In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Aaron Shirley, MD.
This profile was published in the December, 2012 issue of HealthLeaders magazine.
"I hear a lot about studies but the people here have been studied enough. They need medical care."
Aaron Shirley, MD, a retired Jackson, Miss., pediatrician, believes that a primary healthcare model developed in Iran can be used to improve the health of the residents of Mississippi's poverty-stricken Delta Region.
The Iranian health house model is an integrated network that includes hospitals, primary care facilities and "health houses" in Iran's poor rural communities. Services are provided by community health workers who live in and know the localities they serve.
Shirley has spent a lifetime developing programs and outreach for the poor in Mississippi. He was a civil rights activist, the only African-American pediatrician in Mississippi at one time, and the first African-American resident at the University of Mississippi Medical Center. In the 1960s, he worked at the first community health center in the Mississippi Delta. He is credited with installing wells to provide clean drinking water in the area. In 1993, Shirley was awarded a MacArthur Foundation Fellowship, (an award often referred to as a genius grant) for his healthcare leadership.
In the mid-1990s he worked with a group to transform a failing shopping center into a medical mall that provides health services to the poor. In 2009 on a trip to Iran, Shirley witnessed the Iranian health house system firsthand.
"The Iranian experience was the driving force for pursuing HealthConnect," which Shirley says he started about two-and-a-half years ago. HealthConnect is designed, in part, to reduce admissions and emergency department visits at the Central Mississippi Medical Center in Jackson.
In Mississippi, there is the same "general population and similar disparities," Shirley says of the Iranian communities. "You translate the 2,000 people in a neighborhood of a rural city or town, and you've got the same problems." After seeing the Iranian model in action, Shirley says he thought: "Why couldn't we have the same model here? It proved effective there."
His goal is to open 15 health houses in the Delta Region north of Jackson. To date two health houses have opened in schools. "We said, ‘Wow, these schools are located in the village; we got a roof, windows, electricity, now let's train community health workers in that school space," Shirley recalls.
A hallmark of the Iranian system is that the healthcare workers are part of the community they serve. Shirley says the school locations provide the neighborhood connections that are particularly important in the Delta Region where a patient may have the best of intentions to follow doctor's orders, but may lack the resources to do so. That's not something a person might be comfortable confiding to a physician, he explains, but community health workers are from the Delta and more likely to be aware of a patient's personal situation.
Shirley says the two health houses have already helped reduce hospital admissions and he's eager to get more health houses up and running. He says politics—both state and federal—has limited the project's reach so far. "I hear a lot about studies but the people here have been studied enough. They need medical care."
UnitedHealthcare has provided some seed money and Shirley is trying to garner support from healthcare policy makers. It is frustrating, Shirley says, that in spite of the fact that "we spend millions and millions of dollars doing things the same way and getting the same results that a different approach is either threatening or misunderstood."
Shirley was born and raised in Jackson, and his wife, Ollye, is from the Mississippi Delta region. The couple has four children, all of whom work in healthcare. None became physicians, however.
"They remember how hard I worked," he says with a laugh.
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Aaron Shirley, MD.
This profile was published in the December, 2012 issue of HealthLeaders magazine.
"I hear a lot about studies but the people here have been studied enough. They need medical care."
Aaron Shirley, MD, a retired Jackson, Miss., pediatrician, believes that a primary healthcare model developed in Iran can be used to improve the health of the residents of Mississippi's poverty-stricken Delta Region.
The Iranian health house model is an integrated network that includes hospitals, primary care facilities and "health houses" in Iran's poor rural communities. Services are provided by community health workers who live in and know the localities they serve.
Shirley has spent a lifetime developing programs and outreach for the poor in Mississippi. He was a civil rights activist, the only African-American pediatrician in Mississippi at one time, and the first African-American resident at the University of Mississippi Medical Center. In the 1960s, he worked at the first community health center in the Mississippi Delta. He is credited with installing wells to provide clean drinking water in the area. In 1993, Shirley was awarded a MacArthur Foundation Fellowship, (an award often referred to as a genius grant) for his healthcare leadership.
In the mid-1990s he worked with a group to transform a failing shopping center into a medical mall that provides health services to the poor. In 2009 on a trip to Iran, Shirley witnessed the Iranian health house system firsthand.
"The Iranian experience was the driving force for pursuing HealthConnect," which Shirley says he started about two-and-a-half years ago. HealthConnect is designed, in part, to reduce admissions and emergency department visits at the Central Mississippi Medical Center in Jackson.
