had the privilege of
chairing this group, but included were Reid
Blackwelder, and Reid had been former President
of the AMA, a family physician, so AMA, the
American Academy of Family Physicians, excuse me, but
a family physician; Tim Ferriss, who’s a leader
of Population Health at Partner’s Healthcare;
Aparna Higgins, who leads Performance Measurement
and has helped get us to a common ground on
performance measures through AHIP; Dorothy
Teeter, who leads the Washington State
Healthcare Authority and has accountability for
Medicaid as well as the employees of Washington;
Keith Lind, at the AARP Public Policy Institute;
and, Alexander Billoux, who represented a real
talented group of partners at CMS, and I do want to
call out CMS here in the most engaging
and positive way. Under Patrick’s
leadership, the public-private
partnership, the flexibility and
willingness to work across the communities, has been
extraordinary, and the innovation has
been extraordinary. So what were our initial
principles and where did they change? One of the important
elements was to understand that payment is
only a driver. Let me back this
up a moment. That payment is one
of the many drivers of patient-centered care. As I said, an enabler
foundation, it can make a huge difference but it
is only that enabler. We wanted to establish
goals for APM adoption and you know that the original
goal was to have 30% of CMS payment and advanced
payment models by 2016, which was achieved, but
the private sector LAN also was looking at 30%
and we fell a little bit short of that, about 25%
but there were some areas, such as in Medicare
Advantage where there was a 40% adoption. We wanted to identify
those distinguishing characteristics of APM’s
and the conventions for classification and we
also wanted to give recommendations on how to
structure and distribute value-based incentives. Those principles are
largely unchanged. But what are the changes
to the foundational principles? Those include, this first
point I want to make is that payment reform
is that vehicle. It’s not a goal
in its own right. So if we go out there and
achieve 50% by 2020 but we are not delivering more
patient-centered care, if we’re not delivering
better quality, better performance, better health
then we will not have met our goals. Our second point, and this
is vital also, is that, for some providers, the
final place to be is in Category 2. That can be the vehicle
for delivering high quality care. Not everyone has to get
to Categories 3 and 4, although we do believe
that many, particularly larger integrated
organizations will get there. The third point and the
one, again, that is vital for all of us to
understand, is that we want financial incentives
to be in place, but they should be balanced. We can’t have physician
organizations become insurance companies
bearing inappropriate financial risk, so those
were some of the elements that we wanted to
avoid the unintended consequences of
payment reform. So let me share with you
now, what some of those classifications are. First, we established
a new Category 4C for Integrated Finance
and Delivery Systems. We surveyed a lot of
these organizations to see whether they behave
differently if they have the combined
responsibility of both financing care and
delivering care. All of you know Kaiser as
sort of a benchmark for what an integrated
financing and delivery system would be, but, over
the past years, we’ve seen lots of models emerge
where health plans that own provider
organizations, such as Highmark owning West Penn
Allegheny, and working closely there; Anthem
owning CareMore; and, Optum United having a
very, very large physician presence. We’ve also seen the
opposite-provider organizations that sell
insurance products. Two great examples
are Intermountain and Geisinger. And what we wanted to
understand is do these organizations
invest differently? Do they invest differently
in an information platform? Do they invest differently
in their communities? Do they invest differently
in those issues involving social determinants
of health? And we believe that
they likely do. This is all to be studied,
but we believe that this integration of financing
and delivery offer unique opportunities for
transforming care delivery beyond where just paying
in a fee for service environment does. We think that they can
more effectively engage other components of the
communities and other professional caregivers. Over time they will touch
transportation and housing and those models. So let’s look at one other
part that we looked at, which is the expanded
definition of Category 3. Early on, we said that
cost performance for Categories 3 and 4,
against a financial benchmark, was the key
characteristic of Category 3, so against a global
budget, against a medical trend, but it was a
financial performance. But we’re seeing more
and more, in certain circumstances, and the
specific one is the one you heard about today:
primary care for Medicare population. Comprehensive Primary Care
Plus, Track 1, is a great example where you can
see that there can be effective proxies
for generating cost efficiencies and
total cost of care. So, for Medicare
beneficiaries, approximately 40%-45% of
all spending is spent in the hospital, in
the emergency room. So if your measure is
reducing inappropriate or unnecessary
hospitalizations through better coordination of
care or ER visits, then you can see how that
can work very, very effectively as a model
in which there are shared savings that would
benefit those physician organizations within
this Category 3. So we have some concerns
about this, of course, and we need to be
mindful of them. So reduced
hospitalizations may not be fully reflective
of improved care. We want to be sure that
care remains appropriate. We want to have more
and more quality and performance requirements
and we certainly don’t want to reward physicians
or anyone for reducing appropriate and
necessary utilization. This is really about
how we deliver a better outcome of care. Let me now, also
talk about one more classification change
before I close; and that is, an additional
requirement for Categories 3 and 4, and this is about
being patient-centered. This new requirement is
an accountability for appropriate care. Because there are strong
incentives to reduce costs, we want to make
sure that this is a result of removing unnecessary
care, not essential care. We want to strongly
encourage reductions in wasteful care by
evaluating providers on the basis of
what’s appropriate. Here are some examples of
appropriate care that we want, and there are many
national benchmarks that have been achieved here. There’s already been good
progress in preventing hospital admissions and
re-admissions that are unnecessary; unnecessary
imaging; documentation of shared decision-making;
appropriate use of medications; rates of
“never events”; adherence to clinical guidelines,
