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At HLTH, David Feinberg, M.D. Shares Why Geisinger Is Investing in the Full Health of Its Communities

May 7, 2018
by Mark Hagland
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Geisinger CEO David Feinberg, M.D. articled an extremely broad vision of his organization’s role in the health of its communities

During the first full day of a new three-and-a-half day conference being held this week at the Aria Resort in Las Vegas, David T. Feinberg, M.D., the president and CEO of the 13-hospital, Danville, Pa.-based Geisinger health system, articulated a vision of care for the communities the system serves that extends far beyond traditional care delivery, and encompasses literally feeding and housing those in need. Dr. Feinberg’s speech stood out as visionary even among numerous vision-focused statements made at the “HLTH: The Future of Healthcare” conference, sponsored by a team led by HLTH founder, chairman and CEO Jonathan Weiner, who founded and has led Money 20/20, a well-known financial services industry conference, and Shoptalk, a retail and e-commerce conference.

At the outset of his keynote speech, Dr. Feinberg, who became Geisinger’s CEO in 2016, detailed the recent announcement of the MyCode Community Health Initiative, which was first publicly revealed on March 14. As an article co-authored by Dr. Feinberg, Huntington F. Willard, and David H. Ledbetter and published online on March 14 in the Harvard Business Review explained it, “Standard screening tests such as colonoscopy, mammography, and cholesterol measurement are fine for individuals at average risk for cancer and heart disease but are inadequate for people whose genetic profiles put them at much higher risk. Current clinical guidelines, based primarily on families large enough to show a positive family history for that condition, fail to identify about half of the high-risk individuals in the population. For those individuals, we need a different approach that accurately forecasts their risk and anticipates their health needs,” the article’s authors stated. “To this end, Geisinger has launched a DNA sequencing project with the potential to identify virtually everyone in our patient population who is at increased risk for early onset, inherited cancer and cardiac events. Already we have identified more than 500 patients who are at increased risk for disease and have uncovered previously undetected cases of cancer and heart disease, allowing our doctors to treat these much earlier than they could have otherwise.”


David T. Feinberg, M.D.

The March 14 article went on to say that, “In our precision health programs, sequencing the known functional parts of the genome for our patients is becoming a clinical reality, not just as a diagnostic test for patients who present with particular symptoms, but for all patients in our community. Understanding their genome’s warning signals is now an essential part of their health forecasting, wellness planning, and health management. As full partners in their own care, they can now work with their physicians to modify lifestyle or behaviors to mitigate the risks that have been revealed, and to anticipate future health needs. This type of forecasting allows us to provide truly anticipatory “health care,” instead of the responsive “sick care” that has long been the health care system’s default.”

In his speech on Sunday afternoon at the HLTH Conference, Dr. Feininger announced a new care delivery protocol at Geisinger, in which patients undergoing routine testing in a number of areas will be offered genetic testing free of charge. He noted that “We have about 200,000 patients, through a research study with Regeneron, who have consented” to participate in the MyCode Community Health Initiative. “And they’ve come up with incredible research insights,” he said, referring to Geisinger’s genetic researchers. “But we felt the research was going too slowly in crossing the chasm,” which is why, he said, “We’re announcing here today, that when patients come in for routine tests such as colonoscopy and mammography, we will be offering them genetic screening, free of charge.” Sunday’s announcement had been hinted at broadly in an April 30 press release, in which Feinberg had stated that “We think it’s time to transition our successful genomics program beyond the realm of research and into routine clinical care for all of our patients.”

