Journal of America's Physician Groups Conference Issue 2018 by America's Physician Groups

The Journal of

Volume 12 • No. 1 • Spring 2018

ANNUAL CONFERENCE ISSUE

COVER STORY: John Kitzhaber, MD on Oregon’s Healthcare Reform, p.10 In the Eye of a Hurricane, p.20 Regional Focus: Texas, p.27

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TABLE OF CONTENTS

ON THE COVER

John Kitzhaber, MD

Lessons for Today From the Oregon Healthcare Reform Effort The Journal of

DEPARTMENTS Publisher

Valerie Okunami

Home Visit Program: Evolving and Improving Care Delivery

From the President

Editor-in-Chief

Don Crane

Editorial Advisory Board

Lura Hawkins, MBA Amy Nguyen Howell, MD, MBA Mary Kay Payne, Arch Health Partners Managing Editor

Mara McDermott Editorial Assistant

David L. Allen

Contributing Writers

Bill Barcellona Paul Bernstein, MD, FACS Chan Chuang, MD Ryan Clay Don Crane Anas Daghestani, MD Rushika Fernandopulle, MD, MPP John Kim, MD John Kitzhaber, MD Stuart Levine, MD, MHA Glenn Melnick, PhD Raúl Montalvo, MD Griffin Myers, MD Margaret Peterson Faith Saporsantos Richard Shinto, MD Richard Whittaker, MD Journal of America’s Physician Groups is published by

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

Journalofapg.com 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 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. © 2018, Journal of America’s Physician Groups. All rights reserved. Reproduction in whole or in part without written permission is strictly prohibited.

News and Events

Social Determinants of Health: Think Outside the Exam Room

12 Policy Briefing A Bipartisan Health Reform Blueprint Indicates Progress

A New Model of High-Impact Relationship-Based Primary Care for Seniors

Federal Policy Update APG Advocates: Now is the Time for Action

Expanding A1c Testing to Help Control Diabetes and Prediabetes

Telehealth: It’s About Time

APG Member Spotlight Taking Responsibility for Recovery Efforts in Puerto Rico

REGIONAL FOCUS: TEXAS

FEATURES

APG Member List

Breaking Down Silos: Working Toward a Healthier Nation

Quality in Managed Care: The Challenge of Chasing Quality

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Texas Medicaid Program Charts a Course for Value-Based Care

For Medical Home Success, Continue Moving the Bar

Using Evidence-Based Management Techniques to Improve Care

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From the President A M ES S AG E F R O M D O N A L D C R A N E , P R ES I D E N T A N D C EO 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, I am pleased to write my first column for our newly rebranded magazine, Journal of America’s Physician Groups. The magazine’s new name mirrors the rebrand that you heard about earlier this year, and that is also reflected throughout our Annual Conference 2018.

Donald Crane, America’s Physician Groups President and CEO

So why did we rebrand? As most of our members know, our roots are in California. In 2000, we were known as the California Association of Physician Organizations. The following year, the organization name was changed to the California Association of Physician Groups. And in 2013, we became CAPG, the Voice of Accountable Physician Groups. What you see today is a product of our natural evolution—from a group based primarily in California to one with a membership that stretches across the nation and represents the national interests of America’s physician groups. By rebranding to America’s Physician Groups, there’s no question as to who we are and who we represent. Along with our new brand is our tagline: Taking Responsibility for America’s Health. This bold message conveys the essence of our care and business model and recognizes our members— you—as leaders in the movement toward the future of healthcare. You have been committed for decades to finding innovative ways to keep people and communities healthy while embracing payment models that help contain costs. When it comes to change, they say the proof is in the pudding. And since our January rebrand, I have been interviewed by one of the leading health trade outlets. I sat down for one-on-one meetings with the two leading political media outlets in Washington, DC. And I had an exciting meeting with the White House Office of American Innovation, where I met with its head, Jared Kushner, along with the current Administrator of the Centers for Medicare & Medicaid Services, Seema Verma. And what do these results point to? We are making the positive impact we envisioned when we decided to rebrand. So if you’re here in San Diego, I hope you’ll take a minute to stop by our booth and pick up some of our newly branded materials. And if you’re not in San Diego, you can learn more about our rebrand by visiting our website. We’re excited about 2018 and beyond as America’s Physician Groups. And while our name has changed, our commitment to America’s health remains as strong as ever! o

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News and Events PHARMACEUTICAL CARE COMMITTEE

APG COLLOQUIUM

May 16 Location TBD

October 10-12, 2018 Hyatt Regency on Capitol Hill Washington, DC

MIDWEST REGIONAL MEETING

CLINICAL QUALITY LEADERSHIP COMMITTEE

May 17 Columbia, OH

FEDERAL POLICY COMMITTEE

April 19 APG Annual Conference 2018

May 17 WebEx

I AM APG ADVOCACY COMMITTEE

CALIFORNIA POLICY COMMITTEE

April 21 APG Annual Conference 2018

May 24 Sacramento, CA

ACADEMY HEALTH 2018 HEALTH DATAPALOOZA

I AM APG ADVOCACY COMMITTEE June 12 WebEx

April 26-28 Washington Hilton, Washington, DC

APM COMMITTEE

NORTHEAST REGIONAL MEETING May 3 Washington, DC

2017 AMERICA’S PHYSICIAN GROUPS NEW MEMBERS

CONTRACTS COMMITTEE May 8 Los Angeles

SOUTHWEST REGIONAL MEETING May 15 Phoenix, AZ

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June 19 WebEx

2017 was an exceptional year: 33 new physician organizations joined America’s Physician Groups. We added about 41,000 physicians to our family. Groups continued on page 56

Spring 2018

ON THE COVER

Lessons for Today From the Oregon Healthcare Reform Effort BY JOHN KITZHABER, MD

Much of the frustration around last year’s deeply partisan national debate over the Affordable Care Act (ACA) flowed from the false choice between continuing to prop up a financially unsustainable system, and depriving millions of Americans access to healthcare. Fortunately, there is a sustainable solution to this divisive public policy challenge— one embedded in the pioneering work many America’s Physician Groups members have done around organizing and practicing capitated, accountable, coordinated care. The story of Oregon’s Coordinated Care Organizations offers additional insight into the power of this approach and the growing importance of APG’s continuing leadership over the months ahead.

is a huge “There opportunity here to change the fundamental dynamics of the national political debate.”

