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CAPP to Host Better Together Health 2017 in Washington, DC, featuring Biden Cancer Initiative’s Danielle Carnival

On May 24, 2017, the Council of Accountable Physician Practices (CAPP) will host its third annual Better Together Health event, in partnership with the American Cancer Society (ACS) at The Center for Total Health in Washington, DC. Titled “All Systems Go! Closing the Gaps in Cancer Care,” the event will focus on how coverage and accountable healthcare systems can improve survival and reduce morbidity for people living with complex conditions like cancer.

Better Together Health 2017 will showcase stories of medical excellence and patient-centered care delivered by CAPP’s organized systems and medical groups, as well as an exciting policy keynote and panel discussion featuring these national physician leaders, policymakers and patient voices:

Host: Robert Pearl, MD, Chair, Council of Accountable Physician Practices

Moderator: Jayne O’Donnell, Healthcare policy reporter, USA TODAY; co-founder, Urban Health Media Project.

Featured speakers:
Richard Wender, MD, Chief Cancer Control Officer, American Cancer Society
Danielle Carnival, PhD, Deputy Director, The Biden Foundation


    • Alan Balch, PhD, CEO, Patient Advocate Foundation
    • John Bulger, DO, Chief Medical Officer for Population Health, Geisinger Health System
    • John Fleming, MD, Office of the National Coordinator, Deputy Assistant Secretary for Health Technology Reform, U.S. Health and Human Services
    • Michael Kanter, MD, Medical Director of Quality and Clinical Analysis, Southern California Permanente Medical Group
    • Laura Seeff, MD, Director of the Office of Health Systems Collaboration, CDC

Find information and registration for the live event here. To attend via live webcast (1-3:30 pm, ET), register here.

Study Misses the Mark in Suggesting Physician Employment Has No Effect on Hospital Quality Improvement

By Ira S. Nash, MD, FACC, FAHA, FACP, Senior Vice President, Northwell Health

As our country struggles to move our healthcare system toward the Triple Aim of lower costs, higher quality and a better patient experience, it is important to remember that physicians play an integral role in this transition.

Improving quality at every stage of the care continuum requires the collaboration and engagement of physicians. That is why a study published in January in the Annals of Internal Medicine needs to be more closely analyzed. In “Changes in Hospital–Physician Affiliations in U.S. Hospitals and Their Effect on Quality of Care,” the authors conclude that physician employment does not improve hospital care. While this conclusion may be technically correct, it does not have the broad policy implications that the authors suggest.

The definitions used in the study for physicians with an “employment affiliation” are so broad, they almost become meaningless. For instance, a hospital with a small number of employed physicians in a single clinical area such as radiology or emergency medicine was categorized as engaging in physician employment. This very low threshold on the definition of “employed physician” demonstrates a lack of understanding of HOW quality improvement is actually achieved.

It makes little sense to lump a hospital like that with one with a fully employed medical staff who are closely aligned with institutional initiatives around quality improvement.

From the Council of Accountable Physician Practices’ (CAPP’s) perspective, “employment” frames the issue in too narrow a fashion. It is the organization of physicians that is key to providing high-quality care. Specifically, our members have found that an integrated, physician-led care coordinated medical group does indeed equate to higher quality. Nothing in this paper speaks to what CAPP is putting forward as the model for what high-quality healthcare could be.

If the study authors had defined employment in a different way, or provided a measure of the extent of physician employment and organization, the results may well have been different. As CAPP continues to advocate for the longitudinal care of populations, organizing MDs into integrated physician-led medical groups will continue to be a point of advocacy for us. The issue of technical employment is secondary to how physicians are organized in clinical practice. Using such a broad brush to conclude that the employment of MDs isn’t driving the quality agenda is a disservice to us all.

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.


Senator Isakson, CMS, and CAPP at Better Together Health 2016


All agree that a more coordinated value-based healthcare system is required to achieve accountable care.

By Laura Fegraus, Executive Director, Council of Accountable Physician Practices

The leaders of the Council of Accountable Physician Practice (CAPP) have long been committed to accountable, physician-led, patient-centered care. It is our belief that neither the quality of American health care nor its cost can be improved without real systemic change. Such change must be completely focused on the needs of both physicians and patients to be sustainable.