In Mississippi, there is the same "general population and similar disparities," Shirley says of the Iranian communities. "You translate the 2,000 people in a neighborhood of a rural city or town, and you've got the same problems." After seeing the Iranian model in action, Shirley says he thought: "Why couldn't we have the same model here? It proved effective there."
His goal is to open 15 health houses in the Delta Region north of Jackson. To date two health houses have opened in schools. "We said, ‘Wow, these schools are located in the village; we got a roof, windows, electricity, now let's train community health workers in that school space," Shirley recalls.
A hallmark of the Iranian system is that the healthcare workers are part of the community they serve. Shirley says the school locations provide the neighborhood connections that are particularly important in the Delta Region where a patient may have the best of intentions to follow doctor's orders, but may lack the resources to do so. That's not something a person might be comfortable confiding to a physician, he explains, but community health workers are from the Delta and more likely to be aware of a patient's personal situation.
Shirley says the two health houses have already helped reduce hospital admissions and he's eager to get more health houses up and running. He says politics—both state and federal—has limited the project's reach so far. "I hear a lot about studies but the people here have been studied enough. They need medical care."
UnitedHealthcare has provided some seed money and Shirley is trying to garner support from healthcare policy makers. It is frustrating, Shirley says, that in spite of the fact that "we spend millions and millions of dollars doing things the same way and getting the same results that a different approach is either threatening or misunderstood."
Shirley was born and raised in Jackson, and his wife, Ollye, is from the Mississippi Delta region. The couple has four children, all of whom work in healthcare. None became physicians, however.
"They remember how hard I worked," he says with a laugh.
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Bruce Bodaken.
This profile was published in the December, 2012 issue of HealthLeaders magazine.
"All of us have a responsibility to be a part of the system and we need to make a way for those who can't afford to get care."
Bruce Bodaken, the long-time chair, CEO, and president of Blue Shield of California will retire at the end of 2012.
He acknowledges that he is walking away from his healthcare career just as a lot of exciting things are happening in the industry and at Blue Shield. Healthcare reform holds the promise of bringing accessible and affordable healthcare to millions, and Blue Shield is at the forefront of efforts to develop accountable care organizations and other interesting programs.
But Bodaken thinks 12 years is long enough for one CEO to lead a company. "When I took over I told the board that in my vision, for organizations to evolve and make sure they are at their very best requires continuous change," he says.
Bodaken's tenure has included his early support for universal coverage, as well as Blue Shield's 2011 announcement that it would voluntarily limit its income to 2% of revenue and redistribute anything over that amount to its members, providers, and the Blue Shield Foundation.
The Blue Shield that Bodaken is leaving is quite different from the struggling insurer he took over in 2000. That company had around one million members and made its payroll by pulling money out of its limited surplus funds. "It simply wasn't going to survive," he explains.
Today the insurer is a dominant player in the California market. Membership has tripled, its surplus has grown to billions of dollars, and the company is on solid financial ground.
When asked to name his biggest accomplishments Bodaken points to the company's journey toward helping to make sure everyone has access to affordable healthcare, including prevention and wellness services. "All of us have a responsibility to be a part of the system and we need to make a way for those who can't afford to get care," he states.
And he is pleased with the results the 2% pledge has produced so far. Over the years Blue Shield has been roundly criticized for its steep rate hikes and when the pledge was announced, it was greeted with a healthy dose of skepticism by just about everyone. But in 2011, the company paid out around $475 million, including $450 million to members, $20 million to help provider groups form accountable care organizations, and $5 million to the Blue Shield Foundation and community grants.
Bodaken says Blue Shield is trying to convince other companies to join the effort. The ultimate goal, he explains, is for Blue Shield to price its rates "so we don't give money back. We're getting closer to having lower rates and giving less back."
He is proud of the work Blue Shield has done to expand accountable care organizations across the state. It now has eight ACOs throughout California.
Healthcare wasn't part of Bruce Bodaken's career plans when he was working on a PhD in philosophy, but with few teaching job available he accepted a position with an HMO.
He discovered that his sense of social responsibility and interest in making a difference complemented HMO efforts to focus on wellness, prevention, and better care at lower cost. "In a funny way I was able to combine my education and the mission of the nonprofit organization."
He moved to Blue Shield in 1994 and says he once again found himself in an organization that was aligned with his own thinking about the access, delivery, and cost of healthcare.
"I have truly enjoyed and loved being in the business."
