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In New Mexico, a Medical Home Model Created Outside the Hospital

October 12, 2017
by Rajiv Leventhal
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Developed in New Mexico, the Community Oncology Medical Home model builds on the patient-centered medical home concept. Now, its creator ponders if it could become a qualified MACRA APM

It was about six years ago when Barbara McAneny, M.D., an oncologist/hematologist and then-practice manager at the Albuquerque-based New Mexico Cancer Center, was at an AMA (American Medical Association) meeting when a critical recognition about healthcare delivery was realized. It was McAneny who was learning at the time from her practice’s patients that being in the hospital is not only a “medical disaster, generally, due to what they end up with in terms of complications, bacteria, bed sores, and other problems, but it’s also a financial disaster and very disruptive to their lives,” she says.

McAneny also was learning that as an oncologist, any time a patient leaves the hospital, he or she is never as healthy as at the time of arrival. “So we decided in our practice that we wanted to figure out how to keep patients out of the hospital by intervening with the problems of cancer and its treatment earlier in the process. I discovered that this would decrease our hospitalizations, which also meant saving our patients and the health plans a lot of money,” McAneny says.

This was also about the time when the Center for Medicare & Medicaid Innovation (CMMI) was getting off the ground, established under the Obama administration to allow Medicare and Medicaid programs to test models that improve care, lower costs, and better align payment systems to support patient-centered practices. At the AMA meeting, one doctor spoke up about how he was getting frustrated because his hospital’s innovation models were not saving money as expected. McAneny, who was just recently elected president-elect of the AMA, recalled that she told the doctor at the time, “The key is to keep people out of the hospital, so I am not surprised you’re not saving money since a lot of your models are hospital-based. Then I showed him the data from our practice,” she says.

Barbara McAneny, M.D.

Indeed, at the New Mexico Cancer Center, the most important factor to its business success has been its triage pathways. McAneny explains that in most practices, the current triage process is that when patients pick up the phone to call their doctor, they get a recording saying, “If this is a medical emergency, hang up and dial 911.” But McAneny says that this is the first mistake. “Everyone who is calling thinks they have an emergency,” she says. The second mistake, she continues, is that often in a practice’s triage, the nurse who is handling triage that day has no decision support. “Someone calls in and says he or she has a fever, so the nurse will look at the doctor’s schedule, and it’s packed with patient appointments, so the patient is told to go to the ER. And this happens thousands of times a day throughout the U.S. They don’t have the infrastructure setup to manage this as is.”

But what McAneny did was model these triage pathways after a system the EMS uses to train non-medical personnel to send equipment and machinery to the right address with high degrees of accuracy. She notes that the pathways in her practice started with patients’ complaints in the manner in which they would actually address them.

Patients would never call up and say “I have Stage 3B lung cancer.’ They say ‘I have a cough and a fever.’ So we started from the patients’ symptoms, and [then] it is decision support for the nurses [or first-responder phone operators] who are on the phone, backed up by a change in how the practice works. There are mid-level providers, nurse practitioners, and PAs who have an open schedule for that day, so that when patients call and say they have a fever, the person on the triage works down the path to see what the best way to manage them is.”

In essence, the nurses are guided through step-by-step clinical decision making as they discuss and assess a wide variety of patient issues, McAneny explains. She adds, “When people are sick they need someone else to manage their own healthcare; they are too busy being sick to figure out what to do next. Our theory behind this is to make it so that all the patient has to do is show up.”

In 2012, the CMMI awarded a $19.8 million grant to the Innovative Oncology Business Solutions (IOBS), a corporation created by McAneny for the purposes of administering this grant. The money was for the development of a Community Oncology Medical Home model (called COME HOME), and the implementation of that model in seven practices across the country. At its heart, the model is a professional infrastructure built around the patient and their support system and available at the time of greatest need. As such, its target population is newly diagnosed or relapsed Medicare, Medicaid and commercially insured patients seeking oncology care at one of the seven participating clinics.

The protocols have already produced noteworthy results among the seven practices participating in the COME HOME program, who have collectively reduced their overall cost of care by 7.2 percent, driven by decreases in inpatient hospital admissions (12.5 percent), 30-day hospital readmissions (11.7 percent), and ER visits (6.6 percent). In addition, the COME HOME program was recently expanded through a collaboration with the American Society of Clinical Oncology (ASCO) that will see its tools replicated and expanded across the U.S., officials note.

Leveraging I.T.

