The Journal of America's Physician Groups Spring 2021 Edition by America's Physician Groups

The Journal of

COVER STORY: Member Spotlight Clive Fields, MD, p.18 Health Equity and Social Justice, p.24 The Latest on Alternative Payment Models, p.34

Volume 15 • No. 1 • Spring 2021

Serving those who provide care.

IT’S IN OUR DNA. TDC Group is proud to be the exclusive sponsor of the podcast APG on American Healthcare.

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TABLE OF CONTENTS

ON THE COVER

Clive Fields, MD The VillageMD Co-Founder explains how we can eliminate the barriers to advanced primary care. The Journal of

Publisher

Valerie Okunami Editor-in-Chief

Don Crane

Editorial Advisory Board

Lura Hawkins, MBA Dianne Glover, MPH Gregory Phillips Managing Editor

Lura Hawkins, MBA Contributing Writers

Bill Barcellona Don Crane Sanjay Doddamani, MD Garrett Eberhardt Clive Fields, MD Russ Foster Lura Hawkins, MBA Jennifer Jackman Dorothy Lockhart, MBA, MSN, RN Steve Neorr Gregory Phillips Valinda Rutledge Faith Saporsantos, MSN, MHA, RN, CRRN Sheila Stephens Bill Wulf, MD Journal of America’s Physician Groups is published by

Valerie Okunami Media PO Box 674, Sloughhouse, CA 95683 Phone 916.761.1853

apg.org Please send press releases and editorial inquiries to Journalofapg@gmail.com or c/o Journal of America’s Physician Groups, 915 Wilshire Blvd., Suite 1620, Los Angeles, CA 90017

DEPARTMENTS

FEATURES

From the President

News and Events

From the BOD Chair Lessons Learned From the Pandemic

Improving Medication Adherence During a Pandemic

New APG Collaborative Addresses Health Equity and Social Justice

Federal Policy Update As COVID-19 Continues, Physicians Still Need Relief

Policy Briefing California Bill Targets Healthcare Affordabilty

APG Member List

For advertising, please send email to vokunami@netscape.com 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 Journal of America’s Physician Groups. Opinions expressed or facts supplied by its authors are not the responsibility of Journal of America’s Physician Groups. © 2021, Journal of America’s Physician Groups. All rights reserved. Reproduction in whole or in part without written permission is strictly prohibited.

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New APG Manual Offers an Essential Guide to Risk Contracting

Spring 2021

Connecting Key Strategies to Promote Talent Management

Health Is Wealth: The Latest on Alternative Payment Models

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From the President A M E S S AG E F R O M D O N C R A N E , P R E S I D E N T A N D C EO A M E R I C A’ S P H YS I C I A N G R O U P S

Members and friends, Welcome to the Spring 2021 issue of the Journal of America’s Physician Groups. It’s hard to believe that it’s been more than a year since the beginning of the COVID-19 pandemic. Every facet of our day-to-day lives has been impacted. Yet we have persevered in the face of adversity, and there is finally light at the end of the tunnel with vaccination in full swing.

Don Crane, America’s Physician Groups President and CEO

I am pleased to present another outstanding lineup of editorial for you in this Spring issue. In particular, I would like to highlight the following articles: • Clive Fields, MD, Co-Founder and Chief Medical Officer of VillageMD, is this issue’s Member Spotlight. Dr. Fields explains how the COVID-19 pandemic exposed the underdevelopment of community-based primary care—and what we must do to continue to eliminate the barriers to implementing advanced primary care (APC) models. • In March, APG published the Value-Based Contracting Manual: An Essential Guide for Physician Organizations. This Manual is an indispensable resource for anyone who is in risk-based care or who is contemplating risk contracting. Learn more about this invaluable Manual and how to get your digital copy. • APG recently held its first meeting of the new Health Equity and Social Justice Collaborative. Co-Chairs Alyssa Canter, Adrianne Wagner, Sheila Sudhakar, MD, and Pete Fronte explain why this group was established and how they will work together to address the systemic challenges that certain populations face in accessing quality, affordable healthcare. • Sanjay Doddamani, MD, and Steve Neorr, Co-Chairs of APG’s Alternative Payment Model (APM) Committee, describe the Committee’s discussions over the past year around payment reform, delivery reform, and digital transformation. Although we have decided to cancel this year’s Colloquium, I hope you plan to join us Dec. 9-11 in San Diego for the APG Annual Conference 2021 – Emerging From the Pandemic: The Path Forward. The Conference will be an in-person event at the Marriott Marquis San Diego Marina. APG will require that all Conference attendees attest that they have been fully vaccinated for COVID-19. Additionally, we will follow all CDC, state, and local requirements that exist at the time of the Conference, such as social distancing, masking, etc. So please save the date and mark your calendar! Lastly, if you have not already done so, please make sure to subscribe to APG on American Healthcare. Each biweekly podcast episode features an unscripted conversation with a leading healthcare executive, policymaker, or industry expert. If you are interested in national healthcare reform, budget-based prospective payment models, and risk-based capitation or other population-based payment models, this podcast is for you. Stay healthy. o

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News and Events 2021 APG Annual Conference Emerging From the Pandemic: The Path Forward

Regional Meetings

December 9–11 Marriott Marquis, San Diego Marina

Hawaii Thursday, July 22

Northeast Tuesday, June 15

Northeast Tuesday, September 14

Webinar Wednesdays

Northern California Wednesday, September 15

Wednesday, June 9 Wednesday, July 7 Wednesday, August 11 Wednesday, September 8 Wednesday, October 6 Wednesday, December 1

Northwest Regional Thursday, September 23 Southwest Tuesday, October 12

General Membership

For information on all APG events, visit APG.org. o

Wednesday, September 1

HEALTH EQUITY AND SOCIAL JUSTICE COLLABORATIVE 1

New in 2021! Collaborative for APG Members and Partners Designed to create new alliances, discuss undertakings, and share projects and tools Discussions will Include: Health Equity’s Impact on Patient Care SDOH Organizational Culture Diversity in Staffing, Including Leadership Much more Upcoming Meetings: July 12 (webinar) Year-End Summit: December 11 in-person meeting in conjunction with the 2021 APG Annual Healthcare conference

Add Your Voice to the Conversation! Join by sending your name, organization, title and email address to Lura Hawkins, MBA at Lhawkins@apg.org

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SAVE THE DATE APG ANNUAL CONFERENCE 2021 Emerging From the Pandemic: The Path Forward December 9-11, 2021 Marriott Marquis San Diego Marina Early registration opens in June. Visit APG.org for more information.

Summer 2020

JOURNAL OF AMERICA’S PHYSICIAN GROUPS l 9

From the Board of Directors Chair Lessons Learned From the Pandemic BY B I L L W U L F, M D , C H A I R O F A M E R I C A’ S P H YS I C I A N G R O U P S

At this point it is rather trite to say it has been a difficult year … but it’s true. COVID-19 has presented the organizations of America’s Physician Groups with tremendous challenges over the past 14 months, and it continues to impact our lives on a daily basis. Despite these challenges, I believe we would all agree it has been an honor to be a healthcare provider when the need for care has been so great. Our individual organizations, physicians, and staffs have served our patients and communities in a time of unprecedented need and often in the face of personal risk. Our ability to innovate, sometimes daily, has been lifesaving. Many of our organizations quickly developed or expanded telehealth offerings to serve and protect patients and staff. Groups also provided COVID-19 testing using any and every technology we could procure. Today, our members are immunizing patients as quickly as they can obtain vaccine supply. Physicians’ direct involvement in vaccination efforts has surely encouraged their patients and quite likely improved immunization rates. These and many other actions taken by APG members have been critical to protecting our combined 45 million patients. I believe our individual organizations have learned and developed a great deal during this past year that will serve our patients going forward.

THE NEED FOR VALUE-BASED CARE One lesson learned is the necessity to be in value-based contracting. This is a lesson that the early APG members learned many years ago, but it is now clearly understood by the rest of us. During the pandemic, unprecedented underutilization led to financial challenges for many organizations with a largely fee-for-service delivery system. At the same time, organizations with a portion of their contracting in true value-based (at-risk) care saw a financial benefit from this decreased demand for services. The patient-level data available as a result of risk contracting also allowed physician organizations to identify—and reach out to—the most vulnerable individuals within our populations. APG has long supported and advocated for value-based contracting, and we will continue to support and encourage this model for all our members.

ADVOCACY MATTERS A second lesson we learned this year is the value of APG’s leadership team and advocacy support at both federal and state levels. Whether it was Paycheck Protection Program (PPP) loan information or letters and virtual meetings with Congress, APG was front and center in advocating for physician organizations when we most needed it. 10 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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“Our ability

to innovate, sometimes daily, has been lifesaving.”

I believe our interactions with Congress played a significant role in members’ ability to receive PPP dollars and a portion of the CARES Act funding for healthcare. Our advocacy also provided critical support for the much-needed coverage of telehealth services. I also believe our organization’s influence encouraged the Center for Medicare & Medicaid Innovation (CMMI) to move forward with direct contracting and was instrumental in the decision to not delay this program beyond April 1.

membership during this difficult financial time. Instead, we have seen membership grow based on the tremendous value provided by our organization.

Quite frankly, we in APG leadership initially had a concern that there could be significant loss of

Bill Wulf, MD, is CEO of Central Ohio Primary Care (COPC) and Chair of America’s Physician Groups.

On a personal note, I look forward to the next two years as APG Board Chair. I follow a tremendous line of leaders in this role, and I believe our opportunity to help reshape healthcare has never been greater. Thank you for what each of you has done this past year to innovate and serve in a time of tremendous need. o

Spring 2021

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New APG Manual Offers an Essential Guide to Risk Contracting BY J E N N I F E R J AC K M A N , V I C E P R E S I D E N T O F B U S I N E S S D E V E LO P M E N T, A M E R I C A’ S P H YS I C I A N G R O U P S

“This comprehensive publication is now available for digital download— exclusively for APG members.”

Throughout the nation, America’s Physician Groups’ member organizations have been driving the evolution and transformation of healthcare delivery— while navigating financial risk—in the form of value-based contracts. To help our members navigate the details of these contracts and business relationships, APG collaborated with our members to create the APG Value-Based Contracting Manual: An Essential Guide for Physician Organizations.

organizations with many years of experience managing risk and improving the quality of care provided to their patients.

We are pleased to announce that this comprehensive publication is now available for digital download—exclusively for APG members.