When he retires Bodaken says he hopes to get back to being a respectable tennis player. He also wants to teach at a local university and to do some board work. He will continue, in some capacity, to be part of the healthcare reform policy dialogue. "It's too important to me personally and too important to the country," he says.
He expects healthcare affordability to be a continuing challenge. "All of us involved in healthcare—hospitals, physicians, health plans, and pharma companies—need to get our administration costs down." Once that step is taken, he expects, over time, that healthcare will be affordable for the vast majority of Americans.
He notes that the government cannot afford to take the lead forever and that the industry needs to become self-sustaining at some point.
Bodaken says his Blue Shield legacy will be his work in healthcare reform and the risks he took to speak up for change in the industry. "I wasn't the darling of our industry when we first started down this path. But it is what needs to be done if we want to make transformative change."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Risa Lavizzo-Mourey, MD.
This profile was published in the December, 2012 issue of HealthLeaders magazine.
"Not a day goes by that I don’t talk to someone or interact with someone who has been able to achieve something important for the country or community or people who need help."
Risa Lavizzo-Mourey, MD, probably began her preparation to lead the Robert Wood Johnson Foundation when she was a child growing up in Seattle.
Her parents were both physicians—mom was a pediatrician and dad was a surgeon. The Harvard Medical School graduate says she grew up understanding "the incredible privilege and honor it is to be a physician and to have that intimate relationship with a patient."
At the same time conversations with her parents helped her understand the larger forces in society—such as poverty and policy—that can affect whether people have access to physicians and the healthcare they need.
When she began practicing medicine in Philadelphia, Lavizzo-Mourey gravitated toward geriatric patients with complex illnesses who had largely been ignored by the healthcare system. "I found that taking care of them was intellectually challenging. It allowed me to be the kind of doctor I wanted to be—involved with the patient and the family."
It also allowed her to take those first steps toward becoming recognized as a national healthcare policy leader. She looked at how decisions being made in the Medicare program affected her individual patients while studying the importance of those decisions in setting a national agenda for healthcare policy.
In her 10 years as president and CEO of RWJF, Lavizzo-Mourey has deftly guided the multibillion-dollar philanthropic organization to take on and speak out about what she terms "the important cultural changes that are necessary for us as a nation if we are going to become healthier."
She says the foundation is increasingly focused on supporting projects targeted in areas that represent big health concerns for the country. RWJF is also becoming more intentional in its efforts to that achieve large goals and specific outcomes within set timeframes.
One example: a goal to reverse the epidemic of childhood obesity by 2015. Lavizzo-Mourey cautions that while obesity rates probably will not return to the low rates of the 1970s, it is still important to demonstrate that a reversal is under way.
In 2011 the RWJF, which is funded through an endowment, awarded 739 grants worth $397.4 million but Lavizzo-Mourey says the foundation is increasing its use of tools other than grant making, such as strategic communications and collaborations, to try to achieve its goals. She explains that the move is grounded in the realization that RWJF "needs to deliver a very consistent message and develop strong relationship with other foundations, nonprofits, and business leaders to raise awareness and produce the social change necessary to achieve its goals."
Lavizzo-Mourey says RWJF is active in two issues critical to the future of healthcare: how we invest in our health and how we invest in value for our healthcare dollars. The foundation can produce the type of objective evidence that leads the nation to have "constructive dialogue about these issues. RWJF is raising these issues in a thoughtful and explanatory way so people across the country can become engaged in the dialogue."
She explains that RWJF is in the position to help other groups that are working toward the same goals by raising the issues that allow those groups develop other collaborations and investor relationships.
Lavizzo-Mourey says the best part of her job is spending each day figuring out what the foundation can do make meaningful change happen. "Not a day goes by that I don’t talk to someone or interact with someone who has been able to achieve something important for the country or community or people who need help."
An ill wind is blowing in Georgia, and I don't mean Hurricane Sandy.
Two national healthcare organizations, America's Health Insurance Plans and the American Medical Association, are waging a battle of legal documents over an amendment to the state's existing prompt pay law that would extend prompt pay regulations from traditional insurers to include third party administrators (TPA).
The problem, according to AHIP, is that the Insurance Delivery Enhancement Act of
2011, set to take effect January 1, 2013, wades into an area where a decades-old federal law already reigns supreme. The Employee Retirement Income Security Act, commonly known as ERISA, exempts self-funded payers from state health insurance laws.
