HEALTH Vol. 9 No. 3
Special Conference Edition Leonard D. Schaeffer Health Care Reform: A 50-State Experiment, p.10 A Mission to Advance Primary Care and the PCMH, p.20 Medicare Advantage: The Core Line of Business for the Future, p.32
June 2015
Confidence The feeling you have when you are affiliated with Hill Physicians. Anne Hsii, M.D.
Hill Physicians provider since 2013. Uses Ascender preventive care reminders and Hill inSite to review eClaims and eligibility.
At Hill Physicians, we continue to improve upon coordinated care, with remarkable results. We provide the tools and support that practices need to be financially successful and improve the coordinated care experience for their patients. Our advantages include: • Fast, accurate claims payments • Free eReferrals, ePrescribing and online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,800 independent primary care physicians, specialists and healthcare professionals have joined Hill. Feel confident in the future of your practice and your patients by affiliating with Hill Physicians Medical Group.
For more about the advantages of affiliating, visit HillPhysicians.com/JoinUs.
Hill Physicians’ 3,800 healthcare providers accept HMOs and many PPOs from Aetna, Anthem Blue Cross, Blue Shield, CIGNA, Easy Choice, Health Net, Humana, SCAN, San Francisco Health Plan, United Healthcare WEST and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.
The roles have changed. The rules have changed. The patients have changed. • Your patients are living longer with serious, chronic illness. • Fragile patients and their families are frustrated by expensive, disjointed healthcare. • Nearly 50% of US healthcare expenditures goes to 5%
of the population, those patients most at risk.*
VITAS can help. With 35 years of hospice experience, VITAS Healthcare brings end-of-life expertise to patients with complex medical and psychosocial needs. We care for them wherever they reside. We help physicians accelerate the evolution to high-value, high-quality care.
VITAS.com • 800.93.VITAS *Cohen SB and Yu W. The Concentration and Persistence in the Level of Health Expenditures Over Time: Estimates for the U.S. population 2008-2009. Agency for Healthcare Research and Quality, January 2012.
The Impact of
The numbers may surprise you, but the most important number of all is one. It’s our commitment to caring for our community one patient at a time. From our top ranked hospitals to our vibrant and growing primary care network, UCLA is world-renowned but focused right here at home. It’s a commitment we can all count on.
1-800-UCLA-MD1 (1-800-825-2631)
uclahealth.org
uclahealth.org/getsocial
Over
30
years of
managed care experience
1,200 150 40
physicians
Over
community offices
Over
primary care offices
Patients enter our community offices
2.5 million times each year Santa Clarita
N
Simi Valley 118
map not to scale
Porter Ranch
23
210
Northridge
Thousand Oaks
Panorama City
5
170
Burbank
2
Pasadena
134
101
Westlake Village
Arcadia
405
101
Brentwood Malibu
Pacific Palisades
Alhambra
Westwood Santa Monica
10
Century City West Los Angeles Marina del Rey
10
90
60
605
5
110 405
710 105
Manhattan Beach Redondo Beach
91
Torrance
Palos Verdes
Fountain Valley Irvine
TABLE OF CONTENTS
ON THE COVER
10
Leonard D. Schaeffer Health Care Reform: A 50-State Experiment HEALTH Publisher
Valerie Okunami Editor-in-Chief
Don Crane
DEPARTMENTS
FEATURES
7
20
Notes from the President
A Mission to Advance Primary Care and the PCMH
Editorial Advisory Board
Lura Hawkins, MBA Amy Nguyen Howell, MD, MBA Mary Kay Payne, Arch Health Partners Managing Editor
8 Names in the News
Daryn Kobata
Stellar Service: Six Simple Steps to a
Editorial Assistant
Nelson Maldonado Contributing Writers
Bill Barcellona Don Crane Rob Francis Pete Fronte John Gorman Meryl D. Luallin Mara McDermott Marci Nielsen, PhD, MPH Leonard D. Schaeffer CAPG Health Magazine is published by
Valerie Okunami Media PO Box 674, Sloughhouse, CA 95683 Phone 916.761.1853
capghealth.com Please send press releases and editorial inquiries to capghealth@capg.org or c/o CAPG Health, 915 Wilshire Blvd., Suite 1620, Los Angeles, CA 90017 For advertising, please send email to vokunami@netscape.com Subscription rates: $32 per year; $58 two years; $3.00 single copy. Advertising rates on request. Bulk third class mail paid in Jefferson City, MO Every precaution is taken to ensure the accuracy of the articles published in CAPG Health Magazine.
14 Upcoming Events
16
Five-star Patient Experience
28 Healthcare Innovation and Practice
Federal Legislative Update:
Transformation through Clinical Studies:
Pursuing Better Health through Better
The Role of Physician Groups
Payment Models in Traditional Medicare and Medicare Advantage
18
32 Medicare Advantage is the Core Line of Business for the
CAPG Member List
Physician Group of the Future
26
34
Policy Briefing: Coverage Expansion Raises Two Key Issues
Opinions expressed or facts supplied by its authors are not the responsibility of CAPG Health Magazine. Š 2015, CAPG Health Magazine. All rights reserved. Reproduction in whole or in part without written permission is strictly prohibited.
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Special Conference Edition • June 2015
Healthcare Reform Brings New Liability Challenges for Doctors
From the President A M ES S AG E F R O M D O N A L D C R A N E , P R ES I D E N T A N D C EO , C A P G
CAPG Members and Friends: Welcome to our special June Conference Issue of CAPG Health. Whether you’re with us at the 2015 Healthcare Conference in San Diego or receiving your copy elsewhere, I hope you’ll find it valuable. Many of our conference speakers also contributed to this month’s magazine. In recent years CAPG has taken an increasingly active role in helping to shape the future of healthcare. A key part of our mission is to educate and illuminate legislators and other policymakers whose decisions affect our groups. We have had a run of successes this year that I would like to share with you.
Donald Crane, CAPG President and CEO
CAPG has joined a coordinated advocacy effort to protect and strengthen Medicare Advantage. This year, over 300 medical groups and independent practice associations signed a CAPG-led letter to the Administration urging an increase in Medicare Advantage payment. CAPG’s efforts, combined with the efforts of many others, led to an increase in the 2016 payment rates: Rather than a 0.9 percent cut, CMS issued a 1.25 percent increase–a 2 percent–plus improvement in the overall picture for Medicare Advantage. While the success is not ours alone, we know that the physician voice is an essential component to this shared victory. We thank all of the physician groups that added their support to this critical message. CAPG also extends our sincerest thanks to the many members of Congress that weighed in with the Administration to protect Medicare Advantage. In a historic move, a bipartisan majority in both chambers of Congress passed a bill to reform the way traditional Medicare pays doctors. The legislation repeals the flawed, old payment formula and puts in place incentives for physician groups that take financial risk. CAPG has worked on this new payment structure from its inception and we believe that it charts a new course for traditional Medicare that will be favorable to CAPG members and physician groups across the nation. On March 25, CAPG was privileged to join President Barack Obama, Department of Health and Human Services Secretary Sylvia M. Burwell, and other stakeholders at the White House kickoff of the Health Care Payment Learning and Action Network. This Network will serve as a forum for sharing and learning practices for transitioning from volume to value. I was honored to represent CAPG at the launch of this important program. The Administration’s efforts through the Network represent a third area of policy pressure toward capitated, coordinated care models. CAPG looks forward to continuing to work with the Administration as the Network develops. I also consider it an honor to be associated with America’s finest physician groups and their many healthcare professionals. Thanks to all of you for your continued support. o
MARK YOUR CALENDAR
and join us next year! 13th Annual CAPG Healthcare Conference June 16-19, 2016 Grand Hyatt, San Diego Special Conference Edition • June 2015
CAPG HEALTH l 7
Names in the News L.A. CARE HEALTH PLAN RAISES MINIMUM WAGE TO $15 PER HOUR Effective May 4, L.A. Care Health Plan has increased its minimum wage to $15 per hour, a change that the company anticipates will positively impact staff retention and recruitment efforts. As L.A. Care is one of the larger employers in downtown Los Angeles and the nation’s largest publicly operated health plan, CEO John Baackes said, “I believe our compensation structure must be aligned with our mission. This increase in minimum wage will contribute to our employees’ well being and to a more vibrant Los Angeles economy.” The company will also make health insurance and other benefits available to all new hires sooner.
ATHENAHEALTH CORPORATE CITIZENSHIP PROGRAM OFFERS GRANTS FOR COMMUNITY CARE athenaGives, the corporate citizenship program of athenahealth, Inc., has opened its annual grants cycle. Through July 1, nonprofits connecting healthcare in the metro Boston, San Francisco, Atlanta, Austin, Princeton, and Chennai (India) areas, and in coastal Maine can apply for grants from $5,000 to $25,000, with awards totaling $300,000. The grants are an initiative of. To date, athenahealth has donated over $1 million to organizations including The Family Van, a mobile clinic providing wellness and prevention services in underserved Boston communities, and Faith Family Clinic, a clinic in San Antonio, Texas serving the working uninsured. athenahealth, a CAPG partner, also donates its cloud-based electronic health record (EHR) service, athenaClinicals®, to qualified charitable organizations. To apply for a grant or request an athenaClinicals EHR donation, visit http:// www.athenahealth.com/about/athenagives.
