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International HIT Perspectives: In Spain, Healthcare IT Leaders Nurture Creativity—Out of Necessity

March 3, 2018
by Mark Hagland
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Healthcare IT leaders in Spain continue to move forward to advance IT development within their national system
The famous "Cuatro Torres," or "Four Towers," dominate the tony Paseo de la Castellana in Madrid, and represent the new Spain

This is the first in a series of articles highlighting developments taking place in healthcare IT within the Spanish healthcare system.

 The Hospital Universitario Puerta de Hierro Majadahonda, located in the upscale northwestern Madrid suburb of Majadahonda, is as modern as any in Spain. A 613-bed academic medical center with 3,000 professionals, it has been ranked in the top 10 hospitals in Spain by reputation. Furthermore, it has achieved Stage 6 recognition by HIMSS Analytics (the division of the Chicago-based Healthcare Information and Management Systems Society), whose EMRAM model for the adoption of electronic health record (EHR) technology has been applied both in the United States and internationally. The hospital has a high-availability, EHR (from the local Spanish software company Selene—which had been acquired by Siemens, and is now part of Cerner), with full barcoded meds administration. A major impediment to its reaching HIMSS Analytics Stage 7? Like most Spanish hospitals, Puerta de Hierro does not package single-dose medications, a Stage 7 requirement. That smallish fact, like so many others, speaks to differences in European and American hospital organization and culture.

Still, like a number of other major academic hospitals in Spain, Puerta de Hierro is one that is showing the way to a more technologically advanced future, says Juan Luis Cruz Bermúdez, whose Spanish title is “Coordinador, Unidad de Tecnologías de la Información y las Comunicaciones, Instituto de Investigación Sanitaria”—meaning that he is the IT director in the clinical research division of the hospital. He is also acting CISO for the hospital, and its former CIO.

Providing this foreign journalist with a comprehensive tour of the hospital’s operations, including IT operations last November, Cruz Bermúdez was quick to point out that some of the differences between the U.S. and Spanish healthcare systems reflect policy and strategic priorities, while others reflect financial issues and concerns. “As you’ll hear so often said here,” Cruz Bermúdez says, “we are underfunded for information technology, and need to use rely a lot on imagination” in order to fully serve hospitals’ communities. In Spain, as in the U.S., healthcare represents a high cost for the national governments of both nations; in Spain, though, hospital budgets can yo-yo up and down to some extent, depending on the priorities of the government in power at the time, in a parliamentary system in which parties can shift into and out of power relatively quickly.

Still, the Spanish healthcare system has done some things that make it more advanced than the U.S. healthcare system overall in certain very specific contexts, one of them being population health. Dr. Rosa Capilla Pueyo, the ED coordinator at Puerta de Hierro Majadahonda, notes that what in the U.S. has emerged as population health in the past several years, has been practiced, at the primary care level, in Spain, for over 40 years, as a matter of course. That is not surprising, given that spending constraints at the national level have meant a strong emphasis on managing care upstream. Indeed, Dr. Capilla Pueyo, a primary care physician who manages a special program for managing geriatric patients, including those with dementia who are in assisted living and long-term care institutions, to prevent extended hospital stays, reduce length of stay, and enhance health status, notes that, “By 2050, more than 27 percent of Europeans will be over 70 years old. That will be catastrophic. In Spain, population health management has been around for 40 or more years, and is simply called public health.”

Still, even with population health management programs that are advanced by U.S. standards, Spanish clinical leaders face some perhaps-universal issues. “One of the problems,” Dr. Capilla Pueyo says, is cultural, in terms of the population. It’s hard to educate people not to automatically use the emergency room. We need to engage in some very efficient triaging, and strong case management.” In that context, she and her colleagues are leveraging data and IT to support the ongoing development and expansion of algorithms and clinical pathways for managing such issues as COPD (chronic obstructive pulmonary disease), congestive heart failure (CHF), urinary tract infections, and diabetic ketoacidosis. “It is important for clinicians to follow these guidelines or pathways, both to improve patient outcomes and health status, and also to lower costs, in a government-run health system,” she notes.