It was recently announced that Integra Connect, a West Palm Beach, Fla.-based provider of technologies and services for value-based specialty care, would partner with IOBS to incorporate the COME HOME program triage pathways into its Oncology Care Model (OCM) and population health solutions. Oncology practice staff using Integra Connect solutions will now look to leverage IOBS’s set of protocols to provide “aggressive symptom management as part of their patient triage and care coordination workflows, then track and report on results via advanced analytic capabilities,” officials note.

McAneny says that when she first presented this model, the decision support provided for the nurses makes sure that the nurse on the phone is guided through all the different diagnoses possible, so the patients are delivered to the right site of service. For instance, she explains, some services should not be had at the oncology practice, but rather the ER. On the other hand, if the patient on the phone is a woman who has breast cancer in all of her ribs, has rib pain in the left side of her chest, and has already had three cardiac work-ups for left-sided chest pain, there’s no need to go back to the ER for the same thing. McAneny adds that this decision support also protects against medical liability. “We have 29,000 patients going through the triage pathways and we did not deliver anyone to the wrong site of service to where there was an adverse event,” she says.

The next phase, according to McAneny, a step that will “restructure how oncology care works,” will require an incredibly strong data analytics partner, she says, explaining that there are two kinds of healthcare risk—actuarial risk, referring to the people who walk into a practice outside of a provider’s control, and then the risk for a patient who has a set of clinical criteria, such as the type of cancer, what stage it is, what the genomics are, what the comorbidities are, and what the treatment plan is. “You can have a target directly attached to that patient for a risk corridor of what their cost ought to be. And then you can see if you can manage that patient well enough to beat that target. I call that transactional risk, because it is that transaction with that patient which we should be able to manage. I should be able to keep costs within a certain level for a given patient,” McAneny says.

However, she adds this can only happen if it’s known what those costs are, which means “I need to analyze a lot of patients who have that [same thing] so I can track it prospectively,” she says. “You need a way to manage all of this, and that means pulling the data. If you have a practice of 20 doctors, and one decides not to follow the clinical pathways and does something strange and expensive for a drug that wasn’t needed, for example, I need to know that very early so we can intervene. So you need a very strong data system that monitors how well people are compliant with the pathways that the doctors have set up to treat people,” she says. “And then you have to be able to look at outliers, and track if a patient with cancer has something else as well, so therefore that patient will be an outlier in that target corridor. I need a way to know that early and work with the payers to [determine] where a patient fits best. It has to be real-time data and it has to be fast, and practices can’t be paying big fees every time they need to look at the data.”

Becoming a MACRA APM?

Currently, IOBS COME HOME is referred to as a “medical home” rather than a “delivery model” since there isn’t a payment system attached to it. So right now, the medical home is NCQA (National Committee for Quality Assurance)-accredited, but as McAneny explains, “It needs a payment system to go with it because one of the flaws of a medical home is that we provide a lot more services for which there are no fees” attached, such as patient education and nurses talking on the phone. She adds that there is an opportunity cost of leaving an advanced practitioner, nurse practitioner, or PA with a blank schedule, despite the organization’s overhead costs continuing. “And the savings from this go to the payers who don’t have to pay for a hospitalization or an ER visit. So we need to attach that to a payment system.”

When McAneny had the CMMI grant, she was able to pay the practices for those personnel who you can’t bill for—the nurses on the phone, for instance. CMS then said it would embed the COME HOME pathways process as a way to create the savings, and will use its normal ACO (accountable care organization) upside/downside risk opportunities as the payment system on top of it.

But then, McAneny explains, CMS added in a $160/month payment for the nurses who were educating and spending time on the phone, a cost that McAneny’s team calculated should actually have been between $220 to $250 per-patient, per-month. “So they are giving $160, and that’s a problem since that doesn’t totally support [what we’re doing]. So if you don’t have another payer paying for it, that’s another cost.”

Indeed, the current CMS Oncology Care Model will award 15 points for practice improvement under MIPS (the Merit-based Incentive Payment System), just by participating. The COME HOME process already qualifies as that, and it would become an alternative payment model (APM) under MACRA (the Medicare Access and CHIP Reauthorization Act) if the provider accepts risk. “I don’t believe practices have accepted risk yet; sometime in 2018 people are supposed to decide if they can hit the targets CMS has set for spending and be able to accept risk or not,” says McAneny, who adds she “has great concerns for that.”

To this point, she points out that insurance companies “go under” if they don’t have reserves, and they are required to prove that they have reserves. But if practices go at actuarial risk like an insurance company does (for example, if they bet that 5 percent of their patients will be sick and expensive, and it turns out that it’s really 8 percent who are sick and expensive), they don’t have the reserves to cover that two-sided risk. “And that’s a practice-ending event,” says McAneny. “So asking a practice to pretend they are an insurance company without reserves won’t work.”