Our Better Together Health events, coupled with our annual physician and consumer survey, are designed to highlight the concerns and experiences of both stakeholders as the American health system continues its journey toward accountable care.

Our most recent Better Together Health event was held on June 15 at the Kaiser Permanente Center for Total Health in Washington, DC. Once again, we announced the results of our annual CAPP-sponsored Nielsen Strategic Health Perspectives study. Designed to assess progress in achieving coordinated care, the study surveyed 30,007 U.S. consumers and 626 physicians to understand their experiences related to the hallmarks of accountable care: care team coordination, prevention, 24/7 access, evidence-based medicine, and use of robust information technology.

Mixed results

The survey results were both promising and concerning: The use of care teams and care coordination is improving. However, it appears that technology and 24/7 access to care is still not widely available. In addition, preventive primary care is critically lacking.

“This survey is evidence of the failure of American health care to provide coordinated, technologically enabled, high-quality care to the majority of people,” said Robert Pearl, MD, chairman and CEO of The Permanente Medical Group and the Mid-Atlantic Permanente Medical Group and chairman of CAPP. “While it is encouraging that the use of care teams and care coordination seem to be increasing, access and the effective use of technology still need improvement, and tactics that help to prevent illness are still woefully ineffective.”

Following the release of the survey results, policy makers, patient advocates, and medical group and health system leaders convened to discuss meaningful healthcare delivery reform at “Better Together Health 2016: Patient Expectations and the Accountability Gap.” The event was sponsored by CAPP and the Bipartisan Policy Center. The town-hall format of the meeting featured patient videos demonstrating the benefit of integrated care delivery at Southern California Permanente Medical Group and at Billings Clinic, both CAPP member groups.

Sen. John Hardy Isakson (R-GA) speaking at the Better Together Health 2016 event recently in Washington, DC.
Sen. John Hardy Isakson (R-GA) speaking at the Better Together Health 2016 event recently in Washington, DC.


Sen. John Hardy Isakson (R-GA), co-chair of the Senate Finance Committee’s Chronic Care Solutions working group, served as a featured speaker. Tim Gronniger, deputy chief of staff and director of delivery system reform at the Centers for Medicare and Medicaid Services (CMS) also spoke. Both shared strong support for moving our healthcare system toward a more coordinated, value-based healthcare system. The panel discussion was moderated by Ceci Connolly, CEO of the Alliance of Community Health Plans.

Patient stories

The first patient story featured Jenny, a Billings, MT high school teacher who underwent bariatric surgery after a lifelong battle with obesity. Dr. Karen Cabell, director of quality and patient safety at the Billings Clinic, explained how system-ness and integrated, patient-centered care supported Jenny to reach a positive outcome.

“To us, system-ness means having an integrated medical practice where it is the expectation that all of the physicians, nurses and other members of the team coordinate together and communicate with each other on behalf of the patient,” said Dr. Cabell. “The patient is part of that multi-disciplinary team.”

The event’s second story featured Jesus, a food services professional and father of three, who developed severe diabetes resulting from poor nutrition and lack of exercise. Dr. Marc Klau discussed how the Southern California Permanente Medical Group’s Diabetes Complete Care program helped Jesus overcome his chronic condition.

“It’s the best of all worlds,” said Dr. Klau. “You have a team, you activate the patient with resources and then behind it you have this high tech technology world that’s constantly monitoring to make sure Jesus gets everything he should be and if he doesn’t, the system activates.”

By bringing together the nation’s leading and most respected healthcare organizations, patient advocates, and policy experts, CAPP’s Better Together Health series seeks to amplify and accelerate the momentum on changing the health care delivery system so that it is patient-centered, integrated, and physician-led. We look forward to continuing this meaningful and relevant conversation at future events, and monitoring the nation’s progress towards true accountability through the two most important voices – the patient and the physician.

The entire webcast of Better Together Health 2016 will be available through mid-summer here.