It is a good story, and one that will be the focus of my presentation at the America’s Physician Groups Annual Conference in April. And while it is a story written by many authors, it was ultimately made possible by the leadership of Oregon’s physicians and physician groups—who were willing to assume risk and accountability in a new, coordinated, patient-centered delivery model operating on a global budget that grew at a fixed rate. Here is how it came about.

THE STORY OF OREGON’S CCOS In 2011, the Great Recession had left Oregon facing one of the largest per capita budget deficits in the nation, including a $1.2 billion revenue shortfall in the Medicaid program. It became readily apparent that continuing to cover all those eligible for Medicaid, in the absence of any replacement revenue, would lead to a nearly 40 percent cut in provider reimbursement. This was the formula for political disaster in anyone’s book, and yet, something surprising and unexpected happened. With broad bipartisan support, the state transformed its Medicaid care model, demonstrating that growth per enrollee could be slowed without reducing enrollment or benefits—and while also improving outcomes and quality. Through a combination of administrative efficiencies and front-loading of the resources we did have into the first year of Oregon’s two-year biennial budget, we reduced the size of the reimbursement cut to 11 percent, which seemed manageable. But this still left a $240 million Medicaid budget shortfall in the second year of the biennium (with the federal match, it was a $600 million shortfall). We proposed to fill this budget hole with savings realized from transforming the Medicaid care model to get more value for each dollar spent. This transformation would be brought about through new Coordinated Care Organizations (CCOs). First established in 2012, CCOs are local networks of providers who are accountable for managing the cost, quality, and health outcomes of a defined population. It is important to note that Oregon’s 15 CCOs are all different—evolving organically from the communities where they operate. Their

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unique characters did not result from change directed from the top, but rather from a sense of ownership, buy-in, and partnership between local providers and the community. At the same time, Oregon’s CCOs all share a number of key features: • A local governance structure with representation from healthcare providers, Medicaid recipients, and community members. • A global budget indexed to a sustainable rate of growth. • A requirement to improve both quality and health outcomes across the entire population served. • Assumption of financial risk and accountability for managing all services covered by the global budget. • Integration of behavioral and oral health. • Improved care coordination. • Implementation of alternative payment models. Oregon’s Coordinated Care Organizations operate under a Section 1115 Medicaid waiver, first granted in 2012. Under the terms of the original waiver, Oregon received an initial $1.9 billion five-year investment in the CCO model. In exchange, Oregon made a commitment to reduce the Medicaid cost trend from 5.4 percent to 3.4 percent, per member per month, by the end of the second year of the waiver. This was with no reduction in benefits or eligibility, and while meeting rigorous metrics around quality, health outcomes, and patient satisfaction. This was, in effect, a per capita growth cap—one of the main points of contention in last year’s debate over the ACA. The difference, however, was that the Oregon growth cap required a fundamental change in the care model in order to maintain enrollment, benefits, quality, and outcomes. In other words, the $1.9 billion federal investment was not granted to simply prop up the current delivery model during the revenue shortfall of the Great Recession. Instead, it was made to create a glide path for making the transition from the current system to our new care model—with the federal investment gradually declining as the cost savings from the new care model began to accrue. And that’s exactly what happened. Oregon’s first five-year CCO waiver ended in July of last year. During that time, the state successfully operated within the constraints of the per capita growth cap, enrolled over 385,000 more people under the ACA

Medicaid expansion, and all the CCOs met the outcome and quality metrics stipulated under the waiver. We have paid back the initial federal investment and realized a cumulative total fund savings of over $1 billion. This delta of savings is projected to reach $8.6 billion over a decade. As I said, it’s a good story, but there is another good story yet to be written, and APG can be one of its authors.

AN ALTERNATIVE TO THE PARTISAN DIVIDE There is a huge opportunity here to change the fundamental dynamics of the national political debate. With bold leadership from America’s Physician Groups, the Oregon experience could form the basis for an alternative to the partisan and divisive Medicaid reform options proposed last year by Congress and serve as the foundation for a new dialogue that could meet bipartisan goals. Specifically, this model—built around risk-based contracts in an accountable, coordinated, patientcentered delivery system—could provide states the levers necessary to ensure expanded coverage for lowincome Americans, support state-level health system transformation to improve quality and health outcomes, and reduce program costs for both the federal and state governments in the years ahead. If we committed ourselves to using some version of this care model to constrain the average annual per capita Medicaid trend rate by 2 percent, within the context of rigorous metrics around access, quality, and outcomes— and even if we provided an initial $25 billion three-year investment to help states make the transition to an accountable, coordinated, patient-centered system—the net total fund savings over 10 years would be $740 billion. This meets Republican objectives to reduce the cost of Medicaid to the federal government, as well as Democratic objectives to expand access to quality, affordable care. For more on the story of Oregon’s healthcare reform— and how it can show the way for the future—tune into my presentation at the America’s Physician Groups Annual Conference in April. I look forward to seeing you there! o John Kitzhaber, MD, was governor of Oregon from 1995 to 2003 and from 2011 to 2015, and was the chief architect of Oregon’s Coordinated Care Organizations (CCOs). He will be speaking at the General Session at the America’s Physician Groups 2018 Annual Conference, April 19-21 in San Diego. Spring 2018

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Policy Briefing A Bipartisan Health Reform Blueprint Indicates Progress BY BILL BARCELLONA, SENIOR VP FOR GOVERNMENT AFFAIRS, AMERICA’S PHYSICIAN GROUPS

On February 23, 2018, a bipartisan group of five governors—two Republicans, two Democrats, and one independent—released a new healthcare blueprint to improve the nation’s health system performance. The plan, “A Bipartisan Blueprint for Improving Our Nation’s Health System Performance,” was authored by Governors John Hickenlooper of Colorado (D), John Kasich of Ohio (R), Brian Sandoval of Nevada (R), Bill Walker of Alaska (I), and Tom Wolf of Pennsylvania (D). The blueprint lays out guiding principles, core beliefs, and strategies that the governors believe will guide reform, address our most urgent healthcare problems, and sustain broad support. This iteration follows an earlier submission by a larger group of governors prior to Congress considering ACA repeal and replacement.

in this “Much consensusdriven proposal reiterates policies that have been advocated by America’s Physician Groups.”

Here’s a look at the governors’ recommendations:

THE NEED FOR STABILITY Among their health insurance-related recommendations, the governors urge immediate action to stabilize the individual market and note the need to “ensure that all Americans have access to appropriate, affordable, high-quality coverage independent of their health, age, gender, employment status, or financial situation.” They also agree that changes to the healthcare system should build upon existing financial incentives that encourage individuals to enroll in health insurance while also ensuring that each person contributes to his or her healthcare based on financial capacity.