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The CEO of a Nationwide Association of MD Groups Sees the Future—and It’s Not in Fee-For-Service

September 18, 2018
by Mark Hagland
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APG’s Don Crane shares his perspectives on the challenges and opportunities facing physician groups in the emerging healthcare landscape

The world of U.S. healthcare is undergoing massive change these days; indeed, the entire landscape around the healthcare system is shifting now, with new entrants, some of them disruptors, changing the realities on the ground for the leaders of patient care organizations. Meanwhile, the implications are legion, for physician-led organizations, including large and not-so-large multispecialty physician groups. Those subjects were topics of analysis in two of the Healthcare Informatics Top Ten Tech Trends, which appeared in the third-quarter 2018 issue of Healthcare Informatics.

For both the Trend article on the new disruptors entering the healthcare system, and the Trend article on the challenges and opportunities physician groups in the emerging landscape, Healthcare Informatics Editor-in-Chief Mark Hagland interviewed Don Crane, president and CEO of the Los Angeles-based America’s Physician Groups (APG), a nationwide association of physician groups involved in risk-based contracting. Crane, whose association represents more than 300 physician groups operating in 45 states, the District of Columbia, and Puerto Rico, is helping to lead a revolution in the medical group world, facilitating the collaboration around innovation among physician groups across the country.

Don Crane

Don Crane will be delivering a keynote presentation on November 9, during the Health IT Summit in Beverly Hills, sponsored by Healthcare Informatics. He will be speaking on the subject of value-based care and clinical transformation, sharing his perspectives as one of the leaders in the physician group world. Below are excerpts from his interview this summer with Hagland.

Looking at all these new business combinations and alliances—the Aetna-CVS deal, the Amazon/Berkshire Hathaway/JP Morgan Chase alliance, the inroads into healthcare being made by Microsoft, Google, and others—what do all of these business and technological incursions mean?

To me, they signal a very restive employer world, a restive and dissatisfied employer world, certainly, when you talk about Google and Amazon, and so, too, with the carrier-PBM combination. There, it’s more about the players looking for a new model, implying that there’s a dissatisfaction to the point of abandonment of faith in the existing model. So, has the inefficiency of our current healthcare delivery system now produced pain at such a high level that it’s no longer about academic conversations, but time for a variety of different actions? That’s what it’s telling me, that we’re about to hit a pain point. Healthcare is using up more and more of our GPD, and really is hitting our global competitiveness now. So yes, this is very significant.

With regard to the planned Aetna-CVS merger—should physicians feel unsettled?

I have an upcoming board retreat, where we’ll be speaking to the Walmart-Humana, CVS-Aetna, and Cigna-ExpressScripts arrangements; I don’t think that the architects of these various transactions see them all in the same way. They have slightly different strategies, and are facing different challenges. These are smart-darn people, and it’s different from the sort of minute-clinic concept we’ve seen in the past. That concept didn’t really take off. Someone said there’s a Walgreens or CVS within 3 minutes of every American, or something. But the minute-clinic concept didn’t exactly work. But what’s different about these diagonal mergers? I think some of it lies in the data—you’ll be combining the data of a health plan with a pharmacy with a PBM [pharmacy benefit management company]. And we’re moving into an era of artificial intelligence and machine learning and the ability to stack up algorithms to the nth degree and know things we didn’t know before.

There’s also the factor of the idea of the transformation of primary care. I think they envision a world where you don’t have to call your doctor six weeks in advance, drive through traffic, wait for hours, wait for days to get your results—and that just doesn’t seem cool in the second decade of the 21st century. It’s a model begging for revolution.

And how will all this impact physician groups? The short answer is, I don’t fully know. The longer answer is, we’re actively thinking about it. The one thing I have a massive amount of faith in is that when it comes to professional care by doctors, nurses, etc., the Pentium chip is organized physician groups; it’s not Dr. Marcus Welby all alone; nor is it health plans that sit on high in penthouse buildings; nor is it hospitals. It’s aggregations of doctors supported by data and analytics, and supported by a constellation of people—psychologists, social workers, even bus drivers, in terms of transportation. And there, you get quality, and you marry within an organization the desire to improve quality and the health of individuals and the population, and at the same time, be stewards of resources. And that’s important, because healthcare’s single biggest problem is unaffordability. So we need stewardship of resources married to expertise in care delivery. I think the new models to come will float to the top.

And, in terms of the disruptors, they envision a world where you don’t have to call your doctor six weeks in advance, drive through traffic, wait for hours, wait for days to get your results—and that just doesn’t seem cool in the second decade of the 21st century. It’s a model begging for revolution.

With regard to the pace of physician groups moving into risk, is it about at the level you’d expect?