Meanwhile, a program that Dr. Capilla Pueyo is leading, called “UAPI"—which stands for “La Unidad de Atencion al Paciente Institucionalizado,” or Inpatient Care Management Program—has averted 1,743 inpatient admissions in the past 12 months, through intensive care management of at-risk patients. It has also reduced the average length of stay of patients being care-managed in the program.

What’s more, other IT- and data-facilitated innovations are taking place in various departments and areas at Puerta de Hierro. Among them: the development of a consumer-facing app that is helping more than 1,500 cancer patients better participate in their care. Dr. Mariano Provencio, Cruz Bermúdez, and Consuelo Parejo, an engineer, have been leading this development effort. The app was created in late 2015. As Consuelo Parejo explains “OncoApp,” “It begins to guide the patient to manage his or her own symptoms. The patient can share his or her symptoms with the app, and the app will recommend actions, for example, to come to the hospital or take medicine. Or call the oncology department on the phone. It’s new in oncology in Spain.” And it represents, she says, “a more intelligent system.” That system will soon be making use of artificial intelligence. What’s more, she says, “We can follow you in your home, in your life, with wearables, etc.” The app has also been useful in that it provides for integrated appointment-making by patients, as well as the ability to send information campaigns to users regarding their profiles (such as info about clinical trials recruitment).


Built-in interoperability advantages in a single-payer system

One thing is certain: self-development and working within rigorous financial limitations are essential in Spanish healthcare IT. A small number of international electronic health record (EHR) vendors, most notably including the Kansas City-based Cerner Corporation, are active in Spain; but the majority of Spanish hospitals are relatively underfunded in terms of being able to afford international-level EHR information technology, everyone this journalist spoke with, agreed.

Still, within those limitations, there are numerous opportunities for operational innovation. Antonio García García, CIO at the Hospital Infantil Universitario Niño Jesús, a pediatric teaching hospital located on the busy Avenida Menéndez Pelayo, right across from the famous Parque del Buen Retiro (Retiro Park), says that the reality is that hospital IT leaders in Spain need to work as creatively and judiciously as possible. “We certainly can’t afford Cerner,” he says, referring to that vendor’s EHR, though he concedes that it would provide an advantage to be able to do so. Instead, the Niño Jesús Hospital self-developed its EHR, which García García says is working very well. What’s more, he has been able to achieve integration between the hospital’s EHR and its PACS (picture archiving and communications system), and García García is leading his team forward on further integration of clinical and other systems. “We operate on very small budgets here,” García García says, of the financial parameters set for hospitals in Spain. “But we’re able to achieve a lot on relatively small budgets.

One key advantage that Spanish healthcare IT leaders have over healthcare IT leaders in the US is a very fundamental one having to do with the two countries’ vastly different policy and payment landscapes. The Spanish healthcare system, like those of most western European nations, is strongly dominated by its government-financed, government-operated healthcare system. There is a small private sector of privately owned hospitals and medical clinics, which, like the private provider sector in the United Kingdom, acts to some extent as a safety valve on demand, allowing patients who don’t want to wait for elective procedures and other forms of non-urgent care, to access care more quickly—but it is relatively small, and even that system is connected to the government-run system.

And partly because of that, Spanish CIOs and other healthcare IT leaders are blessed with the advantages of a low level of bureaucracy, in terms of a single large payer, and also with the existence of a national patient identifier. Indeed, Spanish healthcare leaders are routinely astonished to learn that a national patient identifier does not exist in the United States. Having that national patient identifier means that a patient’s record is easily identifiable and discernable as unique, across the nation, making referrals and other forms of information-sharing extremely easy, compared within the U.S.