MEDICAID REFORM Although the blueprint does not mention Medicaid work requirements, it devotes a section to expanding state Medicaid innovations. The governors underscore the need to promote value and incorporate social determinants of health in state Medicaid programs. This includes measuring and incenting social outcomes, such as poverty reduction, employment, and reducing criminal recidivism. They also urge the adoption of value-based care and payment models, a reduction in “churn” between Medicaid and the individual market, strong vendor management, and ensuring that risk-adjusted Medicaid costs stay below the national rate of medical inflation.

AFFORDABILITY AND COST CONTROL The governors emphasize the importance of addressing unsustainable increases in the cost of healthcare. Reorienting the healthcare system to focus on value (rather than volume) is described as “our greatest priority,” and the governors urge Congress and the Trump administration to “work with states and make a clear commitment to value-based healthcare purchasing.” continued on page 52 12 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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Federal Policy Update APG Advocates: Now is the Time for Action BY M A R G A R E T P E T E R S O N , D I R ECTO R , 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

With a Congress that is paralyzed by increasing partisanship and infighting, and an Administration that is rocked by scandal after scandal, it’s easy to see why many people are fed up with Washington. Simultaneously, healthcare premiums continue to rise, drug costs are skyrocketing, and many Americans still can’t get the healthcare services they need. With frustrations at their height, it is more important than ever to resist the urge to simply throw up our hands and walk away. We are at a tipping point in the evolution of our healthcare system. An aging and increasingly chronically ill population continues to stretch dwindling healthcare resources, and our current fee-for-service reimbursement system—where physicians are paid “per click” without an eye toward quality, cost, or elimination of waste—is inadequate to meet these needs or to manage resources efficiently. We can and must do better. Rather than shrugging off these challenges as simply “the way things are,” our community must come together to Take Responsibility for America’s Health. By doing so, we aim to ensure that all Americans, particularly the most vulnerable, are able to have their voices heard and have access to the high-quality healthcare services they deserve.

EDUCATION, ADVOCACY, AND COALITION-BUILDING Now is the time for action. Now is the time for education, advocacy, and coalitionbuilding. Advocacy is important! In order for the physician community’s expertise and insight to be genuinely considered in the federal policymaking process, someone must stand up and deliver our message. Our elected officials sincerely want to make smart decisions and support legislation that helps their constituency and our nation overall. However, rarely do these same representatives have the wisdom, experience, and knowledge that the physician community has on issues like payment and delivery reform. That’s what the APG Advocates program is all about. Individual advocacy members at America’s Physician Groups, through the APG Advocates program, have taken responsibility for being part of the solution. The first step to becoming an effective advocate is education. The APG Advocates program ensures that members stay informed and engaged by providing easily digestible updates on changes in federal health policy and events in our nation’s capital that impact physicians and the care they provide. By committing to keep up with current events in an ever-shifting political landscape, members have the opportunity to be influencers. Armed with information, advocates can protect important programs and tools while simultaneously calling for improvements and innovations in the healthcare delivery continued on page 54 14 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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committing “Byto keep up with current events in an evershifting political landscape, members have the opportunity to be influencers.”

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Breaking Down Silos: Working Toward a Healthier Nation BY JOHN KIM, MD

Coordinating effective care is a challenge in today’s healthcare climate. Unexpected medical events, such as hospitalization and terminal diagnosis, can often shift a patient’s medical needs substantially, as well as increase the number of providers caring for that patient. With more parties involved in an individual’s care, it becomes even more critical for these groups to work together to adapt to the patient’s needs. Keeping our communities healthy is why many of us entered the medical field. Creating a healthier nation is a lofty goal, but one we can tackle together. Alignment Healthcare’s Medicare Advantage plan, Alignment Health Plan, structures its partnerships with physician groups to help us both take better care of our patients— aiming to close these potential gaps in care. This is especially critical for the senior population, the nation’s sickest and costliest to treat. According to national health expenditure data released by the Centers for Medicare & Medicaid Services (CMS), per person healthcare spending in 2012 was five times higher on patients over 65 than on children, and three times higher than on working adults.1 Frail and elderly patients, according to a recent report by The Commonwealth Fund, accounted for 43.9 percent of preventable Medicare spending in 2012.2 Alignment invests in its members’ clinical care without replacing the care they receive from their physician groups. This way, both the health plan and provider can focus on doing what’s best for the patient’s health more efficiently, while mutually reducing cost. We become much more cohesive partners in our patients’ care, aligned with their best interests in mind. Below, I share real-life examples of how Alignment has improved patient outcomes in collaboration with our physician partners.

REDUCING HOSPITAL READMISSIONS Dallas, 83, is an Alignment Health Plan member with diabetes who was admitted to the hospital multiple times last year. We enrolled him in our remote monitoring program—which provides patients with a tablet enabled for real-time video consults, a blood pressure cuff, a pulse oximeter, and a scale—to monitor his blood sugar and assist in the management of his diabetes. In addition to the individual member’s electronic medical record, pharmacy and lab data, and claims authorizations, the biometric information from the remote monitoring program is stored in our command center, which uses proprietary algorithms to track and flag any changes in the patient’s health or well-being. All of that information is converted to a user-friendly, 360-degree view of the patient and shared with Dallas’s physicians at AllCare, one of California’s largest independent practice associations (IPAs). Since he began using the remote monitoring kit, Dallas has not visited the emergency room or been admitted to the hospital. We have been able to coordinate 16 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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“Alignment invests in its members’ clinical care without replacing the care they receive from their physician groups.”

visits with his AllCare primary care physician (PCP), as well as schedule follow-ups with an Alignment clinician in Dallas’s own home. He has also grown close to his Alignment case manager, who has helped him navigate the complicated system and alleviate his health concerns. Our partnership with AllCare, represented by physicians in three California counties—Merced, San Joaquin, and Stanislaus—is robust. Alignment’s own clinical team, led by physicians, nurse practitioners, and physician assistants, works in conjunction with AllCare’s team to provide our shared patients with a value-based care model. We co-operate three clinics, and the Alignment team helped AllCare establish its own remote monitoring and hospitalist programs, based on our clinical model. AllCare is our exclusive provider for Alignment Health Plan members in Stanislaus and San Joaquin counties. And we recently launched a home visit program with this group to better serve patients who need more care. Through our partnership, we can all focus on keeping patients like Dallas healthy and out of the hospital, while reducing inefficiency and maximizing revenue for both groups.