As best as I can tell, the pace is going moderately well. Has it accelerated? No. Has it slowed? Probably not. It doesn’t feel like there’s a white-hot fire underneath it at the moment. There is a generalized belief that we need that movement to occur and succeed. At the same time, there are entrenched interests.

Our efforts rise and fall based on what’s going on around the country. And we continue to get new members out of interest in this, but they’re not pounding the doors down yet. They’re reading the signals from the government and commercial payers carefully, and they’re content to sit in the status quo and make a pretty good living, and don’t want to incur enormous cost and effort unless they have to. So the level of push is not as hard as we’d like. But some changes coming out of various rules sets coming out of a very bold and laudable administration, as far as I’m concerned.

When it comes to managing two-sided risk, everyone has spoken of the criticality of data. What’s being learned in that area?

Upside risk makes sense for a while; it’s baby steps. But it’s weak tea in terms of driving real change. If you get lucky with the right benchmarks, you can do well. But it doesn’t induce real structural change. But when an organization faces downside risk, also known as bankruptcy—that really forces change. When you take that higher risk, you’ve got to have the data. You’ve got to risk-stratify your population, and treble down on the resources you’re using on the patients at highest risk. All of a sudden, you move into the big leagues.

Are physician groups beginning to use artificial intelligence and machine learning, in earnest?

The answer is yes. I’m surveying my board next week. But the pioneers are starting to use AI and machine learning, yes.

Do you know yet what they’re learning in terms of process?

Well, of course they’re learning better what the ailments are in a population, etc. They’re just able to do a better job of diagnosis and then care management care planning—being able to treat people more intelligently than ever before.

What percentage of your organizations have unlocked the key around multidisciplinary care teams?

That percentage is very high. Some started a couple of decades ago with this. This is not rocket science, it’s fundamental blocking and tackling. So within my organization, you’ll see a high percentage of organizations making good use of multidisciplinary care teams. Outside my organization, not so much. It’s no secret that you should be using mid-levels to support physicians; but you kind of need the payment model to make it work. Otherwise, you still have doctors working per click, like hamsters on a wheel. As you get into risk-based capitation, that’s where the model changes, and voila—all of a sudden, you have big panels, risk management, and multidisciplinary care teams. You almost can’t separate the organizational model from the payment model.

In terms of physician groups working with social determinants of health data, what are you hearing?

Well, we’re in the early stages of physicians and physician groups moving into working with social determinants of health data. If you talk to a doctor who is still in fee-for-service about the social determinants of health, he’ll say, nice idea, but are you kidding? I didn’t go into healthcare to be a social worker! If you talk to APG members, you’ll see that they totally understand it. You so often need to get into the home, and into transportation, and nutritional support. If a patient can’t get to the doctor’s office, and isn’t eating and is living in a high-crime area, no amount of good diagnosis and prescription will produce a good outcome. In Medicare Advantage, given the latest rate note and the bipartisan Balanced Budget Act, Medicare is basically beginning to cover social determinants of health stuff; that’s in a nascent stage, but people are gearing up for it. I think I saw that Humana and Ascension Health had created a new venture around social determinants.

Meanwhile, we’ve entered into a partnership with Partners in Care, a foundation headquartered in Los Angeles, and they’re available for hire to do home visits and other similar sorts of social work items. And my members are hiring them to do that kind of outreach into patient’s homes. It’s really helpful with the frail elderly and such. So seeing where the puck is headed there, we entered into a partnership with Partners in Care. And that’s a whole new frontier. Now for physicians to be responsible for home visits, well, that’s new. So there’s a transformation underway there as well.

What do you see in the next couple of years around that?

I think it’s just another data set. And if you’re going to start to do home visits to the frail elderly, you’ll need their addresses, of course. And when you do your chops and cuts and sorts, you’ll need to be looking not only at their a1c, but their neighborhood, and their nutritional status, etc., and you’ll now have additional data to help you guide your care plan. It might involve home visits, or Lyft or Uber; so there needs to be data to support that.

How will the data analytics component evolve in the next few years for the leaders of physician groups?

Well, it starts with a recognition of the need for data. Those physicians just wondering what to do about MIPS, etc. They’ll realize they’re utterly unequipped to set up a data analytics shop themselves, so you’ll see movement into groups. And the next step is to get to the facility to do it, and that means joining a group or an IPA. That’s the dynamic we’re going to see. And then we’ll start seeing better results.

And, how do you see the future more broadly?