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The potential for identifying genetic risk factors early enough to appropriately intervene is very exciting, Feinberg said, citing the recent case of a teenaged patient whose genetic testing had a powerful impact on her and her family’s life. “For example,” he said, “I recently met a 16-year-old girl who came into one of our hospitals dehydrated from soccer practice. We did her whole exome sequencing and found two genes associated with fatal arrhythmias in young athletes. And we looked at the 30 members of her extended family whom we had cared for in the past, and were able to discover that 15 of them had that same genetic sequence. In fact, her Uncle Bill had died from ‘choking,’ but further investigation was able to determine that he had actually died of that arrhythmia. And this young woman now has a defibrillator and is on beta blockers. So every patient coming in for tests will be offered free of charge whole exome sequencing. In fact, he said, “We’ve finding that 15 percent of patients need such interventions”—and, those patients are offered genetic counseling via a mobile app that explains the genetic mutation that has been revealed through a patient’s whole exome genetic testing. All of this activity, he noted, is taking place in the context of an overall community in central and northeastern Pennsylvania that is largely rooted to the area, with the health system having cared for multiple generations of many families. As a result, he said, the potential for this initiative to contribute to overall health status across Geisinger’s overall service area is quite significant.

Feeding and housing those in need—a holistic vision of health

Dr. Feinberg went on to articulate an exceptionally expansive vision of the role of the Geisinger Health system in caring for the health, in extremely broad terms, of the communities it serves. First, he shared some information and insights around Geisinger’s Fresh Food Farmacy initiative, which Healthcare Informatics Associate Editor Heather Landi reported on in a Feb. 8 article. As Landi noted in that article, “With the aim of addressing food insecurity, as a significant social factor impacting health, and to improve patients’ diabetes management, Geisinger launched an IT- and data analytics-driven Fresh Food Farmacy initiative to provide fresh, healthy food to diabetes patients, at no cost to the patients. The health system initially launched the program in July 2016 as a pilot project at Geisinger Shamokin Area Community Hospital in Coal Township, in Northumberland County, which has the second-highest rate of long-term diabetes complications in central Pennsylvania.”

Further, Landi noted in her February report, “While Geisinger healthcare leaders are using an old approach, essentially “food as medicine,” to tackle medical conditions, the Fresh Food Farmacy initiative is an informatics-driven project that relies heavily on data integration, analytics and mobile technology to do everything from tracking clinical outcomes to managing the food supply chain.”

Speaking of the Fresh Food Farmacy initiative on Sunday, and contexting the MyCode Community Health Initiative and the Fresh Food Farmacy initiative in the framework of a broader whole, Feinberg said, “We think that that genetic piece is just a sliver of what matters. We spend too much time talking about our great doctors and hospitals and treatments. Access to healthcare probably has a 20-percent effect on your overall health,” he said. “The other 80 percent includes your genetic code, and we’re all in on that. And we’re moving into clinical care for genetics. But as important as your genetic code is, so is your zip code. And we say, as important as your genetic code is, so is your zip code. We say we have to sequence your zenetics. And food insecurity huge. And when you’re food-insecure, you buy high-calorie food that increases the chance of type 2 diabetes. And diabetes affects everything else, bidirectionally. I’m 56 years old, and when I was born, fewer than 1 percent of Americans had diabetes,” he noted. “Now, 10 percent do. And in 30 years, 30 percent will. We call diabetes a foodborne illness.”

As a result of the Fresh Food Farmacy initiative, Feinberg said, Geisinger care managers and dieticians have been able to significantly reduce the documented hemoglobin a1c levels of diagnosed diabetics being treated by Geisinger clinicians. “We have care managers, dieticians, etc., helping these patients, and we have patients who previously should have had hemoglobin a1c levels of 6 or 7, but whose levels were 8, 9, or 10 instead. So we brought patients in and said, OK, let’s give you fresh, healthy food for you and your family. We started with a little market. Next year, we will have served one and a half million meals. And we’ve found that hemoglobin a1cs went from 13 to 7; average 2.5-percent decrease. Metformin will decrease your a1c by 1 point, while eating healthy foods will decrease it by 2.5 percentage points, he said, noting the improved well-being and enjoyment of life that numerous patients have already been able to show, as a result of the initiative.

“And so whether it’s genetic testing for all patients or giving out food, are those practices sustainable?” Feinberg asked. In fact, he said, “Typically, those diabetics were costing us $200,000 a year. Within 3 months in the program, their healthcare costs plummeted to $40,000 a year, and it was costing us about $1,000. So for us, it makes sense, and now we’re scaling it to folks who have pediatric obesity and heart failure. We’re literally opening up Fresh Food Farmacies at every care location, and turning them into places that look like Whole Foods.

