HEALTH Volume 9 • No. 4
June Simmons Social Services: A New Specialty for a New Era of Health, p.10 Building Resilience, Reigniting Primary Care Through Practice Transformation, p.20, 26 IVR Enhances Care Experience, p.22
Summer 2015
Confidence The feeling you have when you are affiliated with Hill Physicians. Dawei Zheng M.D.
Hill Physicians provider since 2000. 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 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.
Make VITAS Your Healthcare Partner In caring for your seriously ill patients
4Coordination
4Collaboration
4A team approach to healthcare
Patients with life-limiting illness benefit from early and regular goals of care conversations. As your partner, VITAS can talk to your patients candidly and professionally about disease trajectories, patient options and care transitions. Together we change patient outcomes. Together we change healthcare for good.
800.93.VITAS • VITAS.com
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
Pacific Palisades
Alhambra
Westwood
Brentwood Malibu
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
June Simmons - Social Services: A New Specialty for a New Era of Health
HEALTH Publisher
Valerie Okunami
DEPARTMENTS
FEATURES
7
16
Notes from the President
Editor-in-Chief
Don Crane
Editorial Advisory Board
Lura Hawkins, MBA Amy Nguyen Howell, MD, MBA Mary Kay Payne, Arch Health Partners Managing Editor
Daryn Kobata
Editorial Assistant
Nelson Maldonado
8
in Accountable Care
Names in the News
20
12
Building Resilience Through Practice Transformation
Upcoming Events
Contributing Writers
Bill Barcellona Don Crane Janelle Howe, RD Amy Nguyen Howell, MD, MBA Michael Young Lee, MD, MPH Stephen J. Linesch, MBA Mara McDermott Richard Pan, MD Jeremy Rich, MD June Simmons, MSW CAPG Health Magazine is published by
Valerie Okunami Media PO Box 674, Sloughhouse, CA 95683 Phone 916.761.1853
14 Federal Legislative Update: Advancing Coordinated Care for Seniors with Chronic Diseases
18 CAPG Member List
capghealth.com
28
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
Policy Briefing: CMS Medicaid Managed
For advertising, please send email to vokunami@netscape.com
30
Subscription rates: $32 per year; $58 two years; $3 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. 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.
6 l CAPG HEALTH
The Coded DOFR and Its Role
Summer 2015
Care Regulation Lays Foundation
Practice Transformation: CAPG and 2.0 Healthcare Join Forces
32 Member Spotlight: Sharp Rees-Stealy Medical Group
33 2015 Annual Conference Highlights
22 Interactive Voice Response (IVR) Enhances the Patient-Care Team Experience
26 The Bridge To Effective, Efficient Quality Healthcare
34 SB 277 Keeps Californians Safe from Preventable Contagions California State Senator Richard Pan, MD, coauthor of SB277, at a press conference on the bill.
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: Thanks to all of you who attended our 12th Annual CAPG Healthcare Conference. More than 1,700 members and friends attended from all regions of the country, setting the stage for an exceptional exchange of ideas, both in and out of the formal sessions. You can read more about the conference in this issue. Next year’s Conference is already on our calendar for June 16-19, again at the Grand Hyatt, San Diego. We hope you’ll put it on yours too.
Donald Crane, CAPG President and CEO
That same dynamic with a different focus will be seen at the 2015 CAPG Colloquium: Achieving Success in Risk-based Coordinated Care, scheduled for October 5-7 in Washington, DC. This high-value event provides the opportunity to see and hear national thought leaders and policymakers who are helping to shape the Medicare-led movement toward alternative payment models. Please plan to join this exciting forum in person in the nation’s capital, or sign up as an online participant. Details are available at www.capgcolloquium.com. The recent U.S. Supreme Court decision on the Affordable Care Act’s government exchanges should bring our members some stability, at least for enough time to write a two-year plan. For years, healthcare providers have faced a huge challenge trying to establish long-term policies and systems amid great uncertainty. The decision certainly does not mean an end to disagreements about the future of our healthcare system, but I believe it provides a “halftime break” that gives us all time to plan and to have some expectation that the plans can proceed. That alone is something to cheer. CAPG has applauded Health and Human Services Secretary Sylvia Burwell’s announced goal of moving 50% of Traditional Medicare enrollees to alternative payment models by the end of 2018. In response, we have adopted our own, more ambitious value goals—to help our members move at least 90% of their Traditional Medicare and Medicare Advantage population into capitated payment plans by 2018. Many of our members are already there; for others, we are committed to providing the necessary education and advocacy support. That’s a promise we intend to keep. o
MARK YOUR CALENDAR
and join us next year!
13th Annual CAPG Healthcare Conference June 16-19, 2016 Grand Hyatt, San Diego Summer 2015
CAPG HEALTH l 7
Names in the News IHA STUDY SHOWS WIDE GEOGRAPHIC GAPS IN QUALITY MEASURES; HEALTH PLAN PRODUCTS WITH INTEGRATED CARE DELIVERY NETWORKS GENERALLY HIGHER QUALITY
mammogram, compared to about 70% of Commercial PPO patients. If PPOs had performed at the same level as HMOs, an estimated 55,356 more women would have received mammograms in 2013.
A new analysis from the Integrated Healthcare Association (IHA) shows wide variation in healthcare quality and resource use across California, and that health plan products with integrated care delivery networks score higher in quality without using more resources.
Another significant finding was wide geographic variation in quality and resource use, such as a 40plus percentage point gap in colorectal cancer screening rates between the highest- and lowestperforming counties (Solano, 76.4%, and Modoc, 33.5%, respectively). Similar gaps exist for other quality measures, including breast cancer screening and blood sugar control for diabetics.
The analysis is based on IHA’s new online tool, HEDIS by Geography, which organizes 2013 Healthcare Effectiveness Data and Information Set results for 11 health plans covering about 19 million Californians to gain a clearer picture of statewide population health. The tool examines performance on six clinical quality measures (e.g., breast cancer screening rates) and three resource use measures (e.g., hospital readmissions) by geography or health plan product line, including commercial health maintenance organization (HMO) and preferred provider organization (PPO), Medicare Advantage, and managed Medi-Cal. The study found that health plan products relying primarily on integrated care delivery networks, such as Medicare Advantage, generally have higher quality scores without using more resources. For example, of the population included in HEDIS by Geography, about 85% of the Commercial HMO women ages 50-74 met clinical guidelines for breast cancer screening and received a
“While the analysis uses only descriptive statistics, such sizeable geographic gaps in healthcare quality mean there are major opportunities to improve care for hundreds of thousands of California residents,” said IHA President and CEO Jeff Rideout, MD. To learn more, visit https://hbg.iha.org.
DELVECCHIO S. FINLEY APPOINTED CEO OF ALAMEDA HEALTH SYSTEM Delvecchio S. Finley has been appointed chief executive officer of the Alameda Health System (AHS), an integrated public health system serving Alameda County residents, effective in August. Most recently, Finley had served since 2011 as CEO of Harbor-UCLA Medical Center, one of five level one trauma centers in Los Angeles County. His experience includes serving as Vice President of Operations at California Pacific Medical Center, as well as at public hospitals including UC San Francisco and San Francisco General Hospital and Trauma Center. Finley holds a master of public policy degree from Duke University, where he also attained graduate certification in health policy, law, and management. Born in a public hospital and raised by a single mother in Atlanta public housing, Finley cites his early lack of exposure to healthcare as a motivating factor for his career in public health. “For me, serving people and helping to make sure as many people as possible can get access to high quality and affordable care has always been an interest of mine.” o
8 l CAPG HEALTH
Summer 2015
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 DR_AD TJ101413
ON THE COVER
Social Services: A New Specialty for a New Era of Health BY JUNE SIMMONS , M S W , C EO , PA R T N E R S I N C A R E F O U N DAT I O N
In a groundbreaking survey of 1,000 physicians, 86% agreed that unmet social needs lead directly to worse health and 76% wished that the healthcare system would cover the cost of connecting patients to services that address health-related social needs . As accountable care, capitation and bundled payments gain ground, this wish can finally come true. Across the nation, community-based organizations that have traditionally addressed health-related social needs are forming networks so that physician groups, accountable care organizations, health plans and health systems can purchase high-value services shown to reduce readmissions and emergency department use and to improve clinical outcomes.
“This is our
moment in healthcare history—we were born for this work.”
In Southern California, Partners in Care Foundation has formed one such network, called Partners at Home. With the guiding principle that “health happens at home,” network members—local community-based organizations (CBOs)—serve as physicians’ eyes and ears in patients’ homes, bringing care transitions coaching, HomeMedsSM medication reconciliation and pharmacist review, in-home safety and psychosocial assessment, and both long- and short-term service coordination. The benefits of linking healthcare providers with local CBOs are many. These organizations are embedded in the local culture and challenges of specific communities, and employ culturally and linguistically appropriate social workers and community health workers. They know and have earned the trust of both people and institutions of the service area, providing improved access for patients who are hard to reach and serve because of language and cultural barriers, financial issues or other social determinants of health. CBOs also come armed with evidence-based interventions approved by the U.S. Administration on Community Living, the Centers for Disease Control and Prevention, and the Substance Abuse and Mental Health Services Administration. In addition, CBOs typically are nimble organizations that can respond in a quick and cost-effective manner to the needs of patients and physician groups. The challenge of working with CBOs is the flipside of their strength—they are small and they are many. That is why CBOs are joining together into regional networks, much as individual physicians joined together to form independent practice associations when managed care began to take hold.
THE VALUE OF CBO NETWORKS A single contract with a CBO regional network can integrate a host of services that benefit patients under the identity of the physician group—from in-home assessment and Stanford Self-Management workshops to special-diet meals, and from care transitions coaching to medication reconciliation. Large provider groups, ACOs, health systems and health plans usually cover large geographies where many smaller local CBOs are focusing on different populations and services. CBO networks blend
10 l CAPG HEALTH
Summer 2015
broad geographic coverage with local trust and quality expertise. As the lead agency of the Partners at Home Network, for example, Partners holds NCQA Complex Case Management Accreditation and has Medicare and Medicaid billing numbers. Network members are subcontractors, held to equally high standards of rigor, performance, staff screening, insurance, and quality.