There’s no future around fee for service; it’s eroding out from under doctors. You look at the Medicare fee schedule and increases slated for the future. What are they? The anticipated increases to physician payment under Medicare are going to be 0.5 percent, 0.25 percent, from here out to as far as the eye can see, they’ll be nearly flat; and the increases in costs of running practices will be increasing 2, 3, 4, 5, 6 percent. So you’re quickly on the way to the poorhouse if you’re trying to stay in a fee-for-service world. So how will we make a living? To make a living doing what you want to do, you’re going to need to find a different way to make a profit under flat revenue. How do you do that? You keep the population healthier. You stare into the data and figure out who will get sick next, by using predictive analytics.


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On Capitol Hill, Healthcare Leaders Raise Concerns with CMS’ Proposed ACO Rule

September 17, 2018
by Heather Landi, Associate Editor
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Healthcare leaders also testified about the need for Stark Law modernization
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A panel of healthcare organization leaders voiced concerns about moving Medicare accountable care organizations (ACOs) to two-sided risk too quickly, as proposed in a recent federal draft rule, and highlighted the need for Stark Law reform during a U.S. House of Representatives Health subcommittee hearing last week.

The U.S. House of Representatives Energy and Commerce Committee subcommittee on Health held a hearing last Thursday examining the barriers to expanding value-based care in Medicare, and panelists used the opportunity to voice concerns to lawmakers about a number of polices and laws that they believe are impeding progress in the transition to value-based care and payment models.

Subcommittee chairman Michael Burgess, M.D. (R-Texas) said the purpose of the hearing was to focus on the evolving transition to value-based care as well as new ways of assuming risk, and the role technology can play in these efforts. In his opening statement, Burgess recognized that value-based care models have been effective at improving quality and lowering costs. “These models are the future of heath care, and it is important that Congress hear from the industry about how the implementation of such models work on the ground or, to the extent it’s not working, it’s important that we hear that as well,” he said.

Many of the panelists shared their opinions on a proposed rule issued by the Centers for Medicare & Medicaid Services (CMS) that proposes a new direction for ACOs in the Medicare Shared Savings program (MSSP), with the goal to push these organizations into two-sided risk models.

The MSSP is the largest value-based payment model in the U.S., growing to 561 ACOs with more than 350,000 providers caring for 10.5 million Medicare beneficiaries in 2018. Under current MSSP rules, new ACOs are eligible to share savings with Medicare for up to six years if they meet quality and spending goals but are not at financial risk for any losses. In the proposed rule, issued Aug. 9, CMS is proposing to shorten that glide path for new ACOs to assume financial risk, reducing time in a one-sided risk model from the current six years to two years. CMS also recommends reducing potential shared savings in half—from 50 percent to 25 percent for one-sided risk ACOs. As such, The proposed rule has so far been met with varying degrees of scrutiny.

During his testimony, Nishant Anand, M.D., chief medical officer for population health services and chief transformation officer for Adventist Health System, and chairman of the Adventist Health System ACO, said he was concerned that policies contained in CMS’ proposed redesign of the MSSP, if finalized, would discourage providers from participating in value-based care.

Anand, who is based at Florida Hospital Orlando and has led value transformations at other health systems, noted that Adventist has ACO arrangements in Kansas, North Carolina and Florida, where the system has 55,000 beneficiaries in its MSSP ACO.

“The existing financial benchmarks, especially in lower cost markets, make it financially prohibitive to transition to a two-sided risk model and will deter providers from participating in the program. If the benchmarks do not provide room for improvement, allowing providers to transition towards value-based care delivery over time, providers will not participate. We must find ways to adjust for the regional variations across the country,” he said.

Continuing, he said, “Second, benchmarks need to be accurately risk adjusted to reflect the underlying health status of the ACO’s population.” And, with regard to CMS’ proposal to limit shared savings payments to 25 percent, he said: “A lower shared savings rate means we will have less to reinvest into population management and care coordination. Limiting the shared saving payments to 25 percent will create an unsustainable business model.”

Anand urged Congressional leaders to consider a “deeper dive into value-based care reforms that will accelerate the journey. “We’re ready to go faster but need additional help with payment reform to focus on holistic care as well as regulatory reform. We need to help ACOs achieve critical mass in order to hit the tipping point where value-based care is what we deliver,” he said.

Michael Robertson, M.D., chief medical officer of Covenant Health Partners and Covenant ACO in Lubbock, Texas, also voiced similar concerns. Robertson, testifying on behalf of the National Association of Accountable Care Organizations (NAACOS), said Covenant Health Partners has operated a clinically integrated network for the past 11 years, through which it has instituted robust health information technology, contracts for hospital services, and quality metrics for measures like hospital-acquired infections.