• Legal issues and general contractual terms

This new Manual covers a host of issues surrounding risk-based contracting and meeting the operational requirements of risk-based agreements. It will be an indispensable resource for anyone who is in risk-based care or who is contemplating risk contracting—even those with significant risk experience. This kind of knowledge is usually gained from personal experience or hired consultants, but we were fortunate to be able to tap into the incredible expertise of our members, who were willing to share their expertise, tools, opinions, and tips. Under the guidance of the APG Contracts Committee, we assembled a voluntary team of remarkable experts with a depth of knowledge in negotiating and managing successful risk-based arrangements. Our editors and contributing authors represent a range of highly successful physician 12 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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The Value-Based Contracting Manual showcases the authors’ expertise, and the references and sample materials provided will give you a leg up in planning and implementing risk arrangements. Not only will you learn about value-based contracting, but there is also vital information on planning, business relationships, financial operations, and administrative operations far beyond a payer agreement negotiation. As risk is often accompanied by the delegation of services and functions traditionally performed by payers, you will also find important information about delegation agreements, performance, and auditing of delegated services. Manual sections include: • Preparation for risk contracting • Sample language • Obligations of the provider organization and the payer • Compensation • Term and termination • Data sharing and use APG acknowledges and thanks the authors for their assistance in preparing and reviewing the Manual’s material. They have our deepest appreciation for their time and dedication to this project. Our sincere gratitude goes out to Jim Agronick, Wendy Bavan, Debra Bohn, Brent Boyd, Norm Davidson, Jackie Luxenberg, Dan Roberts, Kelly Robison, Wayne Sass, Steve Linesch (coeditor) and Bruce Young. We also want to thank APG’s Norma Springsteen for her sharp editorial eye and many contributions. o If you would like a copy of the Manual or would like to join the APG Contracts Committee, please email Jennifer Jackman, APG Vice President of Business Development, at JJackman@apg.org.

Continued Care for COVID Recovery: How LTAC Hospitals Help Post-COVID Patients By Sean R. Muldoon, MD, MPH, FCCP Chief Medical Officer, Kindred Hospitals

The latest studies have identified the most efficient care delivery pathways for severe cases of COVID-19. Coordinated care plans that include continued treatment at a long-term acute care hospital (LTACH) after the initial hospital stay are proving to provide great value for patients. Unique Clinical Presentations Require Specialized Care An important subset of COVID-19 patients require an extended hospital stay, accompanied by mechanical ventilation. As a result, these patients frequently experience significant pulmonary complications, including severe pneumonia and acute respiratory distress-like syndrome. They are also at high risk of developing post-intensive care syndrome (PICS) due to receiving life-saving care in an ICU for much longer than the average stay of three to four days. These complications delay patient recovery and impact the total cost of care. New research shows that specialized care interventions and rehabilitation are needed to address these short- and medium-term consequences and improve patient outcomes.1 New Research on Care Solutions for Post-COVID Patients: The Role of LTACHs A recently co-authored post in Health Affairs highlighted the critical role that LTACHs have played during the COVID pandemic.2 Specifically, the researchers suggest that the clinical expertise in LTACHs with “critical care nurses, respiratory therapists, and intensivists” aligns with the ongoing comprehensive care needs of COVID patients. Additionally, an article in The Boston Globe stated that “COVID-19 has reminded the world of the importance of facilities that occupy the middle ground of the critical care landscape,” championing the importance of LTACHs in responding to COVID. 3

LTACHs are equipped to treat a niche population of critically ill and medically complex patients who require additional acute care after a stay in the ICU. Unlike other post-acute care settings such as SNFs, these hospitals are licensed as general acute care hospitals by the state and certified by the Centers for Medicare and Medicaid Services (CMS) as LTACHs.

LTACHs provide treatment for respiratory failure, septicemia and other severe illnesses complicated by multiple chronic conditions that are often experienced by post-COVID patients. Their specialized, interdisciplinary clinician teams are also adept at liberating ventilator patients and providing pulmonary rehabilitation, both critical components of post-COVID recovery. These specialty hospitals are unlike other post-acute care settings because they are licensed as a general acute care hospital by the state and certified by the Centers for Medicare and Medicaid Services (CMS) as LTACHs. Additionally, LTACHs feature hospital-level infection control, negative pressure rooms where needed and on-site laboratories and dialysis. How Kindred Hospitals Can Help At Kindred, our physician-led clinician teams provide acute-level care for complex medical patients, including those who are post-COVID. We have proven success in improving outcomes for patients with pulmonary disease and respiratory failure, including those requiring liberation from mechanical ventilation and artificial airways. Kindred is also an Associate Partner of America’s Physician Groups. Visit us at kindredmanagedcare.com to request a conversation about how Kindred Hospital’s level of service can help manage your critically complex patients. References 1. MPH, “Medical Rehabilitation in Pandemics: Towards a New Perspective,” Journal of Rehabilitative Management, Vol. 52, Issue 4, April 9, 2020 2. “How Can We Ramp Up Hospital Capacity To Handle The Surge Of COVID-19 Patients? Long-Term Acute Care Hospitals Can Play A Critical Role,” Health Affairs blog, April 13, 2020, DOI: 10.1377/ hblog20200410.606195 3. Dasia Moore, “COVID-19 patients are recovering, but with nowhere to go,” The Boston Globe, May 19, 2020

This Is a Paid Sponsorship Spring 2021

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Federal Policy Update As COVID-19 Continues, Physicians Still Need Relief BY G A R R E T T E B E R H A R D T, D I R EC TO R O F F E D E R A L A F FA I R S , A M E R I C A’ S P H YS I C I A N G R O U P S

In mid-March, President Joe Biden signed into law a $1.9 trillion coronavirus relief package. This historic piece of legislation was headlined by $1,400 stimulus payments to Americans, an increase to the child tax credit, and an extension of supplemental unemployment benefits through Sept. 6. In addition, the package contained a host of funding for the healthcare sector, including: • $8.5 billion for rural hospitals and healthcare providers under the Provider Relief Fund • An increase in federal subsidies for COBRA coverage • A Medicare wage index minimum for hospitals in all-urban states

in “Providers physician practices have lacked the specific financial relief that has been made available to hospital systems.”

• Authority for the Department of Health and Human Services Secretary to temporarily waive or modify certain Medicare requirements concerning ambulance services during public health emergencies • Additional resources for vaccines, treatment, personal protective equipment, testing, and contact tracing • $7.6 billion for the public health workforce • Investment in mental health and substance use disorders • An increase in premium subsidies for the Affordable Care Act (ACA) marketplace Unfortunately, though, providers in physician practices have lacked the specific financial relief that has been made available to hospital systems and those serving more rural and underserved communities. Many of these providers continue to face financial hardships in their work to serve patients during the pandemic—and they are in dire need of financial assistance. APG has been diligent and persistent in our advocacy before Congress and the Biden administration on the many ways that targeted relief for physician practices would support those who have been on the front lines of treating patients with the virus. The importance of ensuring that they receive the assistance and funds needed to serve their patient populations cannot be overstated. Below are two ways in which Congress can offer immediate assistance to providers who need it.

PROVIDER RELIEF FUNDING The Provider Relief Fund (PRF) was established as part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act. It has provided more than $178 billion in relief funding for hospitals and other healthcare providers as they have responded to the virus. The funding supports healthcare-related expenses or lost revenue attributable to COVID-19 and ensures that uninsured Americans can get treatment for COVID-19.

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So far, PRF funding allotments have excluded physicians who practice outside of hospital systems. And yet, these physicians have spent thousands of dollars investing in pandemic infrastructure—such as licensing costs for telehealth services and telework setup, waiving co-pays, and providing COVID-19 testing and vaccination. These investments have led to increases in clinical overhead.

failed to materialize, it triggered the sequestration and its 2% across-the-board cut to Medicare provider payments.

To rectify this oversight, APG sent a letter to Senate Majority Leader Chuck Schumer (D-NY) in March. The letter asked that Congress prioritize future PRF expansions and funding toward these overlooked physician practices and their associated entities.

The recent moratorium on Medicare sequestration cuts first began as part of the CARES Act in 2020. It has since been extended several times, most recently in the December 2020 federal spending bill, H.R. 133. In late March, Congress took one step closer to potentially extending this moratorium, with the Senate passing legislation that extended the suspension of the 2% cuts to Medicare payments by a 90-2 vote.

It is imperative that any additional PRF financial assistance be directed to these practices, which continue to spend thousands of dollars during this pandemic for the betterment of their patients, the healthcare space, and the country at large.

MEDICARE SEQUESTRATION Another issue that has lingered at the forefront of providers’ minds for years now is Medicare sequestration. Sequestration (the process of automatic, acrossthe-board spending cuts) is required by the Budget Control Act, which was signed into law in 2011. It was originally intended as an incentive for the Budget Super Committee, which convened that year to design an alternative package that would achieve $1.2 trillion in budget savings and avoid any cuts. When that alternative

The American Taxpayer Relief Act of 2012 postponed sequestration for two months, but President Barack Obama issued a sequestration order on March 1, 2013, as required by law.

The House of Representatives followed the Senate on April 13, voting by a 384-38 margin to continue the sequestration delay. President Biden officially signed the bill into law the following day, extending the moratorium through the end of 2021. The sequestration moratorium has been an integral part of the overall effort to address provider issues during the pandemic. Providers have spent countless dollars to ensure that patients are well-treated both for COVID-19 and all other ailments and diseases. In the face of this ongoing public health emergency, extending the moratorium will help ensure that physician practices are supported in their extensive work to help curb the pandemic. o

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Policy Briefing California Bill Targets Healthcare Affordability BY B I L L B A R C E L LO N A , E X EC U T I V E V P, G OV E R N M E N T A F FA I R S , A M E R I C A’ S P H YS I C I A N G R O U P S

For many years, California was the home of HMO affordability. The state’s loss of that moniker—due to employer abandonment of HMOs in the early 2000s in favor of full-replacement high-deductible PPO plans—has left California with a slightly higher-than-average cost escalation in the healthcare sector of the state’s domestic product. Policymakers are looking for ways to improve that cost trend. One proposal is California Assembly Bill 1130, an ambitious piece of legislation that would create a state Office of Health Care Affordability. APG’s California Board members recently met with the bill’s author, Assembly Member Jim Wood (D-Santa Rosa), who chairs the Assembly Health Committee, as well as with representatives of the Newsom administration; Office of Statewide Health Planning and Development (OSHPD) Director Elizabeth Landsberg; and Vishaal Pegany, Assistant Secretary of the California Health & Human Services Agency. After a lengthy discussion, APG has moved toward a “support if amended” position on this legislation. APG will likely be one of the few provider-oriented organizations to take this position during this legislative session. What does the Office proposal entail, and what are the ramifications for the California healthcare economy?