PARTNERS IN CARE FOUNDATION AWARDED NCQA ACCREDITATION The Partners in Care Foundation has received a two-year accreditation from the National Committee for Quality Assurance (NCQA), a nonprofit organization widely regarded as representing the gold standard for assessing and reporting on healthcare
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Special Conference Edition • June 2015
provision quality. Partners has championed the concept of community-based care management organizations seeking quality accreditation, and is only the second CBO in the U.S. to receive the NCQA seal. Partners, a CAPG member, is a nonprofit whose mission is to change the shape of health care through transformational care models promoting health, independence, and quality of life. The organization was accredited for case management complex care, demonstrated by its successful Multipurpose Senior Services Program (MSSP). The program provides community-based care management and evidencebased self-management programs aimed at delaying or preventing unnecessary nursing home placement. Partners CEO June Simmons expressed appreciation for the MSSP team’s “extraordinary hard work and commitment,” adding, “This seal of approval is testament to the recognized benefits of communitybased, patient focused care.”
PALO ALTO MEDICAL FOUNDATION AND UNITEDHEALTHCARE COLLABORATE TO IMPROVE PATIENT CARE Palo Alto Medical Foundation (PAMF) and UnitedHealthcare have launched an accountable care organization (ACO) to better coordinate and deliver patient care for 63,000-plus Northern California residents in UnitedHealthcare employer-sponsored health plans. The ACO–one of 250 new accountable care programs UnitedHealthcare has committed to in 2015–will transition PAMF from its current fee-forservice compensation model to a value-based approach. The organization will be rewarded for achieving certain evidence-based measures such as hospital readmission rates, disease management and prevention, and patient safety, as well as cost savings. UnitedHealthcare will provide additional population health management support, including actionable data to help the group’s 500-plus primary care physicians improve quality and lower costs. PAMF is part of CAPG member Sutter Health, a family of not-for-profit hospitals and physician organizations throughout Northern California. continued on page 38
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ON THE COVER
Health Care Reform: A 50-State Experiment BY LEONARD D. SCHAEFFER, JUDGE ROBERT MACLAY WIDNEY CHAIR AND PROFESSOR, UNIVERSITY OF SOUTHERN CALIFORNIA
INTRODUCTION In March, the Affordable Care Act (ACA) marked its five-year anniversary. After the disastrous rollout of the federal and some state health insurance exchanges, there were finally some accomplishments to recognize. The uninsured rate declined, hospitals report lower uncompensated care and health care shows signs of becoming more value based. At the same time, a new environment has emerged where change is the only constant. Health care stakeholders now operate under extreme legislative, regulatory, political and social uncertainty. Yet despite continuous change, one issue remains the same: the problem of health care costs.
THE COST PROBLEM
“
The ACA was mainly about expanding Medicaid and reforming the private health insurance market… Thus, states have become laboratories for state governments and health plans to incubate new ways to control costs.”
The nation’s health care spending accounts for 17.4 percent of GDP and is projected to reach 19.3 percent by 2023. Federal spending on Medicare and Medicaid combined with interest payments drives total spending and the federal debt. In the private sector, high health care costs drain resources that employers need to compete and erode workers’ wages. Long-term, rising health care costs increase the debt and borrowing from foreign lenders, which threatens both the economy and national security. The good news is that, since 2009, health care cost growth has slowed to less than 4.1 percent per year and this slowdown includes Medicare. There is debate about whether the slowdown has been caused by the recession or by structural changes such as insurance design, limits on Medicare and Medicaid reimbursements, and increased provider efficiency. A Kaiser Family Foundation study estimated that economic factors explained 77 percent of the slowdown. If true, this means the bend in the cost curve will not last. Health care spending will accelerate as the economy improves, ACA coverage expansions continue, and baby boomers enroll in Medicare and Medicaid. Indeed, the Congressional Budget Office projects that, beginning in 2014, average health care cost growth will rise to about 6.0 percent per year through 2023. The Kaiser study also estimated that nearly a quarter of the slowdown is due to changes in the health care system. If true, this means a movement to control costs and improve quality through permanent system change may be underway. Accelerating this trend will require implementing incentives that support excellent physician performance.
STATES AS LABORATORIES The ACA included multiple provisions to reduce costs. In addition to direct cuts, many of these provisions are “top-down” Medicare experiments–ACOs, other valuebased payment models, and penalties–to help CMS control service volume (an effort continued on page 12
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Special Conference Edition • June 2015
2015 CAPG COLLOQUIUM
Achieving Success in Risk-based Coordinated Care October 5-7 • Washington Marriott Wardman Park, Washington, DC
Government and commercial payers are demanding that physicians and hospitals move from volume to value— specifically, to move into risk-bearing arrangements. Many providers would like to, but are unsure as to just how to do so safely. If this describes you or your organization, this conference is designed for you.
Featured speakers include: Bernard J. Tyson
Chairman and CEO, Kaiser Foundation Hospitals and Health Plan, Inc.
Meena Seshamani
Joseph R. Swedish
President and CEO, Anthem, Inc.
Suzanne Anderson, MBA
Director, Office of Health Reform, U.S. Department of Health and Human Services
Executive Vice President, Chief Information Officer and Chief Financial Officer, Virginia Mason Health System
Patrick Conway, MD, MSc
Kenneth Cohen, MD
Deputy Administrator for Innovation and Quality and Chief Medical Officer, Centers for Medicare & Medicaid Services
Mark E. Miller, PhD
Executive Director, Medicare Payment Advisory Commission
John Gorman
Executive Chairman, Gorman Health Group
Keith Fernandez, MD
President and Physician in Chief, Memorial Hermann Physician Network; Chief Medical Officer, Memorial Hermann ACO
Chief Medical Officer, New West Physicians; Clinical Assistant Professor of Medicine, University of Colorado School of Medicine
Mariella Cummings
Chief Executive Officer, Physicians of Southwest Washington
John Rother
President and CEO, National Coalition on Health Care
Alan Murray
President and Chief Executive Officer, North Shore-LIJ CareConnect Insurance Co.
Richard Miller, MBA
Senior Vice President, Payer Relations and Contract Development, NorthShore LIJ Health System
Sheila Burke
Faculty Research Fellow and Faculty, John F. Kennedy School of Government, Harvard University; Chair, Government Relations and Public Policy, Baker, Donelson
Edmund F. Haislmaier
Senior Research Fellow, Health Policy Studies, The Heritage Foundation
Chris Jennings
President and Founder, Jennings Policy Strategies, Inc.
Kavita Patel, MD
Managing Director for Clinical Transformation and Delivery, Engelberg Center for Healthcare Reform, The Brookings Institution
Register at capgcolloquium.com or call 800.503.3650 Don’t forget to tell your colleagues! Spring 2015
CAPG HEALTH l 11
Health Care Reform...continued from page 10
continued in the sustainable growth rate [SGR] repeal). The reality, however, is that the ACA was mainly about expanding Medicaid and reforming the private health insurance market for individuals and small groups. Thus, states have become laboratories for state governments and health plans to incubate new ways to control costs. The burden is on health plans to make coverage affordable, but accomplishing this goal will differ across the states. First, health plans face similar factors that impact the strategies they can use. These constraints include insurance reforms such as guarantee issue and renewability, comprehensive benefits, rate bands and medical loss ratios. In addition, the honeymoon period for learning what works will end as health plans lose financial protections provided by the ACA’s risk corridor and reinsurance programs in 2017. Second, at the same time that health plans face some similar challenges, they must also adapt their efforts to different state environments. States vary with respect to politics, regulations, exchange management and competition, Medicaid expansion, delivery system integration, information technology and health status. Some states may also pursue ACA alternatives through section 1332 waivers. Ultimately, geography is destiny: health plans (and, consequently, providers and patients) will experience the ACA differently, depending on the state.
Historically, physician organizations have had to respond to the conflicting goals of a fee-for-service culture. As health care moves toward value-based care, however, new values and behaviors are needed that support primary care, prevention, coordination and integration of care for a population, along with performance measurement to ensure accountability. In addition, an aging population will influence physicians to engage in shared decision-making and advance care planning to improve end-of-life care.
IMPLICATIONS FOR PHYSICIANS As enrollment grows in public (and private) health insurance exchanges, Medicaid, and Medicare Advantage, health insurers are implementing multiple physiciandirected mechanisms to control costs. Current approaches include payment methods that reward outcomes, narrow networks that encourage patients to use cost-effective providers, and high-deductible plans that place greater financial responsibility on patients. As other effective strategies emerge, they too will be implemented in some states. Providers may use legal and regulatory means or market leverage to push back. However, payers will continue to pressure physicians to wring costs out of the system. Achieving greater efficiency will require organizational and cultural change in physician practices. Organizationally, independent practice is waning as physicians join organized delivery systems and hospitals. These larger organizations have the integrated HIT infrastructure and data required to realign financial incentives to support evidence-based care and population health management.
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CONCLUSION ACA and marketplace pressures to control costs are transforming health care. Many payer innovations to address costs will occur in Medicaid and state health insurance markets. Physicians are responding by joining organized delivery systems. For these systems to succeed, physicians need to assume new roles as leaders and managers who can motivate their colleagues to support their organization’s cost and quality strategies. Ultimately, if costs are not controlled, budget hawks will join national security experts to force across-the-board cuts in an effort to protect the nation’s economy and security. o Leonard D. Schaeffer is the Judge Robert Maclay Widney Chair and Professor at the University of Southern California. He was the founding Chairman and CEO of WellPoint (now Anthem), one of the nation’s largest health benefits companies, from 1992 through 2004, continuing as Chairman through 2005. He will present the CAPG Healthcare Conference opening keynote session Friday morning, June 12.
