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CAPP Health Care Primer: What Candidates Need to Know

By Robert Pearl, MD, Chair, Council of Accountable Physician Practices

With thousands of political offices up for election this November, health care will continue to be a complex and frequently debated issue.  To help focus discussions, the Council of Accountable Physician Practices has produced an original primer, “What Every Candidate Should Know About Health Care.” This primer is for candidates running for local and national elected office and details the most critical health reform topics they must understand to ultimately improve the medical care their constituents receive.

The three primary issues highlighted in “What Every Candidate Should Know About Health Care” are:

  1. Payment system reform to enable acceleration of the move towards value-based payment and away from the current volume-based fee-for-service model, aligning incentives to reward better patient outcomes, safety and efficiency.
  2. Expanded use of health information technology so care providers always have the information they need to make the best care decisions.
  3. Consistent and meaningful quality measurements to accurately identify high-performing medical groups and health systems.

By bringing these healthcare issues into the political discourse, the leaders of CAPP believe they can educate and inform elected politicians on the accountable approaches that produce the highest quality and best health outcomes for patients.

We encourage you to read and share “What Every Candidate Should Know About Health Care”  and send us feedback on twitter @accountableDOCS.


Welcome to the New Website and Blog for the Council of Accountable Physician Practices

By Robert Pearl, M.D.Chair, Council of Accountable Physician Practices

“Better Together” is a blog dedicated to sharing thoughts and ideas on how physicians can effectively lead the movement to improve the American healthcare system.  Through articles written by  by  CAPP medical group physician  leaders and others aligned with our mission,  this forum will inform and inspire physicians and healthcare leaders to improve the way we deliver care.

We all know about the gaps in our health care system that make receiving medical care difficult for many  patients, and keep physicians from communicating, coordinating and collaborating with each other to make the best, most timely care decisions. The twenty-eight multi-specialty medical groups and integrated health systems of CAPP are leaders and pioneers that strive to deliver a superior kind of health care – accountable, proactive,  physician led and patient focused. The result is increased preventive services, improved coordination and greater availability of advanced information  technology.

Through the “Better Together”  forum,  I believe that physicians can engage in discussions around ways to deliver and pay for medical care more effectively,  share best practices, propose innovative ideas and wrestle with the common challenges that practitioners and patients across this nation face.

A New Direction for CAPP

This website and the “Better Together”  blog represent a new direction for CAPP, one that seeks to find the signal through the noise, articulates the the benefits of integrated, organized systems of care in a way that we can all understand and helps other physicians embrace a more integrated practice structure.  CAPP has long been engaged in promoting new solutions for care delivery and in leading  the movement towards greater accountablity in healthcare. Our focus now expands to include educating American consumers, healthcare providers and payers about what accountable, coordinated  care actually looks like and the improved clinical outcomes it achieves.

Aligned with that goal, we have organized our first-ever major event to examine the model in greater detail, and allow participants to engage in a dialogue on this topic.

“Better Together – High Tech and High Touch: Patient-Physician Relationships in the New Millennium” will be held on Wednesday, November 4th, 2015, at the Center for Total Health in Washington, D.C.  The three-hour event, in partnership with The Bipartisan Policy Center (bipartisanpolicy.org), will bring together doctors, policy makers, patient advocates and patients to share real stories and the potential that the use of robust technology and video in accountable, coordinated systems can have.

Our members, and many of our colleagues in the healthcare world, continue to be troubled by a persistent knowledge gap and the seemingly low expectations surrounding the transformation of American medicine in the new era of “the consumer.”   In particular, we’re concerned that two important voices – the patient’s and the physician’s – are often conspicuously absent in the national dialogue on this critical subject. This and future events will  amplify those voices to achieve legislative and regulatory  reforms that support the patient-physician relationship.

We invite you to the live webcast of this event and to join the discussion. (For more information about the “Better Together” event, click here.)

Tell us, how do you think we could  be “Better Together” in healthcare delivery? We look forward to hearing your perspective.


Addressing Care Redesign at New England Journal of Medicine, Kaiser Permanente and Harvard Business Review

On September 30, 2015, CAPP Chair, Dr. Robert Pearl, together with other preeminent healthcare thought leaders gathered at the Kaiser Permanente Center for Total Health in Washington, D.C. to discuss Care Redesign: Creating the Future of Care Delivery. The event was webcast live and topics included how to create and sustain the teamwork needed to provide high value care, practical implications of organizing care to enhance health rather than provide sick care, and the evolution of payment systems to reward high value care for chronic disease. The event was sponsored by the New England Journal of Medicine (NEJM) Group, in partnership with Kaiser Permanente and Harvard Business Review.