A DEEPER LOOK AB 1130 would create a framework for collecting information on the healthcare ecosystem within California. The idea is for policymakers to understand where cost drivers exist so they can attempt to correct affordability issues at the state level and perhaps even at the regional or “sectoral” levels as well. In addition to cost control, the proposal’s objectives include the expansion of value-based provider payment, standardized quality metrics, systematic decrease of health disparities, support for primary care and behavioral health integration, and monitoring of healthcare workforce stability. How would all of this oversight come about? The bill creates an Office of Health Care Affordability within the state government. This is different from the direction taken by Massachusetts, with its famous Health Policy Commission model that relies on a public board loosely affiliated with the Commonwealth’s attorney general. Massachusetts created a system in which state staff report to a publicly appointed board of experts, whereas the California proposal would create an advisory board that would debate and recommend strategies to the director of the Department of Health Care Affordability and Infrastructure. Thus, the California proposal vests final authority with the governor, who also controls the

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“It represents a sea change in the approach to strategic oversight of the healthcare market.”

Department of Managed Health Care (DMHC), the Department of Health Care Services (DHCS), and the Health & Human Services Agency. Is this a better approach than the one taken by Massachusetts? We would argue that it is, since a governing board model would likely be more politically oriented in California and less connected to the other chief organs of healthcare oversight, DMHC and DHCS. But it still results in some level of fragmented oversight, and there is potential for conflicting directives between different departments and agencies within the administration. No solution is perfect, and each has its potential weaknesses and/ or advantages. However, like Massachusetts, the Office would rely heavily on market data collected and analyzed by the Health Care Payments Database program (HPD), which is the California version of an all-payer claims database. The HPD was created last year under Assembly Bill 80 and will commence operation in early 2023. The HPD provides the foundation for the Office’s activities.

APG’S POSITION APG has been vocal on the data collection area. This is based on almost 30 years of experience

with collecting cost and quality data from our membership that has been publicly reported through the Integrated Healthcare Association’s P4P, AMP, and Regional Cost & Quality Atlas projects. APG’s support for AB 1130 is qualified on a “universal” data collection and reporting model that includes all providers, all payers, all products, and even the inclusion of employer open enrollment offerings—to show that employers are committed to coverage models that incorporate value-based payment within clinically integrated delivery networks. What are the functions and jurisdiction of the Office proposal? The Office would have “teeth” in its approach to collecting data and enforcing cost targets. This is the result of advice received from Massachusetts that its commission model lacks power to make needed changes to its healthcare system. The Office would issue a baseline study of the California market after its first year of operation. Currently, that’s in 2023, but that could change. The baseline report would set a cost target for the entire state. Similar to Massachusetts, this would continued on page 37 Spring 2021

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ON THE COVER

Member Spotlight Removing the Barriers to Advanced Primary Care BY C L I V E F I E L D S , M D

The last year has been one of the most challenging periods in the history of modern medicine. Healthcare delivery changed at a lightning-fast pace as we adapted to the COVID-19 pandemic and adopted new technology. We saw regulatory relief and changes in the healthcare economic model that we thought would take decades to happen—all compressed into a single year.

before “Never has access to comprehensive primary care been more important.”

The mortality and morbidity of the pandemic can never be minimized, and for most providers, it will always be a defining moment in their career. Now, as the pandemic’s clinical damage comes under control and systemic changes to the larger healthcare system remain, the question becomes: What should we expect for the remainder of this year and beyond? What can we do to promote continuing change? The pandemic laid bare shortcomings in the American healthcare system, particularly the underinvestment in community-based primary care. Never before has access to comprehensive primary care been more important. Not your grandfather’s primary care, but a team-based, proactive, riskstratified model focused on outcomes, not volume. In short, we need to evolve to an advanced primary care (APC) model. Although APC is sprouting up across the country, we must continue to eliminate the barriers that slow down its implementation.

MOVING TO VALUE-BASED CARE The traditional fee-for-service (FFS) payment model has failed us. It doesn’t allow for the infrastructure investment needed to prepare for a populationbased delivery model. The pandemic highlighted the vulnerability of episodic payment, with many small practices surviving only through grants and Paycheck Protection Program (PPP) loans. The Affordable Care Act (ACA) supports care delivery through the patientcentered medical home model, which promotes quality care over quantity and primary care engagement throughout the care continuum. But as long as payment remains episodic, the measurement of volume, not outcomes, is encouraged. During the pandemic, organizations compensated through populationbased payments fared better than their FFS counterparts. We need to promote this payment model and expand it to medical groups of all sizes to truly transform healthcare in the United States. In this area, the Centers for Medicare & Medicaid Services (CMS) continues to lead. The Medicare Shared Savings Program (MSSP), Nextgen, and

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now the Direct Contracting Entity (DCE) models have accelerated the move to population-based payment. Still, a concerted effort by medical groups to move payers across all populations to prospective population-based payment is needed for meaningful healthcare transformation. Sharing our successes and failures, publishing best practices and workflows, and recognizing there are no competitors, only collaborators, will accelerate this change.

TECHNOLOGY INVESTMENT AND ADOPTION The rapid adoption of telehealth and the accelerating use of remote patient monitoring has made us re-evaluate our expected timeline for technology adoption and implementation. The concept that healthcare should be immune to consumer-friendly technology and that the traditional in-person office visit should be the sole source of patient-physician contact has finally been laid to rest. Using technology to extend physicians’

reach and fill the gap between in-person visits is a genie that can’t be put back in the bottle. During the pandemic, the vast majority of COVID19-positive patients did not need hospital care, and most patients who presented to the emergency department did not require admission. The use of technology to deliver education and clinical interventions across multiple platforms, including home-based clinical care, would have gone a long way to decreasing the demand for our acute care facilities—at a lower cost, with higher-quality results. At VillageMD, we implemented a COVID-19 telehealth protocol that decreased ED utilization by more than 49%. (See graph.) These technology advancements aren’t going away at the end of the pandemic. They are here, and they are here to stay. Technology can be a bridge to a more comprehensive patient relationship, not a barrier. Used as part of a comprehensive delivery system, continued on page 38

Spring 2021

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Improving Medication Adherence During a Pandemic BY D O R OT H Y LO C K H A R T, M B A , M S N , R N

When the COVID-19 pandemic arrived in Central Kentucky in March 2020, CHI Saint Joseph Health Partners (Health Partners) recognized the need to develop new strategies to make a difference in our populations. Like many areas of the country, provider offices temporarily closed, appointments were canceled, and patients postponed treatment and preventive screenings even after provider offices reopened. Health Partners leadership knew that a strategy focused on pharmacy quality measures would make an impact, even while patients were not accessing care from providers. As a care management team, we believed that medication adherence was paramount to keeping our patients out of emergency rooms and avoiding unnecessary hospital stays during the pandemic.

PARTNERING WITH PAYERS We began the effort by using data from contracted payers to identify patients who had failed the medication adherence measure the previous year or years. Once the current year data was available, our clinical pharmacist partnered with the payer’s clinical pharmacist to obtain medication reports for each Health Partners market. Once the patient was entered into the measure, the Health Partners clinical pharmacist was able to determine the last date that an intervention could make an impact before the patient would fail the measure for the current year. We then used these reports to monitor adherence on a monthly basis. The streamlined strategy was to first reach out to those identified patients— understanding that if a patient failed the measure in the previous year, he or she would likely fail the measure again. Regional market clinical directors disseminated the reports to our RN ambulatory care coordinators (RN ACCs) and ambulatory care assistants (ACAs).

PATIENT OUTREACH The assigned RN ACC or the ACA called all patients on the monthly list who had a “last impactable date” occurring that month. During these outreach calls, the RN ACC also addressed other quality measure needs, including diabetes control, A1C testing, and the importance of medication adherence. Staff acknowledged that patients may have previously failed the medication adherence measure due to social or economic barriers preventing them from accessing medications. If the patient was unable to obtain medication due to a social determinant of health, a referral was made to the Health Partners social work

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“Medication

adherence was paramount to keeping our patients out of emergency rooms and avoiding unnecessary hospital stays.”

ambulatory care coordinator to assist the patient in overcoming any obstacles. When appropriate, staff assisted patients who wanted to switch their prescription medications to a mail-order pharmacy system. Patients often wanted to do this because of concerns about COVID-19 and entering the pharmacy in their local community. If patients needed a new prescription, staff were able to schedule them for a telehealth appointment with their provider to address any acute care concerns.

5-STAR ADHERENCE Health Partners was able to overcome the multitude of barriers arising from the pandemic and still achieve 5-star medication adherence for our largest Medicare Advantage population in all three categories: diabetes, hypertension, and cholesterol. Data show an increase in adherence over the previous year by an average greater than 2.3%. Acknowledging that complications from untreated diabetes can have many detrimental consequences, we gave additional focus to diabetes patients—resulting in a more than 3% improvement in medication adherence in 2020. Through this effort, Health Partners displayed innovation by utilizing claims information and partnering with each payer to reach the patients most at risk. We improved medication adherence compared with previous years— even in the midst of a pandemic. As the impact of COVID-19 continues, the opportunity exists to impact additional Kentucky populations as we continue this same medication adherence model in 2021. Health Partners is committed to coordinating evidencebased, cost-effective services across the lifespan of those we serve. This means we will do our very best to ensure that the right care is delivered at the right time and at the right place. It includes a promise to communicate clearly to our patients, our providers, and our stakeholders and to coordinate services correctly and proactively. o Dorothy Lockhart, MBA, MSN, RN, is Market Vice President of CHI Saint Joseph Health Partners. She is an active member of APG and participates in the Risk Evolution Task Force (RETF). She can be reached at 714-878-5173 or at dorothylockhart@sjhlex.org. For more information about CHI Saint Joseph Health Partners, please visit CHISaintJosephHealthPartners.org.

ABOUT HEALTH PARTNERS CHI Saint Joseph Health Partners (Health Partners) is a physician-led clinically integrated network based in Lexington, Kentucky. Established in 2012, Health Partners is currently affiliated with 10 Kentucky hospitals, their associated medical groups, and other independent providers. This allows Health Partners to have a unique position to make a real difference in healthcare for those in Central to Southern Kentucky. Through these partnerships—and our alignment with CommonSpirit Health—we are leading the way in value-based care by measuring, reporting, and rewarding excellence in healthcare delivery. Our efforts recognize that long-term solutions to disease management include understanding and managing social determinants of health. The Health Partners team implements advanced data analytics to connect all available wellness resources for a more organized and individualized healthcare experience. By analyzing the health data of our populations, we stratify health risks and work alongside provider offices to deliver customized care to the patient. By focusing on patients who incur the highest medical costs and addressing those at risk for developing more serious health complications, we utilize our skilled multidisciplinary care management team to meet each individual’s needs. Our solutions, designed for a person-centered approach, encourage a 1:1 relationship between local care coordinators and the individual patient. This holistic model integrates an individual’s health, medication management, nutrition, exercise, and stress reduction, which may affect the ability to improve and sustain better health. Our integrated approach improves outcomes and reduces healthcare costs by identifying and monitoring high-risk populations, encouraging adherence to treatment plans, providing patient education, and promoting preventive screenings that can help to prevent further complications and worsening disease conditions.