Not so fast, says the AMA, which along with the Medical Association of Georgia, has filed a petition to be added to the case as co-defendants along with Ralph Hudgens, Georgia's insurance commissioner.
In 25-words or less, the IDE Act, which was signed by Gov. Nathan Deal (D) in May 2011, says TPAs must pay clean claims within 15 days if submitted electronically and 30 days if submitted by mail.
According to a MAG advocacy brief, without the law "there is no deadline for a TPA to pay a healthcare provider or notify the healthcare provider why the claim will not be paid."
Historically, self-funded payers have included large employers that can afford to take on the risk of healthcare coverage. A third party administrator, typically a health insurer, is paid to administer the account, including the claims process. Because the employers aren't insurance companies, regulations such as prompt pay laws don't apply to them.
States have never been happy that this significant chunk of insurance business doesn't fall under their regulations. The tension has mounted in recent years as there has been a move among smaller and medium-sized companies, and even some smaller governments to become self-funded plans. That means that states face having their prompt pay laws cover an even smaller piece of the enrollee pie.
In Georgia, self-funded plans account for 65% of enrollment, according to Donald J. Palmisano Jr., the MAG executive director. That leaves only 35% who fall under the state's existing prompt pay law.
And that frustrates physicians who contend that TPAs slow walk claims payments.
"We have a general idea, from an informal sampling, that a majority of the claims (fully insured and self-insured) were paid after 30 days," Palmisano explained in an e-mail exchange. "The problem is that an explanation of benefits is not clear if it is fully insured or self-funded. That is why the new law gives the commissioner of insurance the ability to get this information."
The lawsuit, which began in late August and is still in the document stage, is filed in the U.S. District Court in Atlanta. On Oct. 26 AHIP filed a number of new documents, including one that requests that a date be set for oral arguments on the case and another that opposes the AMA and MAG efforts to intervene.
Last week I spoke with Robert Zirkelbach, an AHIP spokesperson. He is quick to note that the suit is not an issue about how quickly doctors are paid. "We want physicians to be paid in a timely manner for their services."
This lawsuit, he says, is about preserving the sanctity of ERISA and "enabling self-funded employers to offer affordable, uniform benefits to their employees."
AHIP's concern, Zirkelbach explains, is that without ERISA protection, employers (and health plans) could face a patchwork of insurance laws and that would create "a very troubling precedent." He added that Georgia lawsuit is about "who governs ERISA plans. Longstanding federal law states very clearly that these plans are governed at the federal level. This is not about how doctors are paid."
He noted that AHIP is asking the court to only throw out the part of the IDE Act that applies to self-funded employer plans.
Prompt pay laws have been on the books since the 1990s. Today all 50 states have some type of prompt pay laws that require clean claims to be paid within 15 to 60 days. Noncompliance can result in fines and penalties, including interest payments.
It's unclear which states, if any, have duplicated Georgia's efforts to apply prompt pay laws to self-funded companies.
Jeremy Lazarus, MD, the AMA president told me in an interview that the AMA views the Georgia case as having a "national precedence" that will fill a "regulatory void." The issue is that "physicians want to be taking care of patients and not hassling with insurers to get paid."
In a surprising turn, smaller health plans are taking some of the same approaches to health IT strategies and investments as larger plans, a survey by Medecision shows.
Because of the small size (between 200,000 and 900,000 covered lives) of the some of the responding health plans, Medecision expected them to be in survival mode and focused on cost cutting, operational efficiencies, and core technology platforms, according to Ellen Donahue-Dalton, vice president of marketing at the Wayne, PA-based healthcare management solutions company that sponsored the research study.
What the researchers found instead is that the smaller payers weren't so much in a cost containment mode as "we thought they would be. They were sort of broader in their preparation," says Donahue-Dalton.
That means the smaller plans are just as focused as the big guys on provider connectivity, data, and system interoperability, and consumer engagement.
The survey involved C-suite executives from nine health plans and used an online "bulletin board" focus group, which is a virtual group that can interact with the moderator as well as participants. The responses were collected over three weeks in April 2012 and included one-on-one follow up sessions.
Medecision identified four strategic initiatives common to the responding health plans:
Cost containment Reducing these overhead expenses through automation and analytics was of particular interest.
Provider communications Participants pointed to the need for enhanced collaboration with providers, such as providing guidance and education on healthcare reform, sharing data and analytics, and bringing them into risk/reward sharing programs.
Accountable Care Organizations Health plans recognize that they may need to lead the way in developing new care delivery models, and/or providing the tools and support for health systems and hospitals to pursue the affordable care organization model.