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CAPG HEALTH l 13
E V E N T S
CAPG ANNUAL HEALTHCARE CONFERENCE Thursday through Sunday, June 11–14 Grand Hyatt, San Diego*
NATIONAL CAPG COMMITTEE Thursday, June 11 Grand Hyatt, San Diego*
PUBLIC POLICY COMMITTEE Thursday, June 18 Conference Call*
PUBLIC RELATIONS/MARKETING COMMITTEE Tuesday, July 7 Los Angeles, CAPG Office*
PUBLIC POLICY COMMITTEE Thursday, July 9 Conference Call*
U P C O M I N G
SAN DIEGO REGIONAL MEETING Tuesday, July 14 San Diego, Sharp Spectrum Auditorium*
INLAND EMPIRE REGIONAL MEETING Wednesday, July 15 Riverside, Mission Inn*
ACO COMMITTEE Tuesday, July 21 WebEx*
CONTRACTS COMMITTEE Thursday, July 23 Los Angeles, CAPG Office*
PUBLIC POLICY COMMITTEE Thursday, August 13 Conference Call*
COLORADO REGIONAL MEETINGS Thursday, August 20 TBD*
PENNSYLVANIA REGIONAL MEETINGS Tuesday, August 25 TBD*
PHARMACEUTICAL CARE COMMITTEE Tuesday, July 28 Los Angeles, CAPG Office*
PRIMARY CARE PRACTICE TRANSFORMATION COLLABORATIVE Wednesday, August 12 Los Angeles, CAPG Office*
*For more information contact CAPG at 213.624.CAPG.
If you have an event to list in this column, please submit it at capghealth@capg.org. Include the name of the event, date, location, and where to get additional information.
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cainfo@logisticare.com | 886.246.5875 | www.logisticare.com November/December 2014 Winter 2015
CAPG HEALTH l 25 15
Federal Legislative Update Pursuing Better Health through Better Payment Models in Traditional Medicare and Medicare Advantage BY MARA MCDERMOTT, VP OF FEDERAL AFFAIRS, CAPG
CAPG members are at the forefront of an exciting transition in Medicare payment. Taken together, a number of separate actions in traditional Medicare and Medicare Advantage (MA) by both Congress and the Obama Administration are building momentum toward capitated payment and coordinated care delivery models. THE ADMINISTRATION SETS AMBITIOUS VALUE-BASED PAYMENT GOALS First, the Administration announced goals to move traditional Medicare from fee-for-service to a value-based delivery model. Secretary of Health and Human Services Sylvia Burwell set targets for the delivery system to move 30 percent of Medicare payments to alternative payment models by 2016 and 50 percent by 2018. The Secretary estimates that about 20 percent of Medicare’s payments are in these models today. CAPG was thrilled to join President Obama and Secretary Burwell at the March kickoff for the Healthcare Payment Learning and Action Network. The Network is being established to facilitate movement toward the value goals. Following up our participation in that event, CAPG has set its own ambitious value goals for our members: to move 90 percent of Medicare payments to capitation by 2018. We believe that this is an attainable goal, because of both the incentives put in place by recently enacted legislation and exciting developments in the MA regulatory space. CONGRESS ACTS: THE DEATH OF THE SUSTAINABLE GROWTH RATE (SGR); THE BIRTH OF ADVANCED APM INCENTIVES Second, Congress passed and President Barack Obama signed legislation that transforms the Medicare fee-for-service payment model. This model now provides incentives for physician organizations to take financial and clinical risk and opens the door for the proliferation of capitated medical groups in traditional Medicare.
has set its “CAPG own ambitious value goals for our members: to move 90% of Medicare payments to capitation by 2018.”
The sustainable growth rate (SGR) formula, which became law in 1997, was intended to control physician spending. However, in practice, the law resulted in an annual series of proposed cuts to physician payments, ultimately around a 20 percent reduction each year. In fact, Congress has acted 17 times to avert cuts resulting from the SGR formula. Each time Congress averted the SGR cut, it typically cut funds from other places in the healthcare industry to pay for the “doc fix” legislation. In recent years, Congress had cut from Medicare Advantage to offset the cost of fixing the physician formula. This cycle became unsustainable because of the unpredictability for physicians in traditional Medicare and the risk of cuts to the rest of the healthcare industry.
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Special Conference Edition • June 2015
continued on page 36
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CAPG HEALTH l 17
ORGANIZATIONAL MEMBERS Accountable Health Care IPA George M. Jayatilaka, MD, CEO Druvi Jayatilaka, Vice President
M E M B E R S
Advanced Medical Management, Inc. Kathy Hegstrom, President • Access Medical Group/Access Santa Monica • Community Care IPA • MediChoice IPA • Premier Care IPA • Seoul Medical Group • Adventist Health Physicians Network IPA Arby Nahapetian, MD, CMO Jim Agronick, VP – IPA Operations Affinity Medical Group Richard Sankary, MD, President Scott Ptacnik, COO Alameda Health Partners William Peruzzi, MD, Chairman David Cox, Treasurer/CFO AllCare IPA* Randy Winter, MD, President Matt Coury, CEO All Care Medical Group Samuel Rotenberg, MD, Medical Director Craig Kaner, Administrator Allied Physicians of California Thomas Lam, MD, CEO Kenneth Sim, MD, CFO Alta Bates Medical Group Richard L. Oken, MD, President and Chairman of the Board Evan Moore, Vice President, East Bay Region AltaMed Health Services Corporation* Martin Serota, MD, Chief Medical Officer Castulo de la Rocha, JD, President/CEO AppleCare Medical Group, Inc.* Surendra Jain, MD, Chief Medical Officer Vinod Jivrajka, MD, President/CEO
C A P G
Bakersfield Family Medical Center Ju Hwan Lee, MD, Medical Director Bayhealth Physician Alliance, LLC Joseph M. Parise, DO, Medical Director Evan W. Polansky, JD, Executive Director Beaver Medical Group* Charles Payton, MD, VP Medical Administration/CMO John Goodman, President/CEO Brown & Toland Physicians* Andrew M. Snyder, MD, Chief Medical Officer Richard Fish, CEO California Pacific Physicians Medical Group, Inc. Dien V. Pham, MD, Chief Executive Officer Carol Houchins, Administrator CareMore Medical Group Tom Tancredi, Dir. of Practice Operations Catholic Health Initiatives* Chris Stanley, MD, VP of Care Management Don Lovasz, President, Clinically Integrated Network Cedars-Sinai Medical Group* Stephen C. Deutsch, MD, Chief Medical Director Thomas D. Gordon, CEO Central Ohio Primary Care Physicians, Inc. J. William Wulf, MD, CEO Michael Ashanin, COO
Children’s Physicians Medical Group Leonard Kornreich, MD, President and CEO Chinese Community Health Care Association John M. Williams, PharmD., CEO Polly Chen, Director of Operations Choice Medical Group IPA Manmohan Nayyar, MD, President Marie Langley, IPA Administrator Cigna Medical Group Kevin Ellis, DO, Chief Medical Officer Edward Kim, President and General Manager Citrus Valley Independent Physicians Jorge Reyno, MD, Executive Medical Director Martin Kleinbart, DPM, Chief Strategy Officer Colorado Permanente Medical Group, P.C. William G. Wright, MD, Executive Medical Director Dan A. Oberg, CFO & VP Corporate Development Community Health Innovations Anthony Chavis, MD, VP Enterprise & CMO Liz Lorenzi, VP/COO Conifer Health Solutions Megan North, CEO • AKM Medical Group • Amvi Medical Group • Exceptional Care Medical Group • Family Choice Medical Group • Family Health Alliance • Huntington Park Mission Medical Group • Medicina Familiar Medical Group • New Horizon Medical Group • Noble Community Medical Associates • OmniCare Medical Group • Premier Physician Network • United Care Medical Group • Continucare Corporation Alfredo Ginory, MD, Chief Medical Officer Gemma Rosello, Vice President DCHS Medical Foundation Dean M. Didech, MD Chief Medical Officer Ernest Wallerstein, CEO Desert Oasis Healthcare Marc Hoffing, MD, Medical Director Dan Frank, Chief Operating Officer Dignity Health Bruce Swartz, SVP, Physician Integration Edinger Medical Group Matthew C. Boone, MD, Executive Medical Director Denise McCourt, Chief Operating Officer Empire Physicians Medical Group* Steven Dorfman, MD, President Yvonne Sonnenberg, Executive Director Everett Clinic, P.S., The* Adrianne Wagner, Quality Improvement Consultant Manager Shashank Kalokhe, Associate Administrator of Value-Based Contracting and Coordinated Care Facey Medical Foundation* Erik Davydov, MD, Medical Director James M. Slaggert, CEO Golden Empire Managed Care, Inc.* Michael Myers, President and CEO Good Samaritan Medical Practice Association Nupar Kumar, MD, Medical Director Greater Newport Physicians Medical Group, Inc.* Adam Solomon, MD, CMO Diane Laird, CEO HealthCare Partners* Don Rebhun, MD, Corporate Medical Director Kent Thiry, Chairman and CEO, DaVita
* Indicates 2015 - 2016 Board Members
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Heritage Provider Network* Richard Merkin, MD, President Richard Lipeles, Chief Operations Officer • Affiliated Doctors of Orange County • Bakersfield Family Medical Group • California Coastal Physician Network • California Desert IPA • Desert Oasis Healthcare • Greater Covina Medical Group • HealthCare Partners, IPA, AZ & NY • Heritage Physician Network • Heritage Victor Valley Medical Group • High Desert Medical Group • Priority Care Plus, AZ • Regal Medical Group • Sierra Medical Group • High Desert Medical Group Charles Lim, MD, FACP, Medical Director Anthony Dulgeroff, MD, Assistant Medical Director Hill Physicians Medical Group, Inc.* Tom Long, MD, Chief Medical Officer Darryl Cardoza, CEO John Muir Physician Network Ravi Hundal, MD, Medical Director Lee Huskins, Interim CEO/SVP/COO Lakeside Community Healthcare Kerry Weiner, MD, Chief Medical Officer Jonathan Gluck, Counsel Lakeside Medical Group, Inc. Lakewood IPA Jean Shahdadpuri, MD, MBA, Chief Medical Officer Varsha Desai, Chief Operating Officer • Alamitos IPA • St. Mary IPA • Brookshire IPA • Loma Linda University Health Care J. Todd Martell, MD, Medical Director Maverick Medical Group Warren Hosseinion, MD, Chairman Mark C. Marten, CEO MED3000 Gary Proffett, MD, Medical Director Lynn Stratton Haas, CEO • SeaView IPA • Valley Care IPA • MedPoint Management Rick Powell, MD, Chief Medical Officer Kimberly Carey, President • Accountable Healthcare IPA • Bella Vista Medical Group IPA • Centinela Valley IPA • El Proyecto Del Barrio, Inc. • Global Care Medical Group • HealthCare LA IPA • Jewish Home for the Aging IPA • Pioneer Provider Network, A Medical Group, Inc. • Premier Physicians Network • Prospect Medical Group, Inc. • Redwood Community Health Network • Watts Healthcare Corporation • MemorialCare Medical Group* Mark Schafer, MD, CEO Jennifer Jackman, Chief Operating Officer Meritage Medical Network J. David Andrew, MD, Medical Director Joel Criste, CEO Mid-Atlantic Permanente Medical Group, PC Bernadette Loftus, MD, Associate Executive Director for MAS Jessica Locke, Special Assistant Molina Medical Centers* Keith Wilson, MD, Vice President of Clinical Services Gloria Calderon, Vice President of Clinic Operations Monarch HealthCare* Bart Asner, MD, CEO Ray Chicoine, President and COO MSO of Puerto Rico Richard Shinto, MD, CEO Raul Montalvo, MD, President