Why Do Docs Struggle to Coordinate Care? Blame the Lack of System Support

By Norman Chenven, M.D., CEO, Austin Regional Clinic
Vice-chair, Council of Accountable Physician Practices

A recent 10-nation Commonwealth Fund study of primary care physicians (PCPs) published in Health Affairs revealed that physicians surveyed struggled with care coordination, and that the U.S. has a higher percentage (about 25 percent) of primary care doctors who report that they are not prepared to care for patients with multiple chronic conditions. Additionally, 84 percent of American PCPs felt that they are not able to manage patients with severe mental illness or substance abuse.  As the CEO of a physician-led multispecialty medical group that is committed to and values good care coordination, I believe that the reasons that PCPs responded in this manner is because the majority of American physicians still work in organizations that do not provide them with adequate support.

Even though integrated systems and large multispecialty medical groups are increasingly investing in the infrastructure required to better coordinate care around patients with multiple and complex conditions, barriers created by our fragmented system of disconnected healthcare providers incentivized by a fee-for-service payment structure continue to hinder progress. The Affordable Care Act and the Centers for Medicare &
Medicaid Services have been implementing incremental changes (Accountable Care Organizations, Patient-Centered Medical Homes, Bundled Payments for Care Improvements, etc.) under the banner of value-based payment programs, which in theory could spur increased coordination. However, the underlying fee-for-service payment system used in many of these models does not adequately support or reward providers to invest in the technology and staffing necessary to manage the care of our frailest and sickest.

Evolving technologies could be used to enhance care coordination but the lack of incentives and rewards to do so is a problem. A recent study conducted by Nielsen Strategic Health Perspectives revealed that American physicians still do not utilize readily available technology—such as video, email or text messaging—to communicate with their patients and more than half are still skeptical of the value of telemedicine. We all intuitively understand that educational, social and financial issues are significant factors in influencing healthcare outcomes for patients for complex problems, yet our healthcare system does not encourage or support strong communication using existing technologies or integration with our equally fragmented social service system.

While those of us in the healthcare and social service sectors struggle to manage and coordinate the way we deliver care, tech innovators and venture capitalists are (not surprisingly) developing ways for consumers to get care outside of traditional channels (i.e., stand-alone urgent care centers, episodic online virtual visits, do-it-yourself lab testing, etc.).  While innovation is good, when it comes to health care, good outcomes for the larger system (and for patients with complex problems, in particular) are unlikely to be enhanced by further fragmentation of an already fragmented delivery system and payment mechanism.  Caring for patients with complex health and social needs requires more coordination and communication with providers who know the patient well.

The article further states that America’s efforts to manage the care of high-needs patients are “nascent.”  That may be true for doctors and facilities just starting their accountable care and medical home journeys. But, the members of the Council of Accountable Physician Practices and the American Medical Group Association have been delivering coordinated, accountable care for years.  Many of our physician-led, integrated, and technologically enabled organizations were the first to step forward to test new models of care and payment under the Affordable Care Act, yet improving care delivery under these new arrangements remains a complex endeavor even for us.

The U.S. is lagging in its ability to manage complex care for many reasons other than purely medical/technical ones, for we already have the training, medical technology and facilities that should support good outcomes. The challenge lies elsewhere in a multitude of legal, regulatory, financial and market barriers.


The Future Of Health Care: A Survival Guide

By Robert Pearl, MD, CEO, The Permanente Medical Group
Chair, Council of Accountable Physician Practices

I’m often asked what the future holds for health care. I don’t have a crystal ball, but I know two things are certain.

In the future, health care providers must champion two of Michael Treacy and Fred Wiersema’s value disciplines to survive.

First, the practice of medicine is – and always will be – a great profession. It’s an honor to improve and save lives. Second, doctors and hospitals will be forced to change their practices before they’re ready. For patients, this new reality will be positive. For providers, it is likely to be uncomfortable.

In the book “The Discipline of Market Leaders,” authors Michael Treacy and Fred Wiersema note the companies that attain and sustain market leadership excel in 1 of 3 value disciplines:

1. Customer intimacy (service/relationships)
2. Product leadership (innovation/R&D)
3. Operational excellence (efficiency/effectiveness)

The authors emphasize that the best organizations make a choice of one discipline and, with rare exception, can’t excel in two. Health care will need to be that rare exception in the future. One discipline won’t be enough for providers. And once the transformation to two is complete, the result for patients will be better medical care at lower prices.

