Population Health and ACOs: A Deep Dive Into Model Type and Results To Date

by Gregg A. Masters

As we continue our journey into population health and it’s relationship to and ACO Watch @ACOwatch @ACOalliancesynergies with all forms of innovation enabling the broad brush outcomes of the ‘triple aim’, better health outcomes, improved user experience and lower per capita costs, we shift our focus to the accountable care industry and ACOs in particular.

The month of August we’ll chat with executives from each of the following types of ACOs: physician led, hospital sponsored and health plan enabled.

On the first broadcast at 12 Noon Pacific/3PM Eastern we’ll provide an overview of the space and touch on the history and origins of ACOs, the motivations of the Affordable Care Act (ACA), then pivot to the pros and cons of the various models in the market and to the extent we can compare and contrast results, we’ll offer up data posted to the public domain.

Join Fred Goldstein @fsgoldstein and Gregg Masters @2healthguru for this exploration into an timely and relevant topic.

 

 

Announcing ‘FredTalk’ with Fred Goldstein

by Gregg A. Masters

In addition to our programming at ‘PopHealth Week‘ (@PopHealthWeek), we’re launching a new series tagged ‘FredTalk‘ with our co-founder Fred Goldstein, Founder & President of AccountableHealth, LLC (@fsgoldstein).

In this session Fred outlines a high level framework for ‘Population Health Management’:

Population Health and Primary Care Leadership

by Fred Goldstein and Gregg Masters

In July we focused on Primary Care and Population Health and we had quite the line up.  From some extremely well known experts to hard working physicians in the trenches ‘walking the talk’ of innovation via transformative primary care leadership for over a decade.phw_hinman

We started with Roy Hinman, MD of Island Doctors in St. Augustine Florida.  Island Doctors has been serving global risk Humana Medicare Advantage since 1998 and now manages approximately 18,000 patients! Roy focused on keeping it simple, building out a network of like minded partners, leveraging mid level practitioners at the ‘top of their license’ in the care team, aligning financial incentives, grasping and developing core competencies in clinical risk management and a hospital agnostic approach to prudent utilization of institutional healthcare resources.

We then moved to direct practice pioneer with the CEO and Founder of iorahealth (@iorahealth), Rushika Fernandopulle, MD (@rushika1).  Rushika decided to ‘rebuild primary care from the ground up’ and created a care team model in some respects similar to Roy’s that ‘dis-engages’ from  a volume based, fee-for-service compensation plan. Iorahealth has been experiencing strong growth in the traditional mrushika poseembership or retainer model direct practice milieu where there is no intermediary between the patient and the medical practice. Yet, continuing to innovate in non-traditional direct practice terms iora health as also engaged in the direct employer space via global contracts with Humana. Rushika believes that establishing a dis-intermediated and  thus ‘direct relationship’ with the patient via a coordinated care team is their ‘secret sauce’ and key market differentiator.

Week three’s guest was Jay Lee, MD (@FamilyDocWonk)of MemorialCare Medical Group (@MemoricalCareMG), a historically proactive physician organization based Jay Lee MD @FamilyDocWonk | HiMSS SoCal with Douglas Goldstein @eFuturistin Long Beach, California with a service area reaching into south Orange County established to provide advanced comprehensive, effective and efficient healthcare.  Jay’s primary role is as the Associate Medical Director of Practice Transformation at MemorialCare Medical Group and Director of Health Policy at the Long Beach Memorial Family Medicine Residency Program. He also serves as the President of the California Academy of Family Physicians (@cafp_familydocs). Jay brought some unique insights into physician acceptance of population paul_grundy headshothealth and training of residents, stating that changing the culture and aligning  both docs and payment incentives were mission critical to success in the transition from one-off episodic care to a population level world view.

The fourth week featured the “Grandfather” of the Patient Centered Medical Home, Paul Grundy, MD, MPH (@Paul_PCPCC & @IBMhealthcare), Global Director of Healthcare Transformation IBM, President PCPCC, Ambassador for Healthcare Denmark.  Paul discussed the history of the PCMH and stated that the original concept was based not on being the ‘primary care home’ for the patient per se, but the home for the data about the patient which would allow for better management of the patients condition.  In fact the original PCMH was the transplant surgeons who needed to be sure that they had all the data and could coordinate all of the patient’s healthcare needs.