Further, Dr. Feinberg noted, concerns over Lyme disease and MRSA (methicillin-resistant staphylococcus aureus) are such that “We’ll be giving docs a Lyme score, from 1 to 9, for each patient, based on where patients live. They’ll also get a score indicating their risk of MRSA,” because of the high risk in central Pennsylvania and other farming areas related to the acquisition of MRSA in connection with the slaughter of livestock; as well as a score noting how close patients live to Marcellus Shale drilling activities in Pennsylvania.

What’s more, Geisinger now offers free transportation to those community members in need of it, for individuals within 50 miles of the health system’s cachement area in central Pennsylvania or within 25 miles of the cachement area in the Allentown-Scranton area—not only for trips involving healthcare visits and treatment, but more generally. “We’ll  give you rides to see the doctor, or see your friend or for other reasons. We’re going to eliminate some of the loneliness and isolation that lead to obesity and heart disease,” Feinberg explained.

And then Feinberg went on to share with his audience at HLTH why he’s been leading another initiative, this one to provide housing for pregnant mothers who are opiate-addicted and homeless or at risk of homelessness. “I was rounding with one of our care managers,” he recounted, “and asked her what she’d like. She said, ‘I have this pregnant, opiate-addicted mom, who can’t get housing.’ And so we looked into that and asked, how many opiate-addicted homeless moms do we have? We found we had 17. And we said, this is ridiculous. If you’re an opiate-addicted, homeless mom, the chances of your baby having health problems is huge. So we’ve identified all the opiate-addicted, homeless or housing-fragile pregnant moms, and have been working to provide housing for them. We’re using this vulnerable moment to capture them and help them. We don’t know what the results will be, but 14 people a day are dying in Pennsylvania from opiate overdoses. The death rate from those overdoses in central Pennsylvania is four times higher than in New York City. So for us, a health system engaged in our community, believe that it’s important for us to care for our community.”

Feinberg went on to cast an even wider conceptual net around his vision for healthcare. “For us, what really matters is so much about what’s happening outside the clinics or the hospitals,” he said. “We have 13 hospitals in our system. And I think my job is to close all of them. I know that out of 2,000 beds we have, if people ate right, used alcohol in moderation, didn’t use illegal drugs, wore seatbelts, ate healthily, had access to broccoli and blueberries, and didn’t shoot people with guns, 1,000 of those beds could be gone. Seven out of 10 Americans are on a prescription medication.,” he noted. “So we can have a lot of breakout discussions about what we can do about pharma pricing, or we can get a lot of people off medication. And this is about proven techniques to get us healthy again. This has happened in my lifetime; and I think what we need to do is to reverse course. For the first time in my lifetime, life expectancy has gone down, and to me that’s criminal,” and an issue that healthcare providers must address. Much remains to be done, he concluded, but the future will be about patient care organizations truly looking after the health, and not only the illness of their patients and communities. “This is exciting work.”

 

 


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At the D.C. Department of Health Care Finance, Digging into Data Issues to Collaborate Across Healthcare

November 22, 2018
by Mark Hagland, Editor-in-Chief
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The D.C. Department of Health Care of Finance’s Kerda DeHaan shares her perspectives on data management for healthcare collaboration

Collaboration is taking place more and more across different types of healthcare entities these days—not only between hospitals and health insurers, for example, but also very much between local government entities on the one hand, and both providers (hospitals and physicians) and managed Medicaid plans, as well.

Among those government agencies moving forward to engage more fully with providers and provider organizations is the District of Columbia Department of Health Care Finance (DHCF), which is working across numerous lines in order to improve both the care management and cost profiles of care delivery for Medicaid recipients in Washington, D.C.

The work that Kerda DeHaan, a management analyst with the D.C. Department of Health Care, is helping to lead with colleagues in her area is ongoing, and involves multiple elements, including data management, project management, and health information exchange. DeHaan spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding this ongoing work. Below are excerpts from that interview.