Today’s provider landscape

Although overlap and exceptions exists, most patients receive care in 1 of 3 settings:

1. Community-based providers (local doctors and hospitals)
2. Academic medical centers (university clinics and hospitals)
3. Integrated delivery systems (Mayo Clinic, Virginia Mason, Kaiser Permanente, etc.)

The typical doctor in the community works alone or in a small group. Economies of scale and research opportunities aren’t available, but the structure is conducive to the value discipline of “customer intimacy.” Patients are loyal to their local doctor. The office staff knows every patient by name and some doctors continue to make house calls. Insurance companies have little choice but to pay the higher prices community providers charge.

Academic medical centers, by contrast, have relied on “product leadership” above all else. The buildings are huge and residents rotate clinical services every month. But patients come in search of the latest medical technologies and newest machines. Sometimes these technologies prove effective, but they often cost more without improving outcomes. Insurance companies have few alternatives but to include these higher priced venues as a care option for patients.

Integrated delivery systems have taken a different path, focusing mainly on “operational excellence.” They typically include many salaried physicians from a variety of specialties. They practice together in large, centralized medical buildings. The combination of greater size and fewer locations succeeds in lowering their costs. However, their structure can make service feel less personalized.

The provider landscape is changing quickly

Everything changes. Today, doctors and hospitals face pressure from every direction.

Health insurers are narrowing networks – offering patients a smaller pool of doctors and hospitals in exchange for lower premiums. Customer intimacy or product leadership alone won’t be enough to guarantee doctor or hospital inclusion. With the introduction of health insurance exchanges and price transparency, the shift to lower cost providers will accelerate.

Payment models are evolving, as well. The traditional model was designed as a fee-for-service system that rewarded volume, not outcomes. Organizations like the Pacific Business Group on Health (PBGH) are rapidly transforming that payment model. With PBGH, rather than generating a bill for hundreds of individual pieces, a single price is paid – be it for a total joint replacement or the totality of care given to a patient with diabetes. Those hospitals and physicians that charge more are excluded.

Meanwhile, health care providers are increasingly being measured by patient satisfaction.

Physician-review sites like ZocDocHealthgrades and RateMDs offer patients detailed information to assist them in their choice of doctors. More and more insurance companies are paying based on patient satisfaction.

The prescription for survival

In this new reality, excellence in one value discipline won’t be enough.

Community doctors and hospitals will need to become more efficient. They will need to create Accountable Care Organizations or find other ways to develop economies of scale. Simultaneously, they will need to focus on helping their sickest patients manage health more effectively. Take, for instance, the Camden Coalition of Healthcare Providers, which provides home visits and house calls to the community’s “worst of the worst” medical cases, cutting their $1.2 million in hospital bills by more than half. If community providers don’t figure out how to lower costs, they will be excluded from these new narrow networks and risk being driven out of business altogether. Most doctors who chose community practice did so, in part, for the autonomy. It is unclear how many will be willing to modify their practice styles for the greater good.

Academic medical centers will need to become more business savvy and achieve operational excellence. Already, we are seeing an uptick in doctors pursuing MBAs, but improvements in performance will demand the commitment of all. Many physicians who chose academia for their careers may refuse to divert time and energy away from research and teaching to champion a second value discipline. However, these doctors must learn to balance their academic pursuits with business interests, such as: learning to value supply chain management, improving operating room turnover and increasing collaboration among clinical services for hospitalized patients. Until they do, the care they provide will retain excess costs.

Integrated delivery systems will need to emphasize customer intimacy – as much as they do operational excellence and quality outcomes – to survive. As narrow networks lower prices, these integrated delivery systems risk losing membership and being stuck with high fixed costs. Continued success will depend on high patient satisfaction scores. But will these salaried physicians realize it in time?

Necessity often drives innovation. As health care becomes more competitive, patients will have more choices for improved medical care at lower prices. But while patients will welcome this new reality, doctors and hospitals will find embracing a second value discipline uncomfortable. As economic and competitive pressures increase in the future, providers of medical care will be required to go beyond their comfort zone. Those that fail to do so will be left behind.

Reprinted with permission from Forbes.com.