What’s more, as the OECD (Organization for Economic Cooperation and Development) stated in 2014, Spain spent 9.4 percent of its gross domestic product (GDP) on healthcare in 2011, compared to the United States’ 16.9 percent. Spain’s percentage of expenditure on healthcare was right in line with the expenditures of fellow western European countries Sweden (9.5 percent), Portugal (9.4 percent), Slovenia (9.4 percent), and Norway (9.3 percent), and exactly average among OECD countries (9.3 percent); but lower than those of the Netherlands (11.8 percent), France (11.6 percent), Switzerland (11.4 percent), Germany (11.3 percent), and Denmark (11.1 percent). Of course, even second-place Netherlands, at 11.8 percent, is far below the United States, at 16.9 percent; and of course, as the Medicare actuaries reported, the United States’ proportion of GDP spent on healthcare already reached 17.9 percent in 2016, and is headed towards a mind-boggling 19.7 percent by 2026—leaving the European nations far behind in relative spending.

In that context, it is interesting to read a portion of a transcript of an interview that took place on July 9, 2017, on National Public Radio’s “Weekend Edition program. American journalist Lauren Frayer told program host A Martinez about her experience with the Spanish healthcare system. As Frayer recounted it, “[A]s a legal resident of Spain, I'm entitled to coverage through a public health system there, taxpayer-funded health care for everyone. You pay a bit for prescriptions. But when I say a bit, I mean $2. No co-pays for doctor visits or specialists or anything. And on top of that public health care, I choose to buy private health insurance, through which I can find, if I want, an English-speaking doctor, get certain preventative care that might not be covered by the public system.”

Asked about her experience with the system, Frayer stated that “[I]t’s no frills. I mean, the hospitals are pretty rudimentary. You might not get a private room. But the care is of very high quality. Spain does, you know, interestingly enough, the most organ transplants of any country in the world.” What’s more, she noted, “[A]s an American being in the European health care system, what strikes me as strange—there's no money transactions. You know, there's no cash register in any hospital or doctor office here. This system is a little bit more analog, you could say. Only recently in Spain could you make specialist appointments through—in the public health care system by telephone. I've had to line up in the hospital basement with slips of paper. These are doctor referrals to make appointments with specialists. But you do get the appointments… [I]f you have something serious, you can see a doctor the next day. If you want to go to the dermatologist and, you know, have some moles checked out, for example, have some kind of non-urgent preventative care, in the public system, you might have to wait a month or two or even more.” In addition, she notes, “Doctors and nurses in Spain are sort of mid-range civil servants. Keep in mind the average salary in Spain is about $1,800 a month. Doctors make slightly more than that. But they are not millionaires usually. Anecdotally, I know a cardiologist who - you know, her salary is less than mine. I'm a freelance journalist. She recently started doing botox treatments on the side to supplement her income because that's much more lucrative for her. There are a lot of Spanish nurses and doctors who come here to the United Kingdom because the pay is better. And so Britain's National Health Service is a very diverse health service from - you know, there are workers from all over Europe working here.”

Francisco (Paco) Perez, president of HL7 España, sees all of this in a broad international context. “We continue to face financial challenges in terms of investment in healthcare IT,” Perez says; “at the same time, there is a great deal of ingenuity here, and we have a level of interoperability in our system that is very high.” What’s more, Perez notes, Spanish healthcare IT leaders are involved in numerous international healthcare IT organizations and conferences, and are very aware of developments across Europe and in North America. Spanish healthcare IT, he says, is not isolated from developments in other healthcare systems and countries.

That fact is underscored not only by the fact that some Spanish health system CIOs, among them Cruz Bermúdez and García García, have begun to seek credentialing by organizations like the Ann Arbor, Mich.-based CHIME (College of Healthcare Information Management Executives), which a few years ago modified its CHCIO certification program to allow European healthcare IT leaders to become certified. For example, European CIOS and other healthcare IT leaders have no need to learn the details of the meaningful use program or other U.S.-specific regulatory and policy requirements; but they are required to demonstrate an understanding of broad healthcare IT principles and knowledge.