The results of the assessment are tracked in our command center and shared with the member’s PCP. Our physician partners have access to more comprehensive and up-to-date patient data to keep them abreast of any changes in their patients’ health, as well as real-time clinical alerts that allow them to proactively manage the patients. Dolores’s medical group, AppleCare Medical Group, part of OptumCare, is an IPA with more than 900 physicians serving southeast Los Angeles and north Orange counties. At the time of her assessment with Alignment, Dolores was having trouble managing her diabetes and adhering to her medication regimen. Following her assessment, she was assigned an Alignment case manager and placed on remote monitoring to help her manage her diabetes. An Alignment social worker also assisted her in securing more caregiver hours. Dolores visits the Alignment care center every few months and continues to see her AppleCare PCP. Via data sharing and the remote monitoring, both Alignment and AppleCare can monitor her diabetes in between her in-person visits. Alignment and AppleCare case managers may also work together when patients need additional support. continued on next page

MANAGING A CHRONIC DISEASE Dolores, an 83-yearold Alignment member living with diabetes, visited an Alignment Healthcare Center for a 60-minute head-to-toe health assessment. When a member enrolls in our health plan, we complete a full medical evaluation—including basic lab workups and screenings for depression, dementia, and social determinants of health—to help us better identify the member’s health needs.

Alignment members’ health information and data are tracked in a central command center and shared with our patients’ physicians to enhance continuity of care.

Spring 2018

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ENHANCING POST-DISCHARGE CARE

TAKING RESPONSIBILITY

When Bessie, a 77-year-old Alignment member, was hospitalized in 2016, she was diagnosed with pancreatic cancer. Bessie is a patient of South Atlantic Medical Group IPA, an independent medical group serving Southern California.

Patients, providers, and payers all benefit when we work together. At Alignment, we believe in value-based care and its ability to reduce costs and keep people healthy. As an insurance plan in California, we believe in taking responsibility for our members’ health by becoming an active part of their care team, offering supplemental care to our patients and providing real-time clinical data and clinical and customer service resources to our physician group partners.

As part of our partnership, Alignment offered South Atlantic the use of its case management program and hospitalists to help improve outcomes amongst our shared patients. Following her hospitalization, Bessie was assigned an Alignment case manager and followed by an Alignment hospitalist, first at a skilled nursing facility and then at an Alignment Healthcare Center. Because our partnership with South Atlantic is sharedrisk, we co-manage her care together. Following her new diagnosis, Alignment physicians coordinated a treatment plan for Bessie alongside her PCP. Bessie’s case manager coordinated with South Atlantic to receive authorization for her cancer surgery, which she had later that same year. Bessie is now cancer-free. She has diabetes and continues to follow up with her care team—which includes her Alignment hospitalist and case manager, as well as her PCP and oncologist—to monitor her overall health.

In 2018, we deployed a 24/7 member services and physician on-call program for our highest-risk members across the state; this will be rolled out to a broader population in 2019. By focusing our combined resources on those who need it most, we can free up the load on the healthcare system and improve clinical outcomes while reducing cost. o John Kim, MD, is Chief Medical Officer at Alignment Health Plan. References https://www.cms.gov/research-statistics-data-and-systems/statistics-trendsand-reports/nationalhealthexpenddata/nhe-fact-sheet.html 1

http://www.commonwealthfund.org/publications/in-the-literature/2017/oct/ preventable-spending-high-cost-medicare 2

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3/9/18 11:11 AM

AMERICA’S PHYSICIAN GROUPS

Colloquium 2018

The Essentials of Value-Based Care October 10-12, 2018 l Washington, DC

What you will take away: • Proven strategies for implementing and improving coordinated care: population health management, risk contracting, physician and patient engagement, and more • Insights from executives at leading risk-bearing physician organizations who are deciding how to implement MACRA provisions. Are they choosing MIPS or APMs? • The latest information on MACRA regulations and policy, directly from policymakers themselves • Forecasts from political experts on the current Administration’s potential impact on the future of healthcare policy • Firsthand accounts and lessons learned from organizations who’ve been in risk contracts for 30 years. Hear from them how APMs can succeed and what still needs work • Understanding of how Medicare Shared Savings Program and Next Generation Accountable Care Organizations (ACOs) are positioning themselves for success • Innovative strategies for providing post-acute care in risk-based arrangements • Tactics for improving care management and becoming better prepared to take risk

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APG Member Spotlight Taking Responsibility for Recovery Efforts in Puerto Rico BY RICHARD SHINTO, MD, AND RAÚL F. MONTALVO, MD

As the eye of Hurricane Maria passed over San Juan on September 20, 2017, our team mobilized. MSO of Puerto Rico team members stuck to our organization’s plan and stayed in touch until their cell phones went out. Then they picked up the conversation on satellite phones. Hours after the storm, leaders met to assess the damage and then dispersed to roll out our emergency response. Within one week, our offices and clinics were operational. Our systems never went down.

Richard Shinto, MD

Part of the reason we responded so quickly is because we had a fire-tested crisis plan. Any healthcare organization should have that—at this point, disaster preparedness is table stakes. But we were able to effectively implement our plan because we have more than a decade of experience problem-solving on the ground in Puerto Rico, ensuring patients have access to high-quality, coordinated care. That’s our mission, and our mission doesn’t change during a disaster.

TAKING OWNERSHIP When the storm hit, we knew we would be responsible for leading relief work, not just for our employees and members, but also for their communities. Our disaster response was a heightened example of what we do every day: identify the numerous factors that jeopardize the health of the populations we serve, and mitigate those factors as quickly as possible. Raúl F. Montalvo, MD

“Our responsibility

in a crisis extends beyond our beneficiaries to their families, friends, and neighbors.”

For context, the parent company of MSO of Puerto Rico is New Jerseybased InnovaCare Health, which manages care for 450,000 Puerto Ricans. InnovaCare does this through two main subsidiaries on the island: MMM Healthcare, which operates one of the largest health plans in Puerto Rico, and MSO of Puerto Rico, which represents the provider services arm of InnovaCare’s integrated model. We took ownership of the relief and recovery work in Puerto Rico in several ways. First, we supported our doctors and employees as crucial participants in the response. This is key to disaster preparedness. Second, we leveraged the resources of our parent company. Finally, we reaped the benefits from our commitment to technology, which we’ve seen pay off in our everyday clinical work. It also differentiated us in a crisis.

NO GAS, NO POWER Immediately following the hurricane, we knew we had to begin by accounting for and activating our physicians and employees. Doing so took some innovation. Since there was no gasoline on the island, we rented cars from the airport— because they came with full tanks—and drove through the damage to touch base with our providers. We took inventory and quickly got supplies to clinics that weren’t fully operational.

