On March 25, President Barack Obama hosted an event to launch a new program being sponsored by the Department of Health and Human Services (HHS)—the new Healthcare Payment Learning and Action Network.
President Obama looks on as Nancy Beran, M.D. speaks at the White House on March 25
As the website for the Centers for Medicare & Medicaid Services (CMS) explains it, “To help achieve better care, smarter spending, and healthier people, the Department of Health and Human Services (HHS) is working in concert with our partners in the private, public, and non-profit sectors to transform the nation’s health system to emphasize value over volume. HHS,” the description notes, “has set a goal of tying 30 percent of Medicare fee-for-service payments to quality or value through alternative payment models by 2016 and 50 percent by 2018. HHS has also set a goal of tying 85 percent of all Medicare fee-for-service to quality or value by 2016 and 90 percent by 2018. To support these efforts, HHS has launched the Health Care Payment Learning and Action Network to help advance the work being done across sectors to increase the adoption of value-based payments and alternative payment models.”
According to the U.S. News report on the event, Sylvia Mathews Burwell, Secretary of Health and Human Services, said, “We want to hear about your success and misses. What metrics do you use? How do you define and measure quality? What data can you share? How have you improved the patient experience?” And President Obama said that the project wasn’t about “reinventing the wheel.” “You’re already finding out how to reduce infections and meet needs,” U.S. News quoted him as saying.
Among the healthcare leaders participating in the White House event on Wednesday was Nancy Beran, M.D., the chief medical officer of the Katonah, N.Y.-based Westchester Health, a multispecialty group practice that encompasses 120 physicians practicing at 50 sites across Westchester County in New York. Six of the Westchester Health practice sites have been involved in the Comprehensive Primary Care Initiative, a four-year, multi-payer initiative launched in October 2012 by the Innovation Center at CMS, and designed to strengthen primary care.
Dr. Beran shared her perspectives on her and her colleagues’ participation in the Health Care Payment Learning and Action Network with HCI Editor-in-Chief Mark Hagland. Below are excerpts from that interview.
What brought you and your colleagues into this new initiative?
We have been part of the Comprehensive Primary Care Initiative, with six of our primary care sites participating in that initiative. We’re somewhat unique, with small practice sites, and six sites are in the CPCI; we have about 50 sites. We have a lot of small practice sites. We really brought together existing practices. Our largest site has seven physicians. Some subspecialty sites with maybe 10 people, that’s the most.
When did those six practice sites become involved in the CPCI program?
Those six sites—representing ten physicians—joined the CPCI when it launched in October 2012. All were early patient-centered medical homes, early EMR implementers, and early meaningful use attesters, which is why they were chosen to be part of CPCI.
How broad is the CPCI program?
There are over 70 practices in CPCI in New York. That’s the New York region. There are six different regions with CPCI initiatives across the country. One of the initiatives from CMMI. Looking at alternative payment models, they developed ACOs [accountable care organizations], bundled payments, and this CPCI. They were really trying to take some of these advanced practices that weren’t big enough to be an ACO that were advanced, and give them a way to transform earlier, and built the CPCI for that purpose.
We used the CPCI not just for those six sites, but actually took that model and used it to transform all of our sites. So we use the same technology and workflow in all our primary care sites that we use in the CPCI. So we have 21 PCMHs. In the IT department, what we built for the CPCI, we use in all our sites. We’re a NextGen user, but most of what we needed was not built by NextGen or ready for us in NextGen, when we began this work
One example is population health reports. We’re doing early population health, and we’re a small group, so I don’t have an overlay of big technology. I’m doing it with custom reports. For example, one of our conditions we manage very aggressively is diabetes. So we have reports that allow us to dissect our diabetic population in many different ways.
With regard to our diabetic population, the data points include the date of last visit, date of last hemoglobin a1c, what their LDLs are, because we have integrated lab, so we can analyze how well the diabetic patients are being managed. Those data points are in custom reports, they’re on our SQL server, doctors can run them themselves, and the doctors have dashboards. It’s less for benchmarking, because you can use MU reports somewhat for benchmarking—it’s really for custom reports to see who’s fallen off their radars.