THE VALUE OF HOME- AND COMMUNITY-BASED SERVICES Pilot results achieved by CBO social workers and community health workers have been impressive. The Centers for Medicare & Medicaid Services has funded CBO-hospital partnerships to reduce readmissions for high-risk patients. In a Partners collaboration with UCLA, a root cause analysis was used to derive targeting criteria. Over 3,000 patients have received a combination of Coleman model care transitions coaching with a HomeMedsSM medication review or Rush University’s Bridge model telephonic social service intervention. Compared to patients who met the targeting criteria but did not receive either intervention, patients seen by Partners’ social work coaches had a 60% lower 30day readmission rate. Emergency department use was also reduced by 26%, and the percentage of patients seeing their physician within seven days after discharge increased by 49%. Results like these have been achieved by CBOs across the country. Another example of an evidence-based resource deployed by the Network is HomeMedsSM, a national, carefully targeted in-home medication review and safety program. HomeMedsSM data show that 40 to 60% of elders using home- or community-based services have experienced adverse drug events such as falls or other potential medication-related problems such as orthostasis, therapeutic duplication, uncharacteristic confusion, dizziness, or inappropriate use of NSAIDs. Currently implemented across 45 sites in 18 states, HomeMedsSM has received the U.S. Administration for Community Living’s Highest Evidence Level rating, and was chosen for the ACL’s rigorously screened Aging and Disability Evidence-Based Programs and Practices (ADEPP).
Additionally, a study conducted by a leading physician group on the HomeMedsSM medication management interventions revealed that adults who received a home visit, had their medications reviewed by a consulting pharmacist, and received a psychological/functional needs assessment and home safety evaluation had medication issues in 63% of cases, a 13% lower rate of emergency department use, and 22% fewer readmissions within 30 days when compared to those who received no intervention. This is the moment to extend the definition of “healthcare” beyond the walls of the doctor’s office and the hospital bed, out into the community. The vision of Partners at Home and similar networks across the country is to impact population health management through effective coordination of social care that affords adults with multiple chronic conditions the opportunity to live in the community of their choice with dignity and independence—and at their highest possible level of health and well being. This vision can be achieved by leveraging the wealth of knowledge and resources of CBOs in partnership with physicians, to better address the social factors that undermine healthcare interventions and their intended results. o W. June Simmons, MSW, is the founder and chief executive officer of the Partners in Care Foundation. Partners collaborates with community organizations and funders to develop and implement high-impact, innovative care models to improve health and social services among diverse people and communities.
Summer 2015
CAPG HEALTH l 11
E V E N T S U P C O M I N G
SECOND CAPG COLLOQUIUM Monday through Wednesday, October 5-7 Marriott Wardman Park, Washington, DC*
CLINICAL QUALITY LEADERSHIP COMMITTEE Monday, September 21 Los Angeles, CAPG Office*
NORTHWEST REGIONAL MEETINGS COLORADO REGIONAL MEETINGS Thursday, August 20 Denver Marriott Tech Center*
PENNSYLVANIA REGIONAL MEETINGS Tuesday, August 25 TBD*
MACRA: CHARTING THE FUTURE OF PHYSICIAN PAYMENT Thursday, August 27 WebEx: http://bit.ly/macra2*
32ND ANNUAL UCLA INTENSIVE COURSE IN GERIATRIC MEDICINE; PHARMACY AND BOARD REVIEW Wednesday to Saturday, September 9-12 http://www.cme.ucla.edu/courses/eventdescription?registration_id=94281.
GENERAL MEMBERSHIP - SO. CALIFORNIA/ COMPENSATION SURVEY PRESENTATION
Thursday, September 24 TBD*
CQC SYMPOSIUM: BEST PRACTICES FROM 3 COMPLEX CARE MANAGEMENT PROGRAMS Thursday, September 24 Ontario, Radisson Hotel Ontario Airport https://symposium-ccm-09-2015.eventbrite.com
STATE GOVERNMENT PROGRAMS COMMITTEE Tuesday, September 29 Sacramento, TBD*
INLAND EMPIRE REGIONAL MEETINGS Wednesday, September 30 Riverside, Mission Inn*
CAPG NATIONAL Monday, October 5 Marriott Wardman Park, Washington, DC*
Wednesday, September 16 Los Angeles, CAPG Office*
GENERAL MEMBERSHIP - NO. CALIFORNIA/COMPENSATION SURVEY PRESENTATION Thursday, September 17 Oakland, Hilton Airport Oakland Hotel*
PUBLIC POLICY COMMITTEE Thursday, September 17 Conference Call*
*For more information contact CAPG at (213) 642-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.
12 l CAPG HEALTH
Summer 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.
Keynote Speakers Bernard J. Tyson
Chairman and CEO, Kaiser Foundation Hospitals and Health Plan, Inc.
Samuel R. Nussbaum, MD
Executive Vice President, Clinical Health Policy and Chief Medical Officer, Anthem, Inc.
Patrick Conway, MD, MSc
Deputy Administrator for Innovation and Quality and Chief Medical Officer, Centers for Medicare & Medicaid Services
Bill Cassidy, MD (R-LA) United States Senator
Mark E. Miller, PhD
Executive Director, Medicare Payment Advisory Commission
Physician Group Leaders on Moving into Risk
Health Policy Update
Suzanne Anderson, MBA
Faculty Research Fellow and Faculty, John F. Kennedy School of Government, Harvard University; Chair, Government Relations and Public Policy, Baker, Donelson
Sheila Burke
Executive Vice President, Chief Information Officer and Chief Financial Officer, Virginia Mason Health System
Kenneth Cohen, MD
Edmund F. Haislmaier
Chief Medical Officer, New West Physicians; Clinical Assistant Professor of Medicine, University of Colorado School of Medicine
Senior Research Fellow, Health Policy Studies, The Heritage Foundation
Mariella Cummings
President and Founder, Jennings Policy Strategies, Inc.
Chief Executive Officer, Physicians of Southwest Washington
Chris Jennings
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 Early registration discount ends September 4! November/December Winter 2015 2014
CAPG HEALTH l 13 25
Federal Legislative Update Advancing Coordinated Care for Seniors with Chronic Diseases BY MARA MCDERMOTT, VP OF FEDERAL AFFAIRS, CAPG
The Senate Finance Committee announced in May the formation of a bipartisan working group to explore solutions for improving the health of Medicare beneficiaries with chronic conditions. Senators Johnny Isakson (R-GA) and Mark Warner (D-VA) were appointed to lead the group, which plans to begin advancing legislation later this year. In June, the Finance Committee requested feedback from stakeholders on a broad array of issues, including improvements to Medicare Advantage, modifications to the Medicare accountable care organization (ACO) program, and more effective ways to use primary care providers. Later that month, CAPG met with Senator Isakson to discuss the working group’s efforts to enhance senior care. As our members know, the CAPG model of care delivery—prepaid capitation with clinical accountability and robust quality performance standards—is well-suited to bring better care to seniors with chronic conditions. The payment model promotes investment in the healthcare infrastructure needed to identify, treat, and prevent chronic disease. The delivery model emphasizes team-based primary care with a focus on slowing the progression of chronic disease, ensuring communication between all care team members, reconciling medications, and providing the right care in the most appropriate setting. For patients with chronic conditions, who often take multiple medications and see various specialists in addition to their primary care provider, this model is especially critical. CAPG is engaged with the Senate working group to advance policies in three areas. First, we are encouraging capitated payments to physician organizations in Medicare Advantage. CAPG agrees with Congress and the Administration that risk-based coordinated care offers the best value for Medicare participants. CAPG is encouraging the chronic conditions working group in the Senate to enact incentives for risk-based contracts between health plans and physician groups in Medicare Advantage. Earlier this year, Congress passed a law to make such incentives available in Traditional Medicare. CAPG is calling on Congress to make these same incentives available in Medicare Advantage. Reforming the delivery system requires consistency across payers. Most importantly, we know that Medicare can deliver better value for patients—better care at a lower cost—when care is delivered through physician groups with incentives aligned toward preventing illness. Second, CAPG continues urging Congress to advance the ACO program to capitated payment models. Today’s Medicare Shared Savings Program and Pioneer ACO, and the forthcoming Next Generation ACO program, have created an onramp to risk for providers in traditional Medicare. CAPG is encouraging the chronic care working group to consider improvements to the existing ACO program. At the same time, we are promoting the adoption of models further along the continuum to risk, such as CAPG’s Third Option, which is a step beyond ACOs, yet not all the way to Medicare Advantage. The Third Option’s defining features include empowering beneficiaries to select the best care option for their unique care needs, incentives to seek care from a defined care team, and capitated payments to physician organizations for a defined patient population. Finally, CAPG is encouraging Congress to consider enhancing the development of advanced primary care capabilities. Our members continued on page 33 14 l CAPG HEALTH
Summer 2015
In June, CAPG met with Senator Johnny Isakson, cochair of a Senate Finance Committee working group on chronic conditions, to discuss improving care for seniors.