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Hundreds of our providers needed generators—and we delivered them. We also supplied generators to our employees and their families, some of whom lived without power from the grid for 150 days. In San Juan, we built a pop-up grocery store and laundromat to help our 2,000 InnovaCare employees with their most basic needs. We then deployed mobile clinics to treat people in harder-to-reach areas. Within a couple of months, caregivers at these clinics helped more than 25,000 Puerto Ricans. Most patients were not members of our health plans. As a healthcare leader in the community, our responsibility in a crisis extends beyond our beneficiaries to their families, friends, and neighbors. Our knowledge of the culture deeply influenced our hurricane relief plan. Most of the physicians on the island are independent and practice without nurse practitioners or physician assistants; we contract directly with doctors and independent practice associations (IPAs). Similarly, our beneficiaries are used to working directly with their doctors. We knew doctors needed to be on the front lines of our emergency plan to reach patients.

“WALKING TOGETHER” We had laid the groundwork to mobilize our physicians before the hurricane ever hit. Before Maria, we had launched a theme for open enrollment called Caminamos Juntos, which means “Walking Together.” It was created with our beneficiaries in mind, but we quickly understood how it applies to everyone within the company. The message speaks to our responsibility to the community. It’s meant to convey that whatever we accomplish, we accomplish with the best interests of our beneficiaries, our employees, and our physicians aligned. With this core culture, our employees showed up to help with our relief work—most of them staffing clinics on a voluntary basis. Some didn’t even have electricity or water in their homes, but they still arrived, ready to help. Everybody felt committed to our members and to the people in these communities. Our physicians on the ground were invaluable, as was the infrastructure we had already developed on the island. We were fortunate that our corporate structure was an asset as well; we could leverage our parent company’s resources across the country. continued on page 56

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Quality in Managed Care: The Challenge of Chasing Quality BY FAITH SAPORSANTOS

The old adage, “If it ain’t broke, don’t fix it,” popularized by T.B. Lance, Director of the Office of Management and Budget during Jimmy Carter’s 1977 administration, seems like good advice, but don’t be fooled. The path of least resistance typically leads to unfavorable outcomes. Although it’s been a common theme in today’s healthcare industry, following this motto will not only put a healthcare organization at risk, but also create a culture that is reactive, rather than proactive. Implementation of a comprehensive Quality Improvement Program woven into key functional areas is the better path. The challenge is to establish the structures and processes that support quality improvement efforts in every aspect of the administration and delivery of healthcare, and to ensure that this improvement is ongoing. As more and more people receive healthcare services through managed care, and the healthcare industry increasingly recognizes that quality is cost-effective, the central goal has become ensuring the delivery of high-quality care. And maintaining quality leaves no room for complacency.

QUALITY IN MANAGED CARE Managed care was originally intended to reduce costs in healthcare delivery services, incentives for waste, and inappropriate care. Similarly, ongoing quality management and continuous improvement aligns with the Institute for Healthcare Improvement’s (IHIs) Triple Aim: 1. Improvement in the health of populations. 2. Improvement in the individual experience of care. 3. Reduction of the per capita costs of care. While these points are focused on what and how care is delivered and the related outcomes, chasing quality can also be enhanced through collaboration and oversight of other business areas, including utilization management, grievances and appeals, provider services and contracting, information systems, member services, claims, and finance and accounting. Early detection of quality issues and trends can improve the organization’s ability to accomplish its goal of delivering more efficient, cost-effective quality care and services. Managed care continues to expand and evolve, with payment methodologies increasingly focused on quality. This is evidenced in the various value-based payment methods currently in place across the country. Many managed care organizations understand the role their own organization plays in the overall delivery of care and services and the importance of establishing a quality focus throughout the organization. These organizations will continue to set the industry standard and, through their continuous focus on quality structures and processes, will contribute significantly to value-based care delivery.

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“The present

challenge is to weave quality into every aspect of the administration and delivery of healthcare and to ensure the quest for quality improvement is ongoing.”

QUALITY: STRUCTURE, PROCESS, AND OUTCOME

• Processes to assess and evaluate compliance with utilization management requirements.

There are two key aspects to quality management: quality measurement and quality improvement. Quality measurement identifies healthcare quality indicators and collects, analyzes, and reports the data. Consumer Assessment of Healthcare Providers and Systems (CAHPS), used by the Centers for Medicare & Medicaid Services (CMS), and Healthcare Effectiveness Data and Information Set (HEDIS), developed by the National Committee for Quality Assurance (NCQA), are examples of quality measurement tools that compare experience and performance to national or regional benchmarks.

• Processes related to grievances and appeals.

Quality improvement involves increasing quality of care and quality of service through education, policy and procedure overhauls, and the like. It has been said that quality is characterized by three perspectives: structure, process, and outcome. Structural quality encompasses the notion that the physical circumstances of care could be controlled by optimizing healthcare services. This is reflected in the licensure and accreditation of healthcare professionals and organizations. It provides regulators subject matter that is recognizable and measurable. Structure also includes the written description of the quality management program, accountability at the highest level, oversight, and clearly defined roles and work plans. The quality structure considers utilization management to be an integral part of the overall quality management program, as well as policies and procedures related to timeliness of decision making. Process as an element of quality is characterized by the collaboration and oversight of its functional areas. Quality management processes include: • Service elements such as accessibility, availability, and continuity of care.

• Processes related to provider services and contracting, including those that may impact timely access and availability of services. • Processes in place to ensure information systems, member services, claims, finance, and accounting are operating appropriately and are consistent with regulatory and/or statutory requirements. Outcome as an element of quality refers to the development of clinical practice guidelines accompanied by outcome measures. Although process elements are inherent to clinical practice guidelines, the different approaches to care affecting patient treatment outcomes cannot be ignored. Outcome measures are becoming increasingly important with the growth of value-based payment methods. The patient standpoint as it relates to quality is reflected in consumer protection law, with an emphasis on information access and the development of consumer rights. Quality defined by structure, process, outcome, or patient perspective all intertwine, and as a result, have a collective impact on the delivery and evaluation of healthcare services. Quality management in a complex healthcare delivery system is multifaceted and demands a multidisciplinary approach. It also requires an organizational culture that is committed to continuous improvement. Many of the issues we are currently experiencing in the healthcare industry do not stem from a lack of awareness of the importance of quality management. Rather, they are caused by willingness to accept the status quo, even when we know current practices are less than optimal. The present challenge is to weave quality into every aspect of the administration and delivery of healthcare, and to ensure the quest for quality improvement is ongoing. o

• Processes in place to evaluate the effectiveness in identifying and correcting deficiencies in care or service delivery. • Processes in place to document that quality of care problems are being identified, effective action is taken to improve care, and follow-up is planned, where indicated.

