Meeting the Challenges of Transitioning to Accountable Care

Accountable Care Organizations have been attracting a lot of attention lately, with the recent article in The New York Times and Don Berwick reportedly advising some Pioneer ACOs in their dispute with CMS about how to measure quality. Here on the TJU campus, Jonathan M. Niloff, MD, spoke at the JSPH Forum on ACOs and ways of achieving organizational alignment and management through healthcare transformation. Dr. Niloff, Chief Medical Officer for MedVentive, is responsible for the strategic development of population health analytics and solutions.

ACOs take up only seven pages of the new health law yet have become one of the most talked about provisions. This latest model for delivering services offers doctors and hospitals financial incentives to provide good quality care to Medicare beneficiaries while keeping down costs. An ACO is a network of doctors and hospitals that shares responsibility for providing care to patients. In the new law, an ACO would agree to manage all of the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years.

During his talk at the May 9 JSPH Forum, Dr. Niloff described the often difficult realities of making an ACO work. A successful ACO implies less revenue per patient – a scary proposition for any health system. In an environment of less revenue per patient, it is crucial to keep the patients that were going out of the system, within the system. Growing the network is also vital. “Ultimately, it’s about aligning more physicians, gaining the allegiance of more physicians to your program to drive better coordination of care.” A successful ACO also requires a population health approach to managing healthcare by identifying patients most at risk and putting programs in place that captures those patients and drives specific programs focused on improving quality and coordination of care.

One health provider that seems to have this figured out is Advocate Health Care, based in Oak Brook, Ill. Described in The New York Times piece as an innovator in the accountable care approach, Advocate Health Care has seen hospital admissions decline nearly 9 percent. The average length of stay has declined, and many other measures show them providing less care, too. Under Advocate’s deal with Blue Cross Blue Shield, certain patients are assigned to the accountable care framework – about 380,000 – and their health costs are projected. If Advocate achieves savings below that amount while meeting explicit quality targets, it splits the money with the insurer. If not, its revenue is at risk.

The Affordable Care Act has helped encourage a shift to Advocate’s payment model – an estimated 428 accountable-care organizations now cover four million Medicare enrollees and millions more people with private insurance.

Still, many remain skeptical that we have arrived at the right set of measures to allow us to declare one ACO a success and another a failure. Perhaps what is needed is a set of definitive measures, beyond readmission rates and average length of stay, that can tell us how a specific population is doing.

I’m sure that by now, many of you have had experience with ACOs. What are your thoughts? Are ACOs part of the answer to alleviating Washington’s long-term deficit problems? Feel free to weigh in on this issue in the comment field below.

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An Insider's Look at Comparative Effectiveness Research

Patrick Monaghan

JSPH Director of Communications

The Jefferson community was treated to true insider’s look at comparative effectiveness research last week when Robert W. Dubois, MD, PhD, visited campus to speak at the Jefferson School of Population Health Forum.

Dr. Dubois is the Chief Science Officer at the National Pharmaceutical Council, where he oversees NPC’s research on policy issues related to comparative effectiveness research, as well as how health outcomes are valued.

During his talk at Jefferson, “Applying Comparative Effectiveness Research and Evidence-Based Medicine to Everyday Decisions,” Dr. Dubois provided a simple definition for CER (“CER is what works, for whom, under what circumstances”); described the evidence needed to guide decisions; discussed concerns that evidence is not being used well, and outlined examples of policies impacting individual treatment, evolving payment environment, and use of real-world evidence.

“What I’m hoping is that I’ll open your eyes to some of these choices so that we collectively choose wisely,” Dr. Dubois said. “Once you’ve figured out what to do, you have to do it. None of this is going to work if we don’t make it embedded in how we make choices.”

CER, Dr. Dubois said, if you do it narrowly -- drug A vs. drug B, therapy A vs. therapy B, and looking at the cost of those interventions “you’re going to get it wrong more often than you’re going to get it right.” Policy implications, he noted, are extremely important in the CER world.

Following Dr. Dubois’s talk, members of the School of Population Health’s Grandon Society were invited to remain for a private question and answer session, which led to interesting discussions about bundled payments, rapid-cycle learning in healthcare systems, and the Patient-Centered Outcomes Research Institute (PCORI).  Asked about the political reality of bundled payments, Dr. Dubois replied “I think it’s a reality; the American public is running with the concept,” pointing out that 10 percent of American patients are in accountable care organizations (ACOs), which reward doctors and hospitals for working together to improve quality and to control costs.

Asked about his “take” on bundled payment systems, Dr. Dubois offered, “A lot of this is religion, it’s belief. I, in my core, believe this is the right way to go.”