Winter 2015
CAPG HEALTH l 15
The Coded DOFR and Its Role in Accountable Care BY S T E P H E N J . L I N ES C H , S V P, A D M I N I S T R AT I O N A N D D E V E LO P M E N T, C A P G
The current world of capitated, accountable care is full of complex relationships between contracting parties. To succeed, a physician organization must understand and track its Division of Financial Responsibilities (DOFR), a key capitated agreement component, at the coded level to understand its risk and payment obligations. As the Affordable Care Act (ACA) and other market factors increase the number of capitated and accountable care organization (ACO) models, the DOFR will continue to be an integral component of these risk arrangements. This article updates one I wrote for CAPG Health in 2011 when the Integrated Healthcare Association (IHA) launched the first Coded DOFR. Since then, IHA has been continuously improving the Coded DOFR and, more recently, launched its fifth annual Release 5.0. IHA created the Coded DOFR in collaboration with California health plans, providers, government agencies, and several associations, including CAPG. The Coded DOFR’s purpose: to enable greater transparency and accountability as commercial and Medicare Advantage health plans and providers allocate financial and claims payment responsibilities to the correct payer. Each year, the Coded DOFR is updated and vetted by the multi-stakeholder workgroup, creating an industry standard for health plans and providers. This standardized template provides a set of service categories with associated codes vetted by the workgroup—in total more than 100 service categories mapped to more than 14,000 Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS) diagnosis, and hospital revenue codes. Health plans and providers can use the template to customize and assign risk, and reference the baseline template for comparison, while the standard set of service categories serves as an initial template that
16 l CAPG HEALTH
Summer 2015
“Converting to
a standardized coded template can reduce administrative costs and alleviate ‘DOFR creep’–when ambiguity in contracting language results in a transfer of financial risk not anticipated in the original agreement.”
can be customized through negotiation. Since every shared risk arrangement is unique, the Coded DOFR does not assign risk; instead, financial responsibility continues to be determined by the contractual relationship between the health plan and its network providers.
During CAPG Contracts Committee meetings, we often review issues related to DOFR interpretation. Challenges with non-coded DOFRs include significant variation among health plan agreements and lack of coding detail, which can result in a constant cycle of interpretation. Additionally, lack of coding detail can increase the administrative expense involved with claims ping-ponging back and forth between health plans and providers, which can also have a significant adverse impact on member satisfaction. Although non-coded DOFRs have long been in use in delegated risk agreements, the issues and problems they create can largely be resolved by using an updated model. Enter the Coded DOFR. Converting to a standardized coded template can reduce administrative costs, helping all parties to achieve the ACA health plan requirement
to maintain administrative expenses at or below 20% of premiums in the individual and small group markets, and at or below 15% of premiums in the large group market. The Coded DOFR also alleviates what many physician organizations call “DOFR creep”—when ambiguity in contracting language results in a transfer of financial risk not anticipated in the original agreement. And the Coded DOFR can increase patient experience ratings by reducing the number of misdirected claims and any resulting claim issues involving the member. Adoption of the Coded DOFR in delegated risk contracting arrangements in markets with mature capitated, delegated risk products (as in California) has been slow due in part to health plan legacy systems that make large-scale changes difficult and expensive. Fortunately, organizations implementing capitated ACOs for the first time are not burdened by history, making use of the Coded DOFR more feasible. Providers negotiating their first risk agreements for commercial ACO, Medicare ACO, and Medicare Advantage are highly encouraged to use the Coded DOFR. Implementing the Coded DOFR in multiple health plan agreements has
the added benefit of “apples-to-apples” comparison among similar service categories in multiple health plan agreements. Coding transparency can only be achieved if providers are using the same service category codes as the health plans. Since the Coded DOFR Release 5.0 in March 2015, IHA has implemented quarterly updates to stay current with frequent code set changes, including those resulting from regulatory updates and advancements in technology. IHA also created and launched the DOFR Explorer™, a simple web-based tool that allows users to search and view service categories with their associated codes, and vice versa, enabling views of individual codes with their associated service categories. The Coded DOFR and DOFR Explorer™ are available at http://www.iha.org/dofr.html. o For more information on the Coded DOFR, please contact Ann Hardesty, Integrated Healthcare Association, ahardesty@iha.org, or me, Steve Linesch, slinesch@ capg.org. I invite you to comment on this article at either of the above emails or at twitter.com/slinesch.
Summer 2015
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
Heritage Provider Network* Richard Merkin, MD, President Richard Lipeles, Chief Operations Officer
Choice Medical Group IPA Manmohan Nayyar, MD, President Marie Langley, IPA Administrator
• 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 •
Cigna Medical Group Edward Kim, President and General Manager Kevin Ellis, DO, Chief Medical Officer Citrus Valley Independent Physicians Gurjeet Kalkat, MD, Executive Medical Director Martin Kleinbart, DPM, Chief Strategy Officer
Affinity Medical Group Richard Sankary, MD, President Scott Ptacnik, COO
Colorado Permanente Medical Group, P.C. William G. Wright, MD, Executive Medical Director Dan A. Oberg, CFO and VP, Corporate Development
Alameda Health Partners William Peruzzi, MD, Chairman David Cox, Treasurer/CFO
Community Health Innovations Anthony Chavis, MD, VP Enterprise and CMO Liz Lorenzi, VP and COO
AllCare IPA* Matt Coury, CEO Randy Winter, MD, President
Conifer Health Solutions Megan North, CEO
High Desert Medical Group Charles Lim, MD, FACP, Medical Director Anthony Dulgeroff, MD, Assistant Medical Director Hill Physicians Medical Group, Inc.* David Joyner, CEO Tom Long, MD, Chief Medical Officer John Muir Physician Network Lee Huskins, Interim CEO/SVP/COO Ravi Hundal, MD, Medical Director Lakeside Community Healthcare Kerry Weiner, MD, Chief Medical Officer Jonathan Gluck, Counsel
Allied Physicians of California Thomas Lam, MD, CEO Kenneth Sim, MD, CFO AltaMed Health Services Corporation* Castulo de la Rocha, JD, President and CEO Martin Serota, MD, Chief Medical Officer
• 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 •
AppleCare Medical Group, Inc.* Vinod Jivrajka, MD, President and CEO Surendra Jain, MD, Chief Medical Officer
Continucare Corporation Alfredo Ginory, MD, Chief Medical Officer Gemma Rosello, Vice President
Austin Regional Clinic Norman Chenven, MD, CEO and Founder Kerry Rosker, Executive Administrative Coordinator
Desert Oasis Healthcare Marc Hoffing, MD, Medical Director Dan Frank, Chief Operating Officer
Bakersfield Family Medical Center Carol L. Sorrell, RN, COO Ju Hwan Lee, MD, Medical Director
Dignity Health Bruce Swartz, SVP, Physician Integration
MED3000 Lynn Stratton Haas, CEO Gary Proffett, MD, Medical Director
Edinger Medical Group Matthew C. Boone, MD, Executive Medical Director Denise McCourt, Chief Operating Officer
• SeaView IPA • Valley Care IPA •
Bayhealth Physician Alliance, LLC Evan W. Polansky, JD, Executive Director Joseph M. Parise, DO, Medical Director
C A P G
Chinese Community Health Care Association John M. Williams, PharmD., CEO Polly Chen, Director of Operations
Beaver Medical Group* John Goodman, President and CEO Charles Payton, MD, VP Medical Administration and CMO Brown & Toland Physicians* Richard Fish, CEO Andrew M. Snyder, MD, Chief Medical 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
California Pacific Physicians Medical Group, Inc. Dien V. Pham, MD, Chief Executive Officer Carol Houchins, Administrator
Facey Medical Foundation* James M. Slaggert, CEO Erik Davydov, MD, Medical Director
CareMore Medical Group Tom Tancredi, Director of Practice Operations
Golden Empire Managed Care, Inc.* Michael Myers, President and CEO Steve Bass, MD, CMO
Catholic Health Initiatives* Don Lovasz, President, Clinically Integrated Network Chris Stanley, MD, VP of Care Management
Good Samaritan Medical Practice Association Nupar Kumar, MD, Medical Director
Cedars-Sinai Medical Group* Thomas D. Gordon, CEO Stephen C. Deutsch, MD, Chief Medical Director
Greater Newport Physicians Medical Group, Inc.* Diane Laird, CEO Adam Solomon, MD, CMO
Central Ohio Primary Care Physicians, Inc. J. William Wulf, MD, CEO Michael Ashanin, COO
HealthCare Partners* Kent Thiry, Chairman and CEO, DaVita Don Rebhun, MD, Corporate Medical Director
Children’s Physicians Medical Group Leonard Kornreich, MD, President and CEO
* Indicates 2015-2016 Board Members
18 l CAPG HEALTH
Summer 2015
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
MedPoint Management Kimberly Carey, President Rick Powell, MD, Chief Medical Officer • 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 Joel Criste, CEO J. David Andrew, MD, Medical Director 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 Ute Burness, RN, CEO Steve Kaplan, MD, President
River City Medical Group, Inc. Loren Douglas, CEO Jose Abad, MD, President and Medical Director
Tenet Healthcare Jacob Furgatch, CEO, Coast Health Plan Services Ronald Kaufman, CMO
NAMM California* Leigh Hutchins, President and COO T. K. Desai, MD, SVP and CMO
Riverside Medical Clinic Steven Larson, MD, Chairman Judy Carpenter, President and COO
• 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. •
Riverside Physician Network Howard Saner, CEO Paul Snowden, COO
Torrance Hospital IPA Norman Panitch, MD, President Triad HealthCare Network, LLC Thomas C. Wall, MD, Executive Medical Director Steve Neorr, VP, Executive Director
New West Physicians, PC Thomas M. Jeffers, MD, President and Chair Ruth Benton, CEO Northwest Permanente, P.C. Jeffrey Weisz, MD, Executive Medical Director Harry Stathos, VP and CFO Omnicare Medical Group Toni Chavis, MD, President Ashok Raheja, MD, Medical Director The Permanente Medical Group, Inc. Oakland (North)* Sharon Levine, MD, Associate Executive Director Suketu Sanghvi, MD, Associate Executive Director Physicians DataTrust Anthony Ausband, President Lisa Serratore, Chief Operations Officer
St. Joseph Heritage Healthcare* C.R. Burke, CEO Khaliq Siddiq, MD, Chief Medical Officer • Hoag Medical Group • Mission Heritage Medical Group • St. Mary High Desert Medical Group •
USC Care Medical Group, Inc. Keith Gran, CEO Donald Larsen, MD, Chief Medical Officer