Market share/member retention Health plans are figuring out the best ways to position themselves in the market given the potential effects of the presidential and congressional elections. Donahue-Dalton says they are looking at using automation to grow membership, connect care, and reduce costs.
That means making sure their care management, disease management, and utilization management is "really robust" so they can scale membership—add commercial or government membership—without needing to increase staffing such as nurses or care managers.
"They really want their core systems to do more for less," she explained.
According to the survey, over the next three to five years health plans will focus on these investments areas:
Consumer Engagement
Donahue-Dalton says there will be an emphasis on building personal relationships between an individual and a service provider, with a focus on the individual. "It's not about the health plan. It's about that individual's health, their chronic disease, their caregivers, and how they search for a doctor or hospital. It's personal."
Noting that consumers are comfortable in the online retail world where there is a great deal of price and relationship transparency, consumers are expecting that same level of engagement with their health plans, Donahue-Dalton says.
They want to be able to select a plan, get a cost quote, and have their claims paid correctly and quickly. But they also want their health plans to help them watch their health, remind them about needed tests, and subsidize their weight loss programs and gym memberships.
And, they want all of this in a streamlined process. "It's a huge challenge," says Donahue-Dalton. "Health plans are going to have to take that leap into meeting members where they are."
According to the survey, payers are focusing their consumer engagement initiatives primarily in these areas: enhanced web portals, health insurance exchanges, and member incentives, including wellness programs and education.
Health information exchanges and deployment of interoperability
Participants indicated the need for two-way communication between payers and providers, especially in terms of being able to push data to electronic medical records. As healthcare transforms itself into a more consumer-centric industry, Donahue-Dalton says health plan relationships with providers will be "core assets."
Data aggregation/analytics
Health plans are looking at ways to invest in data warehousing and analytics to use member data more effectively. Analytics will play a critical role in consumer engagement and health plans are looking not only at how to present the data they collect but also exploring what data they need to have to better serve their members and providers.
Survey participants mentioned adding supplemental data from the Centers for Medicare & Medicaid Services, pharmacies, and labs.
I see a lot of survey information that engages the major players and their plans. What this survey helps us understand is that the big ideas of healthcare transformation such as affordable care organizations, the shift to the individual market, and the role of analytics—are permeating throughout the health plan industry.
That's important as we look down the road at how healthcare reform legislation may change depending on the outcome of the elections.
Just in time for open enrollment season, the Centers for Medicare & Medicaid Services has released its annual star ratings for Medicare Advantage, Medicare Cost, and prescription drug plans.
The five-year-old program is an effort to steer Medicare members to high performing plans that meet a checklist of quality and accountability standards. The ultimate goal is to lower the cost of Medicare services.
Plans are ranked with one (poor) to 5 (excellent) stars depending on their performance on 49 measures, including cancer and cholesterol screenings, glaucoma testing, controlling blood pressure, diabetes care, rheumatoid arthritis control, kidney disease control, hospital readmissions, and customer service.
The ratings are based on reviews of billing information, member surveys, and Medicare's regular monitoring activities.
This year CMS looked at 563 health plans and awarded five stars to only 15 Medicare health plans:
Dean Health Plan (Wisconsin),
Group Health Plan (Minnesota and Wisconsin),
Group Health Cooperative (Washington),
Gunderson Lutheran Health Plan (Iowa and Wisconsin);
Health New England (Massachusetts);
Humana (Wisconsin);
Kaiser Foundation Health Plan (California, Colorado, Hawaii, Ohio, the Middle Atlantic states, and the Northwest);
Medical Associates Clinic Health Plan (Washington);
Medical Associates Health Plan (Iowa and Illinois)
A five-star designation is coveted and rare; only a dozen out of 446 plans achieved it in 2011. The plans have a combined total of about 1.2 million members.
Last year health plans with at least a 3-star rating shared in about $3 billion in bonus payments. The 2012 bonus amount is unknown; CMS has not responded to requests for the figures.
Those five-star, gold standard plans enjoy a sweet list of perks.
They can distinguish themselves in the crowded Medicare market by marketing for 12 months a year instead of only during the regular October and November open enrollment period and they can enroll members from the 26 lowest performing plans (2.5 stars or less) at any time during the year.
The high performers can also display a gold star icon on CMS's official Medicare Plan Finder site. Low-scoring, poor performing plans, which have posted 2.5 stars or less for three consecutive years, are marked with an LPI (low performing icon). While that's not quite a scarlet letter, it's another sign that CMS is determined that plans will not be permitted to ignore performance standards and continue as Medicare plans.