even issues you heard shared today in terms of
oncology care and making sure that that remains
patient-centered; preventing pre-term
labor and delivery. All of these will make
a profound difference in care. This is what we want to
measure over time and support over time. So here’s what the new
model will look like. First, let’s look at this
bubble chart on the right side of the screen. Today, we have, as I
said, most of our care in Categories 1 and 2 with
growing amounts in 3 and 4. The future, we believe,
will have far less care in traditional fee for
service, but there will always remain fee for
service care with strong incentives for quality,
but more and more care will be in this
future state. And, as you notice, on the
vertical axis, this is a critical vertical axis
because it is about patient engagement and
patient-centered care. It’s about accountability
for delivering better health and better
health outcomes. It’s about the information
architecture that we need and, it’s in this way, in
advancing care along this continuum that we believe
we can make a profound difference. In closing, I want to
share with you the next steps. The next steps are
actually your steps. We believe that this
Framework is a compelling one. It will address the
changes that we’re seeing in our healthcare
ecosystem, but we need your participation to
measure this and to build on this. So during a public comment
period that will occur within the next weeks to
months, we will be issuing this white paper in
a preliminary way. We want to hear from you. Last time around, we
had, you know, literally hundreds of organizations
and comments-you make this better for us, and we
welcome those comments. We also welcome another
journey and that is your participation as a
nation, as communities, as physicians, as health
professionals, as health plans, as government,
as payers that we work together. The theme of today’s
meeting and what you heard is about collaboration and
building together a better healthcare system. Let’s continue
on that journey. Thank you. MARK McCLELLAN: Sam, thank
you very much for those comments, and I’d like
to thank all of our presenters today, also all
of our participants here in the room with us, all
of you who are online who joined us in today’s
discussion, and Mark, a lot to think about,
from what we’ve heard. It does seem like we’re
in the midst of a journey, even though the principles
may seem pretty simple here: better care, lower
cost, and finding ways to work together to use the
payment systems as a means to an end for that. Boy, implementing this is
a lot of work, and one of the things that I took
away, though, was despite the challenges, we’re
finding some better ways to do it and we’re also
finding some ways to expand and improve the
efforts that have been underway. MARK SMITH: I
think that’s right. I think the other thing
that’s worth noting is that the kind of efforts
that we heard cited, everybody had to give
at least a little bit. Collaboration doesn’t mean
I get to do exactly what I want and you have to
adapt to my standard. It means everybody kind
of has to give at least a little bit to achieve
some common goal. And so, whether it’s
a health plan, or a hospital, a physician
group, the Feds, the state government, trying to
unite around a shared goal and vision of the way we’d
like to see care delivered requires everybody being
willing to concede at least a little in order
to get the kind of collaboration that we
heard several examples of today. MARK McCLELLAN: It sure
does, and we heard, as you said, a lot of examples
of how to do this, both collaboration at the level
of the individual patient, provider, health plan
relationships, that’s where a lot of this begins
in patient-centered care. I was impressed by how
much is happening at the regional and state levels
where, to find ways to put together different
resources, whether it’s social services that you
heard about from a number of our participants, or
just getting organizations that need to build trust
to work better together, a lot of opportunities for
collaboration at the local and state level; and then,
finally, a recognition, I think, as Emily put it,
that, you know, there are a lot of tools out there
that we can use wherever we are and that we don’t
always need to reinvent the wheel when it comes
to quality measures or methods for calculating
benchmarks, or data sharing, or even figuring
out which tools are most relevant for particular
local circumstances. MARK SMITH: I think that’s
right, and I was actually quite impressed by the
diversity of participants and where they come from. Cincinnati, Michigan,
Seattle, St. Louis. And so, I think part of
what we’ve tried to do with the LAN is to give
people examples and actual context, like people’s
e-mail and phone numbers. Here’s who you can contact
to figure out how they did X or Y or Z, and I think
trying to move from setting out a common
vision towards actually incenting collaborative
action together is a lot of where we’ll be placing
our emphasis in the next two years. MARK McCLELLAN: That’s
right, and we are going to move forward from here. We want to build on
foundations like the APM Framework that you just
heard about, like the outputs and tools that are
coming from all of the LAN Work Groups, but we are
aiming to increase our impact with a new focus
on helping healthcare organizations implement
important and effective payment reforms. This has started
with LAN’s Maternity Multi-State Action
Collaborative, and the Primary Care Action
Collaborative that you heard referenced
earlier today. They were launched
at the end of 2016. It also includes an
upcoming collaborative to support effective ACO
implementation, so stay tuned for opportunities
to be involved in this upcoming work and to hear
more about the resources that we’re developing that
support faster, smoother, and more effective
implementation of payment reforms all across
the country. MARK SMITH: So, thanks to
all of you who tuned in. Thanks to all of you who
joined us here in person. We want you to stay
connected to what the LAN is doing so please go to
the website, send your friends to the website to
have them register for the website. This program will be
archived and available on the website for those of
who weren’t able to see the whole thing or who’d
like to refer other people to it, and we want to
also make sure that you understand that last
October there were about 900 people who gathered
at the Fall Summit to have more and more intensive
discussions like this. We’ll be announcing soon
the time and date and place of the Fall Summit
upcoming later on this year, and we’d be pleased
to have you with us for that. So this concludes the
2017 LAN Spring Forum. It’ll be archived
on our website. We really appreciate
your attention to it and appreciate everyone who
came here in person. Thanks for being with us,
and enjoy the rest of your day.