San Bernardino Medical Group James Malin, CEO Thomas Hellwig, MD, President
WellMed Medical Group, P.A. George M. Rapier III, MD, Chairman and CEO Carlos O. Hernandez, MD, President
San Diego Physicians Medical Group Joyce Cook, CEO James Cordell, MD, President
CORPORATE PARTNERS
Sansum Clinic* Kurt Ransohoff, MD, Medical Director and CEO Vince Jensen, COO Santa Clara County IPA (SCCIPA)* J. Kersten Kraft, MD, President of the Board Lori Vatcher, CEO
• Greater Tri-Cities IPA • Noble AMA IPA • St. Vincent IPA •
Santé Health System, Inc Scott B. Wells, CEO Daniel Bluestone, MD, Medical Director
Physicians Choice Medical Group of San Luis Obispo John Okerblom, MD, President Barbara Cheever, Executive Director
Scripps Coastal Medical Center Anthony Chong, MD, CMO Tracy Chu, Assistant Vice President of Operations
Physicians Medical Group of Santa Cruz County* Marvin Labrie, CEO Nancy Greenstreet, MD, Medical Director
Sharp Community Medical Group* John Jenrette, MD, CEO Christopher McGlone, Chief Operating Officer
Physicians Choice Medical Group of Santa Maria John Okerblom, MD, President Barbara Cheever, Executive Director
• Graybill Medical Group • Arch Health Partners • Sharp Rees-Stealy Medical Group* Stacey Hrountas, CEO Alan Bier, MD, President
Physicians of Southwest Washington, LLC Mariella Cummings, CEO Gary R. Goin, MD, President PIH Health Physicians Deeling Teng, MD, Sr. Medical Director, Group Operations Ramona Pratt, RN, COO, Group Operations Pioneer Medical Group, Inc.* John Kirk, CEO Jerry Floro, MD, President Preferred IPA of California Mark Amico, MD, Medical Director Zahra Movaghar, Administrator Prospect Medical Group* Mitchell Lew, MD, CEO Jeffrey Hay, MD, CMO • 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 Health & Services James M. Slaggert, CEO Providence Medical Management Services Phil Jackson, Chief Integration and Transformation Officer • Korean American Medical Group • Providence Care Network •
UCLA Medical Group* Sam Skootsky, MD, Medical Director David Hartenbower, MD, COO
Southeast Permanente Medical Group, Inc., The Michael Doherty, MD, Executive Medical Director and Chief of Staff Southern California Permanente Medical Group* Vito Imbasciani, MD, Director of Government Relations James Malone, Medical Group Administrator Sutter Health Foundations & Affiliated Groups* Jeffrey Burnich, MD, SVP and Executive Officer, Sutter Medical Network Brian Roach, President, Mills Peninsula Division of PAMF • 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 • SynerMed* James Mason, President and CEO George Ma, MD, Medical Director
Anthem Blue Cross of California Athenahealth Boehringer Ingelheim Pharmaceuticals, Inc. Humana, Inc. Merck & Co. Novartis Pharmaceuticals Novo Nordisk Patient-Centered Primary Care Collaborative SCAN Health Plan ASSOCIATE PARTNERS abbvie Arkray Arro Health Astellas Pharma US, Inc. AstraZeneca Pharmaceuticals Bayer HealthCare 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. Lumara Health 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 Global Transitional Care Mills Peninsula Medical Group Nifty After Fifty Monarch LLC Partners in Care Foundation Pharmacyclics, Inc. PsycheAnalytics, Inc. Redlands Community Hospital Saint Agnes Medical Group SullivanLuallin Group Ventegra, LLC
• 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 • Summer 2015
CAPG HEALTH l 19
Building Resilience Through Practice Transformation BY M I C H A E L YO U N G L E E , M D , M P H
Are you feeling run down physically or emotionally? Do you find yourself getting easily irritated and feel that others make your life harder? Do you think you should be more advanced in your career? If you answer yes to any or all of these questions, you may be burned out or showing symptoms of it. According to a recent Mayo Clinic study, 46% of physicians surveyed had at least one symptom of burnout. Those at highest risk were the frontline physicians in specialties such as emergency and primary care. Physician burnout is serious, especially in regards to patient care, since it can lead to increased medical errors, high turnover rates for physicians, and poorer patient and physician satisfaction. (Shanafelt et al, 2012)
“The American
Psychological Association defines resilience as the ‘process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress.’”
What makes physicians more prone to burnout? A culture that starts in medical school. An attitude that self care comes second to work is laid down early in physician training. (Spickard et al, 2002) Many of us can recall in our training and career sacrificing hobbies or things that recharge us to finish charting, see an extra patient, or work an extra shift. A common personality trait among physicians is the “Compulsiveness Triad,” which includes self doubt (Am I a good enough doctor?), self-imposed guilt for not being there for a patient, and an exaggerated sense of responsibility, leading to difficulties in setting boundaries. (Spickard et al, 2002) Our training and practice environment breed a culture of perfectionism where there is little self forgiveness when an error occurs. As Dr. Pam Honsberger, a member of the Kaiser Orange County Wellness Committee and physician leader, said, “We can have many beautiful encounters with patients where lives were saved, but that one patient complaint or bad patient outcome will stick in our minds and lead us to beat ourselves up for days.” Dr. Brene Brown, a research professor at the University of Houston, has noted, “Perfectionism is not about striving for excellence or healthy striving. It‘s a way of thinking and feeling that says this: ‘If I look perfect, do it perfect, work perfect, and live perfect, I can avoid or minimize shame, blame, and judgment.’” Practice transformation has to occur or we will continue to lose physicians to burnout and potentially diminish quality of care. While it’s important to work on improving such factors as electronic medical record skills and time efficiency in clinic visits, it’s equally important to work internally to build resilience. The American Psychological Association defines resilience as the “process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress.” It’s not about not feeling the emotion, but both feeling it and developing healthy coping skills to work through it. The inability to identify, understand, and describe one’s own emotions can lead to higher burnout. (Thomas, 2004). Often in our medical culture, we are taught after a traumatic event, such as a patient death, to put our head to the ground and keep working without
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feeling. Unfortunately, suppressing your emotions and not coping can lead to worsening anxiety, depression, and substance abuse.
they seem trivial or even laughable, you’ll sail calmly past obstacles that have defeated you before . . . and lay down a permanent new route to change.”
Three steps I have found that help build resilience are:
For anyone who needs to hear a positive, encouraging voice, let me remind you: “You are a good physician and as worthy of compassion and care as your patients. You are not perfect but that does not make you any less of a physician or a person. It takes courage each day to do the amazing work you do to care for your patients.”
1. Making connections with others, especially those who are supportive and caring to us. Having a family member or friend who can empathize when we have a rough day at work or a bad patient outcome is vital. You have to schedule and value this time as much as work time. Dr. Dike Drummond, a physician burnout specialist, suggests a “schedule hack,” where you enter time with friends or family in your calendar and carry it with you on your cell phone to avoid scheduling anything in its place. 2. Nurturing a more positive view of self. We are so quick to criticize ourselves or fail to be compassionate and forgiving with ourselves when something goes wrong. Be aware of negative self talk, and try to quiet it with reminders of the gifts you bring to others and the positive things you do daily. Taking time regularly to think about or write down how you positively affected a patient’s life can develop a stronger sense of self and a reminder of the joys in being a physician. 3. Taking care of ourselves and valuing it as much as we value taking care of others. Remember: we are just as human as our patients, and need to recharge and take care of our own health and emotions. Knowing this will help you to draw boundaries, since many of us have a hard time saying “no” and feel the need to sacrifice everything for others. This unhealthy sacrificial attitude in our medical culture is clearly not sustainable, nor beneficial for patients or physicians in the long run. Having a healthy attitude of self care will make it more palatable to let go and approach patient care from more of a team aspect and avoid shouldering all the work on your own. For true practice transformation to occur and be sustainable, it needs to start from within. The key is starting small. Dr. Robert Maurer, an author and clinical psychologist, writes, “By taking steps so tiny that
To build resilience, we as physicians need to be proactive about taking care of ourselves, which will help us to transform our practices and become positive role models for our patients. o Michael Lee is a family physician and member of the Physician Wellness Committee for Kaiser Permanente Orange County in Southern California. A wellness and communications coach for physicians, he has spoken to physician groups and medical students on preventing burnout and building resilience. Mike welcomes comments at mikalee73@hotmail.com. To learn more about the new Practice Transformation Program from CAPG and partner 2.0 Healthcare, please see page 26.
References www.apa.org www.thehappymd.com Brown, Brene. Daring Greatly, Avery Publishing, 2012. Maurer, Robert. The Kaizen Way, Workman Publishing, 2004. Shanfelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, West CP, Sloan J, Oreskovich MR. “Burnout and Satisfaction with Work Life Balance Among US Physicians Relative to the General US Population” Arch Intern Med. 2012;172(18):1377-1385. Spickard A, Gabbe SG, Christensen JF. “Midcareer burnout in generalist and specialist physicians,” JAMA 2002;288:14471450. Thomas, N. “Resident burnout,” JAMA 2004;292:28802889.
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Enhancing the Patient–Care Team Experience Using Interactive Voice Response Technology BY J A N E L L E H O W E , R D , S E N I O R D I R ECTO R , H E A LT H E N H A N C E M E N T, H E A LT H C A R E PA R T N E R S M E D I C A L G R O U P A N D J E R E M Y R I C H , M D , D I R ECTO R , H E A LT H C A R E PA R T N E R S I N S T I T U T E F O R A P P L I E D R ES E A R C H A N D E D U C AT I O N
In this article, we share practical insights from our experience using interactive voice response (IVR) technology at an integrated and coordinated care organization. To better align the intersections of patient needs, care quality, and cost, we will present operational lessons learned about using IVR to help expand clinical capacity and enhance the patient-care team experience.