Faith Saporsantos is Senior Manager, Healthcare Division— Sacramento Office, for Mazars USA LLP.

• Processes related to credentialing providers and practitioners. • Processes by which care and services are approved, modified, delayed or denied, based on medical necessity. Spring 2018

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Home Visit Program: Evolving and Improving Care Delivery BY STUART LEVINE, MD, MHA

In the past few decades, advances in medicine have been swift and staggering in depth and breadth. Healthcare providers have more tools than ever to diagnose and treat disease. With so many choices available, more focus is needed to ensure that we achieve the highest quality of medical care. The 2010 Patient Protection and Affordable Care Act has significant implications for healthcare providers regarding improving quality of care. Through a series of incentives and mandated reporting on quality indicators, providers now have greater accountability for the quality and costs of care provided. This process has shined a light on the need for more effective methods to manage the care of patients who shoulder the greatest burden of chronic illness. These patients are at the highest risk of needing the most care in the years to come.

Home Visit “The Program builds true advocacy and real partnership— trust—between patients, families, and their doctors.”

THE NEED FOR HOME-BASED CARE To improve both the quality and continuity of care for these high-risk patients, new care delivery models have been envisioned and implemented through coordinated care activities. In fact, there is a growing body of literature attesting to the need for home-based healthcare delivery systems to better respond to individuals with extremely complex healthcare issues. Providing in-home primary and coordinated care to high-risk, chronically ill patients has been found to improve quality of care and patient satisfaction, with significant impact on lowering total healthcare costs. Advanced age is often associated with greater likelihood of chronic disease. Behavioral health disorders and social determinants also greatly impact a patient’s health status. Previous studies have reported that by age 65, most individuals have multiple chronic conditions that require services from a team of medical providers—often leading to significantly higher healthcare expenditures. In addition, many chronically ill older people perceive managing their illness as beyond their ability. Several aspects of the current healthcare system are ineffectively designed to monitor and treat chronic conditions that often involve (generally, unnecessarily) multiple medical specialists—instead of a holistically oriented team of physicians, nurse practitioners, pharmacists, social workers, nurse care managers, medical assistants, health coaches, and patient advocates. The relative lack of attention to care coordination has led to poorer health outcomes in the United States and escalated the cost of care. In keeping with our “Big Idea of Evolved, Improved Care Delivery,” agilon health has developed the Home Visit Program as part of our care model, which encompasses the Six Pillars of Care: reinvented primary care, collaborative specialty care, and the “Core Four” of high-risk patient management—advanced facility care (hospitalists, SNFists, care transitions), high-risk Comprehensive Care Centers, home visits, and care management.

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PROGRAM OBJECTIVES

• Integrate behavioral health.

The Home Visit Program builds true advocacy and real partnership—trust—between patients, families, and their doctors. The program’s strategy is about restoring dignity for both patients and doctors. It is about shifting the model so patients engage and focus on the personal interaction with their providers, not just tests. Happy doctors make happy patients.

• Reduce the use of home health agency services provided by contracted providers in the community.

The Home Visit Program delivers high-quality healthcare to patients and their families in their home and outside of traditional settings such as doctors’ offices and hospitals. Patients may also be seen in other community settings where they are already receiving care, such as a dialysis center or long-term care facility. Care is conducted by interdisciplinary teams, which include a physician; nurse practitioner or physician assistant; pharmacists; a care management nurse; and/ or a social worker, care coordinator, or community health worker—based on market/regional needs. Access to care is 24/7, both telephonically and in person as needed. These are the program objectives: • Improve overall quality of care by providing services to patients in the home setting in a cost-effective manner.

• Use employed team members for the provision of care.

ENROLLMENT AND INITIAL VISITS Patients are appropriately risk-stratified during the enrollment process. The level of intensity and the amount of time in the program is adjusted to meet the patient’s and family’s clinical and social needs. The program is designed to be a support or to replace a traditional primary care physician (PCP). The team provides the PCP with information on the ongoing status of the member; PCP endorsement is critical. Once enrolled, all patients begin with two to three comprehensive visits in the first two to four weeks. During this time, multiple members of the healthcare team meet with the patient and family/caregivers. The team works with the patient and family to develop both the clinical and social plans of care going forward. During these visits, the team performs an annual health assessment to assess the patient’s chronic and acute conditions and gaps of care (HEDIS). This helps the team better understand the patient’s overall condition and needs. It also enables the team to assign the patient to

• Reduce admissions to higher levels of care.

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Social Determinants of Health: Think Outside the Exam Room BY GRIFFIN MYERS, MD

On July 13, 1995, the temperature in Chicago reached 106 degrees, the heat index peaked above 120—and it didn’t let up for days. Residents with air conditioning pushed the city to new records for energy use, causing the electrical grid to fail in numerous places. That left nearly 50,000 homes without power. Those without power (and the tens of thousands without air conditioning in the first place) suffered the heat with grave consequences. Hundreds died. Infamously, the city was forced to rent refrigerated trucks to house the remains of those who perished. The Chicago Public Health Department found that the black/white mortality ratio was 1.5 to 1. Men were more than twice as likely to die as women.

IMPACT OF SOCIAL DETERMINANTS The Centers for Disease Control and Prevention (CDC) later published its findings detailing several individual-level risk factors for heat wave victims: living alone, not leaving home daily, lacking access to transportation, not having social contacts nearby, and (naturally) not having an air conditioner. Notice here that none of these risk factors were related to the physiology or realm of traditional medical services. The 1995 Chicago heat wave is studied in settings around the globe as an example of the impact of social determinants on population health, and it provides important lessons for all of us who are committed to delivering high-quality health outcomes to the neighborhoods we serve. Frankly, it makes the statistical reality something highly practical and tangible. But must we have a crisis of that magnitude to remind us of the critical role of social determinants? The CDC defines social determinants of health as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” As clinicians, we most often do our work in the exam room, operating suite, trauma bay, or inpatient ward, but the conditions we manage often originate in the home, in the neighborhood, or in the makeup of the community. That means we must address these social determinants to deliver high-quality outcomes to our patients. In other words, we have no choice but to think about solutions outside of the exam room.