Muir Medical Group, IPA Steve Kaplan, MD, President Ute Burness, RN, CEO NAMM California* Leigh Hutchins, President, COO T. K. Desai, MD, SVP and CMO • Coachella Valley Physicians of PrimeCare, Inc., • Mercy Physicians Medical Group • Primary Care Associated Medical Group, Inc. • PrimeCare Medical Group of Chino • PrimeCare of Citrus Valley • PrimeCare of Corona • PrimeCare of Hemet Valley Inc • PrimeCare of Inland Valley • PrimeCare of Moreno Valley • PrimeCare of Redlands • PrimeCare of Riverside • PrimeCare of San Bernardino • PrimeCare of Sun City • PrimeCare of Temecula • Redlands Family Practice Medical Group, Inc. •
Providence Health & Services James M. Slaggert, CEO River City Medical Group, Inc. Jose Abad, MD, President/Medical Director Loren Douglas, CEO
SynerMed* George Ma, MD, Medical Director James Mason, President and CEO
Riverside Medical Clinic Steven Larson, MD, Chairman Judy Carpenter, President/COO
• Alpha Care Medical Group • Angeles IPA • Crown City Medical Group • EHS Inland Valleys IPA • EHS Medical Group – Central Valley • EHS Medical Group – Los Angeles • EHS Medical Group – Sacramento • Employee Health Systems • MultiCultural IPA • Pacific Alliance Medical Center • Southern California Children’s Network •
Riverside Physician Network Paul Snowden, COO Howard Saner, CEO
Tenet Healthcare Ronald Kaufman, CMO Jacob Furgatch, CEO, Coast Health Plan Services
St. Joseph Heritage Healthcare* Khaliq Siddiq, MD, Chief Medical Officer C.R. Burke, CEO
New West Physicians, PC Thomas M. Jeffers, MD, President and Chair Ruth Benton, CEO
• Hoag Medical Group • Mission Heritage Medical Group • St. Mary High Desert Medical Group •
Torrance Hospital IPA Norman Panitch, MD, President Triad HealthCare Network, LLC Thomas C. Wall, MD, Executive Medical Director Steve Neorr, VP, Executive Director
Northwest Permanente, P.C. Jeffrey Weisz, MD, Executive Medical Director Harry Stathos, VP and CFO
San Bernardino Medical Group Thomas Hellwig, MD, President James Malin, CEO
U.C.L.A. Medical Group* Sam Skootsky, MD, Medical Director David Hartenbower, MD, COO
Omnicare Medical Group Ashok Raheja, MD, Medical Director Toni Chavis, MD, President
San Diego Physicians Medical Group James Cordell, MD, President Joyce Cook, CEO
USC Care Medical Group, Inc. Donald Larsen, MD, Chief Medical Officer Keith Gran, CEO
The Permanente Medical Group, Inc. Oakland (North)* Sharon Levine, MD, Associate Executive Director Suketu Sanghvi, MD, Associate Executive Director
Sansum Clinic* Kurt Ransohoff, MD, Medical Director/CEO Vince Jensen, COO Santa Clara County IPA (SCCIPA)* J. Kersten Kraft, MD, President of the Board Lori Vatcher, CEO
WellMed Medical Group, P.A. George M. Rapier III, MD, Chairman and CEO Carlos O. Hernandez, MD, President
Physicians DataTrust Anthony Ausband, President Lisa Serratore, Chief Operations Officer • Greater Tri-Cities IPA • Noble AMA IPA • St. Vincent IPA • Physicians Choice Medical Group of San Luis Obispo John Okerblom, MD, President Barbara Cheever, Executive Director Physicians Medical Group of Santa Cruz County* Nancy Greenstreet, MD, Medical Director Marvin Labrie, CEO Physicians Choice Medical Group of Santa Maria John Okerblom, MD, President Barbara Cheever, Executive Director
Santé Health System, Inc Daniel Bluestone, MD, Medical Director Scott B. Wells, CEO Scripps Coastal Medical Center Louis Hogrefe, MD, APC, Chief Medical Officer Tracy Chu, Assistant Vice President of Operations Sharp Community Medical Group* John Jenrette, MD, CEO Christopher McGlone, Chief Operating Officer
Physicians of Southwest Washington, LLC Gary R. Goin, MD, President Mariella Cummings, CEO
• Graybill Medical Group • Arch Health Partners • Sharp Rees-Stealy Medical Group* Alan Bier, MD, President Stacey Hrountas, CEO
PIH Health Physicians Deeling Teng, MD, Sr. Medical Director, Group Operations Ramona Pratt, RN, COO, Group Operations
Southeast Permanente Medical Group, Inc., The Michael Doherty, MD, Executive Medical Director and Chief of Staff
Pioneer Medical Group, Inc.* Jerry Floro, MD, President John Kirk, CEO
Southern California Permanente Medical Group* Vito Imbasciani, MD, Director of Government Relations James Malone, Medical Group Administrator
Preferred IPA of California Mark Amico, MD, Medical Director Zahra Movaghar, Administrator Prospect Medical Group* Jeffrey Hay, MD, CMO Mitchell Lew, MD, CEO
Sutter Health Foundations & Affiliated Groups* Jeffrey Burnich, MD, SVP and Executive Officer, Sutter Medical Network Brian Roach, President, Mills Peninsula Division of PAMF
• AMVI/Prospect Health Network • Gateway Medical Group • Genesis Healthcare • Nuestra Familia Medical Group • Pacific Healthcare IPA • Prospect Corona • Prospect HealthSource • Prospect Huntington Beach • Prospect Northwest Orange County • Prospect Orange County • Prospect Professional Care • Prospect Van Nuys • Providence Medical Management Services Bart Wald, MD, Physician Chief Executive Phil Jackson, Chief Integration and Transformation Officer • Korean American Medical Group • Providence Care Network •
• Brown & Toland Physicians • Central Valley Medical Group • East Bay Physicians Medical Group • Gould Medical Group • Marin Headlands Medical Group • Mills-Peninsula Medical Group • Palo Alto Foundation Medical Group • Palo Alto Medical Foundation • Peninsula Medical Clinic • Physician Foundation Medical Associates • Sutter East Bay Medical Foundation • Sutter Gould Medical Foundation • Sutter Independent Physicians • Sutter Medical Foundation • Sutter Medical Group • Sutter Medical Group of the Redwoods • Sutter North Medical Group • Sutter Pacific Medical Foundation •
CORPORATE PARTNERS Anthem Blue Cross of California Athenahealth Bayer HealthCare Pharmaceuticals Boehringer Ingelheim Pharmaceuticals, Inc. Humana, Inc. Merck & Co. Novartis Pharmaceuticals Novo Nordisk Patient-Centered Primary Care Collaborative SCAN Health Plan ASSOCIATE PARTNERS abbvie Arkray Astellas Pharma US, Inc. AstraZeneca Pharmaceuticals Bio-Reference Laboratories, Inc. CVS Caremark, Corp. Daiichi Sankyo Easy Choice Health Plan, Inc. Eisai, Inc. Genomic Health Gilead Sciences Incyte Corporation Johnson & Johnson Family of Companies Kaufman, Hall & Associates Kindred Healthcare, Inc. Pfizer, Inc. Ralphs Grocery Company Sanofi Sunovion Pharmaceuticals Inc. Takeda Oncology The Doctors Company Vitas Healthcare Corporation of California AFFILIATE PARTNERS Alignment Healthcare Altura Childrens Hospital Los Angeles Medical Group Mills Peninsula Medical Group Nifty After Fifty Monarch LLC Partners in Care Foundation Pharmacyclics, Inc. Redlands Community Hospital Saint Agnes Medical Group SullivanLuallin Group Ventegra, LLC
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A Mission to Advance Primary Care and the PCMH BY M A R C I N I E L S E N , P H D , M P H , C EO , PAT I E N T- C E N T E R E D P R I M A RY C A R E C O L L A B O R AT I V E
Primary care is the bedrock of an effective and efficient healthcare system and for nearly a decade, the PatientCentered Primary Care Collaborative (PCPCC) and its members have been dedicated to advancing a healthcare system built on a strong foundation of primary care and the patient-centered medical home (PCMH). Today, PCPCC’s membership represents more than 1,200 medical home stakeholders and supporters throughout the United States, and includes a broadbased coalition of industry leaders, providers, and community stakeholders. Since the inception of the PCPCC in 2006, we have championed legislative healthcare reforms that promote advanced primary care as part of health system transformation, including the passage of the Patient Protection and Affordable Care Act and the recent repeal of the Sustainable Growth Rate formula for Medicare provider reimbursement. In addition, we have voiced strong support for the development and expansion of various Centers for Medicare & Medicaid Services pilots and demonstrations built on a strong foundation of primary care, including those that engage multiple payers, such as the Comprehensive Primary Care initiative and the Multi-payer Advanced Primary Care Practice. The medical home plays an integral role in all of these federal policy initiatives, and the PCPCC analyzes and disseminates information critical to policymakers, providers, and patients regarding the expanding evidence base linking the PCMH model to achieving the Triple Aim. Even with all the progress made, there is still much to be done to secure primary care’s proverbial seat at 20 l CAPG HEALTH
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the table. Through partnership with our thought leaders, Executive Members, and five Stakeholder Centers, we support advanced primary care and the PCMH through three core activities: • Disseminate results and outcomes from advanced primary care and medical home initiatives and clearly communicate their impact on patient experience, quality of care, population health, and healthcare costs;
PCPCC “The analyzes and disseminates information critical to policymakers, providers, and patients regarding the expanding evidence base linking the PCMH model to achieving the Triple Aim.”