Spring 2021

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New APG Collaborative Addresses Health Equity and Social Justice BY L U R A H AW K I N S , M B A , V P, M E M B E R S E R V I C E S , A M E R I C A’ S P H YS I C I A N G R O U P S

“

The collaborative will create opportunities for education, problem-solving, and collaboration among APG members and partners.”

America’s Physician Groups is proud to announce that it has created a new collaborative focusing on health equity and social justice (HESJ) to address the systemic issues that create challenges for individuals from certain populations to access quality, affordable healthcare. The collaborative will create opportunities for education, problem-solving, and collaboration among APG member organizations and partners. The program’s goals include: Pete Fronte, MBA

• Sharing ideas and priorities within APG member and partner organizations • Creating an environment where issues and ideas can be shared without judgment • Fostering collaborations between organizations and individuals with similar goals and priorities • Sharing successes, challenges, and best practices

There will be quarterly meetings with a year-end summit. Members and partners will share programs and goals at each of the meetings, with guest speakers offering advice through keynote presentations. Topics that will be considered for discussion include:

Adrianne Wagner, MHSA, FACHE

• Patient care and cultural considerations • Staffing and leadership diversity • Unconscious bias • Existing tools and programs • Social determinants of health (SDoH) Alyssa Canter

• Social and geographic isolation The collaborative is led by the HESJ Steering Committee, which includes two APG members and two APG partner representatives. Here are some insights and comments from each Steering Committee member. Pete Fronte, Altura APG’s Health Equity and Social Justice Collaborative is an excellent platform to learn and apply best practices to support the evolution of patient-centered healthcare. Altura’s perspective revolves around supporting and encouraging diversity in clinical

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Sheila Sudhakar, MD

trials and health studies of all types. Many APG members conduct studies or can be affiliated with organizations that are enabling studies in the communities they serve. Whether it is a COVID-19, Alzheimer’s, mental health, or cancer study, based on various surveys and public opinion polls, over 81% of people would likely join a study if they were informed by a trusted healthrelated resource such as a doctor, nurse/medical assistant, or other healthcare professional. This is especially true for underrepresented populations. Diversity and equity in health studies includes two important factors. First, it is important to have data related to the safety and efficacy of new and existing interventions to ensure that underrepresented populations (e.g. minorities, elderly) are able to contribute their unique characteristics. As an example, Hispanics/Latinos make up 17% of the population, but less than 1% of participants in NIHfunded research and between 6%-7% of all clinical trials. African Americans comprise 13% of the population but only 5% of clinical trial participants. Second, providing access to clinical trials and health studies allows for equitable distribution and access that can bring value to individuals in the short term and like populations in the long run.

Adrianne Wagner, The Everett Clinic, Part of Optum When approached about the idea of this collaborative, I was really excited at the prospect of taking all the combined experience and wisdom of the top medical groups across the country and working together to create greater equity, fairness, and advancement for marginalized populations that we all serve (and more importantly, those we do not currently adequately serve). Health equity and social justice are both concepts that are anti-competitive in nature, and so calling this a collaboration was really the most fitting way to describe the work we will be doing together to solve large-scale problems that we all seem to be facing. Equity is a key pillar of quality as described in the Institute of Medicine’s Six Domains of Quality.1 We’ve recently been challenging our organization and our teams to think about that concept more broadly and not just in the closed way we used to, which is to say offering the care we deliver equitably to those we serve. Now we are challenging what it really means to deliver equitable care to our communities, beyond our walls, and what it means to have an equitable care delivery system, including diversity and inclusion among our own teammates and providers. continued on next page

Spring 2021

JOURNAL OF AMERICA’S PHYSICIAN GROUPS l 25

continued from page 25

Alyssa Canter, Oscar Oscar is a new partner to APG and, as an organization, we are pleased to have an opportunity to serve as a Co-Chair on the Health Equity & Social Justice Collaborative. Oscar strives to make a healthier life accessible and affordable for all. We recognize that health disparities will continue to persist without addressing culturally competent care that contributes to health outcomes. Innovation and collaboration are key to achieving meaningful change, and this new collaborative is a forum to ignite those discussions through idea-sharing and relationship-building. On a personal level, I am excited to be part of this forum. Addressing health access and the social determinants of health is a passion of mine and an area of policy I have studied and worked on over the years. There is much more work to be done across the healthcare sector, and I am looking forward to collaborating in this forum to carry forward the discussion. Sheila Sudhakar, MD, Cigna Medical Group As primary care physicians, one of our biggest challenges and frustrations is that we know what and how care needs to be provided for our patients to achieve optimal health and cost outcomes. But unless social determinants of health are addressed, it is hard for patients to understand, let alone prioritize, clinical recommendations. While we, as providers of care, want to do all we can to help our patients, it is the underlying SDoH and behavioral health (BH) issues that lessen our ability to deliver optimal outcomes. This is contributing to the decreased interest in practicing medicine and in joining the primary care workforce, which is hurting our already existing clinician shortage. From a population health perspective, it has been known for years that SDoH impact the underlying opportunity to improve health and outcomes. Addressing SDoH has shown significant return on investments by decreasing inpatient admissions and increasing adherence to clinical recommendations. From a healthcare business perspective, while organizations have continually attempted to mitigate healthcare costs and improve quality outcomes through various initiatives, without addressing and improving health disparities and SDoH, our ability to make meaningful impacts will remain limited. The pandemic 26 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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has brought SDoH and BH to the forefront as critical opportunities that need solutions as the landscape of the overall population has deteriorated due to job loss, decreased incomes, increased food insecurities, and worsening underlying BH issues. I hope through this collaborative that we, as a national group of diverse perspectives and experiences, can learn, develop, and implement sustainable solutions to address SDoH that will have positive effects for generations to come. With varying economies, worsening chronic health conditions, and widening health disparities, our need to solve for SDoH will only become greater along with the many other challenges we are facing in the U.S. healthcare system. I look forward to collaborating with APG members and partner organizations as we strive to address health equity and social justice! Additional goals of the collaborative include creating a robust webpage with tools and links to education and information, the creation of a Best Practice Case Studies Manual, and creating core interest groups. o This program is open to all APG member physician organizations and APG partner organizations. For additional information, please contact Lura Hawkins, MBA, at LHawkins@APG.org. Reference: Institute for Healthcare Improvement. Across the Chasm: Six Aims for Changing the Health Care System. http:// www.ihi.org/resources/Pages/ImprovementStories/ AcrosstheChasmSixAimsforChangingtheHealthCareSystem.aspx 1

HESJ Steering Committee Pete Fronte, MBA President and CEO Altura Sheila Sudhakar, MD Senior Medical Director, Practice Excellence, Population Health, Epic Cigna Medical Group, Arizona Adrianne Wagner, MHSA, FACHE Regional Vice President, Quality and Patient Safety for Employed Groups The Everett Clinic, Part of Optum Alyssa Canter Director, Government Affairs & Policy Oscar

ORGANIZATIONAL MEMBERS ACO Management Services, LLC Kamal Jemmoua, CEO Mallory Cary, Regional Director ACO Operations

M E M B E R S

Adventist Health Physicians Network IPA Erica Fraguero, Director of Finance, SCR Arby Nahapetian, MD, CMO

CareMax, Inc. Ben Quirk, Chief Strategy Officer Phillip Giarth, VP Value Based Care

Aegis Medical Group Carl Patten, General Counsel

Cedars-Sinai Medical Group * Caroline Goldzweig, MD, Chief Medical Officer John Jenrette, MD, Executive VP, Medical Network

Affinity Medical Group Richard Sankary, MD, President Melissa Christian, Interim VP of ACO Operations

Central Ohio Primary Care Physicians Inc. * J. William Wulf, MD, CEO Larry Blosser, MD, Corporate Medical Director

agilon health management, inc. Ben Kornitzer, MD, Chief Medical Officer Steven Sell, Chief Executive Officer

Central Oregon Independent Practice Association Divya Sharma, MD, CMO Kim Bangerter, CEO

AllCare IPA Matt Coury, CEO Randy Winter, MD, President Allied Physicians of California Thomas Lam, MD, CEO Kenneth Sim, MD, CFO

ChenMed * Guarov Dayal, MD, President, New Markets and Chief Growth Officer Stephen Greene, Chief of Staff

AltaMed Health Services Corporation Castulo de la Rocha, JD, President and CEO AppleCare Medical Group, Inc. Trish Baesemann, President George Christides, MD, Chief Medical Officer

Children’s Physicians Medical Group Leonard Kornreich, MD, President and Chief Executive Officer

Arizona Health Advantage, Inc. Tanya Sibrava, DO, Senior Medical Director Terry Smith, Chief Operating Officer

Chinese American IPA Peggy Sheng, Chief Operating Officer George Liu, MD, President & CEO

Austin Regional Clinic * Norman Chenven, MD, Founding CEO Anas Daghestani, MD, Chief Operating Officer

Chinese Community Health Care Association Cathy Chan, Director of Operations Peter Hohl, Chief Executive Officer

Bayhealth Physician Alliance, LLC Evan W. Polansky, JD, Executive Director Joseph M. Parise, DO, Medical Director

CHOC Physicians Network Michael Weiss, MD, VP Population Health

Beaver Medical Group John Goodman, President and CEO Raymond Chan, MD, VP Medical Admin/CMO of Epic Health Plan Brown & Toland Physicians * Kelly Robison, CEO Joel Klompus, MD, President & Interim CMO

Canopy Health Mike Robinson, CEO Margaret Durbin, MD, CMO CareAllies Joe Nicholson, DO, Chief Medical Officer Casey McKeon Groups: Accountable Care Coalition of Alabama, LLC • Baldwin IPA • Ben Franklin Physicians IPA LLC • Broad Spectrum IPA • Clarksville Medical Network IPA • Cullman Primary Care IPA • Dallas IPA • DC Qual-Care IPA • Delco Wellness IPA • DFW Healthcare Partners IPA • East Memphis Medical Network • El Paso Integral Care • Emerald Shores IPA • Etowah IPA • Franklin Medical Network • Greater Chicago IPA • Hattiesburg Clinic • KMG IPA LLC • Liberty Independent Physicians Group • Little River Canyon IPA • Memphis Midtown IPA • North Tennessee Medical Network IPA • Prestige Physicians Group IPA • Providence Medical Network • Renaissance Physicians Organization • River Region IPA • Rutherford County Physicians Network • Southern Medical Physicians IPA • St. Thomas Medical Partners, LLC • Summit West IPA • Synergy HealthCare • Tallaco IPA • Tennessee Valley IPA/

Conifer Health Solutions Mary Bacaj, Head of Value-Based Care Groups: Exceptional Care Medical Group • Family Choice Medical Group • Family Health Alliance • Mid Cities IPA • Omnicare Medical Group • Premier Care of Northern California • Saint Agnes Medical Group