So what did we learn?

Fee-for-service payments and its inescapable production oriented ‘do more, to earn more’ incentive basis is a hindrance to implementing population health, and perhaps contrary to emerging ‘conventional wisdom’ that tipping point may not be so close (the best intentions of Secretary Burwell et al at CMS).

Many experts say we are near a tipping point in the approach to medicine and population health, that as soon as we implement just a bit more value based payment methods, we will reach it.  Unfortunately and given the weight of historical inertia, they may be wrong (again?).

In our discussions, there was real and evidence based concern that to do population health requires getting completely away from FFS payments.  Rushika takes none, and Roy claimed to only have a handful of patients on this burning platform. They both stated that FFS payments were a problem and hindered behavior change, as well as not allowing for the justification of many population health approaches. Interestingly at MemorialCare Medical Group , Jay stated they still measure physician productivity using RVU’s; so any work that does not have a billing code (think pop health related activities) has ‘no measure or worth’ (my words).  The point that stuck out most for me is that if MemorialCare Medical Group has 60 to 70% capitated business, yet they still measure using FFS related codes, making it hard to justify population health services, when do we reach the tipping point?

Paul on the other hand felt that we would incrementally reach the inevitable pivot and felt that the recent CMS announcements regarding the more rapid shift to value based payments would be the impetus. Although he felt there were examples of successful capitated contracts he did bring up the fact that this type of payment can lead to an underutilization of appropriate services, while clearly FFS can lead to an over-utilization.

Bringing Joy into Practice

Both Rushika and Jay independently discussed the need to bring “joy” back into the physician experience, a common theme first posited by senior leadership at ACO management company Lumeris as ‘the triple aim, plus 1’ , where the plus 1 is ‘physician satisfaction’. They talked of the drudgery of having to practice in the current system driven by fee-for-service payments, and the well know productivity formula of 30+ patients a day with an average per patient visit in the 7- 8 minute range. Both felt that practices that introduced a patient centered model, focused on relationships and had global payments allowed doctors to practice in a manner that aligned better with why they had called them to medicine in the first place.

Keeping it Simple

Rushika and Roy discussed how they have very simple systems to manage patients, in fact Rushika felt that EMR’s which had been built upon the FFS model and the need to create a bill, were a hindrance and he did not use one. iora health had instead developed their system from scratch.  Roy too discussed how his practice focused on the ‘low hanging fruit’ and that by having no copays for office visits, seeing all walk-ins that day, managing cholesterol, weight and other simple things, they were able to drastically reduce hospitalizations and ER visits.  As Roy said and I’m paraphrasing, you don’t need 15 consultants and a big IT system to do this.

Paul stated that IBM had also gone to a no co-pay model for primary care visits for their employees and wanted to be sure their employees had a relationship with their PCP.

Utilizing your staff based upon their expertise

All of the guests had created systems or discussed having specific roles for each team member in particular to maximize the physician by having them focus on

The Role of Technology

While not all of the guests discussed technology, it was clear from Paul and his work both with providers and one of the strongest IT companies in the world that technology and in particular advanced data analytics combined with mobile will lead to a sea change in health and health care. Moving us to the realm of personalized medicine, providing specific services to a specific person to maintain and or improve their health.

What a fantastic month of guests!

Next month, we’re dedicating our series on ACOs, and diving into one of each entity type: 1) physician led, 2) hospital sponsored and 3) health plan enabled to contrast and compare structural characteristics and the relative market success (or failures) reported to date.

Join us!

Paul Grundy, MD the “Godfather”of the Patient Centered Medical Home

by Fred Goldstein and Gregg Masters

This week on PopHealth Week, in our continuing focus on primary care and population health we are pleased to welcome Paul Grundy, MD, (@Paul_PCPCC) Global Director of Healthcare Transformation IBM, (@IBMHealthcarePresident PCPCC and Ambassador Healthcare Denmark. Paul is known as the “Godfather” of the Patient Centered Medical Home (PCMH). IBMhealthcare

Paul’s work at IBM is directed towards shifting healthcare delivery around the world towards data driven, accountable, consumer-focused, primary-care based systems through the adoption of new philosophies, primary-care pilot programs, new incentives systems, and the information technology required to implement such change.