Progress of Accountable Care Organizations: A View from the National ACO Congress

By John Jenrette, M.D., chairman of the Board, California Association of Physician Groups
CEO, Sharp Community Medical Group

Last month at the third National ACO Congress held in Los Angeles, California, national experts presented up-to-date information about the evolution of Accountable Care Organizations throughout the United States, including the Pioneer and Shared Savings ACOs sponsored by the Centers for Medicare and Medicaid Services (CMS) and commercial payer ACO products.  The discussions were focused on five overarching principles or themes that underlie successful ACO evolution and healthcare reform: payment reform, clinical integration, patient engagement and activation, partnerships and collaboration, and new delivery models.

Payment reform is the movement away from paying for volume to paying for value, i.e., transitioning from the traditional fee-for-service payment model to global payments, bundled payment mechanisms or increasing upside and downside risk on shared saving programs.  While it is widely accepted that payment reform is necessary to curb America’s healthcare expenditures, what has been less discussed is how difficult it actually is to appropriately align incentives among all of the players. As discussed at the Congress, aligning incentives continues to be a challenge even for the formal Medicare ACOs.  Mai Pham, M.D., Director of ACO Programs at the Center for Medicare and Medicaid Innovation, freely admitted that determining appropriate physician-specific incentives was a laggard issue for Pioneer ACOs. Conveners also discussed financial risk,  incentives that would control out-of-network costs, reversing the hospital mentality of “heads in beds,” and acceptance in the healthcare delivery system for tiered and narrow networks. The main takeaway from those discussions is that provider engagement is perhaps the most important component to payment reform. It is not enough that the payment system be changed; physicians and hospitals must commit to the change.  Providers must agree to the new systems and embrace being paid for value rather than volume.

Perhaps less controversial, but no less important, is the need for clinical integration to ensure ACO success in terms of improving the quality of care our system provides.  Provider organizations, health systems and payers must work collectively and collaboratively to coordinate care for patients.  Case studies presented at the Congress highlighted the importance of information technology and clinical decision support as enablers of clinical integration.  However, the culture of an organization, the importance of smooth handoffs of care, effective shared decision-making and the value of population health management were also frequently emphasized as components required in true clinically integrated system that will result in improved health outcomes and quality.

Comprehensive health reform will not take place without the involvement of patients. At the conference, Steve Shortell, PhD, University of California at Berkeley, described an interesting concept regarding patient engagement and activation.  He described how patients need to “co-produce” their care and health outcomes much like how college students must study, work, and be equally responsible for their education.  Patient engagement and activation is no easy task.  As providers, we must partner with patients, understand the role of consumerism, and provide transparency around our services both in terms of quality and cost.  Patient engagement and activation also requires having the right tools, not only technologically but also “human resource” tools, for example,  making good use of social workers, nursing staff, pharmacy staff, community health support (such as promotores, Spanish-language  community promoters), and county health services personnel.

The fourth theme of the conference focused on partnerships and collaborations. Throughout the session discussions, it was commonly believed that partnerships are necessary to bring the appropriate tools, infrastructure, and capabilities to the table in order to move us all in the right direction for the future.  The partnerships under discussion included the expected relationships and ventures between health plans, hospitals, and physician groups but they also included a look at some unlikely “bed fellows” –partnerships that had not been considered in the past, such as the Optum/Monarch collaboration as well as the Healthcare Partners and Davita venture.  The one common thread across all of the collaborations is that each partnership developed at a local level.  What may fit in one community may not fit in another, so understanding your local market well is critical for a successful collaboration.

Of course, new partnerships, clinical integration, patient engagement strategies, and payment reform experiments are all being tested in or are forming the basis of new care delivery models.  Care management and coordination is generally accepted as the key to ending the costly, fragmented, and unnecessary care that is still so common in our country.  The outstanding question is:  What is the best way to effectively coordinate care to achieve the desired outcomes of health reform?  What model is the best?  The answer still eludes us, but in addition to analyzing the status of the 152 CMS ACOs that have been piloted across the country, the conference sessions presented a variety of delivery model possibilities –including limited networks, approaches to develop and sustain primary care, the redesign of care processes and the use of “alternate site providers,” where services can be provided in community and home environments instead of more costly institutional settings.