Some 21 of the 30 contracts that received the LPI in 2011 either improved their ratings this year, or had their contracts withdrawn or consolidated.
Overall, 119 of the plan contracts that received star rating last year and this year improved their star ratings for 2012, according to an analysis from Avalere Health.
Dean Health Plan, a gold-standard Medicare Cost plan, is similar to a Medicare HMO but offers its enrollees the option of receiving out-of-network coverage.
The plan was also recognized last year. The key to maintaining its status from year-to-year is a culture of customer service and a system wide focus on wellness and prevention, explains Pete Thompson, Dean's strategic marketing manager. Its 5-star plan, DeanCare Gold, has about 20,000 members in eight Wisconsin counties.
In an e-mail exchange, Thompson stated that everyone is "on the same page" because its physicians, hospitals and health plan are integrated into one system that shares the risks and rewards associated with patient outcomes. "The clinic, hospital, and health plan relationship facilitates a coordinated approach and high quality care at a lower cost."
The addition of Humana-Wisconsin among the 5-star plans marks the first time a for-profit health plan has cracked the top tier. In recent years Humana, WellPoint, and other for-profit plans have actively pursued improvement in their star ratings.
Last year, during a conference call with analysts, Michael McCallister, Humana's chair of the board and CEO, said Humana "plans to reinvest heavily in improving our stars' processes, procedures and infrastructure to position us for further improvements in star metrics."
Meanwhile, WellPoint has high hopes that CareMore, the Medicare Advantage plan it acquired last year, will lead to higher quality star ratings. This year CareMore posted 3.5 stars.
The star program is not without its detractors. The nonpartisan Government Accountability Office has expressed concerns about the CMS's authority to offer the bonuses. The GAO contends that the existing program is much more generous than the bonus program outlined in PPACA.
That could be but the combination of the carrot (money) and stick (loss of members) seems to have health plans taking notice.
Health Alliance Plan (HAP), a Detroit-based regional health plan, is among a handful of payers experimenting with different payment models and protocols for the treatment of cancers.
According to a study that appeared last year in the New England Journal of Medicine, annual direct costs for cancer care will increase by $69 billion to $173 billion in 2020. Among the cost drivers is the increased cost of therapies. The sales of anti-cancer drugs are second only to those for heart disease.
HAP, along with Cardinal Health Specialty Solutions and Physician Resource Management, an oncology physician consulting firm, are working together on an evidence-based clinical pathways program that it hopes will improve the treatment quality and lower the costs of cancer care.
Cardinal Health Specialty Solutions will provide education and training and the technology used by HAP physicians to implement and monitor the program. PRM is assisting in physician recruitment.
HAP is a subsidiary of Detroit's Henry Ford Health System and has about 650,000 members in Michigan.
Historically, managed care has taken a hands-off approach to oncology services, explains John Calabria, MD, HAP's medical director. But with more than 900 new cancer drugs in the pipeline, it's time to be "proactive and assure our members that evidence-based treatment is being followed."
He notes that over-utilization of less effective drugs is a bad thing and so is under-utilization of effective drugs. "We want to help oncologists assure appropriate care."
The HAP program joins efforts by UnitedHealthcare, Humana, Florida Blue, and other payers, which have focused on bundled payments and accountable care organizations to stabilize revenue streams and payment structures in the emotionally charged cancer treatment arena.
For the first year, the HAP initiative will focus on breast, colon, and lung cancers. Calabria explains that according to national data, these are the cancers with the most drug expenditures and the most variation in patient treatment.
"When we look at the data, these are the cancers where the most opportunity lies to reduce treatment variance. Normally, when you reduce variance, you improve quality and promote efficacy," he says.
The HAP effort will include the appropriate use of generic chemotherapy. "If there's no difference in quality and safety and the generic drug is less expensive, then there's no reason not to use it," says Calabria.
The insurer hopes to enlist 200 oncologists from its network to participate in the voluntary program. Among the program goals is to engage the oncology community, which Calabria says hasn't always been done up to now. In a productive first step, the best practices, or pathways, have been developed by a steering committee comprised of community oncologists and peers.
Down the road, HAP may look at expanding the program to radiation oncology management.
For now, HAP will monitor how physicians perform against the pathways and monitor outcome measures, which may include reduced emergency department visits and hospital admissions as a result of chemo-related complications.