“We then branched out to commercial contracts and, in 2014, made the quantum leap to a three-year Track 1 MSSP agreement. If we had not already had a clinically integrated network in place, where we had already done much of the work to get ready for MSSP participation, it is unlikely that we would have made the decision to participate in the MSSP. It was also important for us that we didn’t have to be concerned about taking downside risk, since we were in a shared savings-only model,” he said.

There has been much debate and contention between CMS and healthcare industry stakeholders on just how much money one-sided risk ACOs are saving Medicare. An independent evaluation by NAACOs published last week found MSSP ACOs generated gross savings of $1.84 billion for Medicare between 2013 and 2015, nearly double the $954 million estimated by CMS. Last month, CMS data showed ACOs generated $314 million in net savings to Medicare in 2017 after accounting for payments earned by ACOs for hitting spending and quality targets.

Moving to value-based care is a massive undertaking that requires changing the behavior of multiple providers, Robertson testified. “Participation in the MSSP has allowed us to reinvest in technology and infrastructure to manage our patient population. In our first year of participation in the MSSP, we saved Medicare $5 million and our share was $2.5 million,” Robertson said. The organization used the bulk of those funds to reinvest in its IT infrastructure and to develop physician dashboard. “All of these things take time and money; pushing too quickly to achieve results and take on risk, without giving ample time for providers to develop the necessary infrastructure, will mean people don’t participate,” Robertson said.

CMS’ recently proposed MSSP ACO rule would improve the existing MSSP in a number of ways, he said, such as implementing ACO-specific payment rule waivers and beneficiary incentives. “Some of these improvements lend stability to the program, which is very positive,” he said.

“I do have significant concerns about the speed in which the agency is asking people to move to risk as well as the proposal to cut shared savings from 50 to 25 percent. Two years is not enough time to take on risk; it took us 11 years and we’re still hard at it,” Robertson testified. “The reduced shared savings amount is going to keep providers out of this program because it does not allow them to keep enough savings to reinvest in the IT infrastructure and the care coordination that is needed to make these programs work. The limitation of the risk score adjustment of +/- 3 percent over the five-year contractual period will also be harmful as it penalizes physicians financially for taking care of patients who are sicker.”

Stark Law and Anti-Kickback Statue Reforms

During the hearing, panelists also shared their perspectives on how legal barriers are preventing healthcare providers from accelerating toward value-based care.

Mary Grealy, president of the Healthcare Leadership Council, comprised of industry leaders from all sectors of the U.S. healthcare system, testified that the Stark Physician Self-Referral Law and the Anti-Kickback Statute were created to prevent overutilization and inappropriate influence in a fee-for-service environment in which healthcare sectors and entities operated in their own individual silos.

“Today, however, in order to make the transformation to value-based care, we need greater integration of services, improved coordination of care with cross-sector collaborations, and payment that is linked to outcomes rather than volume. Adopting these new delivery and payment models becomes difficult when faced with outdated fraud and abuse laws and potential penalties of considerable severity,” Grealy said.

She said, for example, that hospitals can run afoul of current law by offering physicians performance-based compensation to engage in coordinated care and meet high quality metrics.

Adventist’s Anand also highlighted the need for Stark Law modernization, noting that it is an “impediment” to value-based care. “The Stark Law is highly complex and has created a minefield for the health care industry due to its huge financial penalty risks and its unclear provisions. These risks result in health care providers avoiding value-based arrangements,” he said. While Congress authorized the U.S. Department of Health and Human Services (HHS) Secretary to issue regulatory waivers for models of care, such as the MSSP program, these waivers are issued program-by-program and are not permanent, he said.

Michael Weinstein, M.D., a practicing gastroenterologist and president of Capital Digestive Care, a physician practice with 65 GI doctors in the Washington, D.C. area, also urged policymakers to modernize the Stark Law, noting that fraud and abuse laws are an impediment to develop and implement innovative alternative payment models (APMs). “Physician practices are facing increasing challenges competing with mega-hospital systems, in part, because antiquated Medicare law and regulations generally favor hospital systems,” Weinstein testified.

CMS issued a request for information (RFI) this summer for public input on how to address any undue regulatory impact and burden of the Stark Law. HHS also is considering making changes to the anti-kickback statute as the HHS Office of the Inspector General (OIG) is looking for stakeholder feedback, via an RFI issued August 27.

Morgan Reed, president of ACT | The App Association and executive director of the Connected Health Initiative, told the Health subcommittee members that Medicare regulations and payment policies present serious challenges to the incorporation of technology-driven tools that can make healthcare more accessible and user-friendly. He specifically urged policymakers to take a number of steps, including passing the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) to Health Act of 2017 and filing down regulations such as features of the Anti-Kickback Statute and the Stark Law. He also urged policymakers to enhance interoperability and access to data through better guidance from the Office of Civil Rights (OCR) and finalizing the “data blocking” rules.