The Patient Centered Primary Care Collaborative (@PCPCC) is a not-for-profit membership organization dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home

Considering the challenge laid before all healthcare stakeholders, and especially healthcare leadership, to re-tool and transform an ecosystem remarkably resistant to the change – if not, the revolution – imperative, join us for a ‘tour de force’ review of the current state of healthcare transformation, the center core nature of primary care leadership and the many strands that attach to if not energize the re-emerging focus on population health.

 

 

 

Primary Care Innovation and Population Health: A Conversation with Jay Lee, MD @FamilyDocWonk

by Fred Goldstein and Gregg Masters

In our continuing series on innovation in primary care and population health join PopHealth Week co-hosts Fred Goldstein and Gregg Masters Wednesday, July 15th 2015 at 3 PM Eastern/12 PM Pacific for another deep dive into the role of primary care.

Our special guest is Jay Lee, MD, (@FamilyDocWonk) Associate Medical Director of Practice Transformation at MemorialCare Medical Group and Director of Health Policy at the Long Beach Memorial Family Medicine Residency Program. Dr. Lee was also recently honored by his peers and elected as incoming President at California Academy of Family Physicians (cafp_familydocs).Jay Lee MD @FamilyDocWonk | HiMSS SoCal with Douglas Goldstein @eFuturist

Dr. Lee is an innovative Primary Care Physician. As Associate Medical Director of Practice Transformation at MemorialCare Medical Group, Dr. Lee is responsible for leading implementation of the Patient-Centered Medical Home (PCMH) model in practice locations from Long Beach to San Clemente.

As Director of Health Policy, his role is to educate residents and medical students about the policy world that lives “upstream” from the world of patient care and how to integrate this understanding into clinical practice so that the health and well-being of patients and communities are optimized.

So join us on Wednesday July 15 on PopHealth Week to hear from Dr. Lee.

For a recent interview with Dr. Lee courtesy of our colleague Douglas Goldstein (@efuturist) click here.

 

 

Meet Rushika Fernandopulle MD Co-founder/CEO iora Health

by Fred Goldstein and Gregg Masters

This week on PopHealth Week, in our continuing focus on primary care and population health we are pleased to welcome Rushika Fernandopulle, MD, the Co-Founder and CEO of iora health a growing and disruptive force in the direct practice (including membership and retainer practice medicine) market.rushika pose

Rushika has spent more than ten years involved in efforts to improve the quality of healthcare delivered to patients.  He was the first Executive Director of the Harvard Interfaculty Program for Health Systems Improvement, and served as Managing Director of the Advisory Board Company. He serves on the faculty and earned his AB, MD, and MPP from Harvard University and completed his clinical training at the Massachusetts General Hospital.iora health value prop

iora health believes that better health care starts with primary care. The foundation of their practice philosophy and delivery system infrastructure is built upon three core principles:

  • Payment Focused on Outcomes
  • Patient at the Center; and
  • Technologies that Enable Care

One of iora Health‘s goals is to empower the individual and they utilize care teams and health coaches as the connection.  iora health also places a focus on integrating behavioral health. Rushinka Fernandopulle MD Population Health Colloquium 2015

Join Dr. Rushika Fernandopulle as our guest on PopHealth Week and learn more about this growing and innovative primary care model.

For a previous interview courtesy of our colleague Douglas Goldstein (@efuturist) with Fernandopulle MD sourced from the Population Health Colloquium 2015 organized by the Jefferson College of Population Health (@JeffersonJCPH), click here.

PopHealth Week Explores Full Risk Medicare Advantage with Roy Hinman MD, Founder of Island Doctors, a Pioneering Primary Care Physician

by Fred Goldstein and Gregg Masters

On the Wednesday July 1st, 2015 broadcast at 9 AM Pacific and 12 Noon Eastern PopHealth Week pivots to a progressive physician operation in North Florida innovating via Medicare Advantage risk arrangements with major health plans, including Humana.