INTERACTIVE VOICE RESPONSE: THE WHY AND WHEREFORE IVR technology enables the healthcare team to intervene sooner when symptoms worsen, leading to better outcomes for patients and potentially less stress for caregivers. IVR can expand clinical capacity by allowing the care team to focus on higher-risk, vulnerable patients. It can help patients better understand how to manage their conditions and become more engaged in their wellness. Keeping patients in their homes when possible can enhance wellness while reducing the potential need for more intensive settings. When HealthCare Partners launched an IVR pilot in 2011, it was imperative that our system be simple and not burden patients with setup, battery changes, hardware, maintenance periods, or other requirements. These concerns can potentially impede program fidelity among the chronically ill, many of whom have visual, auditory, and dexterity impairment. IVR provides chronic disease–specific survey questions to help patients report their symptoms telephonically and institute a clinician-approved action plan (Figure 1). Professional voice talent is used for the survey and can reflect regional dialects and languages to better serve the linguistically isolated. Patients and care teams worked collaboratively to ensure survey questions appealed to a wide variety of patients and presented practical, actionable data to health teams. Patients complete the IVR survey weekly and enter disease symptoms (Figures 2, 3) using their telephone keypad to record responses. Pressing 1, 2, or 3 corresponds to green, yellow, and red symptom zones of increasing severity, adapted from National Jewish Health’s symptom zones. Red zones indicate an emergent situation requiring care team intervention, while yellow zones indicate less severe symptoms that necessitate health team initiation of an action plan. Green zone symptoms do not require intervention. The data are evaluated the next morning for red or yellow zone or worsening symptoms. Calling frequency, once or twice weekly, is jointly decided by the patient and staff to enhance fidelity. Calls occur at noon, and if no response is received, a back-up call takes place at 7:00 pm. IVR patient reports are transmitted to staff in an actionable, easy-toread format, including total score, change greater than 2 from previous call, longitudinal trending, and no answer or an incomplete survey. 22 l CAPG HEALTH
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BUILDING A FRAMEWORK OF QUALITY ENHANCEMENT BY MELDING RESEARCH INTO PRACTICE Healthcare organizations that carefully design and implement practical, scalable innovations find that they can foster visceral attachments between patients and care teams. In turn, this can help meet patient–health team needs and improve quality of care, fidelity, and cost—factors that can enhance the patient–care team experience. To determine if IVR makes sense for a specific condition, we examine factors including: • Is there a timely opportunity to act and avoid an adverse event? • Is the condition one that may encourage the patient to “sign on” for a survey? Does s/he recognize the potential for clinical trouble and need for action planning? • Are there significant clinical team burdens that could be offset by an automated process that helps to identify vulnerable patients?
Following are some of the key takeaways from our experience. IVR can improve organizational quality through practice redesign to initiate care processes based on patients’ self-reported risk factors. Reports are easy to read and actionable. Personnel note, “We know which symptoms the patient is experiencing, and can reach out with actionable information for follow-up.” The technology can free up time, allowing staff to focus on vulnerable patients at higher risk for adverse events (yellow and red zones). We generally observe that about 5% to 10% of our chronic disease population needs care team follow up. Patients say they do not want to be micromanaged, and appreciate the survey brevity and timely care team action.
• Some patients report feeling overwhelmed by communications from healthcare organizations. Patients feel they already interact with many wellness programs, personnel and caregivers, and want to evaluate if IVR truly adds value. • They view calls as a value-added measure to enhance wellness and keep them in their chosen residence. IVR calls are not seen as intrusive or a chore, which helps patients have a visceral attachment to the program. • When the “pump is primed”—patients/caregivers are contacted by health staff prior to enrollment—they have a choice to opt into the program and receive survey questions in advance (Figures 2, 3). Patients can then complete the survey or not at their discretion.
Our organization ensures that the promised clinical follow-up is consistently delivered. Patients have done their part by completing the IVR survey; hence, care team follow-up is critical to establish their trust in the process. • Even after extended contact with their healthcare team, some patients hesitate to reach out when symptoms are recognized, preferring to wait for followup rather than “bother” the team.
COPD Action Plan Managing Your COPD
• •
GREEN ZONE
YELLOW ZONE
RED ZONE
You feel well.
You feel worse.
You feel much worse or in danger!
You are able to breathe without difficulty while doing your usual activities. There is no change in your cough, sputum, ability to think/ remember, or energy.
• • • • •
Action Plan
• •
Continue your usual activities. Take your medicine as directed by your doctor.
You have more shortness of breath, wheezing, or coughing than usual. Your sputum is thicker, or has turned green or brown. You have a fever of 100°F or more. You may feel forgetful or confused, and may have difficulty concentrating or sleeping.
• • • • •
• • •
You have difficulty coughing up sputum. You have blood in your sputum. You feel drowsy or have difficulty waking up. You are not able to do any of your usual activities.
You feel more tired, and cannot finish your usual activities without resting.
Action Plan
•
You are having trouble breathing.
Increase the use of your “Rescue Inhaler” or Nebulizer (Albuterol or Xopenex). Use Pursed Lip Breathing and/or other energy-saving techniques. Take your oral steroids (Prednisone) and/or antibiotics your doctor has prescribed.
Action Plan
• • •
Follow the Action Plan in the YeLLOW zONe column. Call your doctor or care manager immediately. Go to the nearest Urgent Care/Walk-In Center or Hospital Emergency Department or Call 911 if necessary.
Call your doctor or care manager, or go to the nearest Urgent Care/ Walk-In Center.
Figure 1. COPD patient wellness action plan based on zones of symptoms.
Follow-Up Information
continued on next page
My Primary Care Doctor _________________________________________________________________________________ My Doctor’s Phone Number _____________________________________________________________________________ Summer 2015 CAPG HEALTH
l 23
• Repetition of survey questions continually reinforces the importance of symptoms and further supports self-management. The true “win” is when patients initiate action plans ahead of any follow-up— understanding that their symptoms could lead to an adverse event.
In our experience, IVR has been a cost-effective strategy and we are able to manage a large number of patients. Although we have outsourced the direct calls and data capture, we have managed in house the timely reporting to care teams and patient follow-up.
DELIVERING AN ENHANCED PATIENT–CARE TEAM EXPERIENCE
• We allow patients to skip surveys as long as they still agree to be called regularly; they can restart when experiencing symptoms, which provides a safety net as needed.
Operations and implementation are critical within health organizations. Regardless of a program’s potential merits, it may be a “non-starter” without a realistic, customized operational and implementation strategy.
Using staff “champions” who lead by example can demonstrate to personnel how IVR frees up time to focus on higher-risk patients. Ease of monitoring is important for care team buy-in. Staff have competing priorities and patient care needs, so we want the follow-up process to be quick, easy, and relevant. The program does not enroll patients who appear apathetic or complacent; IVR patients are inherently more activated because they are willing to participate in a wellness program. IVR does not substitute for nurse calls, face-to-face meetings with patients, or hands-on education. The program expands clinical capacity by helping patients self-manage conditions with appropriate team support and intervention.
COPD Symptom Phone Survey
?
Summer 2015
To properly manage your COPD, your Care Coordinator will personally call you to monitor your general health. We also have free, automated phone survey monitoring. These weekly surveys help us to identify Red and Yellow Zone symptoms and stop a COPD flare-up before it starts.
GREEN ZONE You feel well.
• Survey question volume and articulation must be tested with specific patient populations, given auditory impairment, linguistic isolation, and other factors affecting comprehension.
24 l CAPG HEALTH
• As clinical innovations evolve and are refined over time, operations should be customized to
Managing Your Chronic Obstructive Pulmonary Disease
• Technical challenges are possible, including ambient noise (e.g., televisions or air conditioning), which can mislead the IVR system and mistakenly prompt a back-up call.
YELLOW ZONE You feel worse. RED ZONE You feel much worse or in danger!
It’s Easy! Here’s How it Works: 1. Every Monday and/or Thursday, you will receive a phone call between noon – 1 pm. If we are unable to reach you, we will call you again between 6 – 7 pm.
2. After you say “hello,” the automated phone system will begin the COPD Symptom Survey. 3. The survey has nine questions. To save time, you may press the response number that best fits your current symptoms at any point during the survey.
4. It’s fine if you miss a survey call. We know that you may not always be available at the time we call. 11992 12-13
The system can support administration of appropriate prescriptions in some instances, as patients recognize worsening symptoms and initiate clinician-approved action plans. Monitoring is the main reason care teams consider starting patients on IVR, as it frees up time for other professional demands. According to staff, many patients participate in IVR for peace of mind, knowing that “their name and symptoms are in front of their care teams’ eyes” and help is on the way if needed.
• A focused and realistic vision of IVR must be created that resonates with patients and the health team. Administrative buy-in is a key factor for pilot testing and potential dissemination.
Look on the other side of this flyer for a list of the COPD Symptom Phone Survey questions and response options.
Medical Group and Affiliated Physicians
The Right Doctors Make All The Difference
Figure 2. Remote patient monitoring operations document.
}
the organization’s particular culture, personnel experience, and clinical quality strategies.
This is not uncommon in certain cultures; having a chronic disease can be seen as a stigma, a weakness, or an attack on their familial/social standing.
• IVR is adaptive and can be used to help enhance outcomes in a variety of wellness initiatives: diabetes mellitus (DM), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), oncologic protocols, hospital to home transitions, patient satisfaction, and caregiver support.
The IVR enrollment process improved when we devoted a team of recruiters to focus on our vulnerable patient population (those with moderate to severe chronic disease). • This approach received some staff resistance, with personnel feeling overwhelmed by additional responsibilities. Some did not perceive the value IVR could have for care, and felt it was challenging to discern accurate diagnoses in the disease registry.
Patients feel a sense of control in being able to identify symptoms before exacerbation. IVR encourages patients to monitor and report their own symptoms, and appears more effective than handouts or lectures in self-managing disease. Knowing they are being monitored, patients feel empowered to act and are less hesitant to contact care teams.
• Resistance was reduced when staff witnessed how IVR freed up colleagues’ time. “Salesmanship with integrity” was crucial for personnel to see how the program could realistically enhance clinical capacity and care quality by maximizing their time.
Some patients initially refused to participate but later agreed after understanding the survey questions may be helpful in symptom recognition. Moreover, some denied having COPD, diabetes, or CHF.
B
Breathing in general:
C
Breathing while eating:
D
Feet and ankles:
E
Weight:
F
Sleep:
G
Sputum/mucus:
Press 1 if you have no trouble breathing. Press 2 if you have more coughing, shortness of breath, or wheezing than usual. Press 3 if you are having a lot of trouble breathing when at rest.