In her testimony, Grealy also noted that the expanded use of telemedicine is essential in more efficient utilization of healthcare resources and expanding the reach of health providers. “We urge Congress and the administration to further address Medicare’s restrictions on reimbursement for telemedicine services. There is also considerable value to be found in making digital health applications more accessible for beneficiaries,” she said.

Related Insights For: Value-Based Care


Humana’s CMO Speaks of the “Bold Goal” Embedded in the Company's Population Health Work

September 14, 2018
by Heather Landi, Associate Editor
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Almost every major health insurer in the country is now focused on addressing the social factors impacting health, such as housing and food insecurity, as part of broader population health efforts to improve health outcomes and lower healthcare costs. A recent survey by Change Healthcare and the HealthCare Executive Group (HCEG) found that more than 80 percent of payers are integrating social determinants of health into their member programs. According to that survey, 42 percent of payers are integrating community programs and resources into their population health programs, and 34 percent said they are integrating census and socioeconomic data with clinical data to develop new insights.

In fact, among healthcare providers and insurance companies, the increasing focus on addressing the social determinants of health, or the upstream factors influencing health, supports the healthcare industry’s broader transition to value-based care and payment models, which focuses on the quality of the health care provided rather than just the volume of services.

Louisville, Ky.-based insurer Humana is approaching this issue through its “Bold Goal” initiative with the aim of improving the health of communities it serves 20 percent by 2020. Through this initiative, which was launched in 2015, Humana is working with local physicians and community organizations to address physical and mental health conditions as well as social determinants of health (food insecurity, social isolation and loneliness) in seven communities.

Humana measures "Bold Goal" community progress using the U.S. Centers for Disease Control and Prevention (CDC) population health management tool known as Healthy Days, which takes into account the whole person by measuring both mentally and physically Unhealthy Days over a 30-day period. In a report on the "Bold Goal" initiative issued in March, Humana reported that "Bold Goal" markets, on average, managed to reduce their number of Unhealthy Days. Knoxville, Tennessee; Baton Rouge and New Orleans, Louisiana; and San Antonio, Texas all had improved Healthy Days as well as improved clinical outcomes.

During a recent visit to New York City, Roy Beveridge, M.D., Humana’s chief medical officer, sat down with Healthcare Informatics Associate Editor Heather Landi to discuss the drive to value-based care, addressing social determinants of health, and the need for more transparency in healthcare. Beveridge joined Humana in 2013 and is board-certified in medical oncology and internal medicine. Below are excerpts from that interview.

There is growing recognition of how social factors influence an individual’s health. How is the issue of social determinants of health impacting the healthcare industry?

“Social determinants of health” is a buzz word that everyone is using, and many organizations are viewing it as a social “nice-to-have.” We look at it as an essential business component of the care of our patients. We believe that food insecurity affects someone’s health, and if someone’s health is affected, their costs are going to increase. Therefore, we need to improve their health, we have a number of years to do it and we’re willing to look at things in the long term. Now, others are focused on having foundations that donate money toward food banks or other issues. Donations without alignment with business imperatives mean that with the next downturn in the economy, or the next time the foundation sees something else they think is interesting, they are going to go somewhere else. From our standpoint, food insecurity is not going to disappear with the next economic downturn, it’s only going to get worse. We need to make this part of our business think, and that’s what we’re doing.

Roy Beveridge, M.D.

What are some initiatives that Humana is doing to address social determinants of health?

We’re focused on three areas—transportation, food insecurity and social isolation. In the area of transportation, we have been able to build into almost all of our Medicare Advantage (MA) contracts provisions to get people to their appointments for their primary care doctor, to the hospital, and to specialists.  I’m not going to say that it’s not a problem now, but if you go down to Florida, everyone in Florida under our contracts can get to and from the doctor.

We have a number of pilots looking at the issue of food insecurity, with our biggest study in Florida. We screened 1,500 patients and 800 were identified as food insecure and, of that 800, with half of them we took steps to link them with Feeding America, a non-profit national network of food banks. We also used our social workers to engage them and help them to make sure they are getting food stamps. The goal with that study, over the next few years, is to see whether in fact the PMPM (per member per month) decreases in the group that we connected with food resources. We’re also doing another randomized trial looking at connecting with members through social work engagement so that we’re educating them and finding food sources for them in their communities and signing them up for public food services. We’re studying different approaches at different price points to see what is effective for a particular population. It’s a question of how much money you need to invest to get a benefit for what period of time.

What are some of the biggest challenges in this work?