• Educate stakeholders and advocates on public policy that advances and builds support for primary care and the medical home, including payment reform, patient engagement, and employer benefit initiatives; and • Convene healthcare experts, patients, and thought leaders in the private and public sectors to promote learning, awareness, and innovation of the medical home model.
To carry out these endeavors, we release annual publications, host monthly webinars, convene annual conferences with industry leaders, and hold monthly Executive Membership calls to discuss relevant PCMH and advanced primary care policy issues. Together, we share insights, learn from each other, and contemplate what comes next for the primary care and PCMH movement.
Looking to the future, we must bring clinicians, patients, and policymakers along with us through the transformation process to ensure the success of these advanced models of primary care. As the unifying voice for primary care across multiple stakeholders— representing healthcare professionals, technology and pharmaceutical industry, practice coaching organizations, accreditors, communitybased organizations, payers, health plans, policy makers, public health, and most importantly patients and families—the PCPCC will continue to play a critical role in advancing a high quality, cost-efficient healthcare system built on a strong foundation of primary care. Now, more than ever, we need your support and participation in helping us achieve our vision of a
ADVANCING PMB
HEALTHCARE
strengthened primary care workforce and a PCMH for everyone. If your organization believes in this vision for primary care, please consider supporting our efforts by joining the Executive Membership of the PCPCC. To learn more about our Executive Membership and how you can engage with passionate primary care leaders from across the nation at the PCPCC, please visit our website at https://www.pcpcc.org/ executive-membership and arrange a time to speak with one of our staff at 202.417.2081. o Marci Nielsen, PhD, MPH, is Chief Executive Officer of the Patient-Centered Primary Care Collaborative (PCPCC), based in Washington, DC. She will facilitate Primary Care Innovation and the Patient-Centered Medical Home, a preconference session cohosted by CAPG and the PCPCC, on Thursday afternoon, June 11, at the CAPG Healthcare Conference.
DEVELOPMENT | ACQUISITIONS | PROGRAMS & CONSTRUCTION MANAGEMENT STRATEGIC PLANNING & CONSULTING | ASSET & PROPERTY MANAGEMENT
PACIFICMEDICALBUILDINGS.COM Special Conference Edition • June 2015
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Stellar Service: Six Simple Steps to a Five-star Patient Experience BY M E RY L D . LUA L L I N , C EO , S U L L I VA N LUA L L I N G R O U P
THERE’S NO SECRET TO HIGH PATIENT SATISFACTION SCORES Typically healthcare organizations manage their team members in two different ways: clinical/procedural tasks are clearly defined and closely monitored, whereas service issues are addressed in generalities, and left to the good judgment of each individual. As a result, many service quality efforts fail because they are essentially sermons—motivational pep talks that create momentary enthusiasm but don’t produce lasting results. What’s needed is a structured, managed approach to establishing a culture of service.
SIX-STEP APPROACH TO FIVE-STAR SERVICE Successful organizations manage to transform their patients’ experiences and raise satisfaction scores through a series of practical activities designed to assess the current environment; improve patient and employee/provider experiences; and maintain the improvement gains. These actions are implemented in six simple steps.
STEP ONE: CONDUCT A SERVICE ASSESSMENT Most practices and all hospitals today conduct an assessment of their patients’ satisfaction through H-CAHPS (Hospital-Consumer Assessment of Healthcare Providers and Systems) or CG-CAHPS (Clinician Group-Consumer Assessment of Healthcare Providers and Systems) surveys. For a service assessment to be truly useful, an organization must delve beneath the survey data. By conducting mystery patient visits and mystery calls, key executives learn the experiences of faux patients, both in person and on the telephone. Did the receptionist or admitting clerk greet the patient with a smile and pleasantry? Was the caller put on hold without permission? If the mystery patient were an actual patient, would s/he recommend the organization to friends or family? If not, why not? By implementing an employee/provider engagement survey, an organization learns immediately the perceptions of its workforce regarding the importance of the patient experience, working conditions and, particularly, the impediments to delivering outstanding service performance.
STEP TWO: GET LEADERSHIP ON BOARD Providers are persuaded by data. A meeting convened to share with physician leaders their organization’s standings in comparison with others is a powerful strategy for impelling leadership to support a service quality improvement effort. In addition, actual experiences described by mystery patients are equally potent in creating demand for improvement.
“Successful organizations manage to transform their patients’ experiences through a series of practical activities designed to assess the current environment; improve patient and employee/ provider experiences; and maintain the improvement gains.” continued on page 24
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YOU PROBABLY BECAME A DOCTOR BECAUSE... you care deeply about people, their happiness and their health. WellMed shares your healthcare vision. If you’re interested in working with the Medicare population, working in an environment that empowers you and rewards you for your dedication and effort, join WellMed. Call our recruitment partner Provenir today (210) 479-3444. We can help you strengthen your medical practice future. From our WellMed doctors, nurses and physician assistants to our medical assistants and technicians, we have the same focus; to provide the best, most attentive healthcare for our senior patients. WellMed wants to create partnerships that offer physicians who share our vision with the freedom, support, and opportunity for professional growth. We’d like to welcome you to our family.
WellMedHealthcare.com Special Conference Edition • June 2015
CAPG HEALTH l 23 DR_AD TJ101413
Stellar Service...continued from page 22
STEP THREE: CREATE SERVICE PROTOCOLS All clinical staff members understand that established protocols are to be followed regardless of their own personal motivation. For example, a phlebotomist always sterilizes the puncture site. It’s a requirement of the process. Yet, depending on how a receptionist feels, an arriving patient may get a smile and cheerful hello, or not! That’s because the requirements for service performance have never been on par with mandates for clinical performance. That must change.
STEP FOUR: COMMUNICATE PERFORMANCE EXPECTATIONS REGULARLY It’s imperative that all members of the organization know and understand performance expectations. Plus, when recruiting new staff members it’s important that they’re introduced during the interview phase to the group’s service expectations as embodied in the C.L.E.A.R. protocols.
STEP FIVE: TRACK PERFORMANCE/HOLD PEOPLE ACCOUNTABLE
Service protocols that spell out specific behaviors and processes are essential for managers’ use in holding staff members accountable for patient-responsive performance.
All employees have two rights: to know what’s expected of them and to know how they’re doing. While the C.L.E.A.R. protocols communicate what’s expected, it’s up to the manager—with cooperation of the organization—to provide feedback on performance.
While service performance–related acronyms abound, many of them are conceptual rather than action-based. The C.L.E.A.R. service protocol acronym is short, simple to remember—and most importantly, descriptive of the behaviors that are associated with high patient satisfaction scores.
Performance tracking is simple. As mentioned earlier, most healthcare organizations conduct regular patient satisfaction surveys. Setting goals and sharing the data with employees is important in a group’s quest for an improved patient experience and higher satisfaction scores.