Press 1 if you can eat without being out of breath. Press 2 if you are slightly out of breath when eating. Press 3 if you are breathless when eating.
Press 1 if you have no foot or ankle swelling. Press 2 if you have some swelling in your feet or ankles. Press 3 if you have a lot of swelling in your feet or ankles.
Press 1 if you have not gained weight this week. Press 2 if you have gained 2 to 4 pounds over the last week. Press 3 if you have gained 5 or more pounds over the last week. Press 1 if you are sleeping through the night without problem. Press 2 if you are waking up and unable to fall back to sleep 1 to 3 nights a week. Press 3 if you are waking up and unable to fall back to sleep more than 3 nights a week, or woke up gasping for air.
Press 1 if your mucus is clear. Press 2 if your mucus is thick or stickier than usual, or your mucus is turning yellow or green. Press 3 if you are having a lot of trouble coughing up mucus, or you have blood in your mucus.
H
Ability to focus:
I
Appetite:
J
SUMMARY
Press 1 if you can think clearly. Press 2 if you are having trouble concentrating. Press 3 if you are very confused or have slurred speech.
Press 1 if you are eating your normal amount. Press 2 if you are eating a little less than usual. Press 3 if you are eating much less than usual.
Questions? Call your Care Coordinator at
800.335.3362
Energy level: Press 1 if you are not tired doing your usual activities. Press 2 if you are tired or cannot finish your usual activities without getting tired. Press 3 if you are very tired and cannot do any activities.
Figure 3: Patient reported outcomes IVR wellness questions.
Press 7
IVR can help enhance the patient–care team experience by recognizing symptom exacerbations earlier, improving treatment adherence, and decreasing avoidable hospital admissions, readmissions, and emergency department visits. This technology can expand clinical capacity by allowing personnel to focus on at-risk patients within the yellow or red symptom zones. Currently, there is scant information on using IVR to activate caregivers. This may serve as food for thought as organizations strive to offer value-based healthcare among linguistically isolated communities.
ACKNOWLEDGMENTS Support for pilot construction, testing, and refinement was provided by the Center for Technology and Aging, Oakland, CA. The authors are grateful to Ms. Lori Larson, health educator, HealthCare Partners Affiliates Medical Group, for her commitment to patient and caregiver wellness. For more information, please contact Dr. Jeremy Rich, Director of the nonprofit HealthCare Partners Institute for Applied Research and Education, at jrich@ healthcarepartners.com. o Summer 2015
CAPG HEALTH l 25
The Bridge To Effective, Efficient Quality Healthcare BY VA L E R I E O KU N A M I
WellMed Medical Group has introduced a palliative care program designed to bridge what had been a gap in care offerings. Called “Bridges,” the program provides care for some of WellMed’s sicker patients —patients whose needs were beyond what the group’s care management and clinic-based resources could provide, but for whom hospice services would not be appropriate, said Dr. Richard Whittaker, Chief Medical Officer, WellMed. “The Bridges program is providing tailored care for patients,” Dr. Whittaker said. “We’re realizing better utilization of the medical group’s staff and significant cost savings.” Richard Whittaker, MD Chief Medical Officer WellMed Medical Group
“The Bridges
The program uses palliative care–trained physicians, non-physician practitioners and nurses who see the patients in their homes or in a clinic setting. Each patient receives advanced care planning. Care is coordinated between care management and the primary care physician. In many cases, hospice partners become involved as well, said Dr. Whittaker.
program is The Bridges program was designed by Dr. Elizabeth Glazier, Associate Medical providing Director, WellMed, a geriatrician certified in palliative medicine. She was named House Call Doctor of the Year in 2006 by the American Academy of Home Care tailored care for Physicians for work she did with more than 250 homebound elderly residents of an impoverished Washington, DC community. patients,” Dr. Dr. Glazier said she receives great satisfaction in providing in-home care to her Whittaker said. WellMed patients and their families. “I treat patients and their families on many “We’re realizing levels,” she said. One of her concerns is the “high utilization” patient who visits the emergency room for minor problems. Seeing those patients in the home produces better utilization WellMed Network Management amazing results, she said, such as fewer hospital visits and higher quality care. Summary Bridge Dashboard of the medical Dates of Service 1/1/2012 ‐ 04/30/2015 The program has turned out to be a winner, said Dr. Whittaker. “The result is a Report Date: 06/11/2015 group’s staff three-way win—for our patients, our providers and the system,” he said. Sourced from Paid Claims and significant cost savings.” 2012 Total 2013 Total Admissions Per Thousand ER Visits Per Thousand Total Facility Costs PMPM Total Specialty Costs PMPM Total Healthcare Cost PMPM Paid sponsorship
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Pre 1,350 3,394 $2,144 $1,428 $3,572
Post 0 0 $0 $0 $0
Pre 377 825 $577 $324 $901
Post 116 638 $147 $159 $305
2014 Pre 703 1,500 $811 $461 $1,272
For patients and their families, he said, the benefits are improved care in their homes with fewer emergency room visits and hospitalizations and lower out-of-pocket costs. Patients in the Bridges program can enjoy many of the additional services typical in hospice care for significantly longer periods of time than hospice is able to provide. “Providers benefit,” he said, “from improved care for their patients and improved efficiency through the support they get from the palliative care team managing this population of patients for them since many of these patients require a significant amount of their time.” As for the system itself, it benefits from cost savings mainly through avoiding costly hospital and emergency visits and inappropriate or unnecessary services, he said. “A large percentage of all health care dollars are spent in the last three months of life on roughly 5% of the Medicare population,” he said. “This program is essentially funded by curbing some of those costs,” said Dr. Whittaker. o
Bridge Program 4 Q1 2014 Q2 Post Pre Post 703 555 277 1,356 1,324 717 $885 $745 $550 $351 $387 $319 $1,236 $1,131 $869
Dr. Elizabeth Glazier visits a patient in her home.
2014 Q3 Pre 762 1,549 $1,032 $519 $1,550
Post 332 647 $501 $284 $785
2014 Q4 Pre Post 928 381 1,724 1,006 $1,070 $564 $539 $367 $1,609 $931
2014 Total Pre Post 710 376 1,497 872 $882 $575 $465 $330 $1,347 $905
2015 Q1 Pre Post 1,387 738 2,653 1,569 $1,779 $942 $635 $476 $2,414 $1,418
Paid sponsorship Summer 2015
CAPG HEALTH l 27
Policy Briefing CMS Medicaid Managed Care Regulation Lays Foundation for the Next 25 Years of Managed Care BY BILL BARCELLONA, SENIOR VP, GOVERNMENT AFFAIRS, CAPG
On May 26, the Centers for Medicare & Medicaid Services (CMS) issued its first major regulatory update for the Medicaid program since 2002. The goal of this new regulation is to modernize care delivery standards, move toward value-based payment, and implement deeper and broader performance measurement and transparency. The first public comments about the regulation are due on July 27. In the intervening decade, several million additional Americans have become eligible for their state Medicaid program, and several states have rapidly expanded into a managed care model. In some states like California, about one-third of the population is enrolled in the program—more than 12 million beneficiaries. State Medicaid directors are quickly becoming the most influential change agents in the delivery of healthcare, especially in managed care. I believe that Medicaid managed care will have the same influence over provider behavior during the remainder of this decade as has Medicare Advantage (MA). During the next five years, both programs will continue to draw closer together, sharing payment models, beneficiaries (dual eligibles), performance measurement standards, and commonality of health plans. The pending regulation includes several sections that result in the alignment of the integrated and coordinated delivery system emerging under the Affordable Care Act in the commercial and senior programs with Medicaid. Medicaid programs will increasingly require greater organization and coordination of providers in the states. As the level of administrative delegation to providers increases, providers that functioned under a fee-for-service payment model will be required to learn to live in a capitated-delegated environment. Here are some of the more pertinent sections in summary detail:
MEDICAL LOSS RATIO (MLR) PROVISIONS Under the proposed rule, CMS directs states with managed care organizations (MCOs or other capitated entities) to comply with a minimum MLR of 85%. States will use the historic MLR data in the rate-setting process for the next year’s assessment of the actuarial soundness of capitated payments. For example, when an MCO has too high an MLR (say 103%), it may indicate that the prior year’s capitation was too low given the acuity and utilization trend of the plan population. Too low an MLR may indicate that capitation rates were too high, and should be lowered the next year. These MLR standards should be in place for contract years beginning after January 1, 2017. The proposed rule also sets out some standards for what is counted in the MLR calculation, addressing stop-loss and risk-corridor adjustments, as well as payments into Medicaid solvency funds that states may have in place. Some risk-based physician groups already accept per member per month (PMPM) and percentage of premium capitation for Medicaid beneficiary populations. The latter methodology is sometimes used in Medicare Advantage risk-based payment arrangements, and as various states’ dual eligible demonstrations have progressed, this form of prepayment has been adopted by Medicaid plans. Providers accepting risk on a percentage of premium basis must be keenly aware of the parent health plan’s MLR 28 l CAPG HEALTH
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spend and utilization, as this can affect the overall premium in the next fiscal year if other targets are not met—such as performance, quality or utilization. Capitated providers will be required to improve the accuracy of their encounter data reporting to Medicare Advantage levels.
RATE-SETTING PROVISIONS As a follow-on to the MLR provisions above, CMS is directing states to use annual MLR reporting from plans as a part of future rate development. In addition to historical and projected MLR input, rate development standards should include non-benefit costs and budget neutral risk adjustment in the CMS-proposed six-step rate review and approval process. Additionally, the proposed rule expresses concern around the impact of capitation withholding on actuarial soundness, requiring that the portion withheld that is not “reasonably achievable” be excluded in determining rate soundness. CMS is also proposing a review of rates in addition to contracts, with a similar time frame of 90 days prior to implementation. In general, the proposed rule seeks to promote actuarial soundness and transparency in the rate-setting process. Capitated physician groups accepting financial risk for beneficiary populations must seek increased transparency of the rate-setting process in states where it has been historically opaque. We have already seen one major state cut actuarial rates based on expansion population utilization data that indicated a significantly lower risk exposure than originally predicted.