ENABLING WHAT MATTERS TO PATIENTS As a Chicago-based healthcare organization focused on creating access to primary care in medically underserved neighborhoods in our seven markets, Oak Street Health takes our role in addressing social determinants seriously. We focus on care for Medicare patients, more than half of whom are dually eligible for Medicaid, and we have found that our value-based model enables this important work. How? As a full-risk practice, we work within globally capitated relationships with our health plan partners to care for our mutual patients. Rather than orient our practice continued on page 60 26 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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“It’s our

commitment to health equity in the context of a value-based economic model that allows for innovation.”

Te x a s

Fall 2017

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REGIONAL FOCUS | TEXAS

Texas Medicaid Program Charts a Course for Value-Based Care BY RYAN CLAY

The Texas Medicaid program is one of the largest Medicaid programs in the country, with almost $40 billion in annual expenditures. The Texas legislature and the Texas Health and Human Services Commission (HHSC) have implemented myriad reforms that have dramatically transformed and modernized this program, creating one of the most effective and efficient Medicaid programs in the country. Because it is such a significant payer, Texas has transitioned away from fee-for-service to managed care over the last decade and is now charting the course for value-based payments (VBP).

MEDICAID TRANSFORMATION WAIVER

has “Texas transitioned away from fee-for-service to managed care over the course of the last decade and is now charting the course for value-based payments.”

In late December 2017, the Centers for Medicare & Medicaid Services (CMS) approved a new five-year, approximately $25 billion Medicaid 1115 Transformation Waiver for Texas. While maintaining significant funding for uncompensated care payments and Delivery System Reform Incentive Payments (DSRIP), the waiver implements two major changes: 1. Transitioning from the use of the current “UC tool” to a modified S-10 worksheet to calculate and distribute uncompensated care (UC) payments based on hospital charity care costs alone. Medicaid shortfall and bad debt costs will no longer be allowed. According to the Texas Hospital Association, Health Management Associates predicted that Texas hospitals’ UC costs would total $9.6 billion for 2017—well beyond the current Medicaid Disproportionate Share Hospital (DSH) allocation and current UC funding available through the waiver. 2. Winding down DSRIP projects and funding. DSRIP has been a very effective incubator for testing how alternative value-based payment models can support patient-centered care and clinical innovation. A significant amount of these funds goes to community mental health centers. These community centers will be looking for managed care partners to continue many of their DSRIP programs, likely through a value-based payment arrangement. HHSC is working with managed care organizations (MCOs) and DSRIP providers to incorporate clinical models into the Medicaid MCO provider payment stream in the form of a value-based payment model. HHSC is strengthening contracts to require MCOs to: • Establish value-based payment targets. • Devote adequate resources to value-based activities. • Establish and maintain data-sharing processes with providers. • Have a process in place to evaluate value-based payment models. According to a draft HHSC VBP Roadmap published in August 2017, “Each MCO’s targets began with calendar year 2018, starting at 25 percent of provider payments in

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overall VBP and 10 percent of provider payments in riskbased VBP. These targets will increase over four years to 50 percent overall VBP and 25 percent risk-based VBP in calendar year 2021.” The Texas 1115 waiver will face dramatic changes in the coming months. The waiver historically infused about $6 billion per year into the healthcare ecosystem. Redirecting these funds will be largely dependent upon using managed care as the alternative payment platform.

RECOVERING FROM THE ACA The Patient Protection and Affordable Care Act (ACA) reduced the federal funding for Medicaid DSH payments under the assumption that hospitals’ uncompensated care costs would decrease as more people gained health insurance coverage. These Medicaid DSH cuts, which took effect October 1, 2017, create challenging and potentially unstable financial circumstances for Texas’s approximately 180 safety-net hospitals, which could result in reduced access to essential healthcare for uninsured and lowincome Texans. The Texas Hospital Association recently identified that, in 2018 alone, Texas hospitals will lose nearly $150 million from these cuts. The cumulative loss for 2018 through 2025 is over $3 billion. Texas is seeking a repeal of these harmful Medicaid DSH reductions.

FRIENDLIER FEDERAL PARTNER The Trump administration’s policies are having a positive impact on Texas healthcare. Many of the Obama administration’s policies ran directly counter to the conservative political philosophy of the Texas legislature. For example, less than a month after Texas received its 1115 waiver renewal, the Trump administration issued guidance that will allow states to implement work and community engagement incentives among non-elderly, non-pregnant adult Medicaid beneficiaries who are eligible for Medicaid on a basis other than disability.

Texas conservative politicians have long advocated for a work requirement to the state Medicaid program, but they have lacked a friendly federal partner until now. Under new CMS guidance, states like Texas now have the flexibility to identify activities other than employment that promote health and wellness and meet the states’ requirements for continued Medicaid eligibility. These activities include, but are not limited to, community service, caregiving, education, job training, and substance use disorder treatment. However, given the fact that Texas has chosen not to expand Medicaid benefits to ablebodied adults under the ACA, the impact of these new programs will have little effect in the Lone Star state. Finally, earlier this year, Texas Gov. Greg Abbott sent a letter to President Trump seeking to reinstate federal funding to the Healthy Texas Women program, which provides family planning and preventive services to low-income women. This program was defunded by the Obama administration because Texas implemented several pro-life policies into the program.

CONCLUSION As Texas continues to transition toward VBP arrangements, it will be imperative to establish a robust collaboration among all Medicaid stakeholders. The Texas legislature will hold several legislative hearings on VBP interim charges this year. It will reconvene in January 2019 to further define and transform provider reimbursement models to improve outcomes and efficiency in the Texas Medicaid program. o Ryan Clay is a principal at Texas Star Alliance, a government affairs firm in Austin, Texas.

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REGIONAL FOCUS | TEXAS

For Medical Home Success, Continue Moving the Bar BY ANAS DAGHESTANI, MD

“They manage the population, not the contract.” That’s how the research team from Harvard University’s T.H. Chan School of Public Health described our culture at Austin Regional Clinic (ARC) and the overall approach adopted by ARC’s Patient Centered Medical Home division. ARC Medical Home is responsible for managing ARC’s 20-plus value-based payer contracts. The preliminary report, part of an ongoing study cataloging how US clinics care for patients with complex needs, speaks volumes about our focus: people.

“Operating a wideranging care management program has helped us prepare for an anticipated future of accepting increasing responsibility for both quality and cost of care.”