PopHealth Week’s guest on July 1 is Roy Hinman, MD the founder and CEO of Island Doctors which employs more than 50 people within 14 offices in Florida stretching from Jacksonville to Interlachen and New Smyrna Beach. He opened his first family practice office in 1991 on Anastasia Island in St. Augustine, Florida.PopHealthWeek-logo-TWTTR-sq

Dr. Hinman is a ‘back to basics’ pioneer and began to take full risk Medicare Advantage in 1998. Since then, Dr. Hinman’s practice has grown to approximately 16,000 capitated Medicare Advantage patients in Florida. He anticipates having 20 offices by the end of 2015 to meet the demand. In addition to his owned offices, they also manage a network of 32 affiliated providers.

With innovative programs targeting diabetes, COPD, cholesterol, smoking and weight loss, he understands keeping patients healthy and how to manage capitated contracts.  His comments may surprise you.

phw_hinmanHere’s some of Dr. Hinman’s bio.

Dr. Hinman was raised in Tulsa, Oklahoma. He is a graduate of Oklahoma Military Academy, received his Bachelor’s Degree in Psychology from Tulsa University, and his Master’s Degree in Human Resource Management from Pepperdine University in Malibu, California. He completed medical school at Universidad Technologica de Santiago in Santo Domingo, The Dominican Republic. He served his family practice residency with the University of Florida Medical Program at the University Medical Center in Jacksonville, Florida and worked as an emergency room physician at Bradford County Hospital in Starke, Florida and at Ed Fraser Memorial Hospital in Macclenny, Florida.

Commissioned as a Second Lieutenant in the U.S. Armored Cavalry in 1975 at Oklahoma State University, Colonel Hinman ultimately retired from the U.S. Army Reserve in 2014 as a Medical Corps officer, after 37 years of military duty in the United States, Germany, Korea, Kuwait, Nicaragua, Panama, Saudi Arabia, Ecuador, the Dominican Republic, and Iraq where he served three combat tours. He recently served as the Territorial Surgeon of the U.S. Virgin Islands.

Dr. Hinman is Board-Certified in Family Practice and is a member of the Florida Medical Association, the American Association of Family Practitioners, the Florida Association of Family Practitioners, the St. Johns County Medical Society and the American Academy of Anti-Aging, and has full Family Practice admitting privileges at Flagler Hospital in St. Augustine, Florida where he has been an active staff member since 1991.

So join PopHealth Week’s guest, Dr. Roy Hinman and gain valuable insights into how he has been doing what many have, and or will be trying in the not to distant future, full risk capitation.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PopHealth Week Month End Wrap-Up: Wednesday June 24th

by Fred Goldstein, Gregg Masters and Douglas Goldstein

In our second month end ‘news/e/um‘ style PopHealth Week Review Wednesday June 24 at 9 AM PT/12 PM ET we’ll feature hot topics in the news. Our regular panel of Fred Goldstein @fsgoldstein, Gregg Masters @2healthguru and Doug Goldstein @efuturist will identify newsworthy stories and offer commentary along the way.
The initial slate of stories in the news includes:

  • Healthways revised guidance
  • Fitbit’s IPO and Garmin’s lawsuit
  • Ochsner Health System
    • What they are been getting news about Apple Watch – Chronic Care Management
    • News B4 the Release – what they are working on the New Mission Control”
  • The physician led ACO management company Aledade’s VC raise
  • Insights from the Personalized Medicine Coalition Study
  • Anthem’s sparring bids for CIGNA (and Aetna’s pursuit of Humana) Could the ‘Big Five’ be reduced to the ‘Big Three’?

Here’s some background:

Healthways: A Perennial Disappointment?

PHW_healthwaysThis company just reported revised downward guidance and their stock was hammered.  Last month, on May 18th their longtime CEO Ben Leedle stepped down and last year a group of dissident sharedholders filed to take over the Board, though they ultimately came to an agreement with a few of them joining the Healthways Board.  As one of the largest population health companies, with unique programs like Silver Sneakers, the Gallup-Healthways Well-Being Index, and relationships with Blue Zones and Dean Ornish, how can they miss?  Well the irreverent 3 have some thoughts you don’t want to miss this.