In summary, the overall consensus among the Congress conveners was that “the train has left the station.” There is no doubt that we are heading down the track toward drastic changes in our healthcare delivery system.  The political outcomes of the election may not materially alter this course, and although the process is hampered by the various degrees of sophistication of provider organizations, hospitals, and other providers, it is important for all of us to learn and work together to collectively move the nation’s healthcare system in the right direction

Excerpted from the January 2013 edition of CAPG Health, published by the California Association of Physician Groups.

HealthCare Reform: A Time for Innovation

By John Jenrette, M.D., chairman of the Board, California Association of Physician Groups
CEO, Sharp Community Medical Group

Healthcare reform represents a true time for innovation for physician groups and with that comes a world of tremendous opportunity.   California medical groups in particular are now perfectly positioned to forward its message about accountable, coordinated health care driven by aligned incentives and efficient, high quality care.  It is therefore not surprising that we have advanced the California coordinated care model with the development of the six Pioneer ACOs, two shared-savings ACOs, and numerous commercial ACOs throughout our state.  California’s system of delivery is now recognized across the country as leading the way.

In leading the way, two important and substantive processes of care delivery and innovation will see increasing efforts and opportunities for improvement and change:  1) the continued strong focus on managing complex chronic illness, and 2) the need to transform primary care services to complement more accountable delivery systems of care.

The continued focus on managing complex chronic disease is of utmost importance based on the high cost of care for this subset of our population.  Whether it is the top 5% of the commercial population that accounts for 60% of costs, or the top 1 to 2% of the Medicare population that accounts for 20 to 25% of costs, the need for innovation in the medical services we provide to the chronically ill is essential.  We must continue the current effective programs and further advance new approaches to provide coordinated, accountable care in the correct setting of home and/or community, involving both patient and family.  Ultimately, care of these patients must occur outside of the acute hospital setting.  To achieve this, we need to educate the public and our physicians on the best delivery of end-of-life care and services.  When we counsel these patients, we need to be comfortable with the dialogue.  As physicians we must counter inflammatory rhetoric, such as the language of  “death panels,” to focus on meeting the expectations and desires of our patients in their time of need.

The second urgency for physician groups and healthcare reform is the transformation of primary care.  Primary care is the foundation of medicine, but it must evolve to remain vibrant.  Healthcare delivery systems around the world that have primary care as their backbone are shown to deliver higher quality medical care at the lowest cost.

The problem we face here in America, however, is the erosion of the primary care foundation.  A large portion of the primary-care workforce is now approaching retirement age, and current medical school graduates are choosing specialty practice, which is higher paying and offers greater life balance.  Residency graduates entering adult primary care have dwindled to less than half of the rate of 12 years ago, and this trend seems to be getting worse.

The erosion of the primary care workforce is further driven by the changes and demands of healthcare reform, including: greater access challenges for patients to primary-care services; additional paperwork (or EHR requirements) in primary-care offices; keeping up with medical advances; increasing demands to provide wellness services; management of chronic disease; and the need to address important social determinants of health.  These demands and the attendant increased workload should have us all concerned about the future of primary care.

So, how can we support primary care going forward?  What are our plans to replace our aging workforce and to reinvent ourselves for the future?  What innovations are needed to create success for all of us?

Ultimately, we need sustainable solutions.  We must work collectively to advance primary care.  We need primaries to be working at the “top of their licenses” and to engage their office support teams to help deliver outstanding care for patients. We must also provide the tools and technology that advance and streamline these changes and allow for greater focus on populations and gaps in care that lead to poor outcomes.

If we focus our energy and are successful in our efforts, what would primary care look like?  I envision success in the rejuvenation of primary care as a preferred career path for the majority of medical school graduates.  Our success would return joy and fulfillment to the practice of primary care medicine and remove the scut work from physicians’ desks.  It would also rectify and right-size compensation for primary-care services, recognizing and rewarding the real value of a strong healthcare delivery system with its foundation in primary care.

The California Association of Physician Groups will be undertaking many initiatives to address the advancement of primary care over the next few.  I hope that other physician groups and associations across our nation will join us in this effort.