To promote the use of lower-cost generic chemotherapy drugs, Calabria says HAP has worked to increase—not decrease—the provider reimbursement for generic oncology drugs. Cutting reimbursements would be a "disincentive" for physicians to use generics, according to Calabria.
"This isn't a utilization management program," he explains. "We don't want to discourage generic usage by not reimbursing correctly."
Calabria acknowledges that oncology cost and treatment management is a "new frontier. It's emotional." Among the hoped-for outcomes of the program is that the pathways provide physicians and patients with the clinical support they need to feel more comfortable with getting ready for end-of-life care. "At some point we need to stop treatment when there's no support for it anymore."
Calabria expects the HAP program to get underway later this year.
The federal government is pushing hard for accountable care organizations. On July 1, eighty-nine ACOs opened in 40 states. The next wave to become operational on January 1, 2013 is even bigger. It has at least 400 provider groups on board, according to the Centers for Medicare & Medicaid Services.
On the commercial side, the formation of accountable care organizations is also steaming ahead. Aetna began contracting in 2011 and wants to develop a national ACO network over the next five years. With more than 18 million medical members, the Hartford, CT-based insurer has a company division dedicated to ACOs.
Led by Charles Kennedy, MD, CEO of Accountable Care Solutions, Aetna's Aligned Care Solutions division already has 10 ACOs up and running and 14 more under contract. Kennedy and his team are working with another 65 physician practices to lay the foundation for ACOs through a care management infrastructure embedded in physician practices. That's the first step toward getting them comfortable with managing risk.
I recently spoke with Dr. Kennedy about Aetna's ACO process. Here are some excerpts from our conversation:
HLM: How are the ACO contracts implemented? Kennedy: The ACO contracts have to be multi-year because we are trying to reengineer the care delivery process and that can't be done in one year. We like a five-year relationship but we'll work with anything in the three- to five-year range.
We start out with a conversation: Where do you want to go? What's your vision? How do you see yourself achieving your vision? Once we understand that, then we talk about accountable care and what success in the accountable care contract requires.
Finally we focus on finances. What we are trying to do is take inefficiency out of the healthcare delivery system. We're trying to get rid of care that doesn't help people—and maybe even hurts them.
We're having a fundamental impact on the finances so we have to develop a plan that allows rewards for increased efficiency and doesn't harm the financial stability of the delivery system. That takes years to put in place.
HLM: What about risk sharing? Kennedy: We have a variety of risk-sharing strategies that are customized to the needs and capabilities of our delivery system partners. We have some approaches where the risk-sharing is relatively small.
More experienced delivery systems that may have been involved with an HMO operation and have a deep understanding of risk management might take 80% of risk right off the bat.
HLM: Are you developing any specialty ACOs? Kennedy: We do have some pediatric ACOs under development. Our general approach is that when you look at the main driver of healthcare costs, its chronic disease. Oncology is a costly, but 70 cents of every dollar spent on healthcare is spent on chronic disease management. Our priority is primary care medicine and its effect on chronic disease.
HLM: What does Aetna bring to the table? Kennedy: We have deep expertise in financial risk management, which is fundamental for ACOs. We provide sales and marketing support to help commercialize the new value that's created when our partners are more effective and efficient. We bring results in care management. Finally we bring technology, which is increasingly important for ACO success.
HLM: How is success measured? Kennedy: We typically look for quality and efficiency measures. Our quality measures are standard, well accepted, off-the-shelf measures from HEDIS (Healthcare Effectiveness Data and Information Set) and NQF (National Quality Forum). We try to align our quality measures as much as we can with federal measures.
We track financial performance and try to help the delivery system identify areas for improvement, such as looking at ER visits and readmission rates. We're also helping delivery systems understand their financial performance by disease state.
Are they making or losing money on congestive heart failure? Why? Can they do it better and cheaper while still maintaining the financial stability of the delivery system?
HLM: Any surprises? Kennedy: The importance of governmental payment innovation in helping us create the type of financial returns necessary for delivery systems to embrace ACOs was a surprise. It's possible to do ACOs in a commercial environment, but it really sings when you can get Medicare aligned because there's so much waste and inefficiency in Medicare.
I thought there would be a certain amount of reticence on the part of delivery systems to embrace a collaborative relationship with a health plan. It's typically us versus them at the negotiating table.
But once you demonstrate that your business model is a win-win, I was amazed how quickly we shifted from being an opponent to a trusted friend. That's probably the most gratifying success we've had.