We’re sourcing our discussion from recent news: ‘Healthways Revises Financial Guidance for 2015‘ and Healthways (HWAY) Stock Sinks on Lower Full Year Revenue Guidance.

Fitbit: The Wallstreet Darling of the Wearables Industry?

Fitbit went public, Woohoo! Lets take a walk as we discuss:phw_fitbit

  • the opportunities for wearables
  • Fitbit’s first day pop (can you say JUMP) you know, we can get them to exercise, but hey its only the first month, is it sustainable?; and
  • the recently announced Garmin lawsuit (what? So they hired employees from a competitor….. but maybe… they took more than their minds with them)

The company narrative is here, and recent discussions found via CNBC ‘Fitbit soars 20% on second trading day‘.

The good here, and some questions, here and here. And then there’s the ‘always-in America’ litigation angle via ‘Fitbit Sued by Jawbone for ‘Plundering’ Employees, Secrets‘ with all the gory details of the complaint here.

Ochsner Health System: The New Normal?

Doug Goldstein recently visited Ochsner Health and has some interesting insights to bring us. Perhaps more interesting is this announcement:phw_ochsner

Ochsner Health System First in Nation to Manage Chronic Disease with AppleWatch….’

We all know how much buzz the product (better yet, platform) has produced in the digital health and exploding apps market, we’ll lean into the real world implications for its deployment to population health via Ochsner’s first mover vision inside their EHR (uh, can you say EPIC?).

Select Highlights:

…it’s not about the wearable – it’s about the “new mission control” being built into the EPIC workflow that will change how doctors support patients in life, fitness, health and healthcare.’ Douglas Goldstein

Aledade: The Physician Led ACO Management Company “ACOcor” Revisited?

phw_aledadeAledade just completed a $30 million series B raise, see; ‘Bethesda health tech company raises $30 million‘. What implications if any can we draw from this continuing investor confidence in the approach and ‘secret sauce’ enabling the transformation of the U.S. healthcare ecosystem from volume to value? What does this say about the ACO market writ large and the continued embedding of the ACA’s moving parts as the new normal for American healthcare? For discussion of this milestone event, see: Leading the Transformation: Aledade’s Growth authored by Aledade CEO Farzad Mostahari, MD.

Themes: ACOs continue their market penetration, and the need for physician led ACOs can only be expected to continue to grow as well. Someone need fill that void. Aledade intends to be a front runner.

ACA repeal types are increasingly irrelevant and the King V Burwell trial decision –  which could hit this week – is likely to only affirm the continued availability of Federal subsidies within the broad intent of the law and ‘language issues’ notwithstanding.

Physician led ACOs are another shot at the bow of traditional hospital system led innovations including any ACOs the sponsor.

Personalized Medicine Coalition Study 

phw_personalizedmedMost of us have heard about the 17 year time-line for innovation to transfer from ‘bench to bedside’ into mainstream medicine. Clearly in days past, we could tolerate such a delayed ‘on-ramp’. Yet in the Internet age, with Moore’s Law, the explosion medical information and informatics/big data analytics, plus opportunities for crowd sourcing and the connected global village are within the means of anyone carrying a smart-phone, laptop or traditional PC access, such a delay is, well so 1900’s…

Yet, there’s more in the way of ‘innovation uptake’, you know that ‘calcified hairball’ so aptly tagged by the powerhouse Esther Dyson (@edyson). A recent study by the Personalized Medicine Coalition outlines some of these concerns, particularly as it relates to ‘alternate payment models’ (APMs):

“..as APMs continue to develop and these, and other alternate models are proposed, it will be important to consider what effect changing incentives and payment systems will have on the decision by interested stakeholders to invest in personalized medicine. The Report concludes that “if new incentives begin to hamper access to personalized medicines in a meaningful way, the ability to invest in research and development of highly personalized therapies and diagnostics will likely shift to align with the inflexible payment systems.”

“Understanding the dynamics and challenges facing the industry as payors move toward APMs is the first step to ensuring that these therapies can continue to be developed and made available to patients. This Report is an important first step to raising the awareness of these issues as payment models continue to evolve.”

