Payment reform summit

ACOs: How Is All This Working in Massachusetts?

Posted in Payment Reform, Payment reform summit on October 26th, 2010 by Rebecca McDade – Comments Off on ACOs: How Is All This Working in Massachusetts?

One of a series of reports on the October 21 MMS forum, “Toward a Shared Vision of Payment Reform.”

After rundowns on reforms in Pennsylvania, California, and Vermont, the spotlight at the October 21 payment reform conference turned to Massachusetts. The three afternoon presentations that described Bay State success stories all reiterated that payment reform is really a means to the end of delivery improvements.

Dana Safran, Sc.D., senior VP at Blue Cross Blue Shield of Massachusetts, explained how the health plan’s Alternative Quality Contract (AQC) works. She emphasized that AQC incentives are based on three types of measurement– process, outcome, and patient experience, with outcome measures weighted more heavily than process measures. Safran noted that providers in the AQC “class of 2009” exhibited rates of improvement that far exceeded their historical pre-AQC rates of improvement. Safran credited those improvements not only to properly-aligned incentives, “but also to [provider] leadership acting on those incentives.”

Safran also described a variation-analysis exercise similar to the one used by Sutter (see “Van Duren: Doctor-Led, Data-Driven Variation Reduction”) that engages physicians in conversations about cost and outcome implications of clinical decisions.

When asked by an attendee why the five-year AQC contracts build in adjustments based on the consumer price index rather than the typically higher medical inflation rate, Safran said, “We made a conscious decision not to tie it to medical inflation. It’s a way of not accepting the status quo, achieving sustainability, and building in extra accountability for providers.”

Addressing another question about the appropriate role of health plans in patient education, Safran said, “Plans have an important role to play there. Patients are one key to slowing spending growth, and we have to help them understand that, despite what they see on TV or in magazines, more is often not better when it comes to health care.”

Describing Atrius Health as “an ACO without hospital ownership,” Gene Lindsey, M.D., the president and CEO of the 800-physician multispecialty group, reiterated the main theme of the conference when he said, “The answer is not in the money or the payment; it’s in how health care delivery is organized.”

An advocate of “lean” systems, Dr. Lindsey emphasized the importance of enhancing value for stakeholders while at the same time eliminating waste and duplication in health care delivery. At Atrius, leanness requires well-functioning clinical teams and processes that ensure patients get the “right care in the right place.” Atrius, a participant in the Blue Cross Alternative Quality Contract and a pioneer of innovations such as shared medical appointments, is now focused on establishing medical-home concepts in each of its five practice groups.

Dr. Lindsey said the next big step in addressing the root causes of waste in the health care system will require “high–level collaboration between ‘warring camps.’”  In Dr. Lindsey’s opinion, in coming years more people once covered under employer-sponsored insurance will enter state- and federally subsidized programs, which will put downward pressure on prices. If that happens, he said, ACOs will multiply “by necessity, as doctors and hospitals come together to manage financial risk…So we should all learn NOW to eliminate waste and improve quality,” he said.

Barbara Spivak, M.D., president of the Mt. Auburn Cambridge Independent Practice Association, said her IPA’s success derives from the fact that “we focus on quality, and the efficiencies follow.”

Dr. Spivak stressed that the IPA and Mt. Auburn Hospital “share the same goals, even though none of the IPA members are employed by the hospital.” Although the hospital and IPA remain separate entities, “we partner with Mt. Auburn in everything – even our approach to contracting with health plans,” said Dr. Spivak. “Getting to an agreement that leaves the payer, the hospitals, and the physicians feeling positive requires trust all around,” she said.

Dr. Spivak also emphasized the widespread involvement of IPA members in the governance of the physician group and the importance of monthly meetings with primary care physicians, who are reimbursed for attending such meetings.

Video excerpts of their presentations:

Download their presentations :

Hester: Vermont’s Three-Pronged Approach to Reform Centers on Communities

Posted in Payment Reform, Payment reform summit on October 26th, 2010 by Rebecca McDade – Comments Off on Hester: Vermont’s Three-Pronged Approach to Reform Centers on Communities

One of a series of reports on the October 21 MMS forum, “Toward a Shared Vision of Payment Reform.”

Hester_James_60x70Massachusetts wasn’t the only New England state that passed health care reform in 2006. So did Vermont, as James Hester, Ph.D., explained to attendees of the October 21 payment reform conference. Hester is director of the Vermont Health Care Reform Commission, but he spent 14 years working in Massachusetts, qualifying him to compare and contrast.

Vermont’s 2006 health reform law (Act 191) legislated a three-pronged balance between reducing the number of uninsured citizens, deploying health IT, and transforming the health care delivery system.  “Massachusetts tackled covering the uninsured first,” Hester noted. “We were able to do all three concurrently.”