NETWORK ADEQUACY AND BENEFICIARY INFORMATION CMS has proposed network adequacy standards guidance for states, informed by and more closely aligned with Qualified Health Plan (QHP) and MA standards. Included is the requirement of adoption of time and distance standards for primary care, OB-GYN, behavioral health, specialty, hospitals, pharmacy, pediatric dental, and other provider categories. However, CMS states that these standards are to be set by states and not by the federal government. The proposed rule also directs states to require managed care plans to include accurate provider directories and drug formularies on their websites. There already has been a great deal of activity in this area at the state level in 2015, and it may turn out that several states are already far ahead of the curve on this issue.
MANAGED CARE QUALITY RATING SYSTEM Because of the similarities between the Medicaid and Marketplace populations, CMS proposes that states adopt quality rating systems that address the three indicators in the QHP quality rating system: clinical quality management;
member experience; and plan efficiency, affordability, and management. CMS would allow for alternative models of quality rating, pending approval. Additionally, states may default to the MA five-star rating system for plans that serve only the dual-eligible population. CMS is soliciting comments and input on this, with a target to implement within three to five years. Using MA five-star in a state like California, where the Cal MediConnect demonstration has faced significant disenrollment and beneficiary complaints, would have serious negative impacts on plan star ratings during the first few years of implementation. Once the duals population has been transitioned into a managed care model, the benefits of alignment between MA and Medicaid managed care plans will accrue to organized providers that have long experience with five-star compliance.
STANDARDIZATION OF GRIEVANCES AND APPEALS PROCESSES The proposed rule directs states to standardize definitions, timing, and processes for handling of grievances and appeals for Medicaid managed care members. These standards are more closely aligned with MA and commercial insurance standards and also address the state fair hearing process and responsibilities for member notification. Although this area is often overlooked by providers more interested in payment and performance rules, the standardization of common forms, filings, review and hearing processes will assist with migration to a more integrated multipayer payment and oversight system.
ENROLLMENT AND DISENROLLMENT The proposed rule cleans up regulatory language around passive and mandatory enrollment processes, as well as requires a member choice period of at least 14 days for plan selection. Additionally, the rule allows for Managed Long Term Services and Supports (MLTSS) members to disenroll at any time, switching to another managed care plan or to fee-for-service, in the instance that a residential, institutional, or employment support provider is no longer in the member’s plan’s network and remaining in the current plan would impact the member’s residence or employment status. The eventual adoption of new Medicaid managed care rules by CMS will spur conforming legislation across the states to take advantage of the opportunity to coordinate, simplify, and streamline regulatory oversight processes across senior, commercial, and Medicaid product lines. This should be a welcome development for payers and providers. o Summer 2015
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CAPG and 2.0 Healthcare Join Forces in New Practice Transformation Program BY AMY NGUYEN HOWELL, MD, CHIEF MEDICAL OFFICER, CAPG
Inspired by alarming national surveys and reports that tell us U.S. physicians suffer more burnout than other American workers,1 CAPG has developed an innovative Practice Transformation Program with our partner, 2.0 Healthcare. This highly focused, expert-led initiative is designed to equip our physicians to address common daily practice challenges while still striving to achieve the quadruple aim of: • Better patient experience
• Lower total cost of care trends
• Improved population health outcomes
• Improved professional fulfillment and less burnout
The recent AMA-Rand Report on Physician Professional Satisfaction discusses factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. With an understanding of the report’s discoveries, CAPG’s Practice Transformation Program addresses universal challenges facing primary care practices, while still being adaptable to the individual nuances each practice offers to patients and their communities. This flexibility is crucial, given that CAPG members vary in group size, level of integration with organized delivery systems, and affiliation with group-model HMOs, physicianhospital organizations, and large medical groups. In the 2015 Medscape Physician Lifestyle Report, the number of physicians who reported burnout rose from 39% in 2013 to 46% in just two years. An editorial in the Journal of General Internal Medicine reported burnout rates from 30% to 65% across specialties, with the highest rates among primary care physicians at 50%2. In another survey by the Annals of Internal Medicine in 2009, involving a group of 422 primary care physicians, 30% were more likely to leave their practice in two years.3 Burnout—often defined as loss of enthusiasm for work, feelings of cynicism, and low sense of personal accomplishment—has been shown to negatively affect patient care5. That can lead to medical errors, poor patient experience, and reduced patient adherence to treatment plans.3 Additionally, burnout threatens recruitment and retention of primary care physicians, not to mention staff morale. Many factors that lead to burnout, including poor patient access, are associated with a higher likelihood of physicians leaving their practice.4 Rates of suicide are higher in physicians than in the general population,6 with studies indicating that job stress is a factor.7 Physicians perceive bureaucracy, loss of autonomy, insufficient income, and computerization of medical records as causes of stress in their clinical practice.8, 9, 12 Tasks such as adhering to health plan attestation and governmental compliance and regulatory standards weigh heavily on our primary care physicians because they are spending so many hours at work and not at home. Being 30 l CAPG HEALTH
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able to control work hours increasingly is found to play an important role in reducing stress, and therefore burnout, among physicians.9-11 National surveys have reported a burnout rate of 60% in female physicians, higher than that of their male peers.4 Some studies suggest that burnout in men tends to be characterized by depersonalization, while women describe emotional exhaustion.13 Also, physicians who reported their body mass index (BMI) in the Medscape survey do better than the general public, but a significant number report issues with weight. Among the burned-out group, 46% confess to being overweight to obese (36% and 10%, respectively) compared with 39% of those who were not burned out (33% overweight, 6% obese).2 In 2007, the American Academy of Family Physicians established TransforMED, LLC to develop and demonstrate that high-performing primary care networks, based on widespread adoption of the patient-centered medical home (PCMH), were critical to achieving improved healthcare costs, quality, and patient experience. In 2015, key leaders within TransforMED founded 2.0 Healthcare to continue building on its knowledge and to advance the evolution of primary care. 2.0 Healthcare—a physician-led organization staffed by nationally recognized experts in healthcare transformation—denotes the shift from a static system to an interactive and collaborative modality. It’s about helping practices move from isolation to an integrated, connected community. In the CAPG Practice Transformation Program, experienced 2.0 Healthcare staff will provide services that include, but are not limited to, assessment and statistical data analysis, project and practice-level transformation planning services, on-site practice transformation coaching, physician leadership development, and facilitation of change processes.
Please join CAPG’s Practice Transformation Program to reignite the primary care workforce and inspire the movement of advanced primary care through individual practice transformation. Our physicians deserve the same type of attention and care that they so carefully deliver to our patients. Make practice transformation a priority so we will see less physician burnout in the coming years. o For more information on CAPG’s Practice Transformation Program, please contact Dr. Nguyen at anguyen@capg.org. For tips on how to handle physician burnout and build longterm resilience, please see “Building Resilience Through Practice Transformation” on page 20. References 1. Shanafelt TD, Boone S, Tan L, et al. “Burnout and satisfaction with worklife balance among US physicians relative to the general US population,” Arch Intern Med. 2012;172:1377-1385. http://archinte.jamanetwork. com/article.aspx?articleid=1351351 Accessed December 1, 2014. 2. Peckham, Carol. Medscape Physician Lifestyle Report 2015. 3. Linzer et al. Annals of Internal Medicine 2009;151:28-36; Dyrbye, JAMA 2011;305:2009; Murray et al, JGIM 2001:16,452; Landon et al, Med Care 2006;44:234. 4. Linzer M, Levine R, Meltzer D, Poplau S, Warde C, West CP. “10 bold steps to prevent burnout in general internal medicine,” J Gen Intern Med. 2014;29:18-20. http://link.springer.com/article/10.1007/s11606-0132597-8/fulltext.html Accessed December 1, 2014. 5. Shanafelt T, Dyrbye L. “Oncologist burnout: causes, consequences, and responses,” J Clin Oncol. 2012;30:1235-1241. 6. Hampton T. “Experts address risk of physician suicide,” JAMA. 2005;294:1189-1191. 7. Dyrbye LN, Thomas MR, Massie FS, et al. “Burnout and suicidal Ideation among U.S. Medical Students,” Ann Intern Med. 2008;149:334-341. 8. Jensen PM, Trollope-Kumar K. “Building physician resilience,” Can Fam Physician. 2008;54:722-729http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2377221/#b19-0540722 Accessed December 9, 2014. 9. Keeton K, Fenner DE, Johnson TR, Hayward RA. “Predictors of physician career satisfaction, work-life balance, and burnout,” Obstet Gynecol. 2007;109:949-955. 10. Tucker P, Bejerot E, Kecklund G, Aronsson G, Akerstedt T. “The impact of work time control on physicians’ sleep and well-being,” Appl Ergon. 2015;47:109-116. 11. Ruotsalainen JH, Verbeek JH, Mariné A, Serra C. “Preventing occupational stress in healthcare workers,” Cochrane Database Syst Rev. 2014 13;11:CD002892. [Epub ahead of print] 12. Babbott S, Manwell LB, Brown R, et al. “Electronic medical records and physician stress in primary care: results from the MEMO Study,” J Am Med Inform Assoc. 2014;21(e1):e100-e106. 13. Houkes I, Winants Y, Twellaar M, Verdonk P. “Development of burnout over time and the causal order of the three dimensions of burnout among male and female GPs. A three-wave panel study,” BMC Public Health 2011;11:240.http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3101180/ Accessed December 3, 2014. 14. Friedberg et al. “Effects of Health Care Payment Models on Physician Practice in the United States” 2015.
Summer 2015
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Member Spotlight Sharp Rees-Stealy – New Leadership, Core Values Spell Future Success At 92 years old, Sharp Rees-Stealy is San Diego’s first multispecialty medical group and a pioneer in the coordinated care model. Most of the services that patients need are provided by Sharp Rees-Stealy primary and specialty physicians—usually all under one roof. The medical group also was one of the earliest adopters of the managed care payment model, a foundation of success and innovation that will be important to its growth as it adapts to external and internal changes.