Dr. Gene Lindsey: Atrius Health’s No Loss Pioneer ACO Results

By Eugene Lindsey, MD, president and CEO, Atrius Health and Harvard Vanguard Medical Associates

Those of you who follow the journey of accountable care probably heard that Atrius Health was one of two of the Centers for Medicare and Medicaid Services’ Pioneer Accountable Care Organizations (ACOs) for 2012 that would incur a shared loss.  In full, 14 ACOs showed a loss, but 12 did not share in the loss because of the financial models they chose. There were nine Pioneers who chose to move to the Medicare Shared Savings Program– a similar program with less risk and less potential upside–or to leave the program.

We are very pleased to be able to share that, upon recalculation of the numbers at the end of our 12-month performance year, Atrius Health does not have a shared loss in the first performance year of our Pioneer ACO model. The financial plan that that we selected with Centers for Medicare and Medicaid Services (CMS) for our first 12-month performance period ended on March 2013, and our final numbers show that our loss was .98%, not the previously reported 2.1%. This loss is small enough that it is considered within the statistical range of error.  CMS publicly reported findings before our full performance year number had been finalized.

This news underscores what those of us working in this space already know:  that we must give any accountable care venture time before trying to assess the overall effectiveness of the model.  Some of the articles that came out upon the release of CMS’s initial findings implied that the Pioneer ACO Model is not accomplishing its means. (Some of those same voices are the ones that have been continuously attacking the Affordable Care Act since the moment it was conceptualized.)  But the reality is far more positive:  In its first year, the Pioneer model produced a savings of nearly $33 million to the Medicare Trust Funds and demonstrated overall quality performance better than the national average for all 15 clinical quality measures for which comparable data are available. As strong supporters of the ACO model of care, it is important that the program in total be successful, so it is good news that the program was net positive in its first year.

I feel good about our performance in the Pioneer program this year. To understand the initial confusion on the findings, it might help to know something about the mechanics of our Pioneer ACO financial result.  They are complicated because the mechanics are built on continuous improvement.

First, your progress is measured against a budget that starts with the actual experience of weighted total Medicare expenses for the prior three years for the patients for whom you provided much of the care during those years. The patients have been attributed to your ACO because your medical practices provided most of their primary care.

That is the easy part. Then the formula adds in growth based largely on a comparison to a national matched population to arrive at your budget.  The final calculation of actual shared expense and loss includes factors that affect the amount of risk in your particular financial option, such as the percentage of sharing with Medicare, a risk cap, and a noise level above or below which nothing is shared. Because of the timing issues with CMS delivering data in the first quarter this past year, we were allowed a one-time option to shift our first year to the 12 months ending March 31, 2013, for settlement purposes. The calculation will become even more complicated starting next year when the 33 quality measures that attempt to capture patient experience, care coordination and patient safety, preventative health, and healthcare for the at-risk population (largely related to diabetes and CAD) are factored into the sharing percentage.  For this first year, 100% quality was achieved by reporting on all of the measures, which sounds simple, but actually involved a tremendous amount of work to establish the right fields in our EPIC system for counting and a lot of manual chart review in some cases.

It is our opinion that even “losses” at this stage constitute an investment in the future. We believe we have to make these changes to meet the challenges ahead of us because we know that federal reimbursement will continue to fall in the future. Even tougher will be the relatively flat reimbursement from our commercial insurers.  Our Board was very positive in its support on the front end. We prudently reserved in 2012 for a four million dollar “loss” because we knew that it would be hard to beat a budget of less than $900 a month for each Pioneer patient. We started the year constructing the programs that by mid-year were making measurable improvements. We are now running at rates that are impressive and that suggest that by next year there is the possibility that we will have improved care to the point that we are positive financially as well as in quality.

Not to negate our first year quality measure:  as reported to us by the CMS Innovation Center, the quality of our care was “spectacular.” As measured against the other Pioneers (whose combined performance far exceeds the national average), we had five metrics that were among the highest and 23 metrics that were greatly above the mean

In short, as I remind our staff and physicians, we are in a five-year process to improve care–not a one-year contest to see how much money we can make.  I hope that those of you participating in accountable care ventures pay attention to this message and work to stay the course.

The Importance of Healthcare Hand-offs

By Donald H. Crane, president and CEO, California Association of Physician Groups

The passage and implementation of the Affordable Care Act has made health care a topic of everyday conversations around our dinner and conference tables. However, most of the discussion is political and not about whether our healthcare system works for its intended audience–patients.