C ONNECT
Acknowledge patients immediately, even with a non-verbal if needed Use eye contact and smile Introduce yourself, and tell what your job is (if appropriate) Wear your name badge so patients can see it and read it Use the patient’s name Keep your voice warm and welcoming; be polite; say “please” and “thank you”
L ISTEN
Use eye contact and a pleasant expression Use head nods to indicate that you’re paying attention
E XPLAIN
Tell patients what you’re doing Use simple language (not abbreviations or acronyms) Tell patients what’s going to happen
A SK
Ensure patient’s comfort with information, surroundings Ask for other questions
R E-CONNECT
Check with roomed patient every 10 minutes and say, “Thanks for your patience” Acknowledge patients/others as they depart, saying, “Take care”
© 2015 SullivanLuallin Group 24 l CAPG HEALTH
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STEP SIX: RECOGNIZE/REWARD To achieve a five-star patient experience and the resulting CMS and other payer bonuses, it’s vital that providers and staff in an organization recognize their importance to the effort. Top-rated healthcare organizations recognize physician and employee contributions to patient satisfaction in a variety of ways. Sharp Healthcare System in San Diego, California, holds an annual employee appreciation day at the San Diego Convention Center. During the much-anticipated event, speakers share extraordinary experiences with the crowd, and the system’s Chief Executive Officer, Mike Murphy, expresses appreciation for the physicians and employees. It doesn’t always take money to make money. Ongoing recognition for a job well done—particularly from providers to staff members—goes a long way in motivating employees to deliver a five-star service experience to patients, family members and each other. When the patient has a positive experience, everyone profits! o Meryl D. Luallin is CEO of SullivanLuallin Group, based in San Diego, California. SullivanLuallin Group offers fullservice patient experience transformation and participates in CAPG’s group purchasing program.
Special Conference Edition • June 2015
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Policy Briefing Coverage Expansion Raises Two Key Issues BY BILL BARCELLONA, SENIOR VP, GOVERNMENT AFFAIRS, CAPG
As the Affordable Care Act unfolds and millions more gain healthcare coverage, there is no shortage of policy issues that arise. Two important issues concern—“surprise billing” of patients with coverage by out-ofnetwork providers, and the adequacy of provider networks, including the accuracy of provider directories. These are both topics that we will cover in depth at various sessions of the CAPG Annual Conference. Surprise billing of patients is a new description of an old problem for many of us who have worked on the related issues of networks and contracts for the past fifteen years. A newly covered patient under a state-based exchange seeks covered services in an in-network facility only to discover after the fact that somewhere in the process he or she received services from an out-of-network provider. If the services are emergent, most state laws require health plans to cover and pay–but if not, sometimes the patient can be left exposed to a high services bill, or possibly a balancebilling demand from the provider after the plan has made partial payment at in-network rates. The most common example occurs in a hospital during a procedure. The patient has made certain that the facility and providers are all in-network, and then discovers later that a non-contracted anesthesiologist subbed in for the procedure since that doctor was on call that day. Sometimes the bills can exceed two or three times the normal contracted rates, at high multiples of Medicare-equivalent fees. Patients with high-deductible coverage plans are left exposed after having done the requisite due diligence. Since this is happening to many legislators, their family members and constituents, policy makers are searching for solutions. The common issues that arise in legislation and regulation include whether to force providers to 26 l CAPG HEALTH
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identify their contracted status in advance, perhaps to provide a good faith estimate of charges to patients prior to service; whether to set default payment rates for out-of-network providers; and finally whether to establish an independent dispute resolution process for payers and providers. A 2013 study by the Kaiser Family Foundation identifies 13 states that have prohibited out-of-network providers from balance billing managed care enrollees. Protections vary significantly from one state to another. For example, Maryland and Connecticut provide state protections for all covered benefits, whereas Pennsylvania and Illinois provide limited protection, covering only emergency services and ambulatory services, respectively. Delaware and Florida both have a formal dispute resolution system available to resolve billing conflicts between providers and plans. New York has the most comprehensive regulations regarding balance billing. The state’s 2014 legislation bans balance bills for out-of-network emergency care, requires insurers to allow patients to see out-ofnetwork doctors at regular costs when the network cannot meet a patient’s needs, and sets new rules for insurers and providers to disclose network status online or before a procedure. Disputes between providers and health plans over the fee charged for medical services go through an independent review process that ties payments to a floor based on the 80th percentile of the Fair Health Database. Fair Health was established as part of a settlement between then–Attorney General Cuomo and health insurers over disputes on the accuracy of the Ingenix database, which was used by insurers and other payers in these situations. New York has also mandated costly triple arbitration for payerprovider billing disputes. California banned patient balance-billing by noncontracted providers in 2007, but only for emergent services and with respect to certain HMO and PPO patients. Now, the legislature is considering a uniform ban of balance billing in all non-contracted hospitalbased settings, for both emergent and non-emergent services. That legislature is also grappling over whether to include an independent dispute resolution program and a mandated floor for payments in the legislation.
California has in past years considered IDRPs, default payment rates, and prior notice of contracting status provisions—but all proposals have failed. CAPG is conducting a market survey of 2014 payments to non-contracted providers by delegated physician groups to determine whether a proposed adoption of the Fair Health Database would inflate costs in the healthcare system and expose patients to higher cost sharing under their high deductible plans. CAPG is also advocating for inclusion of payment-based elements in the state standards for determination of reasonable and customary payments to non-contracted providers, since the current regulatory standard is biased toward charge-based references. Colorado is also considering how to ban balance billing in situations with non-contracted emergency services providers and for procedures at in-network facilities performed by out-of-network physicians. Colorado’s version of the statute currently includes language that mandates a healthcare facility to notify the patient in advance of his or her legal protections against balance billing. Failure to comply is a deceptive trade practice. Provider network adequacy and transparency is an issue closely related to that of surprise billing by out-of-network providers. It arises out of the impact of newly formed narrow networks in the exchanges, with employer group-sponsored coverage, Medicare Advantage plans, and Medicaid managed care plans. California has long-established rules on network adequacy under its HMO statute, the Knox-Keene Act. The standards were adopted in the 1970s and borrowed from internal Kaiser Permanente staffing guidelines. The current law requires one primary care provider for each 2,000 enrollees and one physician for each 1,200 enrollees. There are also subsequently added requirements for geographic and timely access to care standards and initial and annual network filing requirements, as well as language access rules. Newly enacted laws may increase health plan provider network filings from 400 to as many as 4,000 annually, and have caused the California Department of Managed Heath Care to increase its licensing staff to handle the volume. Health plans will soon need to file provider directories for each product that they sell, and differentiate their reporting between commercial and Medicaid networks. The California Department of Insurance adopted emergency regulations at the beginning of 2015 that incorporate many of the historic Knox-Keene Act
standards and some of the recently adopted New York standards. California is also considering tougher laws on health plan provider directories, following the lead of both CMS and New York. Senate Bill 137 contains proposed requirements to update on a weekly basis, and requires plans to “ping” network providers when they become dormant and eventually remove them in the absence of responses. In February, CMS tightened network rules for Medicare Advantage plans. CMS has recently established new regulations that require Medicare Advantage plans to increase their provider directory updates to a weekly level. MA plans have been narrowing their networks over the past few years as Five Star compliance has required increasingly higher performance from the plan and its contracted providers. The agency has said Advantage plans could be fined or sanctioned if they “fail to maintain complete and accurate directories” or do not have an adequate network of providers accepting new patients. CMS has been less aggressive with coverage exchanges, stating in February that it will not make further changes to network adequacy rules until the National Association of Insurance Commissioners finishes work on a model law. An NAIC workgroup is meeting weekly to discuss a 50-state standard. At the very least, Exchange plans will be required to update provider directory information at least once a month starting in 2016, as well as to include 30 percent of essential community providers. Most states’ rules on provider directory accuracy will impact providers themselves, as statutes and contract requirements increasingly place responsibility on physician groups, individual doctors and hospitals to accurately identify their providers and their contracting status, as well as whether they are accepting new patients. No doubt independent physicians will chafe at stricter rules concerning when and how they can decide and declare whether their practices are open or closed for patients. o Bill Barcellona is facilitating Hot State Issues – Recent Changes to Network Adequacy and Transparency Rules, Patient Protection Against Surprise Billing, and Outof-Network Provider Payment, a panel on state and federal legislative and regulatory updates, at the CAPG Healthcare Conference on Saturday afternoon, June 13. Attorneys Carol Lucas and Curtis Leavitt will present Children’s Hospital vs. Anthem: An End to Out-ofNetwork Price Gouging? on Saturday morning, June 13. Special Conference Edition • June 2015
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Healthcare Innovation and Practice Transformation through Clinical Studies: The Role of Physician Groups BY P E T E F R O N T E , M B A , P R ES I D E N T, A LT U R A , L LC
in order to have a positive impact on patient-centric outcomes.”
Today, many organizations, including employers, government agencies, foundations, health systems, insurers, and pharmaceutical, biotech and medical device companies are supporting or performing real-world studies and clinical trials to better understand how to improve healthcare costs, quality and access. Since clinical data and large numbers of patients and physicians are required, these studies are best conducted in structured, coordinated healthcare settings. A 2007 article in the Journal of the American Board of Family Medicine said it best: “There is an increasing recognition that research not only about, but also within, primary healthcare is essential in all countries.”
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Complex Research
FDA Phase I-IV NIH/Grant Studies
Complexity
At the CAPG Annual Conference in June 2014, Mark Smith, MD, former and founding President and CEO of the California HealthCare Foundation, provided examples of how other industries study all aspects of their customer needs, including the use of control groups. He also asserted that most industries do a much better job than healthcare in understanding the behaviors and psychographics of their customers. Dr. Smith added, “PGs [physician groups] and hospitals do not invest in nor are equipped to study and understand the psychographics of their patient population, or the patient/doctor relationship. We need to know what a patient’s life is like, such as their priorities, fears and aspirations,
Leading PGs utilize workflow reengineering and quality improvement (QI) methods such as Six Sigma and Lean. However, structured and well-designed studies bring an additional element of validation and prestige. Internal evaluations and improvements of existing programs of care, service, and education are not considered research. A way to distinguish between QI and research is to understand the intent. If the purpose of the data collection is to contribute to “generalizable” knowledge that is applicable outside of the research setting, the activity is usually classified as research. Such activity is likely subject to Institutional Review Board (IRB) approval and informed consent. An internal, PG based IRB is not required. On the other hand, if the results stay entirely in-house and are used for administrative purposes only, many institutions do not consider this to be research. The continuum of clinical studies is depicted in the graph below.