Stressing the need for “building ‘system-ness,’” Hester explained that Vermont’s foundation of system-ness is the patient-centered medical home. The state’s three medical home pilot projects currently cover 10 percent of its 600,000 residents.

Vermont’s version of accountable care organizations are “neighborhoods” of medical homes called community health systems. “Patients change health plans more often than they change communities,” observed Hester, citing the stability of the community as “the focal point of Vermont’s delivery-system reforms.”

At the heart of each community health system is the community health team (CHT), which links medical homes to a broader range of health care services. Staffed by five full-time professionals (nurses, community health workers, mental health professionals, and others) per 20,000 patients, each CHT is funded by all of Vermont’s three commercial and two public payers. Any provider can refer any patient to a CHT.

The payment reform aspect of Vermont’s reforms, said Hester, is a “necessary but not sufficient condition” for success. Vermont’s community-centric pilots rely on a state-mandated single system of aligned incentives through which providers receive sliding-scale “management fees” linked to their performance on 10 medical home criteria from the National Committee for Quality Assurance.

Hester reports that he frequently hears from participating doctors that the medical home pilots “have revitalized their love of primary care.”

Video excerpts of his presentation:

Download his slide presentation. (.pdf, 14 pages)

Van Duren: Doctor-Led, Data-Driven Variation Reduction

Posted in Payment Reform, Payment reform summit on October 25th, 2010 by Rebecca McDade – Comments Off on Van Duren: Doctor-Led, Data-Driven Variation Reduction

Michael van Duren, MDOne of a series of reports on the October 21 MMS forum, “Toward a Shared Vision of Payment Reform.”

Physicians tend to be disgruntled with most of the data they get from insurance companies, partly because much of it is used to pigeonhole them into often-inaccurate efficiency-based performance categories.

But at the recent MMS payment reform conference on October 21, Michael van Duren, M.D., chief medical officer at Sacramento-based Sutter Physician Services, explained how he facilitates discussions among small groups of physicians using drill-downs of such data to uncover and resolve variations in care.

“Data that’s used and displayed differently than how insurance companies provide it can be very actionable,” Dr. van Duren said.

To prove his point, he took the audience through two sample “explorations” using Sutter’s Care Pattern Analyzer, an Ingenix-driven, episode-based tool containing data on individual physicians as well as groups and regions.

In one example, the average cost of an episode of chronic sinusitis without surgery varied from $300 to $600. Using facilitation skills that he characterized as the trickiest part of the variation-reduction exercise, Dr. van Duren led a small group of physicians in discussions to determine why such variation existed. Often, there are patient-specific and clinically important reasons for the variations, but sometimes, as these conversations determine, it’s a matter of ingrained practice patterns.

Discussions about low-cost physicians almost always lead to debates over outcomes, data that insurance companies typically can’t or don’t deliver, but which physicians can discuss meaningfully.

“When physicians explore this without judgment in a safe, respectful environment, they learn a lot and sometimes make improvements to clinical practice,” Dr. van Duren said. It’s not an insurance company edict, but a thoughtful consensus among peers, all of whom want to do right by their patients.

Dr. van Duren described another doctor-led analysis that resulted in a 20-percent reduction in imaging rates for patients with low back pain of less than 30 days duration and no indication of cancer. “There can be losers in this,” Dr. van Duren admitted. “If you have a financial interest in a radiology center, this could be uncomfortable.”

Video excerpts of his presentation:

Download his presentation. (.pdf, 18 pages)

ACOs and the Law: An Evolving Issue

Posted in Payment Reform, Payment reform summit on October 25th, 2010 by MMS – Comments Off on ACOs and the Law: An Evolving Issue

One of a series of reports on the October 21 MMS forum, “Toward a Shared Vision of Payment Reform.”

Sara Rosenbaum, JDAn expert on health care law told attendees at an MMS forum on payment reform that the legal parameters for accountable care organizations are in transition, and that will probably change over the years.

Sara Rosenbaum, JD, chair of Department of Health Policy at the George Washington University school of Public Health and Health Services, reviewed the basics of how anti-trust law treats physician practices, and discussed the kind of integration that the law currently accepts. The key decision, she said, occurred in a 1982 case in Arizona, when the physicians of Maricopa County Medical Society were found to be colluding on prices.

But she said that today, when health policy is encouraging broad integration of the health care delivery system, there’s a strong tension between the objective of anti-trust law to promote competition, and new health care policy.

However, she said the potential benefits of such collaboration are so compelling that “the anti-trust imperative will in time give way to the integration imperative, because you cannot deliver these kind of results with that kind of integration.”

This forum was co-sponsored by the Massachusetts Medical Society and the Commonwealth Fund.