I think the big issue is to figure out whether it is a ‘nice-to-have’ or a ‘must-have.’ I think a lot of people are paying lip service to social determinants by saying it’s ‘nice to have’ and we’re going to have our foundation give this amount of money to a food bank. But unless you drive it down and use analytics and figure out how it really works for your population, I’m not sure you can get the benefit that you need. I think many well-intentioned folks are giving large chunks of money for housing. I think that’s very noble, but I don’t know how you can use that approach to take care of a broad number of people. If a significant percentage of the population have these housing problems, how are we helping the population as a whole?

Humana launched its "Bold Goal" initiative in 2015. How is that initiative progressing?

If you think about population health as a whole, "Bold Goal" is almost a subsegment of that. What "Bold Goal" says is that we at Humana can’t do this by ourselves, Blue Cross can’t do it by themselves, United can’t do it by themselves, a hospital system can’t do it by themselves and I don’t think the government can do it. If you think that any one entity can, then they are going to fail. The reason that Bold Goal has been successful in San Antonio, Louisville, Tampa, Miami or New Orleans, is that we made a commitment—we’re there and we’re not moving. We meet with all of the stakeholders six times a year and we’re doing projects that engage everyone.  The very first meeting we had in San Antonio, we had six non-for-profit diabetes entities that had never talked to each other, and we had multiple food banks that had never coordinated with each other. And, in fact, one of the food banks said, ‘We’ve got all this food, we just don’t know where it should be distributed.’ We were able to build strong relationships between physicians, communities and patients, and four of these communities demonstrated improvements in health over the past year.

More broadly, how would you describe the evolution of value-based care and payment models?

Our net promoter scores for our physicians who are in risk or value-based contracts are significantly higher than those in fee-for-service. [Editor’s note: In a value-based care report issued last year, Humana reported that patients treated by physicians in Humana MA value-based agreements had more preventative care screenings and better health outcomes compared to patients in Humana MA fee-for-service agreements.] We know is that in order for a value-based provider to be successful they need our data, and we have a mutually aligned interest, which is the health of that patient. And, if you improve the health of the patient, then the cost follows. It might take another year or two, for the cost to get there, but improved health always leads to reduced costs.

I was worried a few years ago whether physicians were really beginning to understand how quickly things were changing to value-based care and payment and to risk-based arrangements. As I travel around the country, I think more and more people are getting it. I continue to see that there is not a complete understanding of what full risk means. With regard to the MSSP [Medicare Shared Savings Program] accountable care organization (ACO) program, people still think ‘If I just take a little bit of upside [risk], I’m doing value-based care.’ However, I think the more organized, larger provider groups and hospital systems, they get it and they are investing a lot of money in population health now.

As you mentioned, providers need actionable data to successfully make this transition to value-based care and payment models. How do you see data sharing and interoperability playing into this movement towards value-based care?

When you look at the current Administration’s push, (U.S. Department of Health and Human Services) Secretary Azar basically said interoperability is one of the very important things that he wants to get done, so Blue Button 2.0 is something that they are pushing hard on. [Editor’s note: The Centers for Medicare and Medicaid Services (CMS) is encouraging health insurers to use data release platforms for enrollees that either “meet or exceed the capabilities of CMS’s Blue Button 2.0,” according to an announcement from the agency on 2019 capitation rates and payment policies. And, the announcement goes on to state that “CMS is contemplating future rulemaking in this area to require the adoption of such [Blue Button 2.0 compatible] platforms by Medicare Advantage plans by CY 2020.”]

Then look at what’s happening at Google or Apple and these other companies—the amount of interoperable data coming down is just profound. Right now, the EHR entities have to push data into their portals and then the portals connect to that, through Apple. And so, you’re getting this massive amount of data, which is becoming available, and interoperability is fundamental for the transparency piece so that patients understand what is happening with them. And, we applaud that 105 percent, because, unless you have that transparency, it’s hard to engage someone. So, I can talk to you about your mother’s health, but if on her iPhone, she can get all of her data from every hospitalization and every lab and make appointments, and then allow you as a caregiver to get in, that’s where you begin to get engagement.

HHS Secretary Alex Azar and CMS Administrator Seema Verma have made it clear their intention to push hard to transition the industry to value-based care and to empower patients. Do you agree with the direction they are taking?

No matter how you look at it, regardless of what risk model you look at, the quality scores are higher and the costs are lower. As we continue to move into member transparency and consumer transparency, consumers want to see the quality scores. That’s the transparency that needs to get out there, and I think they are right for pushing this from a quality standpoint. In fee-for-service, it’s the Wild West; quality scores are meaningless in fee-for-service.


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