The Top 5 Things Medical Groups Can Do to Prepare for System Reform

By Robert Nesse, MD, chief executive officer, Mayo Clinic Health System

In my previous writing for this Accountable Care column, I stated that to embrace our current healthcare challenges and move toward solutions, we must address these three questions:

  • What can we do to solve the problems of health care in America?
  • What are fundamental attributes that medical groups must have to succeed in the future?
  • Why should we do it now?

You can read the answer to that first question here.  In this column, let me discuss question number 2:  What are fundamental attributes that medical groups must have to succeed in the future?

While there are many requirements, I suggest that medical groups concentrate on these five areas to start:

    • A network of providers
    • Aligned purpose among those providers
    • Coordinated care systems
    • Aligned financial model
    • Practice analytics

In the old model, we could pick and choose what we wanted to focus on in our business. All too often this was done by taking a close look at payment for specific services, and then tailoring the business toward the most profitable ones. In our new world, the usual profit centers will become cost centers counted against payment for outcomes and the total cost of an episode of care. Your organization will need to develop a network that provides continuity for populations of patients.  Then that network needs to be aligned-culturally and financially– around the shared purpose of providing quality outcomes and cost efficiencies for populations of patients (also known as the Triple Aim). The majority of providers in this country work in groups of less than 10 physicians. Those small groups will face significant challenges as they try to successfully achieve these goals, so it is anticipated that smaller groups will continue to merge with or align with larger groups to achieve the desired results.

Once you have your network, you need to coordinate the care. Care coordination reduces waste and rework—a benefit in itself.  However, just as importantly, good care coordination embeds patients in a system that meets their needs.  They do not have to act as independent agents churning through resources as they bounce from provider to provider getting each of their body parts evaluated.

Unfortunately, all of this will just be a hobby if we don’t align the financial model with our best practices and our network. We must advocate for our accountable care model and drive the system to support it.  A good number of people are making a lot of money from our current dysfunctional system. Wherever possible, we should engage with payers and others to change rather than continue a one-sided vendor relationship with mysterious justifications for cost and payment increases and murky data.

This brings me to the last requirement and perhaps the most important:  practice analytics.  If you don’t know what your physicians and group are doing and are not able to track your performance, your future will never be in your control. You will be victimized by new payer contracts and pilloried by public displays of your performance data.  There are new technological systems out there that will support your transformation, but embracing practice analytics must be an urgent priority for your group. In our new world, clinical knowledge and data sharing not only supports our patients’ medical interests and needs, it supports our future viability as healthcare providers.

Working on developing these five attributes is, in my view, the best approach that physician groups can take now to prepare for the future.  Each of these will take time, but each is attainable and will contribute greatly to the success of the accountable care model.

In the next “What the Experts Say” column, Dr. Nesse will address the third question: Why should the healthcare industry tackle delivery system reform now?

A “Wicked Problem”: Healthcare System Reform and Change

By Robert Nesse, MD, chief executive officer, Mayo Clinic Health System

In light of the Supreme Court review of the Affordable Care Act and the political brouhaha that surrounds it, I know that many providers of health care have mixed feelings about the future of our industry. Let me share with you my cautious optimism as we work to design and then implement the new system of health care in America.

First, we must remember that we are already well into change and every healthcare organization in America must adapt and deal with our current reality. We must accept these incontrovertible facts:

  • The number of people who require care and the percentage of our patients with      chronic comorbid disease will increase, increasing the demands on our systems.
  • The government does not want to or even have the money to cover the costs of our current system, so we should expect that reimbursement for our services will decrease.
  • New payment systems will hold us accountable for the quality and safety of our care, and we will be at risk for our costs and outcomes.
  • By 2020, greater than 66% of the American public will get their health care coverage from a government-sponsored program. In 2025, the Advisory Board estimates the total will rise to 70%.

How do these facts make you feel?  I suspect that for most, optimism (even cautious optimism) is not the feeling.  Some of our colleagues are stuck in pessimism because they are in love with the problem. They painstakingly examine each facet of the problem and continue to bemoan our current state.

I believe that the healthcare industry is spending too much time trying to defend our past successes and preserving old systems.  It is time to move on.  We need to change. We need to understand the issues and accept the truth; discover and design our response; and move on.

And as we move on, we must address these three questions:

  • What can we do to solve the problems of health care in America?
  • What are fundamental attributes that medical groups must have to succeed in the future?
  • Why should we do it now?