The audio portion of Dr. Dubois JSPH Forum presentation is available on Jefferson Digital Commons  by clicking here.

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Checking in on the ACA, Three Years Down the Road

We may be a little late to the dance on this, but it needs to be acknowledged that the Affordable Care Act marked its third anniversary in March…despite 39 (unsuccessful) attempts to have it repealed.

So, three years down the road, the question, with a nod to the late Ed Koch, needs to be asked: “How’m I doin’?” Well, despite Republican leaders in Congress who regularly denounce the ACA, vow to block funding to carry it out or even repeal it, the answer is “not bad.”

Although the date for full implementation of most provisions of the law is January 1, 2014, the ACA has already had an impact on the goals of expanded coverage of the uninsured, improved access and better care delivery models, broader access to community-based long-term care, and more integrated care and financing for beneficiaries who are dually eligible for Medicare and Medicaid. While the ACA remains controversial, with many debates about its future as well as provisions already implemented, implementation is moving ahead.

Beginning in 2010, young adults up to age 26 can remain on their parents’ insurance policies even if they are no longer living with a parent, are not listed as a dependent on a parent’s tax return, or are no longer a student. According to Census data, over two million young adults have gained coverage under this provision, contributing to the decline of 1.3 million in the number of uninsured Americans in 2011.

Additional highlights include:

• 17 million Americans now receive some kind of free preventive service, such as flu shots, and 34 million Medicare recipients received free preventive services in 2012
• 17 million children with pre-existing conditions are now protected against being uninsured
• More than 107,000 adults with pre-existing conditions finally have insurance under the federally run insurance program
• 21 million received care from expanded community health centers; 3 million more than previously served
• $1.1 billion in rebates, an average of $151 per family, was paid by insurers that failed to meet the benchmark of 80 to 85 percent of premium revenues on medical claims or quality improvements
• Since 2010, more than 6.3 million older or disabled people have saved more than $6.3 billion on prescription drugs.

Perhaps most importantly, there are signs that the ACA has already started to help slow the growth of health care costs and improve the quality of care through value-based purchasing programs, strengthened primary care and care coordination, and pioneering Medicare payment reforms. For each year from 2009-2011, National Health Expenditure data show the real rate of annual growth in overall health spending was between 3.0 and 3.1 percent, the lowest rates since reporting began in 1960.

Speaking of primary care, providers get increased Medicare and Medicaid payment rates under the ACA, according to a Kaiser Family Foundation report. The law provides for a 10 percent bonus payment on top of the regular Medicare fee schedule amount for many services provided by primary care physicians (and other practitioners) from 2011 through 2015. The law also requires states to raise their Medicaid payment rates in 2013 and 2014 to Medicare payment levels for many primary care physician services. As a result, Medicaid primary care fees will increase by 73 percent, on average, in 2013 although the size of the increase will vary by state.

As a recent editorial in The New York Times noted, one of the most promising aspects of the ACA is its focus on improving quality. According to the editorial, the percentage of Medicare patients requiring readmission to the hospital within 30 days of discharge dropped from an average of 19 percent over the past five years to 17.8 percent in the last half of 2012, an improvement due in large part to penalties imposed by Medicare to providers to encourage better coordination of care after a patient leaves the hospital.

It’s also worth noting that, as we here at JSPH have, the ACA supports population-based prevention activities through a new Prevention and Public Health Fund. This Fund has been used to make over $1 billion in critical investments in programs aimed at reducing the burden of chronic disease an improving overall health of communities. Funding has supported Community Transformation Grants in 36 states to reduce the incidence of heart attacks, strokes, cancer, and other diseases; rebuilding the immunization infrastructure, tobacco cessation programs; and substance abuse and suicide prevention activities.

Happy(belated) Birthday, ACA. This School of Population Health feels you’re on the right track, and we feel we are, too.

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Meeting at the Crossroads of Social Work and Public Health

Patrick Monaghan

JSPH Director of Communications

The School of Population Health acknowledged National Public Health Week (NPHW) by hosting a lunchtime symposium, “Meeting Again at the Crossroads: Social Work and Public Health.”  Since 1995, the first full week of April has been a time when communities across the United States recognize the contributions of public health and highlight issues that are important to improving our nation.

This year, JSPH took a closer look at the connection between public health and social services. Although the two fields share historical roots, their paths have diverged until recently.  But today’s complex health issues require the expertise of both professions and the lunchtime symposium explored the intersection of public health, social services, health care, and health policy.