Stacey Hrountas Senior Vice President and CEO
Sharp Rees-Stealy is part of Sharp HealthCare, San Diego’s largest integrated healthcare system. The medical group comprises 475 primary care and specialty physicians, 76 nurse practitioners and physician assistants, and 2,400 employees who care for more than 200,000 patients annually at 21 medical centers throughout San Diego County. Stacey Hrountas, Senior Vice President and CEO, Sharp Rees-Stealy Medical Centers, has been running the operational side for three years. Her counterparts in the Sharp Rees-Stealy Medical Group are Dr. Steven Green, Chief Medical Officer, and Dr. Alan Bier, President, The three leaders have collaborated in one capacity or another for almost two decades, and each says their unique backgrounds and strengths give them the ability to meet challenges from all sides. Before becoming CEO, Hrountas worked for Sharp HealthCare as Vice President of Managed Care. The knowledge she gained and payor relationships she developed helped provide her with key insights to make her successful in this key leadership position.
Dr. Alan Bier, President
Dr. Green, a family medicine physician, has cared for generations of families in his 26 years at Sharp Rees-Stealy. Dr. Bier, a cardiologist, also has been with the medical group for 26 years and a board member for 17. The two physicians make a good team, said Dr. Green. “Dr. Bier has a great understanding of the financials, and he is an outstanding clinician who understands the world of the specialist. We work very well together and see pretty much eye to eye on where we want the group to be going.” The three leaders have a great working relationship, Hrountas said, and physician engagement is crucial to their mutual success. “This is not an ‘us or them’ situation,” she noted. “We must be successful together. I really see this not as a business but as an organization dedicated to keeping the community healthy enough that they rarely need to see us.”
Sharp Rees-Stealy has enjoyed success on a number of fronts over the last decade. One of the most telling statistics is the 11% growth the group enjoyed in 2014, among the most tumultuous years in healthcare. “The three of us, as well as our entire leadership teams, are culturally aligned. We all put the patient first, the group second, and the individual physician third,” said Dr. Bier. “This culture has helped us adapt to the changing marketplace and meet our patients’ desire for quality healthcare, when and how they want it.” Dr. Steven Green Chief Medical Officer
Sharp Rees-Stealy lives up to its patient-first culture by offering telemedicine appointments with patients’ personal physicians, who have access to their complete electronic health records. Also available are after-hours and Saturday appointments in pediatrics, cardiology, and gastroenterology, with plans to expand to other service lines. Other adaptations include a program called Connected to Care®, where patients can speak to a nurse practitioner or physician assistant weekday mornings to get information and guidance on seeking care. Kiosks for self-service check-ins help shorten lines and free up staff for more complex issues, and text-messaging programs and remote monitoring technology are engaging and motivating patients with chronic conditions. Close on the horizon is an e-consult program between primary care and specialty physicians that could save patients timeconsuming and costly consultation appointments. Hrountas envisions that within five years, it will be routine for a patient to continued on next page 32 l CAPG HEALTH
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2015 Annual Conference Highlights CAPG’s 12th Annual Healthcare Conference drew more than 1,700 attendees—a close to record number—to the Grand Hyatt San Diego June 11-14. With the theme Accountable Care: Accelerating the Evolution, the conference featured thought leaders from across healthcare sectors discussing a wide range of clinical, policy, and management issues related to coordinated care.
Primary Care Innovation and the Patient-Centered Medical Home, a preconference co-hosted with the Patient-Centered Primary Care Collaborative (PCPCC), featured two panel discussions with primary care experts. From left, moderator Dr. Diane Rittenhouse and panelists Dr. Sunny Ramchandani, Jessica Osborne-Stafsnes, and Dr. Brad Stuart greet each other before their session on patient and community partnership.
Opening speaker Leonard D. Schaeffer (right) engages in Q&A with Don Crane following his presentation.
Highlights included a preconference, Primary Care Innovation and the Patient-Centered Medical Home, and keynote speakers Leonard D. Schaeffer; Brent C. James, MD; Alan Weil; and Daniel Kraft, MD. A plenary panel on California managed care, moderated by CAPG President and CEO Don Crane, featured Bill Gil, CEO, Providence Health Network, Southern California; Leeba Lessin, President and CEO, CareMore Health System; and Barry Arbuckle, President and CEO, MemorialCare Health System. Super sessions and over a dozen breakout sessions offered insights on topics including direct provider contracting, federal and state policy, moving into risk, predictive analytics, and more. Complementing the outstanding program sessions, the popular networking events included CAPG’s signature golf and bowling tournaments; the Friday evening Exhibit Fair and Strolling Dinner, and the Saturday evening cocktail reception and dinner-dance gala. CAPG thanks the sponsors and exhibitors who helped make the conference a success, especially our Diamond Sponsors: Aetna, Anthem, Cigna Healthcare, Health Net of California, Humana, Novo Nordisk, Optum, and United Healthcare. Be sure to join us again at the Grand Hyatt for the 13th Annual Healthcare Conference, June 16–19, 2016! o
CAPG’s ninth annual Standards of Excellence™ Elite honorees were announced at the opening session. In 2015, a record 65 member groups attained the coveted five-star Elite status for high-quality coordinated care provision.
Member Spotlight...continued from page 32
Federal Legislative Update...continued from page 14
have a video chat with her or his primary physician, who will then email a question or photo to a specialist and respond back to the patient via text or email.
are well aware that primary care is a foundational element to a high-functioning delivery system, particularly for patients with multiple chronic conditions. CAPG has called on the working group to consider ways in which optimal primary care capabilities improve the overall health and well being of seniors with such conditions.
“Because of our history of innovation, we are ideally positioned to handle the changes in health care,” Hrountas noted. “We will continue to keep the cost of care down and provide the highest quality through our coordinated, efficient model. We are continuing to evolve by putting the patient first.” o
CAPG looks forward to pursuing these and other policy ideas with the committee over the summer and into the fall. o Summer 2015
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SB 277 Keeps Californians Healthy and Safe from Preventable Contagions BY RICHARD PAN, MD, M P H , S TAT E S E N ATO R , C A L I F O R N I A D I S T R I CT 6
I attended medical school at the University of Pittsburgh, where Dr. Jonas Salk invented the polio vaccine. As a medical student, I learned about vaccinepreventable diseases including measles and polio. My professors taught us that due to vaccination, we were unlikely to ever see these diseases in the United States. However, I worked at a community clinic in Philadelphia my senior year. An outbreak of measles spread across the city, including groups of unvaccinated children. Measles was no longer a textbook disease, but a real contagion infecting over 900 people and killing nine children. A generation of parents has not experienced vaccinepreventable illnesses, and they do not understand the danger. In 1998, Andrew Wakefield authored a now-retracted study of 12 developmentally delayed children purporting a link between autism and the measles vaccine. Numerous studies worldwide involving hundreds of thousands of children proved measles vaccination did not cause autism, and further investigation showed Wakefield falsified data and a product liability attorney was paying him for the study. When the truth was discovered, the damage had already been done. Parents became anxious and hesitant about vaccines. Compared to seemingly nonexistent diseases, the possibility that vaccines might cause autism or other ailments, as trumpeted on talk shows and over the Internet, made some parents hesitate. Unscrupulous people profited selling books and products hyping the risk of vaccines and minimizing the risk of disease. But as they became more successful in deceiving parents into not vaccinating their children, diseases began to return. 34 l CAPG HEALTH
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Every state has laws requiring school vaccinations; however, California allowed unimmunized children to enter school with a personal belief exemption. Over the past two decades, exemption rates rose threefold, concentrated in particular schools and communities.
“A generation
of parents has not experienced vaccinepreventable illnesses, and they do not understand the danger.”
The measles outbreak beginning at Disneyland was a wake-up call. In 2015, measles exposures occurred in clinics, ERs, and a maternity ward, as well as stores, restaurants, public transit, theme parks, schools, and day care centers. Parents demanded leadership to halt the spread of preventable diseases. I authored SB 277 to abolish the personal belief exemption allowing unvaccinated children in schools. A medical exemption remains available for children who should not be immunized. SB 277 does not remove a parent’s choice to vaccinate their child. Parents who decide to not vaccinate can have their children home schooled or take independent study. All children deserve to be safe at school, and refusal to vaccinate endangers other children. Thanks to a broad coalition of parents and health, education, and child advocates, including CAPG, Governor Jerry Brown signed SB 277 in June. But this fight is not over. Because of my leadership in passing SB 277, antivaccination groups filed papers to recall me, and they intend to pursue lawsuits and a referendum to overturn the bill. I ran to keep Californians safe and healthy in my election for the Senate, and SB 277 is an example of that promise. As medical groups, you are dedicated to the same. I ask your continued support for me to keep up this work. o
For more information, visit STELARAhcp.com
Providing services for Janssen Pharmaceutical Companies of Johnson & Johnson Š Johnson & Johnson Health Care Systems Inc. 2015
April 2015
032372-150401
Creating a Patient-Centered Healthcare Experience Brown & Toland Physicians launched My Health Medical Group, a patientcentered medical home physician practice, in 2012 to provide a better healthcare experience. My Health Medical Group brings together a team of physicians and other healthcare professionals to better coordinate care, achieve higher quality outcomes, and reduce the overall cost of care. The value of a “medical home” is important, as it focuses on providing patients, specifically those who need extra care and support, with personalized care delivered by a team. This “team approach” ensures a higher degree of collaboration and care coordination, and has resulted in better outcomes. By providing “high-touch” care to patients or to seniors with complex health situations, the overall cost of care, and emergency room visits, are down. Additionally, patient care costs have dropped 15 percent compared to other primary care practices treating seniors. In 2013 My Health Medical Group was named the first Level 3—the highest designation—patient-centered medical home in San Francisco by the National Committee for Quality Assurance (NCQA). Additionally, the practice was named the Patient-Centered Medical Home Practice of the Year by the California Academy of Family Physicians. For more information, please visit myhealthmedicalgroup.com and brownandtoland.com.
Keeping the San Francisco Bay Area healthy for more than 20 years
brownandtoland.com