An important story lost in the clutter of healthcare politics is the patient’s experience when he or she leaves the hospital and returns home. For the millions of Americans who are too often readmitted to the hospital, the story does not have a happy ending. However, with a common-sense change in the delivery of health care, we can improve these health stories and save money in the process. What we need to do is better coordinate the hand-offs that go on all across our healthcare system. And we know this because, for millions, these hand-offs are being done successfully.

So what is the problem? How and where does the fumble happen? After a patient is admitted to the hospital with a serious condition, he or she is treated by more than a dozen physicians, nurses and other providers, many of whom do not seem to speak to each other as they come in and out of the room asking the same questions over and over. The patient is then sent home without clear instructions and maybe not even feeling better. The patient is confused and alone–left to navigate a complex maze of choices on his or her own. This fumble is our healthcare system’s dirty little secret; it is the way the healthcare system works for too many Americans.

But, millions of patients in pockets across the country are telling a dramatically different story. A system exists that eases them through the transition of hospital to home. There is no fumble with these patients because care coordination ensures a smooth handoff.

Imagine a patient who is sent home from the hospital in a coordinated model. Before the patient even leaves the hospital, a care team springs into action. At an appointment with the care team, the patient and any family caregivers are given written, clear instructions on whom to call if they have questions or if the unexpected arises before their follow-up visit. The care team calls the patient the day before the appointment to reconfirm.

At the follow-up visit, the team works to ensure the patient’s total care needs are addressed. A pharmacist reviews all medications the patient is taking, including herbal supplements, over-the-counter medication and medication prescribed before the patient was in the hospital. A social worker and case manager address coordination of various health insurance coverage plans, as well as emotional, social and other issues that may impact a patient’s recovery. A physician reviews the hospital stay and the patient’s medical history and provides personalized education for the patient. The entire physician-led team generates a summary of what they have done and sends one complete note to the patient’s primary care physician.

To be sure, this doesn’t happen every time a patient goes to the hospital across the United States. But, for the more than 18 million Californians our physicians treat, care coordination is no secret.

So how do we create these smooth handoffs all across America? First, we have to get rid of fee-for-service payment as a dominant payment model. In fee-for-service, the physician receives a payment for each procedure done or test ordered. This system of payment simply encourages more tests and more procedures, without an eye on the most effective, high quality care for a given patient. This model must go.

Second, we have to pay for the type of care we want. If we want team-based, forward-thinking, prevention-focused health care, we have to pay doctors to work in teams, think ahead and keep their patients healthy. Instead of paying each individual physician for each medical procedure performed, Medicare and other payers should make defined payments to physician organizations based on quality, taking into account who they treat and how sick their patients are — the higher the quality, the higher the pay.

Finally, we have to look for and encourage what works in health care. A number of physician payment experiments are currently under way, including Medicare and commercial accountable care organizations (ACOs) and patient-centered medical homes. Testing these models to determine what works is incredibly important. In addition, attention must be paid to Medicare Advantage, where care coordination is currently under way and producing better outcomes for patients.

Coordinated care is no secret for millions of patients. But we must continue to work to ensure that care coordination is a reality across the United States. We need to listen to the patient’s stories, work to ensure that the dirty little secret of health care is no more and ensure the smooth hand-off from hospital to home.

Donald H. Crane is president and CEO of California Association of Physician Groups, which represents groups in 20 states with more than 60,000 members providing care to more than 18 million Americans.

Clinical Integration: Lessons from Dean Clinic

By Craig Samitt, MD, president and CEO, Dean Clinic

Dean Clinic has been described as a present-day Accountable Care Organization (ACO) and a model of clinical integration. We’ve also been called a “structurally integrated organization,” an “economically integrated organization,” and even a “technologically integrated organization.” We are admittedly all of these things because we chose to pursue “better care at a lower cost”—the value path—long before the ACA was passed.  But there are even more important types of integration than these to succeed as a high-performing Accountable Care Organization, as we have learned:

Lesson 1: Shared Accountability Is Far More Important than Structural Integration