Video excerpts of Ms. Rosenbaum’s presentation:

Download her slide presentation. (.pdf, 10 pages)

Grant: Bringing Geisinger Reforms to Lahey Clinic

Posted in Payment Reform, Payment reform summit on October 22nd, 2010 by Rebecca McDade – Comments Off on Grant: Bringing Geisinger Reforms to Lahey Clinic

One of a series of reports on the October 21 MMS forum, “Toward a Shared Vision of Payment Reform.”

Several audience members at the October 21 payment reform conference asked Howard Grant, M.D., chief medical officer at Pennsylvania’s Geisingner Health System, “Could we do what you do here in Massachusetts?” After revealing that he was about to become CEO at Burlington-based Lahey Clinic, Dr. Grant said, “Call me in about six months, and I’ll let you know.”

Geisinger’s often-praised integrated and coordinated system in central Pennsylvania is facilitated by relatively homogeneous patient populations, a large percentage of Geisinger-employed physicians, and most importantly by Geisinger owning a local health plan, what Dr. Grant referred to as the “sweet spot.” All parties – physicians, hospitals, and insurer – are at the table for every systemwide clinical and business decision that Geisinger makes.

Even if a framework like that can’t be replicated in Massachusetts, Dr. Grant observed that several aspects of Geisinger’s success could be. For example, advanced medical homes flourish in the Geisinger system. Geisinger hired 250 additional nurses who are “embedded” in the medical homes to provide what Dr. Grant called “concierge care for the sick, a 24/7 continuum of care.” The results include a 25 percent reduction in hospital admissions and a 53 percent reduction in readmission after discharge. Just as important, Dr. Grant said, “Providers are happier, and patients are thrilled.”

Geisinger’s so-called value reimbursement program is another potentially replicable innovation. The program begins with fee-for-service payments (“We didn’t want to perturb the system too much,” said Dr. Grant) and stipends to help practices invest in care-delivery innovations. Incentive payments based on quality and efficiency are added, and they are significant. One five-physician primary care practice realized $300,000 in incentives in one year, Dr. Grant reported.

The forum was co-sponsored by the Massachusetts Medical Society and the Commonwealth Fund.

This video clip provides more details about the clinical improvements that Geisinger achieved.

Download his slide  presentation. (.pdf, 26 pages)

Bigby: Finding the Balance between Regulation and Innovation

Posted in Payment Reform, Payment reform summit on October 22nd, 2010 by MMS – Comments Off on Bigby: Finding the Balance between Regulation and Innovation

One of a series of reports on the October 21 MMS forum, “Toward a Shared Vision of Payment Reform.”

JudyAnn Bigby MDGovernor Patrick’s point person for health care told attendees at the MMS payment reform program this week that that best role for government is to provide the right balance between regulation and flexibility, and to provide protections for both health care consumers and providers.

JudyAnn Bigby, MD, is secretary of the Massachusetts Executive Office of Health and Human Services and chairs the state’s Health Care Quality and Cost Council. She also leads the large committee of government and health care leaders that is now debating the principles for payment reform.

They’re looking what such issues as the kind of ACOs that should exist, the kind of oversight they need, the rights of patients and providers, and more. These discussions will inform any legislation that would be filed in next year’s session.

Bigby said she favors a balance between regulation and flexibility. The role of regulation, she said, is to protect both providers and consumers. She added, “This transformation has the potential could harm certain providers in a way that would be harmful to the health of the community.”

On the issue of flexibility she said, “We believe ACOs should very diverse.”  She said an ACO could consist solely of primary care doctors, could be an integrated delivery system, or virtual networks of providers.

But she added, “We do want to set baseline parameters for how ACOs function, so we don’t wake up one day and say this isn’t what we were anticipating.”

She said, “There is recognition that you can’t move providers from one form of payment to another overnight,” and that it takes investment not only in infrastructure, but in understanding that if some quality objectives are achieved, it could represent revenue losses for some providers, “and we need to acknowledge that.”

One attendee later asked Dr. Bigby how much control the government will want to exert over health care under a new payment system.

She said, “The [oversight] board is not bow viewed as having a centralized approach to managing health care or medicine. It’s seen as an instrument to make sure that the payments are not disadvantageous to providers or patients, and that we have the best opportunity to control costs.”

She added, “I believe there has to be a lot of diversity, not only in how payment reform is done, but also in the definition of ACOs. … Diversity and flexibility is the theme I keep promoting.”

“Payment reform in and of itself is not the goal,” she said. “We all have other things we want to achieve” namely, universal coverage, broad access to care, and controlled growth in health care costs.

This forum was co-sponsored by the Massachusetts Medical Society and the Commonwealth Fund.

Video excerpts from Dr. Bigby’s presentation:

Download her slide presentation. (.pdf, 13 pages)