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At the Philadelphia HIT Summit, One Healthcare Leader Parses the Current State of Payer-Provider Convergence

May 24, 2018
by Heather Landi
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Capital BlueCross' Mark Caron says the move to accountable care could result in a need for fewer hospitals, as the next-generation of care will be delivered somewhere else
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As the healthcare industry continues a steady transition from fee-for-service payment models to value-based care models, one healthcare thought leader sees the commercial payer market playing a larger role, going forward, in pushing provider organizations into value-based care arrangements.

Mark Caron, executive vice president, business platforms and solutions, Capital BlueCross, provided a sweeping overview of the market forces driving change and convergence in healthcare in the current moment and what may be ahead, during the Health IT Summit in Philadelphia, sponsored by Healthcare Informatics. Caron, who also is CEO of Geneia, a subsidiary of Capital BlueCross that provides analytics and technology solutions, shared his perspective on the regulatory, market and demographic forces driving change and the impact on healthcare delivery organizations.

Harrisburg, Pa.-based Capital BlueCross, a regional payer, launched its first value-based care partnership, what it calls accountable care arrangements (ACAs), back in 2011. There are now more than 2,800 physicians and 362,000 customers participating in Capital BlueCross’ ACAs.

At the federal policy level, Caron noted that federal healthcare leaders have made it clear that CMS (the Centers for Medicare & Medicaid Services) is committed to moving toward value-based care, however he contends that commercial payers are making more strides in this area, especially with bundled payments.

“Contrary to what I had earlier thought—that the federal government would be the Goliath to push things over the hump—I’m now sensing that there is more impetus with the commercial payers. In fact, with employers engaging more, because now their self-funding and there are more transparency requirements, I think the commercial is going to have the stronger push,” he said. “That’s not to say CMS is backing away. Like every major program in our country, I think they underestimate the complexity. Healthcare is local, and one local market is different from another.”

He added, “I think commercials are going to continue to make more strides there. I think they see bundled payments a way to help do that and when delivery systems get more comfortable with that, they’re going to take those things on and slowly move away.”

Addressing the progress toward value-cared care, and specifically the lack of readiness among organizations in some markets, Caron said. “I would argue that part of the reason that we’re way behind is that we, first, underestimate how hard this is. And, another reason we’re not seeing a quick evolution is that as healthcare organizations implement EMRs (electronic medical records) in their own shops, and acquiring other organizations that might have the same or different EMRs, and synthesizing all of that, I think M&A (mergers and acquisitions) has slowed down some of this,” he said, adding, “I’m concerned about the rural market. If you get out to some of the more rural markets around the country, you see that; it’s a challenge.”

Market and Government Forces Driving Change

Caron noted that there continues to be uncertainty about the future of the Affordable Care Act (ACA), as Congress passed a tax bill repealing the individual insurance mandate. Insurers continue to price in uncertainty on ACA plans, he said, noting, “Hospitals are telling us, the payers, that their uncompensated care is increasing because some people are no longer on exchanges or subsidies. We’re starting to see a downward trend on the exchange population,” he said.

Under new leadership, specifically U.S. Department of Health and Human Services (HHS) Secretary Alex Azar and CMS Administrator Seema Verma, CMS is moving forward with new priorities, such as rebranding the meaningful use program as “Promoting Interoperability.” CMS continues to advance forward with value-based care initiatives, although mandatory bundled payments have been delayed. “We’re seeing more hospital systems moving towards that, and in fact, employers are more interested in that too, which we haven’t seen in the past,” Caron said.

These developments are unfolding as healthcare costs continue to rise. Caron noted that federal healthcare programs—Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) and the ACA marketplace subsidies—accounted for 26 percent of the federal budget in 2016. According to data from the Healthcare Cost Institute, in 2016, there was a 4.6 percent increase in healthcare spending per capita and 12 percent cumulative growth in out-of-pocket spending from 2012 to 2016. The price of an emergency room visit increased 34 percent from 2012 to 2016 and the price of surgical admissions increased 30 percent in the same time period.

“What’s Interesting here is that it’s not so much utilization that is driving these costs, it’s unit price. I would submit that one of the unintended consequences of the ACA, in creating these integrated systems, is taking competition out,” he said. “From a payer perspective, we saw that with imaging systems, as independent imaging centers got merged in with hospital systems. In one year’s time, the same number of images doubled in cost.”