You’re involved in a number of data management-related types of work right now, correct?

Yes. Among other things, we’re in the midst of building our Medicaid data warehouse; we’ve been going through the independent validation and verification (IVV) process with CMS [the federal Centers for Medicare and Medicaid Services]. We’ve been working with HealthEC, incorporating all of our Medicaid claims data into their platform. So we are creating endless reports.

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Kerda DeHaan

We track utilization, cost, we track on the managed health plan side the capitation payments we pay them versus MLR [medical loss ratio data]; our fraud and abuse team has been making great use of it. They’ve identified $8 million in costs from beneficiaries no longer in the District of Columbia, but who’ve remained on our rolls. And for the reconciliation of our payments, we can use the data warehouse for our payments. Previously, we’d have to get a report from the MMIS [Medicaid management information system] vendor, in order to [match and verify data]. With HealthEC, we’ve got a 3D analytics platform that we’re using, and we’ve saved money in identifying the beneficiaries who should not be on the rolls, and improved the time it takes for us to process payments, and we can now more closely track MCO [managed care organization] payments—the capitation payments.

That involves a very high volume of healthcare payments, correct?

Yes. For every beneficiary, we pay the managed care organizations a certain amount of money every month to handle the care for that beneficiary. We’ve got 190,000 people covered. And the MCOs report to us what the provider payments were, on a monthly basis. Now we can track better what the MCOs are spending to pay the providers. The dashboard makes it much easier to track those payments. It’s improved our overall functioning.

We have over 250,000 between managed care and FFS. Managed care 190,000, FFS, around 60,000. We also manage the Alliance population—that’s another program that the district has for individuals who are legal non-citizen residents.

What are the underlying functional challenges in this area of data management?

Before we’d implemented the data warehouse, we had to rely on our data analysis and research division to run all the reports for us. We’d have to put in a data request and hope for results within a week. This allows anyone in the agency to run their own reports and get access to data. And they’re really backed up: they do both internal and external data reports. And so you could be waiting for a while, especially during the time of the year when we have budget questions; and anything the director might want would be their top priority.

So now, the concern is, having everyone understand what they’re seeing, and looking at the data in the same way, and standardizing what they’re meaning; before, we couldn’t even get access.

Has budget been an issue?

So far, budget has not been an issue; I know the warehouse cost more than originally anticipated; but we haven’t had any constraints so far.

What are the lessons learned so far in going through a process like this?

One big lesson was that, in the beginning, we didn’t really understand the scope of what really needed to happen. So it was underfunded initially just because there wasn’t a clear understanding of how to accomplish this project. So the first lesson would be, to do more analysis upfront, to really understand the requirements. But in a lot of cases, we feel the pressure to move ahead.

Second, you really need strong project management from the outset. There was a time when we didn’t have the appropriate resources applied to this. And, just as when you’re building a house, one thing needs to happen before another, we were trying to do too many things simultaneously at the time.

Ultimately, where is this going for your organization in the next few years?

What we’re hoping is that this would be incorporated into our health information exchange. We have a separate project for that, utilizing the claims data in our warehouse to share it with providers. We’d like to improve on that, so there’s sharing between what’s in the electronic health record, and claims. So there’s an effort to access the EHR [electronic health record] data, especially from the FQHCs [federally qualified health centers] that we work closely with, and expanding out from there. The data warehouse is quite capable of ingesting that information. Some paperwork has to be worked through, to facilitate that. And then, ultimately, helping providers see their own performance. So as we move towards more value-based arrangements—and we already have P4P with some of the MCOs, FQHCs, and nursing homes—they’ll be able to track their own performance, and see what we’re seeing, all in real time. So that’s the long-term goal.

With regard to pulling EHR information from the FQHCs, have there been some process issues involved?