One of the common misconceptions about an organization’s ability to succeed in accountable care is the belief that vertical and structural integration is critical to achieve synergy. The Dean/SSM Healthcare of Wisconsin partnership illustrates that this is not necessarily the case. These two separate corporations have worked shoulder-to-shoulder for over nearly 100 years with a common purpose and shared vision for excellence and value-based care—a virtually-integrated system from a structural standpoint. While we have, in recent years, become more structurally integrated via joint-ventures, these forms of partnership have not nearly been as important as the alignment of our value-based cultures. We have a common vision toward value, even at a time when financial incentives encouraged us to pursue a volume-based path. Together, we chose not to divide a fixed and shrinking revenue pie between us and instead have found ways to share gains, risks, higher-margin services, and investments to improve our performance.

There are three accelerating and competing structural integration verticals emerging today, each aimed at dominating markets: health plans that are seeking to acquire delivery systems, hospitals that are moving to employ doctors, and physicians that are embracing full-risk and vending downstream services to hospitals and others. In our view, the ability to become a high-performing accountable care organization is less about which of these models is preferred or even where their journey began, but rather more about achieving a state that represents a “team of equals.” In our organization, each effort to improve patient satisfaction scores, raise ambulatory or core hospital quality measures, or improve efficiency involved the attention and expertise of physicians, hospitals and health plans in partnership. In short, it’s the alignment over a common set of goals, the singular focus on a common set of metrics, and the power of shared accountability that is far more important than structural integration in driving our system’s performance.

Lesson 2: Aligned Incentives Are Far More Important than Economic Integration

What motivated Dean’s journey down the value-based path was our recognition at one point in our history that we had a “foot on a dock” (volume-based revenues via fee-for-service payers) and a “foot in a canoe” (capitated payments via our owned health plan)—and the recognition that the dock was burning and the canoe was leaking. Ultimately, we chose to pursue the value path and deliver better care at a lower cost in earnest for all our patients, regardless of payer.  Many believe that we’ve had the freedom to pursue value because we’ve owned our own health plan (whereas others are starting their journey standing on a burning dock with no canoe in sight). While there is some truth to that premise, we would argue that Dean’s transformation to value had more to do with the fact that the bearing of risk catalyzed a paradigm shift in our approach to care and a transformation of our operations. If it were not for our economic integration, we would not have had the toolkit of processes, technologies, strategies, and innovations to maximize value-based care that we have today.  However, at the end of the day, it’s the toolkit along with aligned incentives (regardless of payer) that is far more important than the economic integration.

Fast-forward to present day and we find that we have stepped off the burning dock and have patched the canoe. While our health plan is strong and growing, we have pursued gain-sharing and risk-sharing payment methodologies with most of our other payers, including Medicare via the Shared Savings Program (MSSP). In our view, the beauty of the Medicare MSSP, Pioneer, and Bundled Payments programs is that they offer health systems the opportunity to step into their own canoes.  Ultimately, our desired end-state is to not only be clinically accountable, but to be economically accountable for all our patients, and to have most, if not all, of our incentives aligned toward value over volume.  This alignment of incentives is not only important in the payer-provider relationship, but is even more important between a provider organization and its doctors. We’ve learned quite clearly that you can’t pay doctors for volume when your organization is paid for value.  ACOs must also learn how to re-design physician compensation models and align incentives from the very top to the very front line of our organizations.

Lesson 3: The Ability to Compile, Compare, Analyze, and Report Information Is as Important as Technological Integration

Along with shared accountability and alignment of incentives, two of the most crucial drivers of the transformation at Dean have been our willingness to embrace the use of technology and to use data effectively to drive decisions and motivate change. Implementation of an electronic health record is essential but not sufficient to become a high-performing health system. Likewise, meaningful use of EHRs is essential but not sufficient to be “accountable” in the future. We would argue that our greatest organizational success will only be achieved when we “optimally use” our technologies and integrate them into the very fabric of our care-delivery model. ACOs must make sure that we are using EHRs to their fullest potential to influence improvement in quality and maximize preventive screenings, service enhancements, patient adherence or cost reductions.