The challenges associated with adapting clinical health information technology to ACO operations surprised us. People seem to think if they buy an EMR or they have a health information exchange in place, then they are in great shape for ACO operations.
The challenge has been to get the technology adapted so it supports the contract variables for success. Most of the stuff that's out there isn't designed that way so that was more of a challenge.
I was surprised at how much help many of the delivery systems need. Some have technology that can't help them with an ACO, and they don't have a clear understanding of what they need to do to be successful at this.
Technology is a fundamental problem. The EMRs of today grew up before there was a notion of accountable care. If you're operating in a fee-for-service world, you need better documentation to maximize reimbursement. The challenge with an ACO is to turn that information into something that can be sent back to doctors to help them make decision consistent with evidence-based medicine.
As insurers seek ways to control the price point at the entry level of the healthcare system, health plans such as Blue Cross Blue Shield of North Carolina and Highmark Blue Cross Blue Shield in Pittsburgh are turning to developing urgent care center networks.
This month, for example, the NC Blues announced that it is investing an undisclosed amount in FastMed Urgent Care, a North Carolina-based company with 29 locations throughout the state. Last year, Highmark Inc. bought into the MedExpress Urgent Care chain. And Highmark rival UPMC offers eight "full-service, walk-in" clinics for patients seeking immediate care.
Slideshow: How to Open an Urgent Care Center Urgent care delivery models can be attractive options for healthcare leaders weighing new business strategies. These guidelines are excerpted from the book, The Healthcare Executive's Guide to Urgent Care Centers and Freestanding EDs. >>>
As cost pressure has risen, the typical ways of reducing demand?increased copayments and high deductible health plans have not reduced the demand for medical services. Investing in UCCs puts health plans closer to the point of care where they can more directly influence treatments and healthcare costs, explains David Windley, a Nashville-based research analyst with Jeffries & Company. Profit, in other words, is not the primary goal.
Increased demand for primary care services also plays a role in insurer interests in UCCs. Health insurers and hospitals are competing for ownership positions in physician groups. But for insurers, an investment in a UCC, which can provide basic medical services at lower costs, is "less intensive" than investing in a primary care practice, says Windley.
It can also provide insurers with leverage when negotiating reimbursement rates with hospitals for emergency department services, Windley adds.
Insurers are also investing in UCCs in preparation for the advent of health insurance exchanges in 2014, says Brett Hickman, a partner with PwC's health industries advisory practice. With millions of people joining the ranks of the insured pent-up demand for medical care is expected to strain the primary care sector.
Payers are looking at the rich benefit packages that will be offered through the exchanges and seeing an opportunity for UCCs to provide an alternative not only for expensive emergency department visits but also for physician office visits.
Urgent care centers typically employ doctors, nurses, and physician assistants. They treat common injuries and illnesses such as sprains, cuts and bites, and colds and ear infections. Many also can provide immunizations, blood and urine tests, EKGs, occupational health services, and even on-site pharmacy services.
UCCs are usually equipped with the latest healthcare technology including electronic medical records, electronic prescriptions and digital X-rays. They are typically open night and weekends, when physician offices are usually closed.
Although UCCs often tout drop-in wait times of less than one hour, many centers are now offering online reservations.
Business is booming. The 9,000 UCCs in the U.S. receive an average 342 patient visits each week, or 3 million visits annually, according to the Chicago-based Urgent Care Association of America.
UCC costs are significantly less than an emergency department visit but can be comparable to a typical physician office visit. The NC Blues estimates that the average cost of an ED visit is $1,500 and about 20% of ED visits could be effectively treated at an urgent care center where the average cost per visit is $142. The insurer estimates that a 5% shift from ED use to urgent care centers could reduce medical spending by $8 million annually.
With its ownership position, BCBSNC can entice its members to use the FastMed facilities by offering lower copayments and lower in-network charges.
Although BCBSNC declined to give specifics about its financial investment in FastMed, Darcie Dearth, a BCBSNC spokesperson, said the investment will allow FastMed to expand its network of physician-owned clinics across the state over the next two years.
Underserved areas will be a priority, Dearth explains. In some areas of North Carolina, a visit to the ED is the only option for immediate care. Expanding into those areas will enable the NC Blues plan to divert non-emergency care from expensive EDs.
Hickman says the investment in urgent care centers provides insurers with the opportunity to proactively influence cost and quality. "It's really a means to an end. It's a way to get the right treatment to the right people at the right time."