So we started this project in 2012, and we’ve seen the meaningful use reports get better. Where we can drill down, the MU reports are better than they were in 2012, but they’re still clunky. We’ll be attesting to Stage 2 this year. Where we were behind was in the requirements around patient portal, interoperability, and linking to cancer registries. Our six CPCI sites were ready, though.
As you’ve said, executing on population health from an EMR platform can be challenging, correct?
Yes, when you start out, it’s as though the EMR is the alphabet, and you’re just learning to write. And population health is really about using the EMR to do aggressive chart review. And we’re at the point where if you track things right, you can do aggressive chart review from the EMR, but it requires that you standardize processes across your practice, whether it’s big or small. Because if everyone’s recording mammograms the same way and not just scanning documents, you can really leverage check boxes; then the check box has meaning.
So tell me about your charter participation in the new Healthcare Payment Learning and Action Network. What led you and your colleagues to decide to participate?
Secretary Burwell is trying to develop more alterative payment models. HHS wants 30 percent by 2016 and 50 percent by 2018, in alternate models. And the Healthcare Payment Learning and Action Network is pulling together the public sector, private payers, physicians, and consumers, to talk about ways to bring more organizations into value-based programs. It’s similar to what we’ve been doing in the CPCI. That’s not just CMS. We work collaboratively with the payers, doctors, consumer groups, and we meet monthly.
In a sense, it’s expanding the Comprehensive Primary Care Initiative?
It’s expanding all the innovative projects, and saying, how can we build on these models and hit the goal of more value-based programs? What can we do in these models, in CPCs, ACOs, and outside of them? How can you contract with commercial payers, what can we do with state programs? All to create more models to pay doctors more on value. Looking to get more and more primary care practices involved in the transformation that we at Westchester ….
Overall, how would you describe your philosophical perspective on participating in this initiative and other initiatives like this?
The philosophical commitment is that we really believe in delivering excellent community-based care for our patients. We’re smaller practices; and if we’re going to be cutting-edge and effective going forward, we’re going to have to be involved in alternative payment models. Consumers are looking for value-based healthcare, and value is quality over price; and we’re looking to provide that. We’re doing it all for the right reasons.
Are your physicians on board with your organization being so much in the leadership on this?
Sometimes yes, sometimes, no! Change is always hard. And it’s not always fair to put everything on the physicians, because they’re asked to practice in both worlds; and to produce value but be paid on volume, doesn’t work. You can’t ask someone to do the right care for the right reasons and to give more time to their patients, and make sure they track every transition in care, not compensate them for any of that work, and expect them to do well in that framework. The system has to change.
And that’s what the Network has been set up to do. We can change more if we have more funds to change. And if you want to see if new models can work, you have to fund those models; and you can’t fund things at the end. This costs a lot upfront. I had a really big fight with a major payer recently, because tracking every transition in care and really care-managing the sickest patients, is really expensive. If doctors see three fewer patients a day, and you’re essentially being penalized by the payer, where’s the economic model in that? Then I have to let people go. The margins in medicine have gotten so tight. So basically, if we want these models to work, we have to fund the goals and pay people appropriately. For a small practice, I have to do be doing one process for everybody.
So with regard to population health, you’re finding that you have to treat all patients the same way, regardless of their program status?
Yes, we basically have to have a critical mass of our patients involved, to fund this appropriately. With CPCI, they picked practices in which 60 percent of their population or more would be affected, because you can’t allow too many payers to be free riders. When I’m working in a new model, I can’t stop to think, is this patient in a plan that doesn’t support this?
The Network will shine a light on helping to create greater harmonization?
I think it will ultimately create interest, opportunity, and innovation. It may take things happening on a national level to the state level. I think there will be more and more pilots on the state level. We’re seeing that in New York. You’re going to see a lot of state-level innovation projects now in New York. A lot of money will come into New York, and be in the state innovation models.
What would you like the world to look like, as the U.S. healthcare system moves towards more accountable and care-managed types of care delivery?
My holy grail of quality is, even we’re going to align in all these programs, we should align around disease process as well. If payers can agree on things, we should agree on what the right measures are, and see who’s got that data. And we shouldn’t focus on HEDIS measures that really aren’t quality measures but are claims measures. We should be deciding all together what the five best measures are for any particular thing. That’s my holy grail. Otherwise, we work to numbers that are irrelevant.