Meanwhile, it remains to be seen what might happen with regard to the HIMSS Analytics EMRAM requirements around single-dose medication barcoding, for Stage 7 certification. In any case, what is clear is that Spanish healthcare IT leaders want their patient care organizations to achieve international-level recognition for their IT development and advancements. And what’s clear is that Spanish healthcare IT leaders, like their colleagues across western Europe, are continuing to press forward to improve their facilitation of the highest levels of patient care quality and availability.

In the next article in this series: Catalonia moves forward at the regional healthcare authority level.

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Healthcare Groups to CMS: ACOs Need More Time in One-Sided Risk Models

October 17, 2018
by Rajiv Leventhal, Managing Editor
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A new survey from NAACOS also reveals that many ACOs would likely have not entered the MSSP under revised policies laid out in a proposed rule by CMS

Healthcare associations have written to the Centers for Medicare & Medicaid Services (CMS), urging the agency to reconsider its proposed regulation that would push accountable care organizations (ACOs) more quickly into two-sided risk models.

About two months ago, CMS dropped a rule that proposed sweeping changes to the existing Medicare Shared Savings Program (MSSP), by far the most popular federal ACO model with more than 560 participants. At the center of the proposed rule, called “Pathways to Success,” is a core belief that ACOs ought to move more quickly into two-sided risk payment models so that Medicare isn’t on the hook for money if the ACO outspends its financial benchmarks. Indeed, when ACOs are in a one-sided risk model, they do not share losses with the government when they overspend past their benchmarks, but they do share in the gains.

Specifically, in the rule, CMS is proposing to shorten the glide path for new ACOs to assume financial risk, reducing time in a one-sided risk model from the current six years (two, three-year agreements) to two years total. This proposal, coupled with CMS’ recommendations to cut potential shared savings in half—from 50 percent to 25 percent for one-sided risk ACOs—will certainly deter new entrants to the MSSP ACO program. So far, the proposed rule has been met with varying degrees of scrutiny.

What’s more, the proposal looks to redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years: the BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase-in higher levels of risk; and the ENHANCED track, which is based on the program’s existing Track 3, providing additional tools and flexibility for ACOs that take on the highest level of risk and potential rewards. At the highest level, BASIC ACOs would qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program.

ACOs Need More Time, Stakeholders Say

Now, in public comments sent to CMS, stakeholders are officially making their stances known. Yesterday, groups such as Premier, Inc., the National Association of ACOs (NAACOS), and the American Medical Group Association (AMGA) wrote to the federal agency, sharing the consensus opinion that ACOs should be afforded more time in one-sided risk models before they are required to take on downside risk.

NAACOS, an association comprised of more than 360 ACOs across the U.S., wrote to CMS that ACOs entering the program should be able to remain in a shared savings-only model for four years with an additional fifth year available for those that demonstrate superior performance. The association pointed to data that shows that of the 142 ACOs that earned shared savings payments in 2017, 36 percent had losses in one of their first two years of the program, illustrating the need to allow ACOs adequate time to prepare for risk.

To this same point, Premier recommended in its comments to allow at least three years in an upside-only model for new ACOs entering the MSSP. And AMGA similarly wrote that CMS should allow ACOs to have the option to remain in an upside-only track for three years, rather than the two years that CMS has proposed.

Additionally, all three groups are also urging CMS to reverse its proposal on cutting potential shared savings in half—from 50 percent to 25 percent for one-sided risk ACOs. NAACOS specifically believes in “reversing the agency’s proposal to reduce the shared savings rate from 50 to 25 percent for ACOs in shared savings only or low risk models. Instead, NAACOS recommends that shared savings rates should be 50 percent for Basic Levels A and B, 55 percent for Basic Levels C and D, and 60 percent for Basic Level E.”