Moderated by Darlyne Bailey, PhD, LISW, Dean and Professor at the Graduate School of Social Work and Social Research (GSSWSR) of Bryn Mawr College, panelists included Cindy Sousa, PhD, MSW, MPH, an Assistant Professor at GSSWSR; Jennifer Campbell, PhD, MSW, a consultant, and Lecturer at GSSWSR; JoAnne Fischer, MSS, Executive Director of the Maternity Care Coalition and Bryn Mawr alumna; and Christina Miller, MSS, Senior Program Director of the Health Promotion Council, and also a Bryn Mawr Alumna.

Each provided a vital element of the formula that fuses public health and social work, from Christina Miller’s work with the Health Promotion Council, which has programs that include chronic disease risk reduction and professional education and consulting; to Cindy Sousa’s research on investigations of violence, stress and trauma and their relationships to health and well-being; to JoAnne Fischer’s work making the needs of mothers and their families visible through policy advocacy and research  as executive director of the Maternity Care Coalition; to Jennifer Campbell’s work strengthening grantmaking for an aging society.

The symposium served as a poignant reminder that many quality improvement techniques – including the promotion of evidence-based treatments and well-coordinated care – can improve health outcomes, but their influence is often limited by factors beyond clinicians’ control, such as patients’ education, employment, and social support. In order to address the social and economic factors that affect health, quality improvement initiatives must reach beyond the traditional boundaries of the health care system. The panelists gathered at JSPH this week was representative of the community-based partnerships that bring a wide range of stakeholders – health care providers, educators, business leaders, social service providers, community organizations, and clergy – together to promote healthy behavior, improve access to primary and preventive care, and reduce health disparities.

The program also further strengthened the partnership between JSPH and GSSWSR. Last fall, the schools began offering a dual degree MSS/MPH program, acknowledging the long-standing synergy between social work and public health, and also recognizing the growing interest among professionals to further their preparation by earning multiple graduate degrees.

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A Civil Dialogue on a Traditionally Volatile Topic

Patrick Monaghan
JSPH Director of Communications

If there was one thing that the inaugural Bernard Wolfman Civil Discourse Project proved, it’s that two people from differing sides of the health care debate can come together and have an intelligent conversation about this traditionally volatile topic.

Thursday evening’s public forum was conducted at Beth SholomCongregation in Elkins Park, the spectacular synagogue designed, appropriately enough, by Frank Lloyd Wright. Wright’s structures, of course, were designed to work in harmony with humanity and its environment.

The event is the brainchild of Dina Baker, a congregation member who works in the healthcare field, to honor her late father. The experts were our very own David B. Nash, and Stuart Butler, director of the Center for Policy Innovation at the Heritage Foundation in Washington. Moderating the event was Chris Satullo, vice president for news and civic dialogue at WHYY/Newsworks Philadelphia. Satullo set the mood for the evening in his opening remarks: “Tonight is not a debate. No one will win, no one will lose. Disagreements will remain.”

And that’s pretty much how the discussion unfolded. If you’re into labels, Dr. Nash’s leanings are more liberal; Dr. Butler’s, conservative. Regardless, these two health policy experts were clearly on the same page more often than not. When Dr. Nash said cutting waste, not cost, is the right tact for improved performance in our healthcare system, Dr. Butler concurred, adding that the problem is determining what, exactly, is waste. When Mr. Satullo suggested that electronic medical records have not proven to be the efficient, waste-cutting tool advertised under the Affordable Care Act, both parties agreed. The bigger problem, Dr. Nash said, is that we still fail to practice basic care coordination.

Dr. Nash did draw what was perhaps the biggest applause of the evening when he defended the ACA as an attempt by the Obama Administration to do the right thing. Perfect? Far from it. A good start? Yes. And something that previously had never been accomplished in this country.

Still, countered Dr. Butler, the federal government needs to realize its limitations when it comes to fixing our healthcare system. The U.S. healthcare spend, he noted, is equivalent to the sixth largest economy in the world.

In the end, both agreed it is important for all citizens to engage in the conversation on health care. There are steps we can all take to influence how healthcare dollars are spent, be it by exercising more, initiating important conversations with family members about end-of-life care, or, as Dr. Nash said, practicing charity.

Disagreements may have been hard to come by at the inaugural Bernard Wolfman forum. Smart, civil dialogue certainly was not.

Drs. Butler and Nash authored commentaries that ran in last Sunday's Philadelphia Inquirer. You can read Dr. Nash's commentary here, and Dr. Butler's, here.

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Join Grandon Society for 'Brown Bag' Lunch with Dean

 
Amanda Solis
JSPH Project Director

When you join the ranks of JSPH, you quickly learn the unintended consequences of working in an office full of faculty and staff members who are passionate about wellness, health policy, and population health. Most days, this results in a fascinating dialogue on the current state of events. On the other hand, it also forces you to be mindful of your own habits and diet.