But even that will not be enough to be sufficiently high-performing in the world of accountable care.  From our vantage point, the ability to compile, compare, analyze, and report information is the most important component of the world of integrated health information technology and data. As Dean has evolved from a system of volume-based care to population-based care, we have vigilantly benchmarked our performance against other organizations, shared un-blinded comparative data with clinicians regarding service, quality and cost, and transparently reported data to our markets as a means of growing our practices and competing in the world of health insurance exchanges. We’ve also developed a comprehensive “big data” data-warehouse and analytics shop so that we can predicatively model clinical information, identify areas of quality/safety/cost concerns, and assess variations in practice patterns. While we struggle every day with the accuracy, transparency, format, and availability of data today, we’ve invested heavily in data creation, analysis, reporting and modeling at Dean because it is quite clear to us that data will be king in the world of value.

The original version of this article was published by Accountable Care News, December, 2012.

Good, Affordable Health Care for All: How Long Will It Take?

By Eric Larson, MD MPH, vice president for Research, Group Health
Executive Director, Group Health Research Institute

With the recent Supreme Court ruling on health reform, many at Group Health Research Institute (GHRI) felt relieved.  The decision to uphold most of the Affordable Care Act (ACA) should put our country on a straighter path toward improving access, affordability, and quality for all—imperatives in our Institute’s mission.

Still, we live with great uncertainty.  How will the ACA affect the business of health care?  What will the fall elections mean for health care policy?  What’s the future of research funding, given shaky economies here and abroad?  How will the federal budget impact jobs at GHRI and elsewhere?

Answers will emerge over time, but not knowing can be unsettling.  In times of hardship and uncertainty, it’s natural to wonder: How will this all turn out?

Taking the long view can help.  My friend Dr. Steven Schroeder of the University of California, San Francisco reminded me of this with his speech to the Society of General Internal Medicine (SGIM) in May.  He reflected on several recent assaults to scientific integrity, care for the disadvantaged and other values most doctors hold dear.  Despite grim evidence, he insisted, “Hope is still alive.”  He’s seen it in many places: Advances in public health; civil rights; treatment for AIDs; his medical students’ idealism.  To them, he quotes Dr. Martin Luther King: “I know you are asking today, ‘How long will it take?’  …Not long, because the arc of the moral universe is long, but it bends toward justice.”

So how long will it take to achieve our mission (and the mission of many in our industry) “to improve health and health care for all”?  You could say, “not long,” because improvement is incremental and we work at it every day.  Looking back at Group Health, we see the arc clearly: in 1947 our organization was established by labor unions, Grange farmers, and local activists “to serve the greatest number.”  During 1950s’ McCarthyism, Group Health won a legal battle with the King County Medical Society, over claims the Cooperative was un-American.  And through the 1960s, we overcame racism to integrate our medical staff.

Amidst challenges, Group Health has grown in numbers and influence.  With GHRI’s founding in 1983, it began to rigorously study its population’s health, sharing discoveries globally.  As this chart shows, the Institute’s work on prevention, cancer screening, vaccines, chronic illness care, primary care design, and more has been translated into better care for Group Health members and others nationwide.

Now, with the ACA upheld, our work and the work of many health care systems in this country who view themselves as learning institutions could not be more relevant.  A recent example: The University of Chicago’s study in the Journal of the American Medical Association (JAMA) last week linked the patient-centered medical home (PCMH) model to higher costs at 669 federally funded community health centers.  This is an important contrast to GHRI’s 2010 evaluation of Group Health’s PCMH pilot.  With colleagues, Dr. Rob Reid, Group Health’s associate medical director for research translation, found that Group Health recouped its PCMH investment through savings in emergency and hospital care.  In an invited JAMA editorial, Rob and I explained that practices in the University of Chicago study could not claim such savings because, unlike organizations like Group Health, their medical homes aren’t integrated with emergency and inpatient care.  And we stressed that primary care practices cannot achieve the promise of the PCMH—improved care, lower costs, and higher patient and provider satisfaction—without strong financial support.

Translating such knowledge into better care won’t come easy.  In his speech to SGIM, Steve Schroeder offered six suggestions for making a lasting difference in the dynamic times ahead:

  1. Work on things that are important to you.
  2. Be reliable.
  3. Model your values.
  4. Avoid the false dichotomy of having to choose between professional and personal satisfaction.
  5. Be resilient.
  6. And believe that the arc of history can be bent toward justice.

By following his advice, perhaps we can join the force that makes it so.