Outcomes/ Observational Studies
Practice Optimization Studies Quality Improvement
Retrospective Studies Quality Assurance
QA Internal Altura, LLC 2015
External
Funding Source continued on page 30
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Transitioning to value-based healthcare and improving productivity, efficiency, and outcomes is a survival imperative for your practice.
The KairoiCareLogic process and software generates:
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Real-time dashboard reports to manage provider productivity
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CAPG HEALTH l 29 For more information visit: www.kairoicarelogic.com/YES or call Spring us at2015 415-684-1670
Healthcare Innovation...continued from page 28
Today most physicians and PGs are not involved with clinical studies of any type. One limitation is that many PGs believe research is mostly about FDA-mandated clinical trials for investigational medications and devices. The fact is that approximately 3 percent of physicians in this country have been involved as investigators for FDA-mandated studies, and most PGs do not have the structure or resources to conduct these types of studies. Experienced staff, dedicated space, standard operating procedures that comply with federal regulations, and custom operating structure are just a few of the elements needed to run the most complex studies. For most PGs, being involved with complex FDA studies is attainable. However, it requires a clear vision by leadership and a long-term commitment of resources. According to Marc Hoffing, MD, medical director at Desert Oasis Healthcare, “We started with an NIH grant studying depression in the elderly, in collaboration with UCLA, that ultimately was published in JAMA. Over time we realized that our patient population, EMR and physician base allowed us to conduct research of all types. Now we conduct a spectrum of clinical studies including phase II–IV FDA-based clinical trials, as well as outcome and proof-of-concept studies.” Communicating results via clinical studies is an effective way to build a PG’s image and brand and will help drive growth. When asked about increased brand awareness as a result of clinical studies in PGs, Dr. Robert Margolis, chief executive officer emeritus and co-chairman of the board, DaVita HealthCare Partners, commented, “Organizations that invest in clinical studies and participate in these types of programs are able to attract and retain skilled clinicians and researchers who want to be part of innovation and progress. This establishes a heightened culture of creativity and innovation that is very positive internally and externally, which results in the satisfaction of our customers.” According to Dr. Magued Beshay, research director and principal investigator of the Facey Medical Group, “Involvement in clinical studies is very important to the physician and the patient. Most physicians appreciate the break from the routine, experiencing increased 30 l CAPG HEALTH
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intellectual stimulation and attaining the prestige of contributing to the community medical knowledge base. They become part of the progress of medicine and this can help prevent physician burnout.” Practice transformation is essential even though PGs face economic and operational burdens that limit their involvement in healthcare innovation. Forwardthinking PGs that conduct clinical studies leverage this effort by bridging research activity to QI. As an example, Geisinger’s 2013 System Report, Transforming Healthcare Through Innovation, states that clinical research is one of the foundations of Geisinger’s QI efforts. Clinical studies can be aligned with government, ACO and health clinical quality initiatives such as “pay for performance.” Dr. Hoffing added, “Our aim is to maximize the integration of clinical studies with our core business, which results in studies being aligned with our core initiatives. As an example, a clinical study’s enrollment screening can also support participation in our patient portal or diabetes screening program.” Bill Gil, chief executive of Providence Health Network, Southern California, commented on the strategic focus needed for clinical research. “Many times when organizations commit to clinical research, they isolate and segregate the effort and it does not enter into the strategic value proposition that determines the future of the organization. Clinical studies must become part of the PG’s value proposition, not just another department.” PGs that continuously improve systems and processes to enhance quality and contain costs will succeed in attracting and retaining patients. Compelling reasons exist for PGs of any size and structure to be part of internally or externally driven clinical studies in a direct or indirect manner. An important strategic question for PGs is not if, but to what extent and how, they should participate in these studies. o Altura is a CAPG Affiliate Partner that has been providing specialized services to physician groups, healthcare organizations and study sponsors for over 15 years. Our mission is to accelerate healthcare innovation by optimizing patient and physician participation in quality initiatives and clinical studies. Mr. Fronte can be reached at pfronte@altura2000.com.
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3/31/15 12:33 CAPG HEALTH l 31PM
Medicare Advantage is the Core Line of Business for the Physician Group of the Future BY J O H N G O R M A N , F O U N D E R A N D E X EC U T I V E C H A I R M A N , G O R M A N H E A LT H G R O U P
Since its inception in 1965, Medicare has always been the bedrock of physician group revenue. Recently it’s become apparent that the days of traditional feefor-service Medicare are numbered. • Last month, for the first time, a prominent Wall Street analyst—Josh Raskin of Barclay’s—projected a path to 100 percent penetration of Medicare by health plans. This will occur by natural transition of Boomers to health plans, and to enactment of a Paul Ryan–like entitlement reform driving most beneficiaries into capitated arrangements. In the near term, he projects 29 million Medicare beneficiaries in Medicare Advantage by 2023, up from 17 million today; • The recently passed “doc fix” didn’t solve the traditional Medicare sustainable growth rate (SGR) problem at all, and it even dealt a blow to Medigap by eliminating first-dollar coverage in supplemental insurance; • President Obama and HHS Secretary Burwell recently announced a push to value-based payment in Medicare and Medicaid, putting much more skin in the game for physicians for poor quality; • It’s been clear for several years that most Medicare Accountable Care Organizations (ACOs) will fail to produce a profit for their sponsors. Many ACOs will make a lateral move to Medicare Advantage.
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Signs abound that Medicare’s old ways of doing business are dying off. The program is lurching toward its only savior: capitation, risk adjustment and value-based payment for performance. This means the core line of business for the physician group of the future is Medicare Advantage. And the timing couldn’t be better, as the program emerges from its worst rate environment in years and is poised for another surge in growth. Thanks to a rousing victory by program advocates in this year’s annual “Call Letter” rate-setting exercise, Medicare Advantage avoided a proposed cut and emerged in positive territory for 2016. This was the last threat to the program, as the Affordable Care Act requires that MA rates be pegged to the rate of increase in fee-for-service Medicare in 2017. That means a tailwind for plans in MA rates for the foreseeable future—a perfect time for physician groups to “double down” on their commitments to and investments in Medicare Advantage, and even to move up the food chain and sponsor a plan of their own. To take advantage of this new environment, forwardthinking physician groups will do the following: • Master Star Ratings for those measures relevant to your group’s scope of practice: Stars have become the fulcrum of competition in Medicare Advantage. Starting in 2015, scoring less than four Stars and losing the quality bonus is a slow-acting kiss of death; •
Master risk adjustment coding, reporting, and evaluations: Risk adjustment accounts for 30 percent variability in MA payments,
and is entirely under the control of physicians for complete and accurate coding. The risk adjustment function must be embedded within medical management and the data collected used to close gaps in care, not just submitted to CMS for higher payments; • Embrace the collaborative/ accountable care model: This decade will mark a true shift away from the failed 1990s style of managed care that included preauthorizations, referrals, and concurrent review, none of which make serious contributions to costs or quality. Successful physician groups in MA are data driven and focused on the 5 percent of patients who account for 60 percent of spending; • Recalibrate your group around the “whole patient” and build more holistic capabilities: Forwardlooking physician groups recognize that multiple social factors including poverty contribute hugely to patient compliance, access to care, and effective management of chronic illness. These groups have the minds of accountants and the hearts of social workers, and organize their staffs around total patient management. As Charles Darwin pointed out, evolution isn’t about being the biggest or the smartest, but the most adaptable. Physician groups that adapt to the constantly rising quality bar and exploding numbers of Medicare Advantage will still control their destinies years from now. o John Gorman is Founder and Executive Chairman of Gorman Health Group, specializing in government-sponsored health program strategy, compliance, and operations. He will present The Future of Government Programs, a CAPG Healthcare Conference super session, on Friday afternoon, June 12. Special Conference Edition • June 2015
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Healthcare Reform Brings New Liability Challenges for Doctors BY R O B F R A N C I S , C H I E F O P E R AT I N G O F F I C E R , T H E D O CTO R S C O M PA N Y
With the Affordable Care Act (ACA), newly insured patients now have access to preventive care and treatment of chronic illnesses, thus potentially reducing adverse events. At the same time, healthcare reform poses new liability challenges. More patients, more treatment options, and other new risks could generate more adverse events and a resulting increase in malpractice suits. The ultimate impact on liability claims from the ACA will depend on healthcare providers’ awareness of risks and the steps they take to reduce liability. The Doctors Company, the nation’s largest physician-owned medical malpractice insurer, has heard from our physician members and industry experts about their insights on the changing healthcare environment and potential new risks. These risks include the type of patients entering the healthcare system, the requirement for electronic medical records (EMRs), the potential for default standards of care being tied to reimbursement, and allegations of financially motivated care.
THE NEWLY INSURED PATIENT When these new patients were uninsured, they tended to seek care on an acute basis. Many were not receiving care for chronic conditions or health maintenance, so they are now often entering the system with more serious health problems. Under the ACA, there will be more significant discussions between the physician and the patient about recommended care. If something does go wrong, the patient will likely feel more invested in the outcome and, therefore, may be more likely to sue. With the options available under the ACA insurance exchanges, new patients also tend to have large deductibles. If they have an underlying condition and delay seeing the doctor because of their deductible, risk increases as their condition worsens.