Similarly, AMGA wrote that “CMS’ proposal of a 25 percent shared savings rate for Basic Levels A and B further weakens what are already nominal financial incentives. The shared savings rate should be no less than 50 percent for upside-only ACOs.  Upside only low revenue ACOs should receive higher earned shared savings, for example, 75 percent or 80 percent.” Premier noted much of the same in its comments, attesting that the shared savings rate should be increased to 50 percent.

Will ACOs Stay in the MSSP?

At the core of the debate around the new proposal is if one-sided risk MSSP ACOs are saving the government enough money to warrant more time in these upside-only risk arrangements. CMS Administrator Seema Verma has been steadfast in her comments that these ACOs are not saving Medicare any money. In fact, she said in a press call following the proposed rule’s release in August that “[Upside-only] ACOs have no incentive, at all, to reduce healthcare costs while improving outcomes, as they were intended.” Verma also said she believes that the proposed changes outlined in this rule will result in $2.24 billion in savings to Medicare program over next 10 years.

On the other side of the savings argument are NAACOS and others, who attest that one-sided risk ACOs are saving Medicare significant money, to the tune of $1.84 billion in gross savings over the span of 2013 to 2015. To this point, some healthcare stakeholders fear that the CMS proposals, if finalized, will deter ACOs from staying in the MSSP, as well as prospective new ones from joining. But the federal agency, to this point, seems to be fine with these ACOs leaving the MSSP if they are unwilling to take on more risk.

A new poll from NAACOS, in conjunction with its comments to CMS, has revealed that 60 percent of ACOs who were surveyed oppose the proposed rule, while 27 percent are in favor. For the research, 127 current MSSP ACOs’ responses were included.

The NAACOs survey found that the four biggest challenges in the proposed rule, as noted by the surveyed ACOs, were: reducing the shared savings rates for one-sided risk ACOs; requiring more risk sooner for “high revenue ACOs,” which are typically hospital ACOs; shortening the shared savings-only timeframe for all new and some existing ACOs; and the proposed risk adjustment cap of plus or minus 3 percent, applied across the five-year ACO contract agreement period.

According to the research, after weighing the collective proposals in the rule, almost half of ACOs reported they are likely to continue participating in MSSP. While more ACO respondents report being likely to continue, more than a third report they are unlikely to continue.

What’s perhaps even more concerning to NAACOS is that a high number of ACOs, 60 percent, reported they would be unlikely to begin the MSSP if their ACO was not already participating and if they were evaluating the program under the revised policies.       

ACO contract agreements typically renew at the start of the calendar year, so it would be expected that CMS, after weighing the comments, would finalize the rule by January.

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CMS Announces 1,300 Participants for New BPCI Advanced Initiative

October 10, 2018
by Rajiv Leventhal, Managing Editor
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The new bundled payment initiative is voluntary, will qualify as an A-APM, and builds on the original BPCI model that ended in September. However, CMS has admitted that the first initiative did lose Medicare money

The Centers for Medicare & Medicaid Services (CMS) has announced that nearly 1,300 hospitals and physician group practices have signed agreements with the federal agency to participate in the Administration’s Bundled Payments for Care Improvement—Advanced (BPCI Advanced) model.

The participating entities will receive bundled payments for certain episodes of care as an alternative to fee-for-service payments that reward only the volume of care delivered.

According to CMS, the model participants include 832 acute care hospitals and 715 physician group practices—a total of 1,547 Medicare providers and suppliers, located in 49 states plus Washington, D.C. and Puerto Rico.  Of note, BPCI Advanced qualifies as an Advanced Alternative Payment Model (Advanced APM) under MACRA, so participating providers can be exempted from the reporting requirements associated with the Merit-Based Incentive Payment System (MIPS).