Working at JSPH also presents opportunities to interact with thought leaders in population health and outcomes research. Naturally, we regularly have face-to-face time with Dr. Nash at brown bag lunch discussions…and I will always remember how we all sat in our conference room to await the Supreme Court’s decision on the Affordable Care Act. You also never know who is going to show up in the conference room – be it the CEO of Humana or Jeffrey Brenner (who most likely rode his bike here to discuss his latest work in Camden).

In an effort to share this sense of community with each of you, we developed the Grandon Society. Read more about this 100+ member group here, where the rates and benefits are more formally outlined. Ultimately, our goal is to invite you into our office culture and have you join our “water cooler” discussions.

To this end, we are hosting our first members-only “Brown Bag” webinar with Dr. Nash. Join us on Wednesday, April 3, 2013 at 12 pm for a one-hour chat. This unscripted, off-the-cuff session is your chance to hear about his favorite “aha!” moment from the Population Health Colloquium, learn where he traveled that week and who he met with, and witness his unbridled enthusiasm for all things related to population health. Truth be told, we can’t predict what he will say or surprise us with on any given day – and we (gulp) invite you to become part of our team.

Curious? Click here for information on joining the Grandon Society; as a member you will receive invites to discounted programs and be able to join us on April 3rd for a glimpse into Dr. Nash’s candid thoughts on all things population health.

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March Madness... JSPH style!

It's already March and I am thinking about the crazy month ahead. Not about basketball but about all of the amazing activities that await us. Starting this week I will have the distinct privilege to deliver the plenary address at the QSEA meeting in Tempe, AZ.

QSEA -- the quality and safety educator's academy! This is the premier group in the nation composed largely of medical school-based faculty who teach the tenets of quality and safety to young physicians across the training spectrum. QSEA is at the leading edge of the movement to bring these tenets into the medical education mainstream. This remains an uphill battle!

Next week the JSPH will host the 13th Annual Population Health Colloquium. We will break all of our previous attendance records and faculty from around the nation will present dozens of plenaries, workshops, and break out sessions. Headliners include Jeff Brenner, Paul Grundy, Sue Dentzer and scores more. Our Professional Development team has worked tirelessly for months to build this program.

As soon as the Colloquium ends I will be on a train to Washington, DC to deliver the Saturday plenary address at the Annual Meeting of the American Medical Student Association (AMSA). With over 1,000 students in attendance, the AMSA meeting is a "cultural happening". I intend to deliver a veritable "call to arms" to encourage students everywhere to create bottom up changes in the medical school curriculum. I hope students will petition their own faculty to include more training on the tenets of quality, safety and population health.

JSPH is on the move and this is our brand of March Madness!

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Honoring a Father's Legacy Through Civil Dialogue

  

Nash on Health Policy is pleased to present this guest blog by Dina Wolfman Baker.

By Dina Wolfman Baker

My father died in August 2011 after a life as a champion of civil rights and a respected scholar of legal ethics and tax law. He sought justice through lifelong learning and action and he believed that civil dialogue was key to those outcomes.

When we were young, my father exacted ten cents whenever he heard me or my brothers dismiss each other with the phrase “shut up.” That was our earliest lesson in civil discourse:  We were to find respectful ways to disagree.

While reflecting on my father’s life, I thought about the state of discourse around public policy. If people with differing views could not talk among and truly hear each other, how could we learn?  If we could not learn, how could we take meaningful, informed action? And if we could not take action, how could we progress? 

So I decided to honor my father’s legacy by creating The Bernard Wolfman Civil Discourse Project. Its centerpiece is a forum for exploring critical policy issues while modeling civil dialogue between leading experts from differing positions and providing concrete opportunities to take action.

I’m incredibly excited that our inaugural forum on March 28^th features two nationally recognized experts to discuss the federal government’s role in health care policy. One is Dr. Nash, and I’m delighted to be his guest on this blog.  The other speaker, Dr. Stuart Butler, is director of the Center for Policy Innovation at The Heritage Foundation in Washington, D.C. Dr. Butler, also an adjunct professor at Georgetown University Graduate School, has been a fellow at Harvard University's Institute of Politics, and serves in major national health policy roles.

Working with Dr. Nash and Dr. Butler has been incredibly gratifying, because they treat each other—and each other’s ideas—with genuine respect and enthusiasm. Imagine how much my father would have loved to be in their audience!

The Bernard Wolfman Civil Discourse Project will be 7:30 pm, Thursday, March 28 at Beth Sholom Congregation, 8231 Old York Road, Elkins Park, PA. Register by clicking here.

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