Cornerstone Health Enablement Strategic Solutions (CHESS) Yates Lennon, MD, Chief Transformation Officer Dan Roberts, Chief Operations Officer

DFW HealthCare Partners LLC Osehotue Okojie, MD, IPA Chairman Josh Cook, President DuPage Medical Group Paul Merrick, MD, President, Co-CEO Mike Pacetti, CFO, Co-CEO East Coast Medical Services, Inc. Ismary Gonzalez, MD, President Edinger Medical Group Stan Arnold, MD, Senior Physician Executive Denise McCourt, COO El Paso Integral Care, IPA Hector Lopez, DO, Chairman of the Board Tony Martinez, IPA Administrator EPIC Management, LP Raymond Chan, MD, VPMA & CMO John Goodman, President & CEO Groups: Beaver Medical Group, L.P. • Pinnacle Medical Group • Tri-Valley Medical Group

Choice Medical Group Tammi Castro, Director of Operations Manmohan Nayyar, MD, President CHS Physician Partners IPA, LLC Patrick M. O’Shaughnessy, DO, EVP & Chief Clinical Officer Jonathan Goldstein, MBA, Executive Director Cigna Medical Group Kevin Ellis, DO, CMO Citrus Valley Independent Physicians Gurjeet Kalkat, MD, Executive Medical Director Martin Kleinbart, DPM, Chief Strategy Officer Collaborative Health Systems, LLC Anthony J. Valdes, President Colorado Permanente Medical Group, P.C. Margaret Ferguson, MD, President & Executive Medical Director Claire Tamo, CFO and VP, Business Operations CommonSpirit Health * Gary Greensweig, DO, SVP Physician Enterprise, Chief Physician Executive Tom McGinn, MD, MPH, System EVP Physician Enterprise Groups: Catholic Health Initiatives: Architrave Health • Arkansas Health Network • CHI Franciscan Health • CHI St. Joseph Health • Colorado Health Neighborhoods • KentuckyOne Health Partners • Mercy Health Network • Mission HealthCare Network • PrimeCare Select • St. Luke’s Health Network • TriHealth • UniNet Dignity Health Medical Foundation: Dignity Health Medical Group Arizona • Dignity Health Medical Group Nevada • Dignity Health Medical Network - Santa Cruz • Foundation Physicians Medical Group • Identity Medical Group • Mercy Imaging Medical Group • Mercy Medical Group • Woodland Clinic Medical Group

Spring 2021

Commonwealth ACO Petar Novakovic, MD Lance Donkerbrook, CEO

Desert Valley Medical Group, Inc. Imran Siddiqui, MD, Medical Director Marie Langley, IPA Administrator

Children First Medical Group James Florey, MD, Chief Medical Officer James Slaggert, Chief Executive Officer

California Pacific Physicians Medical Group, Inc. Dien V. Pham, MD, CEO Carol Houchins, Administrator

A P G

Huntsville • Trendsetter Physicians IPA • TriStar Medical Network • Valley Forge IPA • Valley Organized Physicians • Walker IPA • West Alabama IPA LLC

Equality Health – Q Point Pedro Rodriguez, HMA Board Member Mark Hillard, President Emerging Markets Groups: Equality Health, LLC • Equality Health Network, PC • Equality Health Texas, LLC

Evolent Care Partners Michael Margolis, MD, Chief Medical Officer Asit Gosar, Chief Executive Officer Facey Medical Foundation * Erik Davydov, MD, Medical Director David Mast, Chief Executive, Medical Group Foundations Good Samaritan Medical Practice Association Nupar Kumar, MD, Medical Director Greater Newport Physicians Medical Group, Inc. * Adam Solomon, MD, CMO Deeling Teng, MD, Senior Medical Director Hawaii IPA Greigh Hirata, MD, President Julie Warech, Administrator Hawaii Pacific Health Kenneth B. Robbins, MD, CMO Maureen Flannery, VP, Clinic Operations Hawaii Permanente Medical Group, Inc. John Yang, MD, Area Medical Director Heritage Provider Network * Richard Merkin, MD, President Richard Lipeles, COO Groups: Affiliated Doctors of Orange County • Arizona Health Advantage, Inc. • Arizona Priority Care Plus • Bakersfield Family Medical Center • California Desert IPA • California Physician

JOURNAL OF AMERICA’S PHYSICIAN GROUPS l 27

M E M B E R S

Network • Coastal Communities Physician Network • Desert Oasis Healthcare • Greater Covina Medical Group • Heritage Physician Network • Heritage Victor Valley Medical Group • High Desert Medical Group • Lakeside Community Healthcare • Lakeside Medical Group • Regal Medical Group • Sierra Medical Group

Mercy Health Physicians Michele Montague, COO

Hill Physicians Medical Group, Inc. * David Joyner, CEO Amir Sweha, MD, CMO

Monarch HealthCare * Bart Asner, MD, CEO Ray Chicoine, President

Hoag Clinic Kris Iyer, MD, Sr. Vice President & Chief Administrative Officer Scott Ropp, Vice President and CFO

Montefiore Medical Center/IPA Stephen Rosenthal, SVP

Meritage Medical Network Wojtek Nowak, CEO J. David Andrew, MD, Medical Director

Monterey Bay Independent Physician Association James N. Gilbert, MD, President & Chairman of the Board Michele Wadsworth, Network Management Associate

In Salud, Inc. Armando Riega, President Carmen Ramos, CPA, Executive Director Innovare Health Advocates Charles Willey, MD, President & CEO Paul Beuttenmuller, CFO

Mount Sinai Health Partners * Niyum Gandhi, EVP, CFO & Chief Population Health Officer Robert Fields, MD, SVP and CMO for Population Health

IntegraNet Health Lawrence Wedekind, CEO Jaime Duarte, MD, Medical Director, Outpatient

Pacific Medical Administrative Group Donna Mah, MD, President Michael Chang, MD, Executive Director Pediatric Associates Peter Shulman, MD, CEO Scott Farr, COO PHM MultiSalud, LLC Roberto L. Bengoa Lopez, President Lynnette Ortiz, MD, Medical Director Groups: Advantage Medical Group • Alianza de Medicos del Sureste • Centro de Medicina Familiar del Norte • Centro de Medicina Primaria Advantage del Norte • Centros Medicos Unidos del Oeste • G.M.D.C., Inc. • Grupo Advantage del Oeste • Grupo Medico de G.M.B., Inc. • Grupo Medico de Orocovis

Physicians Care Network Mary Anderson, MD, Medical Director Denis McDonald, Executive Director

Intermountain HealthCare * Rebekah Couper-Noles, COO, Community Based Care

MSO of Puerto Rico * Richard Shinto, MD, CEO Raul Montalvo, MD, President

Physicians DataTrust Lisa Serratore, CEO Grace Bender, VP of Finance

Iora Health Inc. * Rushika Fernandopulle, MD, MPP, CEO Tyler Jung, MD, CMO

NAMM California * Paul Lim, MD, CMO Leigh Hutchins, CEO

Groups: Empire IPA • Equality IPA • Golden Physicians Medical Group • Greater Tri-Cities IPA • Noble AMA IPA • St. Vincent IPA

Jade Health Care Medical Group, Inc. Edward Chow, MD, President & CEO Thomas Woo, Manager of Operations

Groups: Empire Physicians Medical Group • Mercy Physicians Medical Group • Primary Care Associated Medical Group, Inc. • PrimeCare Medical Group of Chino • PrimeCare Medical Network, Inc. • 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

Physicians of Southwest Washington, LLC * Melanie Matthews, CEO Gary R. Goin, MD, President

naviHealth, Inc. Jay LaBine, MD, CMO Gina Bruno, MBA, VP, Clinical Strategy

Portland IPA Susan Clack, MD, President and Board Chair Pamela Bauer, CEO

NeueHealth * Martin Serota, MD, Chief Medical Officer Megan North, Senior Vice President

Preferred IPA of California Mark Amico, MD, Medical Director Zahra Movaghar, Administrator

New West Physicians, P.C. Ken Cohen, MD, CMO

Premier Family Physicians Kevin Spencer, MD, CEO and President Mat King, CFO

John Muir Physician Network * Lee Huskins, President & CAO Ravi Hundal, MD, CFO Key Medical Group, Inc. Brent Boyd, CEO James Foxe, MD, Medical Director Landmark Medical, PC Michael H. Le, MD, President Leon Medical Centers, Inc. Rafael Mas, MD, SVP & CMO Julio G. Rebull, Jr., SVP Loma Linda University Health Care J. Todd Martell, MD, Medical Director Managed Care Management and Educational, LLC Luis Deliz Varela, MD, Medical Director Guido Lugo Modesto, Esq., Administrator

A P G

Orlando Family Physicians Penelope Kokkinides, Chief Administration Officer Roslynn ORourke, Chief Operating Officer

Northwest Permanente, P.C. * Colin Cave, MD, Director of External Affairs, Government Relations and Community Health Marilyn Weber, Chief Financial Officer

Marshfield Clinic, Inc. * Narayana Murali, MD, EVP & CSO Martin Luther King, Jr. Community Medical Group John Fisher, MD, MBA, President Laurie Gallagher, Practice Administrator Medicos Selectos del Norte, Inc. Mildalias Dominguez Pascual, MD, President Fernando A. Garcia Cruz, MD MedPOINT Management Kimberly Carey, President Rick Powell, MD, CMO Groups: • Associated Hispanic Physicians of Southern California IPA • Bella Vista Medical Group, IPA • Centinela Valley IPA • Crown City Medical Group • El Proyecto del Barrio, Inc. • Family Care Specialists IPA • Global Care Medical Group IPA • Golden Physicians Medical Group, Inc. • Health Care LA IPA • Integrated Health Partners • Pioneer Provider Network • Premier Physicians Network • Prospect Medical Group-LA Care • Prudent Medical Group • Redwood Community Health Coalition • Watts Health Corporation

MemorialCare Medical Group * Mark Schafer, MD, CEO Laurie Sicaeros, COO, VP of Physician Alignment 28 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

PIH Health Physicians Rosalio J. Lopez, MD, SVP & CMO Andrew Zwers, Chief Operating Officer Pioneer Medical Group, Inc. * Jerry Floro, MD, President Andrew Zwers, Chief Operating Officer

PrimeHealth Physicians, LLC Mark Kutner, MD, Board Member Cesar Ortiz, CEO

Northwest Physicians Network of Washington, LLC Jesse Gamez, COO

PriMed Physicians Mark Couch, MD, President Robert Matthews, VP of Quality

Ochsner Clinic Foundation Philip M. Oravetz, MD, Chief Population Health Officer

Prisma Health * Angelo Sinopoli, MD, Chief Clinical Officer Peter Tilkemeier, MD, Chair, Department Medicine