And, Caron noted that the move to accountable care models would continue to have a significant impact on hospitals and hospital-based systems moving forward. “One of the things that we’ve overlooked in this country, with moving to accountable care, is that many hospitals have a significant debt load that they carry from investing in EHRs, investing in diagnostic imaging systems and oncology programs. We have this hangover of debt, if you will, and that is going to continue to be figured into cost, because you’re getting less business, but you need to keep the lights on and pay your staff,” he said.

He continued, “I think there is going to be a period of time, it might be an unintended consequence or a direct intent, that we need fewer hospitals and the next-generation of care is going to be delivered somewhere else.”

Demographic trends also will put demand on healthcare delivery systems, as current data shows about 50 percent of adult Americans, about 117 million people, have at least one chronic condition and more than 25 percent have two or more chronic conditions.  Three-fourths of those 65 and older have multiple chronic conditions. “By 2050, 20 percent of Americans will join the Medicare system, that’s up from 15 percent today, or 40 million more people on Medicare. That’s the silver tsunami,” he said.

Payer and Provider Performance and Capabilities

With all of these market forces at play, the shift to value-based care is well underway, Caron noted, as the major private health insurance companies—Aetna, Anthem and UnitedHealth—currently have 50 percent of their reimbursements through value-based care models. Aetna plans to grow its value-based care contracts to 75 to 80 percent by 2020, Caron said. Currently, 19 million Blue Cross Blue Shield members receive care through value-based care models.

Early results for value-based care programs show promise, he noted, with improvements in utilization, cost and quality. In 2017, Medicare ACOs generated more than $466 million in total program savings and 125 ACOs met quality standards and savings thresholds to qualify for shared savings payments. Among commercial payers, Anthem and UnitedHealthcare have reported a reduction in acute patient admissions and cost savings per participating patient.

What’s more, Capital BlueCross’ accountable care providers are outperforming their peers with lower acute inpatient hospital admissions (down between 4.7 percent to 7.2 percent) and hospital readmissions (down between 8 percent to 14.8 percent), fewer ED visits (down 8 percent) and ACOs are meeting or exceeding agreed-upon quality goals and exceeding the regional average for Healthcare Effectiveness Data and Information Set (HEDIS) measures for chronic disease management.

“There are concerns about whether value-based care is working, but we have proven in our own marketplace that it is. There is room for improvement, as we bring in other data and get more knowledgeable and intelligent about how we use that data, we’ll get better around these programs,” he said. However, he also acknowledged that the move to take on more risk has been slower than expected.

“We expected by year three that physicians in hospital organizations would be taking risk on. That has not been the case. It’s a lot harder than the power points show, but I think as you start to see some of the benefits, it is showing its value.”

There are also market shifts among employers impacting the healthcare industry, namely, a huge shift among employers to self-funded health plans since the passage of the ACA, Caron said. In 2017, 60 percent of employees were in plans fully or partially self-funded, up from 54 percent in 2005.

“Many employer groups are diving into understanding their costs. They are demanding more of payers to understand where are my costs, what are you doing for value, what are you doing for patient engagement?” Caron noted that employers like GE and Walmart are buying directly with bundled payments for joint replacement, spinal and bariatric surgery. According to a recent survey, 21 percent of large employers will promote or contract directly with an ACO in 2018, and another 26 percent are considering doing so within two years, he said.

This trend of taking on more risk is fueling explosive expansion of ACOs, from 64 in the first quarter of 2011 to 836 in Q1 2016, with 2.7 million covered lives in 2011 increasing to 28.3 million covered lives in 2016, he said, citing data from Leavitt Partners Center for Accountable Care Intelligence. “The horse is way out of the barn; we’re not turning this one around,” he said, noting that this growth, in turn, fuels the need for data and analytics.

However, U.S. healthcare is still in the early stages of building the technology capabilities to support value-based care, he said. Citing the Chilmark Research’s payer provider convergence model and timeline, which outlines three stages of maturity to get to a value-based platform and capability, he noted that U.S. healthcare was still in stage 1, with disparate capabilities across most of the country.

“I would submit that, by 2021, we’ll start to see that maturity shift, and it’ll be three years before we have fully integrated systems,” he said.


2018 Raleigh Health IT Summit

Renowned leaders in U.S. and North American healthcare gather throughout the year to present important information and share insights at the Healthcare Informatics Health IT Summits.

September 27 - 28, 2018 | Raleigh


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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