Yes, absolutely. There have been quite a few process issues in general, and sometimes, it comes down to other organizations requiring us to help them procure whatever systems they might need to connect to us, which we’re not against doing, but those things take time. And then there’s the ownership piece: can we trust the data? But for the most part, especially with the FHQCs and some of our sister agencies, we’re getting to the point where everyone sees it as a win-wing, and there’s enough of a consensus in order to move forward.

What might CIOs and CMIOs think about, around all this, especially around the potential for collaboration with government agencies like yours?

Ideally, we’d like for hospitals to partner with us and our managed care organizations in solving some of these issues in healthcare, including the cost of emergency department care, and so on. That would be the biggest thing. Right now, and this is not a secret, a couple of our hospital systems in the District are hoping to hold out for better contracts with our managed care organizations, and 80 percent of our beneficiaries are served by those MCOs. So we’d like to understand that we’re trying to help folks who need care, and not focus so much on the revenues involved. We’re over 96-percent insured now in the District. So there’s probably enough to go around, so we’d love for them to move forward with us collaboratively. And we have to ponder whether we should encourage the development and participation in ACOs, including among our FQHCs. Things have to be seen as helping our beneficiaries.

What does the future of data management for population health and care management, look like to you, in the next several years?

For us in the District, the future is going to be not only a robust warehouse that includes claims information, vital records information, and EHR data, but also, more connectivity with our community partners, and forming more of a robust referral network, so that if one agency sees someone who has a problem, say, with housing, they can immediately send the referral, seamlessly through the system, to get care. We’re looking at it as very inter-connected. You can develop a pretty good snapshot, based on a variety of sources.

The social determinants of health are clearly a big element in all this; and you’re already focused on those, obviously.

Yes, we are very focused on those; we’re just very limited in terms of our access to that data. We’re working with our human services and public health agencies, to improve access. And I should mention a big initiative within the Department of Health Care Finance: we have two health home programs, one for people with serious mental illness issues, the other with chronic conditions. The Department of Behavioral Health manages the first, and the Department of Health Care Finance, my agency, DC Medicaid, manages the second. You have to have three or more chronic conditions in order to qualify.

We have partnerships with 12 providers, in those, mostly FQHCs, a few community providers, and a couple of hospital systems. We’ve been using another module from HealthEC for those programs. We need to get permission to have external users to come in; but at that point, they’d be able to capture a lot of the social determinants as well. We feel we’re a bit closer to the providers, in that sense, since they work closely with the beneficiaries. And we’ve got a technical assistance grant to help them understand how to incorporate this kind of care management into their practice, to move into a value-based planning mode. That’s a big effort. We’re just now developing our performance measures on that, to see how we’ve been doing. It’s been live for about a year. It’s called MyHealth GPS, Guiding Patients to Services. And we’re using the HealthEC Care Manager Module, which we call the Care Coordination Navigation Program; it’s a case management system. Also, we do plan to expand that to incorporate medication therapy management. We have a pharmacist on board who will be using part of that care management module to manage his side of things.

 

 


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At the Beverly Hills HIT Summit, APG’s Crane Offers a Vision of the Future of Medical Care

November 11, 2018
by Mark Hagland, Editor-in-Chief
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Don Crane, CEO of APG, a nationwide association of physician groups involved in risk-based contracting, offered Beverly Hills HIT Summit attendees a vision of a coordinated care-based future

The signs are that the policy and payment incentives around value-based healthcare are accelerating now and may soon become much clearer, a nationwide physician leader told attendees at the Beverly Hills Health IT Summit, being held in Los Angeles this week and sponsored by Healthcare Informatics. Don Crane, the president and CEO of the Los Angeles-based APG (America’s Physician Groups), a nationwide association of more than 300 physician groups involved in risk-based contracting in healthcare, though participation in accountable care organizations (ACOs) and in all types of value-based contracting, which his association refers to as coordinated care.