Ohio Integrated Care Providers Cindy M. Baker, CEO Patrick Goggin, MD, Quality Improvement Medical Director

Privia Medical Group LLC Keith Fernandez, MD, National Chief Clinical Officer Graham Glaka, SVP, Strategy & Innovation

OHSU Health IDS, LLC Katrina McPherson, MD, Chief Medical Officer Jeff Conklin, Chief Executive Officer Omnicare Medical Group Toni Chavis, MD, President Ashok Raheja, MD, Medical Director Optum (Formerly HealthCare Partners) * Amar Desai, MD, President Coastal Region Don Rebhun, MD, Regional Medical Director OptumCare Network of Connecticut Karen Gee, SVP & COO Rob Wenick, MD, VP & Medical Director

Spring 2021

Prospect Medical Group * Jeereddi Prasad, MD, President/Acting CMO Jim Brown, CEO Groups: AMVI/Prospect Medical Group • Cal Care IPA • Genesis Healthcare of Southern California, Inc., a Medical Group • Los Angeles Medical Center IPA • Nuestra Familia Medical Group, Inc. • Pomona Valley Medical Group, Inc. • Prospect Health Source Medical Group, Inc. • Prospect Medical Group, Inc. • Prospect NWOC Medical Group. Inc. • Prospect Professional Care Medical Group, Inc. • Prospect Provider Group RI, LLC • Prospect Provider Group CTE, LLC • Prospect Provider Group CTW, LLC • Prospect Provider Group NJ, LLC • Prospect Provider Group PA • Prospect

Health Services TX, Inc. • StarCare Medical Group, Inc. • Upland Medical Group, a Professional Medical Corporation

Signify Health Marc Rothman, MD Kim Holland

UCLA Medical Group * Sam Skootsky, MD, CMO Regina Green, Director of Managed Care Operations

Providence Health & Services

Southern California Permanente Medical Group * Diana Shiba, MD, Director of Government Relations Todd Sachs, MD, Medical Director of Operations

US Health Systems, LLC Amish Purohit, MD

Groups: in Alaska, California, Montana, Oregon, Washington

Providence Medical Management Services Groups: Providence Care Network

Regional HealthPlus Nick Ulmer, MD, Chief Medical Officer, VP of Clinical Integration Chris Skinner, Executive Director Reliant Medical Group, Inc. Michael Sheehy, MD, Chief of Population Health & Analytics Tarek Elsawy, President & CEO Remedy Applications, Inc. Ronald Dixon, MD, CMO John Schmucker, VP of Clinical Operations and Chronic Care Renaissance Physician Organization Clare Hawkins, MD, IPA Board Chair Whitney Horak, President River City Medical Group, Inc. Keith Andrews, MD, Executive Medical Director Kendrick T. Que, CEO Riverside Medical Clinic Steven Larson, MD, Chairman Judy Carpenter, President and COO Riverside Physician Network Howard Saner, CEO Paul Snowden, CFO St. Joseph Heritage Healthcare * Kevin Manemann, President and CEO David Kim, MD, Medical Director Groups: Hoag Medical Group • Mission Heritage Medical Group • St. Mary High Desert Medical Group

St. Vincent IPA Medical Corporation Jeffrey Hendel, MD, President Leesa Johnson, Director of IPA Operations Sansum Clinic * Kurt Ransohoff, MD, CEO & CMO Chad Hine, COO Santa Clara County IPA (SCCIPA) J. Kersten Kraft, MD, President of the Board Janet Doherty Pulliam, CFO

Southwest Medical Associates * Robert B. McBeath, MD, President & CEO Greg Griffin, COO

USMD Richard Johnston, MD, CEO & Chief Physician Officer Michelle Speck, CAO

Southwestern Health Resources Andrew Ziskind, SEO Danny Irland

Valley Care IPA Sonya Araiza, CEO Michael Swartout, MD, Medical Director

SpineZone Medical Fitness Kian Raiszadeh, MD, Chief Executive Officer Pam Erickson

Valley Organized Physicians William Torkildsen, MD, Chairman of the Board Sarah Wolf, Senior Administrator

Starling Physicians, PC Jarrod Post, MD, CEO Tracy King, Chief Administrative Officer

VillageMD Clive Fields, MD, CMO Paul Martino, Chief Strategy Officer

Summit Medical Group, PA * Jeffrey Le Benger, MD, Chairman & CEO Jamie Reedy, MD, Chief of Population Health

Washington Permanente Medical Group Steve Tarnoff, MD, President & Executive Medical Director David Kauff, MD, Medical Director

Summit Medical Group, PLLC Jeff Stevens, MD, Chairman of the Board Ed Curtis, CEO Sutter Health Foundations & Affiliated Groups * Larry deGhetaldi, MD, Division President, Palo Alto Medical Foundation Kelvin Lam, MD, MBA, Chief Medical Officer, Sutter Health Bay Area Groups: Central Valley Medical Group • Palo Alto Foundation Medical Group • Palo Alto Foundation Mills Division - MPMG • Sutter East Bay Medical Group • Sutter Gould Medical Group • Sutter Independent Physicians • Sutter Medical Foundation • Sutter North Medical Group • Sutter West Bay Medical Group

Swedish Medical Group Meena Mital, MD, Medical Director Bela Biro, Admin Director, Accountable Care Services Synergy HealthCare, LLC James Jones, MD, Chairman of the Board Austin Burrows, Sr. Administrator, CareAllies

WellMed Medical Group, P.A. * Carlos O. Hernandez, MD, President Robert McBeath, MD

CORPORATE PARTNERS AbbVie Amgen Anthem Blue Cross of CA Boehringer Ingelheim Pharmaceuticals Episource, LLC InnovaCare Health, LP Mazars USA, LLP Novo Nordisk Patient-Centered Primary Care Collaborative Sanofi, US SCAN Health Plan

ASSOCIATE PARTNERS

Tandigm Health, LLC Lee Buttz, MD, CMO Frank Ingari, President & CEO The Everett Clinic, PLLC Michael Millie, MD, Associate Medical Director of Surgery Adrianne Wagner, Vice President, Quality Improvement

Santé Health System, Inc. Scott B. Wells, CEO Daniel Bluestone, MD, Medical Director

The Permanente Medical Group, Inc. * Stephen Parodi, MD, Associate Executive Director Traci R. Perry, Director, TPMG, Advocacy and Political Affairs

SeaView IPA Lynn Haas, CEO Anil Chawla, MD, Medical Director

The Portland Clinic * Amy Mulcaster, DO, Chief Medical Officer Dick Clark, Chief Executive Officer

Scripps Coastal Medical Center Anthony Chong, MD, CMO Tracy Chu, Assistant VP of Operations

The Southeast Permanente Medical Group, Inc. Michael Doherty, MD, Executive Medical Director and Chief of Staff

Scripps Physicians Medical Group Joyce Cook, CEO James Cordell, MD, Medical Director

The Vancouver Clinic, Inc., P.S. * Mark Mantei, CEO

Sentara Quality Care Network Jordan Asher, MD, Senior VP, Chief Physician Executive Grace Hines, Corporate VP, System Integration; SQCN President

USC Care Medical Group, Inc. Donald Larsen, MD, CMO

Torrance Hospital IPA Norman Panitch, MD, President Triad HealthCare Network, LLC* Steve Neorr, VP, Executive Director

Sharp Community Medical Group * Paul Durr, CEO Kenneth Roth, MD, President Groups: Graybill Medical Group • Arch Health Partners

UC Davis Health Michael Hooper, Medical Director, Care Services & Innovation Ann Boynton, Director, Care Services & Innovation

Sharp Rees-Stealy Medical Group * Stacey Hrountas, CEO Alan Bier, MD, President

UC Irvine Health Natalie Maton, Executive Director of Operations

Arkray Apixio Astellas Pharma US, Inc. Exact Sciences Corporation Genentech, Inc. HealthAxis Group, LLC Kindred Healthcare, Inc. Merck & Co., Inc. Moss Adams, LLP Novartis Pharmaceuticals Oscar Health Ralphs Grocery Company Soleo Health, Inc. Sound Inpatient Physicians Sunovion Pharmaceuticals, Inc. UCB Pharma Vifor Pharma, Inc.

AFFILIATE PARTNERS Altura Children’s Hospital Los Angeles Medical Group Curation Healthcare Partners in Care Foundation Pharmacyclics, Inc. Pinnacle Brokers & Insurance Svc, LLC ProActive Care RCxRules Redlands Community Hospital RepuGen Stellar Health Ventegra, LLC Wellth, Inc.

* Indicates 2021-2022 Board Members

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Connecting Key Strategies to Promote Talent Management BY R U S S F O S T E R , S H E I L A S T E P H E N S , A N D FA I T H S A P O R S A N TO S , M S N , M H A , R N , C R R N

Talent management is a key organizational strategy and one that is currently at the forefront for organizational leaders. This is not a fad strategy—rather, it is rooted in the knowledge that acquiring exceptional talent can significantly contribute to the organization and effectively assist in achieving successful outcomes. While acquiring new and excellent talent is essential, it is also critical to recognize the importance of managing existing talent. Talent management, new and existing, begins with connecting talent management strategy to other key strategies within the organization. Connecting key strategies promotes synergy and helps maximize strategic impact—especially at ground-level management of new or existing talent. Russell Foster

It takes work to connect the dots between strategies and ensure successful execution on all fronts and at all levels. However, the first step is to understand the strategies. For example, the recent focus on talent management challenges us to understand what it is—and what it is not.

THREE STRATEGIES IN CONCERT

Sheila Stephens

Writing for The Complete Leader, Ranjit Nair, PhD, explains, “A talent strategy isn’t about musical chairs and who sits in what seat and when. It’s about building an authentic culture around all people.” This means honoring them, enabling them to unleash the best they have to offer, and then capitalizing on their individual strengths. Given the opportunity, everybody brings something to the table.1 This is why you need an inclusive strategy that is built on recognition, development, and nurturing of internal talent, as well as recruitment of new talent. Similarly, most organizations have adopted communication strategies. The successful ones understand that an effective communication strategy is not a one-time event; it is ongoing and multidirectional.

Faith Saporsantos, MSN, MHA, RN, CRRN

Another key organization strategy is ongoing performance improvement and related staff development. Successful organizations understand that performance is not just the responsibility of the individual team member, but it is also the responsibility of leadership. This includes implementing key measures, developing a performance road map to achieving results, and providing the guidance and constructive feedback necessary for success. All three of these strategies—talent management, communications, and performance improvement—are inseparable, complementary, interconnected, and interdependent. Each contributes to the overall success as well as to each

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assume “Dothatnoteveryone on the team has a clear vision of the bigger picture.”

other. Therefore, these three strategies in concert, like the triple aim, are a winning combination.