BPCI Advanced will initially include 32 bundled clinical episodes—29 inpatient and three outpatient.  Currently, the top three clinical episodes selected by participants are: major joint replacement of the lower extremity, congestive heart failure, and sepsis, according to CMS.

Back in January, CMS announced the launch of the voluntary BPCI Advanced model, noting that it “builds on the earlier success of bundled payment models and is an important step in the move away from fee-for-service and towards paying for value.” CMS Administrator Seema Verma stated yesterday in the announcement of the model’s participants that “To accelerate the value-based transformation of America’s healthcare system, we must offer a range of new payment models so providers can choose the approach that works best for them.”

Verma added, “The Bundled Payments for Care Improvement – Advanced model was the Trump Administration’s first Advanced Alternative Payment Model, and today we are proud to announce robust participation.  We look forward to launching additional models that will provide an off-ramp to the inefficient fee-for-service system and improve quality and reduce costs for our beneficiaries.”

Last year, CMS officially finalized a rule that cancelled mandatory hip fracture and cardiac bundled payment models. Verma has said in the past that she doesn’t think bundled payment models should be mandatory, a sentiment that some industry experts wholeheartedly agree with.

In contrast to the traditional fee-for-service payment system, in this new episode payment model, participants can earn an additional payment if all expenditures for a beneficiary’s episode of care are less than a spending target, which factors in measures of quality. Conversely, if the expenditures exceed the target price, the participant must repay money to Medicare.

How Did BPCI Fare?

The original BPCI initiative ended on September 30, and BPCI Advanced picks up where it left off, starting on October 1, and running through the end of 2023. This prior initiative included three models that tested whether linking payments for all providers that furnish Medicare-covered items and services during an episode of care related to an inpatient hospitalization can reduce Medicare expenditures while maintaining or improving quality of care. Model 2 episodes begin with a hospital admission and extend for up to 90 days; Model 3 episodes begin with the initiation of post-acute care following a hospital admission and extend for up to 90 days; and Model 4 episodes begin with a hospital admission and continue for 30 days.

According to CMS, the evaluation from these models revealed that BPCI Models 2 and 3 reduced Medicare fee-for-service payments for the majority of clinical episodes evaluated while maintaining the quality of care for Medicare beneficiaries. It also should be noted that spanning over the two years that participants were able to join the risk-bearing phase of the initiative, 22 percent of Model 2 participants, 33 percent of Model 3, and 78 percent of Model 4 participants ended up withdrawing. Most BPCI participants were in eithers Model 2 or 3; in 2017, just five hospitals belonged in Model 4, in which Medicare makes a prospective payment for the episode.

CMS noted in its report of the BPCI initiative, “Despite these encouraging results, Medicare experienced net losses under BPCI after taking into account reconciliation payments to participants.  Technical implementation issues, including the specification of appropriate target prices, contributed to these net losses. We are optimistic that Medicare will achieve net savings under a new episode- based Advanced Alternative Payment Model, BPCI Advanced, because it addresses the challenges BPCI experienced.”

To this point, a report from the Lewin Group, a healthcare consulting firm, found that in the most popular track of BPCI, Model 2, Medicare lost more than $200 million ($268 per episode) from 2013 to 2016. In Model 3, Medicare lost slightly more than $85 million ($921 per episode) over that same time period, according to the report.

Moving toward BPCI Advanced, the federal agency points out some key differences between the original model and the new one, such as:

  • BPCI Advanced offers bundled payments for additional clinical episodes beyond those that were included in BPCI, including, for the first time, outpatient episodes.
  • BPCI Advanced provides participants with preliminary target prices before the start of each model year to allow for more effective planning. The target prices are the amount CMS will pay for episodes of care under the model.
  • BPCI Advanced qualifies as an Advanced APM and is eligible to earn the 5-percent bonus in the Quality Payment Program.