Crane, whose organization counts member physician groups in 43 states, the District of Columbia, and Puerto Rico, told his audience at the Sofitel Hotel Los Angeles at Beverly Hills that he believes that the most senior federal health officials—at the Department of Health and Human Services (HHS), at the Centers for Medicare and Medicaid Services (CMS), and at the Center for Medicare and Medicaid Innovation (CMMI), are planning to move forward rapidly and decisively to push as many physicians and physician organizations as possible into risk-based contracting, through a variety of means. Statements from HHS Secretary Alex Azar, CMS Administrator Seema Verma, and CMMI director Adam Boehler, have made it clear that plans are afoot to accelerate the transition from fee-for-service payment to risk-based and value-based reimbursement, he said.


Don Crane

Speaking of his own organization, Crane said, “What distinguishes us from similar trade organizations is that capitation is the preferred model. Probably half of my members are already there in terms of professional or global risk. And what we’re developing is the antithesis of fee-for-service [healthcare delivery]. We’re very much central to the value movement.” Further, he said, “Capitation is the destination” of the current evolution of the U.S. healthcare system. “Groups everywhere are experimenting with Medicare ACOs, other kinds of programs and projects,” he noted, adding that physician groups are advancing forward organically through a series of phases, “starting with fee-for-service with some sort of bonus-based quality incentives, moving next to some sort of shared savings program, then shared-risk, leading to primary care-based capitation or shared risk, and ultimately to global capitation or full risk.”

Further, speaking of APG’s member organizations, Crane told his audience, “All of us see capitation as the destination; our hair is on fire about it; we’re excited about it. We want to move the system to that model, because it produces higher quality at lower cost. As you all know, we’re at 18 percent of GDP right now, with really poor results, and we want to change that, through coordinated care.”

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Speaking of the mid-term legislative elections that had taken place three days earlier, Crane told his audience, “This election on Tuesday means a number of things: for one thing, repeal and replace is dead, yes,” referring to efforts to eliminate the Affordable Care Act over the past two years. “The big takeaway for us in the healthcare industry is the extent to which the ACA has been cemented into our landscape, right there with Medicare and Medicaid,” he said, referring to the legislation, which had been signed into law by President Barack Obama in March 2010. “So with the Democrats controlling the House, there’s nary a chance that it will be repealed or replaced in the next two years. Also, in three states, initiatives were passed that would expand Medicaid.”

Asked by an audience member about the sustainability of the state-based health insurance exchanges, Crane said, “The notion is that, if you don’t get everybody to pay into the risk pool, how can you get everyone covered? The answer is, time will tell. People have worried that the repeal of the mandate would undermine the exchanges; that hasn’t happened. And in fact, premium costs have seen a fairly moderate risk in the past year of about 2 percent.”

Meanwhile, Crane said, moving into the core of his presentation, “Whither and what of the value movement? The value moment got started with the ACA in 2010 with ACOs. More recently, in 2015, MACRA, the Medicare Access and CHIP Reauthorization Act, was passed, and that gave us MIPS [the Merit-based Incentive Performance System] and APMs”—alternative payment models. “So a big tailwind was put behind the whole value movement, where physicians and physician groups would be graded on quality measures, and that so that was brought into the fabric in 2015. And we’re well into the value landscape now.”

Documented evidence of the value of coordinated care

What’s more, Crane told the audience of healthcare leaders, “the announcements that you’re hearing from Alex Azar”—the Secretary of Health and Human Services—“are ones in which he repeatedly says that one of their missions is to accelerate the value movement.” Indeed, he said, referring to the proposal by CMS and referred to as “Pathways to Success,” “We’ve seen a pending rule soon to be made final, that will basically push these 400-plus Medicare ACOs much more rapidly into downside risk. And that’s hard to do unless you’ve got a sophisticated system with rich informatics. Many will be afraid of that, but those who are afraid will be winnowed out, and it will leave a more robust, stalwart cohort.”

And, Crane continued, referring to Adam Boehler of CMMI, “We’ve participated in a number of roundtables with Adam Boehler; in fact, I’m seeing him again next Thursday. We haven’t seen any pending rules yet, but we need to get ready for some bold moves in Medicare, where they accelerate the movement. One thing that’s gotten a lot of attention is delegating large portions of the country to players that want to take risk, and then turn around with physicians and hospitals to deliver care to employers like Google. That would allow for prime contracting that would lead to subcontracting for the delivery of care. Much of it is conjectural, but I think it’s coming. With regard to their request for proposals on direct contracting a few months ago—one can see, coming in from out of the mist, as you read the tea leaves, you can see some profound changes in original Medicare that will accelerate this forward.”