“the whole is greater than the sum of its parts.” 2 It is the combined effort of a group of individuals who work together to achieve a common goal, and it most often includes sharing of talent, knowledge, expertise, and experience.

However, as with any enterprise-wide strategy, sometimes the basics of good leadership and strategy implementation can get lost in the grind of everyday operations.

Synergy can be magnified by effective talent management, quality communications, and performance improvement that considers the achievements of the team as well as the individuals. Synergy can be further enhanced by ensuring that each team member has an understanding of the bigger picture.

For example, an organization that prides itself on excellent leadership and quality communication can sometimes forget to ensure that everyone understands the big picture and how each individual contributes to the project at hand and to the organization’s mission and vision. This is increasingly important as more and more jobs are now dependent on teamwork and collaboration, and a remote environment makes this challenge even greater.

WHY THE BIG PICTURE MATTERS

Promoting and facilitating effective teamwork by stimulating synergy allows each individual to contribute to the whole and allows the team to achieve more. Synergy can be summarized by the physics concept of

Awareness of the bigger picture is rooted in all three strategies. Without having a clear vision of the larger picture and its related parts, an individual is unnecessarily placed at a disadvantage—a bit like being asked to design a building without understanding its function or purpose. We have all seen projects adversely impacted by team members dragging down the overall effort due to a lack of information about the larger context. Interdependency and efficiency are just two of the many reasons why understanding the big picture is important. continued on next page

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guidance, and provide mentoring as needed. This is especially important for less-experienced team members.

continued from page 31

A friendly reminder: Do not assume that everyone on the team has a clear vision of the bigger picture. This assumption is a common pitfall when managing projects that on the surface appear to be similar to previous projects. Keep in mind that no two projects are exactly the same. The desired outcome may be the same, such as obtaining licensing or completing an acquisition. However, several dynamics can change the big picture, including finances, players, and timing. The larger picture must consider all dynamics to achieve the desired outcome in an efficient manner. Every project has a unique context. The scope, setting, phase, decision processes, and stakeholders affect the opportunities on any project. Understanding this context is critical to achieving the project goals. Context should be viewed as both a constraint and an opportunity.3 Failure to ensure that all team members are properly informed—not only about the end goal, but also about the context, variables, and dynamics that make up the big picture—is a guarantee for rework, wasted time, team frustration, and inefficiency. On the other hand, recognizing the interdependency of team members and how each person’s work contributes to the whole generates synergy and efficiency and contributes to a quality end product.

TIPS AND REALITIES Here are some basic tips to ensure everyone on the team understands a project’s big picture: • Ensure that everyone receives an overview of the project or work to be done, including key background information and project scope. • Provide all team members with a clear description of the overall project, including how each piece interrelates and contributes to the whole. • Keep communication open and frequent. • Establish processes for quick “sanity checks.” This allows individuals to quickly ask “does this makes sense” or reinforce their understanding before wasting time going down the wrong path or pursuing erroneous information. • Ensure processes are in place for individual team members to receive additional information and

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Engaging employees is critical. When leaders take the time to translate their complex language of strategy into a common language of execution, individuals can make better decisions and take ownership. The results include better outcomes, improved productivity, and increased job satisfaction.4 As organizations set out to connect their strategies, it is important to keep three realities in mind: 1. All team members are customers of organizational strategy. This is a key understanding to ensure that all members of the team are included. Remember: Organizational learning and execution speed is not determined by the speed of the brightest individuals, but by the average speed of the entire organization. 2. People will tolerate the directives of leadership, but they will ultimately act on their own. Empowering team members with knowledge and understanding of the organizational strategies enables them to invest their time and talent as “owners” and allows for quality decisions and work. This is a key reality of change and a basic tenant of successful leadership. As former President Dwight D. Eisenhower said, “Pull the string, and it will follow wherever you wish. Push it, and it will go nowhere at all.”

This is an ongoing management decision: push versus pull. In terms of leadership, “push” is topdown command and control, while “pull” is motivating and teaching to create alignment of purpose. The “pull” leadership approach is clearly more aligned with today’s organizational strategies and supports inclusion, knowledge sharing, talent development, high performance, and efficiency. These are all key to a successful organization.

3. Everyone must see and understand the big picture. This does not negate the need for detail. Rather, you need to analyze, interpret, and report the detail within the framework of the larger picture. When individuals understand the greater context of their work, their improved performance results in a better product that benefits the entire organization. Connecting strategies to achieve efficient work performance and project management is an everyday effort that starts at the top. However, both upper and

middle management must do their part to ensure that individuals are aware of the big picture and all key context elements.

EVERYDAY EXAMPLES The following are two common examples of how leadership can adversely impact a project by not fully employing the three winning organizational strategies. Example 1: John John, a top-performing data analyst in a large healthcare organization, is asked to collect and analyze a snapshot of claims data for accuracy of claims payment and to develop a report summarizing findings and recommendations. The information that John receives is minimal, and guidance is lacking. No one tells John that his analysis will be part of a larger organizational response to regulatory audit findings. Additional details integral to the assessment—such as inaccurate interest payment on late paid claims, use of inaccurate fee schedules, and noncompliance with provider contracts—are also not shared. This creates a limited and narrow view for John. Because he does not understand how his puzzle piece contributes to the bigger picture—including the context and key information—his analysis will likely not add value and will result in considerable rework and missed opportunities to focus on key issues. This will inevitably lead to frustration for all team members involved and the potential for wavering commitment to the project objectives and organization. Example 2: Mary

(CMS). This significantly impacts the financial forecasting. The lack of information regarding the big picture and context will likely prevent Mary from delivering a comprehensive, quality product to meet both state and federal requirements. Her projections will not meet expectations and will require considerable rework to ensure compliance with the big picture and project objectives. Unfortunately, these and similar scenarios occur on a daily basis and contribute to inefficiencies and rework, leading to lost hours and higher organizational costs. Moreover, the information gaps cause perceived productivity issues, impacting morale and leading to job dissatisfaction and frustration at all levels. The real tragedy is that the adverse impacts could have been avoided. All would have benefited from simple information sharing, including the key details that make up the big picture to ensure proper context. The results would have likely been a “one and done” with no additional rework and improved performance and job satisfaction. By managing talent and maximizing individual strengths, ensuring two-way effective communication and continual performance improvement—including guidance and constructive feedback—your organization can create project synergy, efficiency, and effectiveness. o Russell Foster and Sheila Stephens are Senior Advisors for Mazars USA LLP. They can be reached at Russ.Foster@MazarsUSA.com and Sheila.Stephens@ MazarsUSA.com. Faith Saporsantos, MSN, MHA, RN, CRRN, is Director of Health Care Consulting at Mazars USA. References: Nair, Ranjit, PhD. Look Carefully, Dig Deeper, Connect The Dots: Fixing Talent Management Blind Spots. The Complete Leader. Retrieved December 27, 2020, from https://thecompleteleader.org/blog/lookcarefully-dig-deeper-connect-dots. 1

Mary, a top-performing financial analyst in a midsized provider organization, is assigned to prepare financial projections required for state licensing of her organization. The information Mary receives is limited to projections of revenue, expenses, and enrollment. She is not provided guidance on the overall big picture of the licensing application or any information related to provider contracts—many of which are capitated agreements impacting projected expense calculations. Further, no one tells Mary that the organization also plans to submit a Medicare Advantage application to the Centers for Medicare & Medicaid Services

Federer, Denise (2013, December 6). How to build team synergy. Businessobserverfl.com. Retrieved January 4, 2021, from https://www. businessobserverfl.com/section/detail/how-to-build-team-synergy/. 2

Understanding the Context of a Project, United States Department of Transportation, INVEST. https://www.sustainablehighways. org/1089/understanding-the-context-of-a-project. html#:~:text=Understanding%20the%20context%20of%20a%20 project%20is%20important%20to%20evaluating,incorporate%20 sustainability%20on%20any%20project. 3

Haudan, Jim. 3 Key Tips to Engage Your Employees in the Big Picture. Root, Inc. October 22, 2020, https://www.rootinc.com/blog/engagingemployees-big-picture/. 4

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Health Is Wealth: The Latest on Alternative Payment Models BY S A N J AY D O D DA M A N I , M D , S T E V E N EO R R , A N D VA L I N DA R U T L E D G E

As Americans emerge from the pandemic, there is heightened awareness of the importance of having adequate healthcare coverage, managing out-of-pocket costs, and recognizing how risk factors play into surviving an illness. It is also vital to preserve access to ongoing care for chronic conditions and acute care for emergencies. Both chronic and acute care were impacted by the pandemic:

Sanjay Doddamani, MD

• In the early phase, death rates were higher for acute events when patients avoided hospitals for strokes and heart attacks. • By failing to control chronic conditions, patients who missed testing and preventive care experienced worse health outcomes.

“Physician, heal

thyself, brings new meaning by embracing payment reform, delivery reform, and digital transformation.”

• Primary care physicians whose sole revenue was fee-for-service experienced adverse financial impact in 2020. • Meanwhile, payers showed record earnings during the same period.

Steve Neorr

Both patients and physicians can agree that the current payment model does little to provide value or patient experience commensurate to the level of healthcare spending. So what comes next? As a professional association with more than 350 medical groups, health systems, and independent practice associations accustomed to bearing substantial financial risk, America’s Physician Groups (APG) members have been leading participants in alternative payment models (APMs) for years. APG has a dedicated APM Committee that addresses payment model options and facilitates discussion and sharing of best practices by national experts. The idea is to further the development of APMs—including accountable care organizations (ACOs), medical homes, and bundled payments—across all payers.

Valinda Rutledge

The committee’s discussions cover a wide range of topics but mostly revolve around three areas: payment reform, delivery reform, and digital transformation. Below is a look at some of our discussions over the past year with several national experts.

1. PAYMENT REFORM David Muhlestein, PhD, JD, Chief Research Officer at Leavitt Partners, a leading healthcare consulting firm, spoke at our March 23 committee meeting. Dr. 34 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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Muhlestein spoke of the coming tsunami of healthcare reform while acknowledging the pandemic’s many unknowns. Of the known issues, he addressed weaknesses in the system that need to be identified and urgently addressed. These include the disproportionate federal spending on traditional healthcare, which is threatening the solvency of the Medicare trust fund. This traditional approach perpetuates volume-overvalue payments and highest-paid services, rather than building low-priced services that meet patient need. It also focuses on filling capacity instead of preventing high-cost care. How can we shift from these traditional objectives for growing market share and margin to ones that lower total cost of care and reduce the amount of services? This can be achieved with better aligned incentives that produce greater savings relative to the benchmark—while maintaining higher quality and experience. The biggest example of this alignment has been the profusion of ACOs and improved financial performance with increased years of ACO experience.