Keely Macmillan, the general manager of BPCI Advanced for Archway Health, a Massachusetts-based company that helps providers get started in bundled payment programs, says she is happy with the level of participation so far. She did add that one thing her company noticed immediately, regarding the participant list, was the popularity of joint replacements and cardiac bundles. “Research coming out in the last few months has proven that these bundles do particularly well, and we’re excited to help our participants and see others industrywide continue to drive improvement in the new program,” she says.

Meanwhile, Clay Richards, president and CEO of naviHealth, a post-acute care management company based in Tennessee, and which is a BPCI convener, notes that its hospital and health system partners saved more than 8 percent, or approximately $2,000 per episode, which translates to more than $83 million in the BPCI initiative. “With the increase in BPCI Advanced participation, we expect the impact to be even greater,” says Richards.

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On the Road to Risk, Summit Medical Group is Driving in the Fast Lane

October 2, 2018
by Rajiv Leventhal, Managing Editor
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Dr, Jeffrey Le Benger, M.D., CEO of Summit Health Management and Summit Medical Group, discusses how his organization is succeeding in a mostly value-based care environment

At Summit Medical Group (SMG), the oldest independent multispecialty physician group in New Jersey, Jeffrey Le Benger, M.D., has been providing high-level leadership for 16 years. With more than 800 providers at 70 locations, multiple comprehensive ambulatory care campuses and a strategic partnership with MD Anderson Cancer Center, SMG handles more than 1.5 million patient visits annually. Its officials believe that its performance is marked by a sustained enhancement to clinical quality and patient outcomes, ongoing participation in emerging value-based reimbursement initiatives and meaningful cost containment.

Indeed, after devising and refining a highly effective practice management and patient care model at SMG and extensively studying the condition of mid-range and large-scale independent physician groups nationwide, Dr. Le Benger spearheaded the formation of Summit Health Management (SHM) in 2014 to share SMG’s formula for success via strategic partnerships and customized managed services contracts. Now, Le Benger serves as chairman of the board and CEO of Summit Health Management and Summit Medical Group.

SHM is now poised to become a national organization, with the aim to positively impact the delivery of patient care across the country, as Le Benger envisioned, with the 2017 establishment of a major agreement with the Bend Memorial Clinic in Oregon and an alliance with Arizona Primary Care Physicians (APC) that resulted in the formation of Summit Medical Group Arizona. 

In a recent interview with Healthcare Informatics, Le Benger outlined the progress and evolution of his organization and how it is continuing to plunge ahead into the world of risk and value-based care. Below are excerpts from that discussion.

How is your organization progressing when it comes to taking on risk for your patients?

We are at a point in which 65 percent of our patient base is based within risk-based contracting, and it’s a continuum, so you have fee-for-service and then percent to premium is on the other side. And then there are all aspects of risk in in between; there is pay-to-play, shared savings, and full risk. Most of our contracts that have upside and downside risk have a shared savings component. But as soon as we increase the size of our attribution and can mitigate our risk more evenly, then we will look to go to percent to premium as a group.

Jeffrey Le Benger, M.D.

Can you detail the ACO (accountable care organization) work that you’re involved in?

We are a part of the Trinity Health ACO [which serves patients in Illinois, Michigan, New Jersey and Ohio], and are in the Centers for Medicare & Medicaid Services (CMS)’ Next Generation ACO Model. Over the past two years we have received shared savings and we do take on upside and downside risk. The issue with Next Gen is that you are benchmarked against yourself [rather than against outside ACOs], so you have to improve [internally] every year. In Medicare Advantage, you are benchmarked against the community that you have the product within. So the house always wins. The government knows that shared savings pushes the envelope, but the cost to create that savings far outweighs the savings they get in a trend demonstration.

What are your thoughts on the recent CMS proposed rule for ACOs? Do you think it’s too aggressive or fair?