Crane went on to review in some detail the results of a study released on March 1 of this year. As the press release announcing those results noted, “Health care quality and cost for commercially insured Californians varied dramatically in 2015, indicating that where you live affects the care you receive and how much it costs, just one of the new findings from the California Regional Health Care Cost & Quality Atlas. Developed by the nonprofit IHA, in partnership with the California Health Care Foundation (CHCF) and California Health and Human Services (CHHS) Agency, the Atlas is the state’s source of comparable performance information about the quality and cost of care provided to 29 million Californians.”

Further, the March 1 press release noted, “The second edition of the Atlas brings together 2013 and 2015 multi-payer data by geographic region—including commercial insurance, Medicare, and Medi-Cal—on more than 30 standardized measures of health care quality, cost, patient cost sharing and utilization to help purchasers, health plans, and policymakers target performance improvement initiatives. An IHA fact sheet provides more details about the Atlas and measures. In 2015, clinical quality varied across the state’s 19 geographic regions by an average of 25 percentage points and costs ranged from 22 percent below to 29 percent above the statewide average. These differences mean: If care for all commercially insured Californians were provided at the same quality as top-performing regions, nearly 205,000 more people would have been screened for colorectal cancer and 31,000 more women would have been screened for breast cancer in 2015. [And] If care for all commercially insured Californians were provided at the same cost as observed in San Diego―a relatively high-quality, low-cost region―overall cost of care would decrease by an estimated $2.6 billion annually, or about 5 percent of the $55 billion total cost of care for the commercially insured.”

That study’s press release included a comment by CHHS Secretary Diana Dooley, who noted that “Increasing transparency is essential for improving quality, lowering cost and gaining consumer confidence. Atlas 2 shows where quality and cost are trending in the right direction and where there is room for more improvement.”

As Crane noted at the Summit, “This was a meta-study commissioned by the Secretary of State for California and the California Health Care Foundation. It aggregated the data of 29 million Californians participating with 10 of the major health plans in CA, all the physician groups. The study had two purposes: one, it looked at geographic variation; the other focus was to compare and contrast the two predominant models in California and elsewhere—fragmented, fee-for-service PPO, compared to capitated, integrated HMO. They were looking at products, but that’s how they looked at the delivery and payment models under those products.

There were three domains—familiar HEDIS measures in the quality domain, which was the first domain; hospital utilization measures in the second domain; and then third and finally, and this is where this is such a distinguishing study, total cost of care—not just premium, hospital fees, physician fees, but also the patient’s share of the premium pay and of co-pays and deductibles. So you get quality and spend, so you have what you need to get to the question of where the value is,” when evaluating data from all those domains.

“So you see 19 different contracting regions through CoverCalifornia, the California exchange,” Crane noted, as he shared a slide with visual results from Atlas 2. “The chief thing is that you should look at the little blue pyramids, commercial HMO, and the orange dots, commercial PPO results. The HMO measures show HMOs outperforming PPOs on quality—very important,” he said, referring to the slide, which showed all the blue pyramids rising above the orange dots. “The chief takeaway here is that PPO products are costlier nearly everywhere, with a few small outliers; and we’re not talking about premium here, but about total cost of care. HMOs—representing capitated, integrated delivery models—performed better on cost and quality across the board.”

Importantly, Crane noted, with regard to quality outcomes among Medicare Advantage-enrolled seniors in California over those enrolled in basic Medicare, “Medicare Advantage outcomes were all superior to those in original Medicare.” Indeed, he noted, “Medicare Advantage outperforms fee-for-service Medicare on hospital utilization, on all-cause readmissions, on ED use, on length of inpatient stays. In short, all Medicare Advantage is shown to be of higher quality and lower-cost than original Medicare—and, importantly, our APG members outperformed everyone else on all of these measures.”