I will address the first question in this column today:   What can we do to solve the problems of healthcare delivery in America?

The answer:  We won’t solve the problem.

Reform and change of the American healthcare system carry all of the attributes of a “wicked problem. ” “Wicked problems” are a common occurrence in other industries. The term originated in the software industry, which faces a wicked problem almost every time they release a new product. No software product is perfect, so when is it good enough to release to the public?  Success varies.  Think Windows Vista vs. Windows XP or Windows 7.

Wicked problems have the following characteristics:

Different stakeholders describe the problem differently depending on what aspect of the problem they deal with. Consider the views of healthcare costs. Providers think of patient compliance, preventive services and cost shifting. Payers think of excess utilization, provider strongholds, and waste.  The government apparently thinks we haven’t got enough regulations, and the patients think we are all at fault for the entire mess!

Changes that address one aspect of a wicked problem will influence other aspects of the problem.  Here are a couple of examples. If we are able to change the sustainable growth formula and implement new payment models,  we may finally get an opportunity to reward high-value care. However, if we increase support for primary care, specialty-care reimbursement will likely decrease. If we increase eligibility for low income populations and they join Medicaid we will decrease the uninsured in America. This is laudable but the cost of the program will increase for both the federal and state government

Wicked problems have no stopping rule. This basically says that you can’t “solve” a wicked problem. This is really hard for clinicians to grasp. In our  clinical practice all our patient problems have a stopping rule. They recover and go home. They transfer to another system, or they die. Healthcare system challenges are not going anywhere. We have discussed the many problems of health care for all of my 31 years in practice, and we will be doing it for the next 310 years.

To address the wicked problem of new health care models what we need to do is choose to work on one aspect of the entire problem that seems to have the best potential for improvement.  Fix that.  Review the result and see if other opportunities emerge based on your previous effort. Remember that changing one aspect of a wicked problem can impact other areas of the problem.

For the next few years, my choice for that one aspect to work on is to become competent in accountable care delivered through integrated physician group practice, and seek to be competitively relevant in a system that will reward outcomes and total cost of care. This, I believe, is our best first step forward.

This commentary was first presented as part of the opening remarks delivered by Dr. Nesse recently at the annual Amerian Medical Group Association conference held in San Diego, California. In the next “What the Experts Say” column, Dr. Nesse will address the second question: What are the fundamentals that physician groups must have to be ready for the future?

American Health Care Without Accountability

By Francis J. Crosson, MD, chair of the Council of Accountable Physician Practices
Senior fellow at the Kaiser Institute of Health Policy

The accountable care organization (ACO) was conceived as a model for improved care delivery that would provide value to the American health care system by
improving quality and controlling cost.  The model is being considered and piloted both for Medicare and for non-Medicare commercial health care services. However, ACOs –and specifically, the Medicare Shared Savings Program—have come under criticism from providers, health plans, hospitals, regulators, and policymakers alike.

Much of the criticism is valid (in fact, we will look at some of the specific criticism in future columns on this website).  And many of the concerns are being addressed by CMS and others.  However, it is my opinion that none of the expressed concerns should prevent the evolution of the ACO model, because, frankly, what’s the alternative?  What happens next if the accountable care organization idea fails?

Let’s think about it:  Looking  past issues of ACO structure and payment design,  and even to trying to ignore current political disagreements  about the Affordable Care Act, if ACOs prove their value in improving quality and moderating cost increases, then the future for American health care will look good.  Improving the health of a population, the experience of care by the people in this population, and the cost per capita of providing care for this population will be feasible.

But if ACOs fail and are not allowed the chance to prove their value, then we are looking at a bleak future:  public and private payers may be forced into across-the-board reductions  in payment rates to providers (similar to the “default” position proposed for the new  bipartisan congressional debt reduction committee), because there will be no other obvious course  to pursue in the effort to bend America’s health care cost curve. If that happens, we may see consequent reductions in quality and access.  In an attempt to make up for lower payment rates, providers will likely continue to increase the volume of services and will not be motivated to take accountability for population health and costs.

The nation will lose a lot if we do not seize this moment and support the evolution of ACOs, payment for value, and provider accountability for the cost and quality of care for a population of patients.  Rather than succumb to self-interest and fear, and resist change, we need to stand firm in our belief that it is in our common interest to see that ACOs succeed and can make good on its promise. A high value, effective, and efficient health care system for our country will benefit us all.