We are a large group of [nearly] 900 providers that is fully integrated and not consolidated, so pushing into risk is not an issue. We are already capable of handling more risk in the organization. But when you have a consolidated network, or an individual doctor or smaller group, the amount of data analytics that’s needed to manage risk is financially unaffordable. For a hospital institution, I think you will find that they will have a hard time on the payment schedule as they move towards risk on fair market value. So the small practices will have to figure out how they will consolidate into a larger group to help defray some of their costs for the data analytics they need to do in order to take on risk.

How are you currently handing MACRA/MIPS?

We are in an advanced alternative payment model (A-APM) since we are in Next Gen, though we still have physicians who come on that are required to do MIPS. For us, we have the data analytics to handle it and we have achieved a fair amount of savings in MIPS. Now they are moving to bundling programs, so we can manage that with the data analytics that we have. The government has demonstrations to see what makes sense and what doesn’t, and then you have all these practices figuring out how they could justify moving in and out of all the programs, and where the best economic value is. And it doesn’t mean you will have the best quality outcomes, but rather you are looking to move to the program where you see the best economic value.

How are things progressing with Summit Health Management?

[In 2014], we broke out all of management from Summit Medical Group and we started Summit Health Management. It started with 500 employees, and we have full coding compliance, we audit within it, as well as having all revenue cycle, accounting, and MSO (managed service organization) services within it. Also within it is a large population health department that we offer services to the three groups that we have MSA agreements with: Summit Medical Group New Jersey, Summit Medical Group Oregon, and Summit Medical Group Arizona. So we can scale the commitment and the resources within the management company to the three groups in order to run what is needed in that organization for its value proposition.

Each location is different, so we are ahead of the curve with upside and downside risk in New Jersey, with 65 percent of our population at full risk. In Oregon, it’s a little bit of shared savings and a little pay-to-play, and in Phoenix, besides the MSSP (Medicare Shared Savings Program) product and managed Medicare, on the commercial side it’s only a little pay-to-play. So we are able to adjust and scale what’s needed in the different organizations in the management company.

What are the keys to having 65 percent of your patient population in New Jersey at full risk?

It has to do with the governance and leadership of the organization, and how we structured the culture as an all-for-one. We also don’t differentiate in how the doctor sees a patient from the PPO world versus the HMO world. In all of our products, we heavily manage the sickest percent of the patient population, and we decentralize preventative care in the organization. We see it as “payer-blind” in terms of how we compensate within the organization. So they do not know who is a fee-for-service patient and who is an HMO patient because we don’t want to make a distinction on how they care for the patient. And that was culturally how it was developed in the group.

And on the back end, yes, sometimes we do a little more care management for one [side] or the other because it’s [needed], but we do try to manage all patients the same way. We know that all of our payers will eventually move to higher risk, so when you are in the fee-for-service world, these payers know what the total cost is because claims adjudication is still based in a fee-for-service world.

[Essentially], you are still putting in individual claims, but you are rolling up all those costs and then comparing it to your total costs to the total costs on the outside. If you cannot demonstrate savings to a payer, even in a fee-for-service world, they will go after your rate structure, and you essentially will be at risk because you will lose revenue if they decrease your reimbursement in that program.

How important are payer-provider relationships? Have they improved in recent years?

You cannot look at your payer relationships as adversarial when you are in a large group practice. Think of them as your partners, because as all insurers move to high-deductible or employer-based [plans], you have to look at how you achieve savings moving forward. When you look at shared savings, who is benefitting in the shared savings? It has to either be either the employer, the insurance company, the beneficiary, or the provider.

We are in a full-risk contract with Horizon Blue Cross Blue Shield in New Jersey, and they are a very good partner. We have more than 60,000 attributed lives who are at full risk with Horizon in the state, and we have seen that we have lowered the cost of care with this product over the past five years, and we have consistently beat the market in lowering the cost of care. So the payer is happy, the employer base is happy and the individual, who might not realize it, is happy because we look at the sites of service and we lowered the out-of-network or deductible cost for that patient.

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