Practical Impact or ‘Reading the Tea Leaves’

As the challenge of integrating the promise of precision medicine (utility of biomarkers and better understanding of disease pathology and associated risk management opportunities) informing and guiding to day to day lifestyle (including health) choices, another potential uptake inhibitor are the hoops payors or risk bearing organizations may require before deeming the application of such technology to better patient outcomes. So in a way, it’s not just about tech innovation adding value to medicine and healthcare, but also the bureaucracies we create to protect the public while stimulating innovation.

PM remains an on the come potential to current medical practice. The theory is compelling, but the 17 year bench to bedside standard is not likely to step aside any time soon. Perhaps incentives [and compelling outcomes studies] can accelerate an otherwise glacial pace of [tech transfer] adoption.

Anthem’s Determined Dance to Acquire CIGNA

Are we revisiting the Big 6, then Big 4, and ultimately fill in the ____ of the too big to fail accounting firms [RIP Arthur Anderson] but now squarely laid at the feet of America’s Health Insurance Industry market leaders….?phw_anthem

This is a story on a number of levels! See: Anthem continues $47B Cigna takeover battle and Anthem offers $47 billion to buy Cigna.

Themes: Is health plan consolidation the antidote to counter the recent and persistent wave of hospital, health system and medical group mergers? One CEO’s post merger standing in way of merger. Will investors stand by and watch a premium bid sit idle?

Bottomline? Might market consolidation for price leverage (and oh yeah, scale and operating efficiencies) enable the construction of a virtual single payor (or Ellwood vision of “SuperMeds”) via acquisitions or arrangements? Is this scale required by ACA as some opine? Or just more opportunity to generate fees and exit packages for senior executives? When has scale reduced costs?

So pull up a chair, get out on a walk, put on your headset, and tune in to PopHealth Week!

 

Meet Steven Blumberg AtlantiCare Health Solutions

by Fred Goldstein

This week on PopHealth Week oPopHealthWeek-logo-TWTTR-squr special guest is Steven Blumberg, Senior Vice President and Executive Director of AtlantiCare Health Solutions, AtlantiCare’s accountable care organization. A member of AtlantiCare’s executive leadership team, he has responsibility for development of population health models, programing and delivery. Blumberg works with payors and employers to bring value-based purchasing of health services to the marketplace. Blumberg’s more than 25 years of health care leadership experience includes strategic planning, business development, joint ventures, group practice leadership, risk model development and operational integration. He has worked with both large group practices as well as major health systems.

AtlantiCare, located in New Jersey is the region’s largest healthcare organization and largest non-casino employer with more than 5,170 employees and 600 physicians in nearly 70 locations.atlanticare

AtlantiCare Health Solutions is an accountable care organization (ACO). Services offerd through their ACO includes Primary Care Plus, data analytics and information sharing through an EMR, integrated care managers, a hospitalist program and an employee engagement, prevention and wellness program.  The program also offers a patient portal, mobile app and Well4Life, whose mission is to build healthy communities.  So join PopHealth Week as we discuss ACO’s, population health and some of the innovative services offered by AtlantiCare Health Solutions.

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Frederic S. Goldstein is President and Founder Accountable Health, LLC, Past Board Chair, Board of Directors, Population Health Alliance, and co-founder of PopHealth Week.

Meet Kaveh Safavi MD Accenture

Join PopHealth Week Wednesday June 10 at 12 PM Eastern/9AM Pacific with our special guest:

kaveh_safavi-21

Kaveh Safavi, MD, JD managing director for global healthcare business at Accenture. Dr. Safavi is responsible for developing and driving a growth strategy that differentiates Accenture’s offerings for providers, health insurers and public and private health systems across the globe. PopHealthWeek-logo-TWTTR-sq

Accenture Health Management Services offer solutions to help patients, providers and risk-bearers coordinate and manage population health and wellness across care settings in a way that ensures optimal health outcomes, efficient healthcare spend and drives affordability.

We’ll be discussing some of Kaveh’s thoughts on population health and where he believes providers should be focusing their efforts.