Further, Crane said, “Capitated, integrated care delivery was found to be 14 points higher in quality, and 9 percent lower in total cost of care in commercial health insurance products. And there was $4,450 less total cost of care PMPY [per member per year] in Medicare Advantage in California.”

As the Atlas 2 report itself notes, “In 2015, HMO products delivered clinical quality that averaged 14 percentage points higher than PPO products at an 8% lower total cost when member cost sharing is included. PPO members paid, on average, $620 more out of pocket for care in 2015 than HMO members. HMO hospital utilization was generally higher than PPO even though total cost was lower. Given HMO products typically offer networks composed of integrated providers to a greater degree than PPO products, integrated care (HMOs) offered superior value.”

What’s more, Crane said, “Atlas 2 confirmed a total spend of $16,000 a year on average for seniors; that’s 25 percent lower than in original Medicare. Think of the savings that would be achieved if we overlaid this across all the seniors in California or the United States. This is proof positive of a better model, the model of the future, and one on which we will depend on your participation and your leadership.”

APG’s initiatives around advanced payment models

Crane went on to describe initiatives taking place at APG; in particular, he pointed to the Risk Evolution Task Force, and Third Option, two programs that he said show the way to the future for physician groups and for coordinated care. “The Risk Evolution Task Force,” he explained, “is essentially a benchmarking program mostly for our Medicare ACO and Next Gen participants. In the past, twice, I tried to initiate benchmarking programs, in which members had to submit data.” The mechanics of doing so turned out to be difficult to sustain those past initiatives, he conceded. “But moving forward, this data will be freely available in Medicare off 1500 forms.” Meanwhile, he continued, “Third Option is our proposal that we think will see light of day in a month or so. A few months ago,” he said, “CMMI issued an RFI on director-provider contracting. We said, we have the model. Direct contracting with CMS and a sophisticated qualifying medical group. It would have a capitated payment model. The benefit design would be a hybrid of Medicare Advantage—integrated, capitated; but it would be like original Medicare in that enrollees would still have freedom of choice; but the catch is if you went out of network, you’d pay more. It’s very much like a point-of-service model. So it drives patients in network. We think we’ll see a model that bears some resemblance to this model, coming out of CMMI. That will be a red-letter day for us.”

Importantly, Crane said, “We see a model like this as offering the antidote to single-payer proposals,” including proposals that governor-elect Gavin Newsom indicated interest in, during the gubernatorial campaign that he won on Tuesday. “We’ve been dialoguing with Gavin Newsom,” he reported, “and we’ve said, look, look, if you were to take the capitated, integrated model and spread it across all of California, the savings would be more than the savings needed to generated universal coverage. All we would need would be subsidies and other support.”

In response to a question from the audience about physicians’ reactions to practicing under capitation, Crane said, “The overarching reaction has been extremely good. Physician burnout nationwide is driven by the fee-for-service model. The fee-for-service physician is a hamster on a wheel, continuing to try to see more and more patients, as Medicare payments go down. Contrast that to where you can focus on the patients with highest needs. Take WellMed in Texas,” Crane said, referring to one APG member group, WellMed Medical Group, based in the Dallas area. “Their PCPs are seeing 15 patients a day, and they want to drive that down to 13, using a multidisciplinary team of clinicians and others to drive down the levels of work” to allied health professionals, in order to relieve some of the burdens physicians are facing in their work lives. “And so one of the byproducts is higher levels of physician satisfaction. So just as this model produces results around the Triple Aim, a byproduct is improved physician satisfaction.”

Finally, in closing his address, Crane addressed the healthcare IT leadership audience directly, saying, “You guys are so central to the management of a population. Informatics has been important in the FFS world to a certain extent. But to a physician group being paid through capitated, needs to know who’s’ diabetic, who’s being admitted to hospitals, who will become sicker in the next year, all of that depends on informatics. So I see our fates as inextricably linked.”

 

 


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