REQUIREMENT FOR EMRS While doctors are virtually unanimous in agreeing that EMRs can advance patient care, EMRs require substantial data input. In our surveys, physicians complained that they have to pay more attention to the computer screen than to the patient. This distraction may result in missed diagnoses and could potentially harm the physician-patient relationship by shortcutting communication. The massive amount of data and the format of that data in EMRs can present problems with numerous checkboxes, drop-down lists that can perpetuate errors, and cut-and-pasted information that creates voluminous records and difficulties in accessing relevant clinical data. Drug interaction lists generate frequent, annoying, and disruptive alerts, causing “alert fatigue.” The records metadata in an EMR shows when alerts are overridden or ignored. If it can be shown that following an alert, rather than dismissing it, would have prevented an adverse patient event, the physician may be found liable. 34 l CAPG HEALTH
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ultimate “The impact on liability claims from the ACA will depend on healthcare providers’ awareness of risks and the steps they take to reduce liability.”
Under the ACA, physicians and hospitals are encouraged to aggregate information and provide that information to other providers, but the diversity of input through different systems creates complications. There are differences in the quality of data and how it will be made available, an overwhelming amount of data that providers can’t use, and no common Health Information Exchange.
DEFAULT STANDARDS OF CARE Physicians are concerned that many provisions of the ACA that deal with reimbursement, or reporting on patient satisfaction and outcomes, will lead to default standards of care. This would take away physicians’ and other healthcare providers’ ability to vary clinical decisions based on judgment—resulting in significant liability exposure. The Patient-Centered Outcomes Research Institute has been formed to establish evidence-based standards, a major component of the ACA. The standards are intended to become the reimbursement guidelines, not to establish a new standard of care, but the fear is that they will. The legal standard of care for a claim recognizes variation in situation, judgment, and outcome. The legal standard is the level of care that an ordinary, prudent professional with the same training would provide under the same or similar circumstances. It is not standardized practices or even optimal outcomes. Patients, however, are expected to rely on reimbursement guidelines when judging the quality of care they received. If the federal government says a patient shouldn’t have to be readmitted to the hospital, but the patient was readmitted, that may lead to a lawsuit. Medicare aggressively pursues practitioners to recover payments for what CMS deems non-evidence-based care. This may also prompt plaintiffs to file suit claiming unnecessary care, such as unnecessary procedures. Healthcare industry experts believe that allegations arising from payment denials will be the next big problem in medical liability. Reimbursement guidelines that create their own standards and outcome expectations expose every doctor to more risk.
ALLEGATIONS OF FINANCIALLY MOTIVATED CARE The ACA’s goal is to eliminate fee-for-service medicine in favor of value-based, pay-for-performance compensation and to implement quality-based penalties, such as those associated with hospital readmissions and never-events. The ACA has 48 bundled payment programs to build this new model of managed care—a “bundled payment” being capitation by another name. Doctors, other practitioners, and hospitals will share risk in new ways. We will see increasing allegations that care is being withheld for the financial gain of the providers, as occurred in the 1990s during the managed care movement. Allegations of financially motivated care have caused losses of hundreds of millions of dollars.
WHAT’S NEXT? While the ACA is improving access to care for millions of Americans, doctors must be aware of its potential to increase liability risks. By understanding the risks they may face, healthcare providers in all practice environments can carefully assess their systems and processes to determine where changes can be made to reduce liability risks and enhance the quality of patient care. o Rob Francis, chief operating officer of The Doctors Company, can be contacted at rfrancis@thedoctors.com. Mr. Francis also discusses these issues in the YouTube playlist “Malpractice Lawsuit Trends Under the ACA” at http://ow.ly/LIfIb.
Federal Legislative Update...continued from page 16
Ultimately, both the House and Senate passed legislation to repeal and replace the SGR formula once and for all. Both chambers passed the legislation with tremendous bipartisan support. The legislation is an achievement for all involved, in part because of the greater stability it creates for traditional Medicare and Medicare Advantage. Importantly, the new law creates incentives for riskbased coordinated care. As one example, beginning in 2019, the legislation makes available a 5 percent incentive payment for physicians that participate in twosided financial risk arrangements in Medicare Part B. Between now and 2019 when those incentives kick in, CAPG and other advocacy groups have a remarkable opportunity to continue to build and refine two-sided financial risk models that qualify for the new incentives. The new payment law creates incentives for traditional Medicare payment models to catch up to advanced capitated payment models in Medicare Advantage. While traditional Medicare’s physician payment has lagged behind capitated contracts in MA, the 5 percent bonus will give a big boost to advanced payment models, including capitation, in traditional Medicare. This transformation is already underway. As one example, the Centers for Medicare & Medicaid (CMS) Innovation Center announced a new model called the Next Generation Accountable Care Organization (ACO). Building on the Pioneer ACO and the Medicare Shared Savings Program (MSSP), the Next Generation ACO program continues to evolve toward more sophisticated payment, alignment, and beneficiary engagement models. The Next Generation model includes features of high interest to CAPG as we continue to urge the federal government to develop sophisticated risk models in traditional Medicare: 1. Capitated payment to the ACO will be available in the 2017 contract year; 2. ACOs will have the ability to seek voluntary alignment of ACO beneficiaries (certain beneficiaries can attest that they want to be assigned to the ACO); 3. Beneficiaries will receive a payment from the federal government of $25 every six months for using services within the ACO.
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While the specifics of this model may or may not work for individual organizations, from CAPG’s perspective the Next Generation model and its new features are significant steps toward coordinated, capitated care in traditional Medicare. MA RATES IMPROVE; ADMINISTRATION RECOGNIZES ROLE OF ADVANCED PAYMENT MODELS IN MA Lastly, CAPG sees this same momentum toward riskbased coordinated care in MA. Consistent with past practice, in February 2015 CMS proposed cuts to MA rates. CMS estimated that the average cut was about 0.9 percent; however, as CAPG members know, the actual cut can be substantially more for any individual group. Numerous stakeholders launched an intense, coordinated advocacy campaign to demonstrate the importance and value of MA. CAPG worked hand in hand with many advocacy groups, industry representatives and MA seniors in Washington, DC and across the country to protect and advance MA. For our part, CAPG sent numerous letters to Congress and the Administration on the value of MA to physicians and, most importantly, beneficiaries. Over 300 physician groups signed our letter to CMS urging the agency not to cut MA funding. We are pleased to report that CMS released final rates in early April that were about 2 percent better than the proposed rates. CMS estimated the average impact would be a 1.25 percent improvement in MA rates. For the first time, CMS also recognized in the final rate guidance the important role that MA plays in advancing the healthcare delivery system. CMS indicated that it will continue to work with health plans and other stakeholders to learn about how plans pay physicians downstream. CAPG looks forward to working with CMS to encourage the advancement of capitated, coordinated delivery models in Medicare Advantage. CONCLUSION CAPG’s work continues as lawmakers turn to implementation of the new Medicare Part B payment system and further development of a regulatory framework to guide alternative payment model deployment. In Washington, DC, CAPG will continue to press for a more favorable environment for capitated, coordinated care. o
New at Individual Advocacy Membership For the first time, CAPG is offering a membership level for individuals who would like to become more involved in our federal advocacy efforts. Benefits include exclusive invitations to learning events and hands-on advocacy opportunities. To learn more, please join us for a reception and launch at the CAPG Healthcare Conference on Saturday, June 13, 3:45 pm, Golden Hill AB (third level) at the Grand Hyatt San Diego.
You can also learn more online at capg.org/join#advocacy or by contacting Mara McDermott at mmcdermott@capg.org
Special Conference Edition • June 2015
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Names in the News...continued from page 8
MEMORIALCARE MEDICAL GROUP OPENS NEW LOCATION MemorialCare Medical Group, an affiliate of MemorialCare Health System, has opened its newest office at Orange Coast Memorial Patient Care Pavilion in Fountain Valley. The location is home to seven primary care providers: internists Ihong Chen, MD and Lalita M. Komanapalli, MD; family medicine physicians Nasrin S. Damoui, MD and Linda Sanfilippo, PA-C; and pediatricians Lori A. DeBold, MD, Margaret A. Zimmerman, MD, and Laura Sayle, NP (nurse practitioner). Care includes health promotion, disease prevention and treatment, health maintenance, counseling, patient education and diagnosis, and onsite lab and imaging services. The medical group accepts HMO and several Medicare Advantage health plans, as well as Medicare, PPO, and EPO plans. The Orange Coast office can be reached at 714.861.4770 or www. memorialcare.org/newoffice. o
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Accountable Care 2.0: Taking Data to the Next Level The ability to share data across a network of providers has become more important than ever. Sharing data helps large medical groups reduce costs, improve care delivered to patients, and creates more opportunities to participate in innovative products. Access to data, plus advanced analytics, do even more. Transforming raw clinical data into useful information at the point of service has allowed Brown & Toland Physicians to become one of the nation’s leading clinically integrated medical groups with positive population health management outcomes, including reducing the total cost of care. Using data and analytics for the Innovation Centers’ Pioneer Medicare Accountable Care project, Brown & Toland Physicians reduced hospital bed days, hospital readmissions, and increased preventative screening rates for close to 18,000 Medicare patients in the Bay Area, saving the Medicare program more than $15.1 million over two years. Data can be a “game changer.” With the right tools, medical groups can keep patients healthy, help physicians deliver patient-centered care, and reduce overall healthcare costs. Patients, doctors, and payers all benefit from use of data and analytics through population health management programs. To learn more about Brown & Toland Physicians, please visit our website at www.brownandtoland.com.
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