2. DELIVERY REFORM Payers promoting delivery reform at scale began largely at the federal government. Today, delivery reform continues to expand across the private sector, from payers and employers. The Health Care Payment Learning & Action Network (HCP-LAN), an active group of public and private healthcare leaders, promotes accelerating the percentage of U.S. healthcare payments tied to quality and value in each market segment. Speaking at an APM Committee meeting in January, Marion Couch, MD, PhD, MBA, FACS, a former senior adviser to the Centers for Medicare & Medicaid Services (CMS) administrator, explained that both government and private sector health spending can be better controlled by adopting APMs with two-sided risk. Dr. Couch has participated in HCP-LAN meetings and serves as Senior Vice President and Chief Medical Officer at Cambia Health Solutions, which includes six health plans and related health and life-science companies. By facilitating an economically accountable relationship between patients and providers through two-sided risk, providers are incented to transform care delivery from one of traditional ”sick care” to one focused on wellness and prevention, she said. Margin can truly be reimagined and created through keeping people well—instead of through admissions, procedures, and testing. The goal is not only to make healthcare more affordable, but to also change care delivery to be better aligned with the well-being of patients. Cambia adopted a next-generation human services platform with a strong digital backbone to make data more accessible and transparent with providers. This enables Cambia to share quality and encounter data in near real time and help practices become more efficient in care delivery, with better outcomes and financial performance. Another guest speaker, Mike Palena, Vice President of Network Strategy and Performance at Meridian Health Plan, a Centene company, laid out innovative solutions augmented by actionable data continued on next page

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continued from page 35

from a quality reporting package and standard reporting suite. Meridian Health Plan reimburses primary care physicians under a capitation model distributing shared savings or provider surplus within a total cost of care model. There is also a “light” version for those who are new to receiving valuebased payments. The goal of these new platforms and partnerships with providers is to change the way care is delivered. APM Committee Co-Chairs Sanjay Doddamani, MD, and Steve Neorr are both part of integrated delivery systems with accountable care or delegation across multiple product lines. They both say that capturing risk adjustment when patients stayed home or avoided seeking medical care has been extremely challenging. In committee discussions over the past year, they described ways to help providers manage risk in the time of COVID-19: • At Southwestern Health Resources (SWHR), network physicians closed thousands of quality gaps using home vendor services where needed—a preemptive attempt to stem the drop in quality scores seen nationally. • At Cone Health, one strategy deployed through its ACO, Triad HealthCare Network, has been to go upstream and initiate prospective, not retrospective, reviews to help inform providers of outstanding HCCs (diagnosis codes) prior to a visit.

3. DIGITAL TRANSFORMATION COVID-19 vaccines hold great promise for giving people much-needed reassurance to resume preventive care and healthy living after they have been vaccinated. But vaccine hesitancy and other factors have held back some of the highest-risk patients. Using advanced data analytics and artificial intelligence to prioritize high-risk patients is an approach that has been developed and modeled to save more lives and reduce avoidable hospital costs. By applying machine learning algorithms for vaccine prioritization, high-risk patients can receive coordination of care, scheduling, and other services to register, travel, and complete their COVID-19 vaccines. Andrew Eye, CEO of ClosedLoop.ai, a finalist in the CMS AI Health Outcomes Challenge, spoke to our

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committee this spring. Eye explained how simply following the Centers for Disease Control and Prevention vaccine rollout guidelines cannot discern who among the 1b population (frontline essential workers and people age 75 or older) has incremental risk for being hospitalized due to COVID-19 beyond simply age and comorbidities. Running an AI analysis on a large population at SWHR’s clinically integrated network revealed that patients in the highest-risk cohort were four times more likely to be hospitalized for COVID-19 over the conventional 1b list. This has great implications for reducing the number of unvaccinated high-risk patients. With over 1,500 variables in the algorithm— including a frailty index and other variables, like the number of prescription drug classes or social factors—machine learning can explain at the population and individual level which risk factors have the greatest impact on adverse outcomes. If you look beyond the pandemic, there are vast use cases at the population level to recognize and mitigate risk, especially when there are clear levers for intervention. This can help providers find the right patient who will derive the best outcomes from an intervention and can be applied to frail and sick patients and those with social risk factors. The future of U.S. healthcare can become secure when better value, health equity, and consumer empowerment become the centerpiece. The APM Committee will continue to discuss and share best practices among various payment model options that liberate physicians from a predominantly fee-for-service model to a brighter and more sustainable future in value-based care. Physician, heal thyself, brings new meaning by embracing payment reform, delivery reform, and digital transformation. o Sanjay Doddamani, MD, is Chief Physician Executive and COO, Southwestern Health Resources (sanjayd@southwesternhealth.org), and Steve Neorr is Senior Vice President of Population Health for Cone Health (steve.neorr@conehealth. com). Valinda Rutledge is Executive Vice President, Federal Affairs, for America’s Physician Groups (vrutledge@apg.org).

California Bill...continued from page 17

be in the form of a percentage of California’s gross state product, with a percentage for escalation. Massachusetts has issued cost targets in the range of 3.5% to 4.5% in past years. As the Office develops, it would dig further into the regional markets and determine whether certain plans and/ or providers are sticking to the targets. If they aren’t sticking to them, the Office would have a “gradual enforcement approach” that would include public transparency, corrective action plans, and ultimately monetary fines. Appeals processes are included in the enforcement approach. APG was obviously concerned that high-quality, low-cost providers could be squeezed further within a regional cost target enforcement model. Policymakers have responded that they will focus on equitable mechanisms to ensure that this does not happen. But the bill needs further work, or a more detailed approach through implementing regulations is necessary to defend “good actors” within a region. The tough nut here is creating a threshold for monitoring, oversight, and enforcement. How big or small a provider or health plan should be included within the Office’s oversight? Currently, the HPD will only collect data from health plan and thirdparty administrator payers—and only if they have enrollments of 50,000 lives or greater. The HPD will not collect data directly from providers. However, this will likely change over the next several years, if and when the HPD meets certain implementation milestones. Should certain providers be exempted from cost target oversights? APG has been adamant: Everybody is in, or it won’t work. Data collection from the Medi-Cal system is important to determine the extent of cross-subsidization occurring in the commercial market, as well as whether the elimination of that cross-subsidization will result in provider instability and potential collapse. Lastly, an entire article of the proposed bill is devoted to the transition from fee-for-service (FFS) provider payment to population-based payment models. The Office would have the ability to monitor payers annually for transition to value-based payment models and would include public reporting on status. APG has urged policymakers to go further, to analyze regions where employers are not offering open

enrollment options that include coverage plans that incorporate capitated payment mechanisms for providers. The bill will also require total cost of care measurement and reporting. This would likely lead, based on our experience with the California Regional Cost & Quality Atlas, to HMO plans that use capitated provider networks scoring higher on both quality and cost metrics than high-deductible PPO plans. The bill has not yet addressed the employer shared responsibility issue. APG continues to argue strongly for including employers in the oversight structure. If employers only offer high-deductible, FFS-based plans to their employees, there is little likelihood for improvement in the system. In our view, this change is critical to the eventual success of the Office.

WHAT’S NEXT? AB 1130 was heard in its first policy committee on April 6. It is now progressing through fiscal review and to the Assembly floor. If it proceeds to the state Senate, the process will be repeated, and the bill must be voted out by the Legislature no later than Sept. 10. The governor would then have 30 days to sign or veto the bill. Chairman Wood has been working closely with Newsom administration officials to craft a bill that is acceptable to the governor for signature. AB 1130 faces stiff opposition and could likely be turned into a “two-year” bill at some point to allow further research and deliberation. It represents a sea change in the approach to strategic oversight of the healthcare market in California. Meanwhile, another bill, AB 1400, looms close by. AB 1400 proposes to scrap the existing system in favor of a single-payer model. That bill would create an even greater regulatory oversight approach to the healthcare market—tightly regulating provider payment rates, excluding certain players, and removing health plans from the ecosystem. It is important to remember that AB 1130 does not exist in a vacuum. Other options are available to policymakers that would be even more intrusive to our membership in California. o

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Removing the Barriers...continued from page 19

technology can create and nurture a patientdoctor relationship— allowing patients to partner more closely with their providers, improving access and patient satisfaction, and ultimately driving down medical costs. One exciting trend in patient care—and potentially the most disruptive—is the Internet of Medical Things (IoMT). Wearable, connected medical monitoring devices play a new role in tracking patient health and helping physicians prevent or better manage chronic disease. Connected medical devices collect health-related data, then transmit the data and any associated images to a patient’s healthcare provider or a secure, cloud-based repository for review and analysis. From real-time blood glucose monitoring to medical-grade ECG monitors and much more, IoMT helps patients better manage their health while providing more information to help their physicians deliver a higher level of results-driven care. With the impact IoMT will have on healthcare, providers need to engage in developing and implementing these new technologies. We must lead instead of waiting to be the customer. We can’t sit back and let companies solve problems they think exist or identify a problem and create a solution for us without our guidance and input.

REGULATORY RELIEF For most of my career, regulatory change has lagged clinical need, but this has drastically changed in the past year. CMS continues to lead the way in removing regulatory barriers from the delivery of population-based care. Payment for telehealth, remote patient monitoring, and the simplification of evaluation and management (E&M) coding are only some of the changes we saw in 2020. Showing regulatory agencies and payers that these changes accelerate the movement to advanced primary care 38 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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will only increase the speed of future change. This regulatory relief is essential. Without it, the movement to a prospective, value-based care model and the use of advanced technologies will slow down. It took a global pandemic for doctors to change compensation for telehealth sessions. Let’s not wait for another pandemic for more relief.

THE FUTURE OF PRIMARY CARE Our healthcare system is broken for patients, providers, and payers. Government agencies and employers across the country have paid too much and received too little. An advanced primary care model—data-driven, team-based, and focused on outcomes, not volume—can change this trend. Putting the patient at the center of the system, using technology to extend care outside the exam room, and delivering care in the home for our most vulnerable patients should be critical competencies of medical groups in the future. The pandemic brought great change, and in its aftermath, many opportunities. We owe it to those who have suffered to not let this opportunity pass. o Clive Fields, MD, is the Co-Founder and Chief Medical Officer of VillageMD, a national leader in value-based primary care through its practices, Village Medical. He is a member of America’s Physician Groups.

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The InnovaCare Partners network, part of InnovaCare Health, is proud to be a partner and sponsor of America’s Physician Groups.

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The Journal of America's Physician Groups Spring 2021 Edition

Articles inside

Health Is Wealth: The Latest on Alternative Payment Models

Connecting Key Strategies to Promote Talent Management

New APG Collaborative Addresses Health Equity and Social Justice

Improving Medication Adherence During a Pandemic

Member Spotlight

Policy Briefing: California Bill Targets Healthcare Affordability

Federal Policy Update: As COVID-19 Continues, Physicians Still Need Relief

New APG Manual Offers an Essential Guide to Risk Contracting

Lessons Learned From the Pandemic