ARC Medical Home provides value-added services for patients with multiple chronic conditions, cognitive and/or behavioral issues, functional limitations, and socioeconomic or socio-demographic challenges. It is also responsible for monitoring quality parameters for the larger, overall population and for providing outreach services to identify and contact patients who haven’t kept up with scheduled preventive care measures or who are failing in their ability to manage chronic conditions such as diabetes and hypertension. The program, now in its seventh year, serves a variety of health plans and private employer and governmental contracts (i.e., Medicare Shared Savings Program Accountable Care Organization (ACO), Medicaid, Children’s Health Insurance Program (CHIP), and the Health Insurance Marketplace). The general framework for each contract is the same and includes: • Predefined quality targets. • A negotiated care management fee (typically a per member, per month amount). • Total cost of care targets for shared savings. • Currently no downside risk. • An attributed patient population.

IMPROVING PERFORMANCE These three numbers tell the story of ARC: • 235,000: the total number of patients under contract for value-based management at year-end 2017 (up 11 percent year-over-year). • $4.5 million: the total shared savings collected by ARC during 2017. • $16.5 million: the net aggregate shared savings collected since program inception. ARC Medical Home has grown to 65 people and an annual budget of approximately $6 million. The entire program is paid for by the negotiated care management fees received from payers. Staffing includes care managers, nurse navigators, outreach staff, analysts, medical oversight, and administrative and support staff.

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The program has driven the medical group to improve its performance in many quality metrics that impact medical home patients. For example: • Rates for screening patients 65 or older for depression and fall risk increased to 72 percent in 2017 (up from 38 percent in 2016). • Tobacco screening reached 95 percent in 2017. • The hypertension control rate improved to 74 percent, significantly higher than the national rate of 54 percent. • Colon cancer screening rates improved by 13 percent. • Diabetic retinopathy screening improved by 10 percent.

HOW DO WE DO IT? To fully care for patients, it takes steady commitment from executive leadership on down, hard work, and a willingness to embrace new, more effective methods. It also requires an aspirational approach that sets—and meets—meaningful goals. As a large multispecialty clinic responsible for the care of more than 471,000 people within Central Texas, ARC focuses on the greatest opportunities for improvement. Here are some examples:

1. ROBUST ELECTRONIC MEDICAL RECORDS ARC was an early EMR adopter. Easy access to each patient’s full medical history allows us to see the latest

medical data, identify any apparent care gaps, and encourage a patient to get needed screenings and tests. It also lets us initiate and execute population health management programs more easily and at levels impossible without technology. ARC grows its EMR capabilities as technology improves. It has been painful at times, particularly as we continue to wrestle with the challenge of making it easier (and less time-consuming) for physicians and staff to use and update EMRs. But overall, it has proven to be worthwhile—and financially rewarding. And these rewards will continue as we see more payments tied to meeting quality measures.

2. HIGH BAR FOR CLINICAL QUALITY Our objective is to become one of the nation’s highest quality performers. Last year, that led to rolling out an organization-wide physician scorecard to accumulate actionable data on doctors’ performance and, ultimately, improve care in measurable ways. This tool will help our doctors better understand how they can implement improvement measures on a daily basis—and be proactive versus retroactive. We’re also continuing our commitment to year-over-year increases in screening, vaccination, and disease control rates that are meaningful to patients’ health and well-being. continued on page 62

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REGIONAL FOCUS | TEXAS

Using Evidence-Based Management Techniques to Improve Care BY RICHARD WHITTAKER, MD

In our quest to achieve the Institute for Healthcare Improvement’s Triple Aim, we are all trying to take advantage of the same opportunities and solve the same challenges. Care transitions and high-risk population management are two areas of “low-hanging fruit”—key first steps on the journey toward improved population health.

results “Producing with predictability and order is a textbook definition of management competency.”

But while the evidence for improving these areas is fairly well-known and undisputed, achieving reproducible and sustained results across the care continuum has been elusive for many in healthcare. To tackle this challenge, WellMed created Practice Transformation Groups (PTGs), which use evidencebased management techniques to implement clinical best practices, build care team engagement, and produce breakthrough results with predictability and order.

OUR HISTORY AND CHALLENGE WellMed is a large primary care-centric care delivery system that is full-risk, fulldelegation, multispecialty, multipayer, and senior-focused. We have operations in 13 markets across Texas and Florida and care for 335,000 full-risk Medicare Advantage patients with over 14,000 providers, as well as more than 280,000 patients under a mixture of Medicare fee-for-service, Tricare, Medicaid, and commercial plans. George Rapier, MD, our founder and current chairman, launched the group in 1990 and engaged WellMed in its first full capitation arrangement with PacifiCare in 1997. Much of our early success was rooted in a highly engaged employed physician model that focused on providing the right care, for the right patient, in the right setting, and at the right time. WellMed aligned with OptumCare in January 2011 and has experienced extremely rapid membership growth ever since. This rapid growth resulted in a paradigm shift in the legacy business platform—altering the ratio of employed and contracted physicians, with a commensurate decline in the level of care team engagement. This engagement is an essential driver of our care delivery model. The composition of our PCP network is now approximately 70 percent contracted and 30 percent employed. We have historically experienced about a 25 percent variance in value-based outcomes between our contracted and employed clinics, which we have attributed to differences in care team engagement.

PURSUING PREDICTABILITY WITH 4DX WellMed needed a reproducible, evidence-based approach to deliver improved care outcomes in a predictable manner. This predictability is an essential business requirement to support rapid growth in the future.

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Producing results with predictability and order is a textbook definition of management competency. Therefore, we chose to apply a proven management approach called “4DX,” as outlined in the book, The 4 Disciplines of Execution, by Chris McChesney, Sean Covey, and Jim Huling. In 2015, we partnered with a Franklin Covey consultant, Bryan Ritchie, to improve our management rigor at WellMed. Our leadership team benefited significantly from the coaching and guidance Franklin Covey outlined in the above book and then taught us firsthand. We highly recommend that other organizations consider engaging this group in a consultative relationship. There are four important concepts to understand in 4DX: • First, focus on the “wildly important goals” (WIGs) you wish to improve upon. These are the small number of critical items that are most important to your organization’s success. • Second, focus on highly controllable “lead measures” that you must improve to achieve your wildly important goals. • Third, develop a compelling team scoreboard. • Fourth, ensure a cadence of accountability— meeting regularly to review the scoreboard, improve accountability for lead metric performance, and recognize improvements and setbacks.

REDUCING READMISSION RATES

a basic care management team at 15-minute weekly meetings, where we discussed improving care for highrisk patients in transition. Our medical directors individually coached and mentored each Practice Transformation Group throughout the process—from identifying lead measures to creating performance improvement plans, and finally to measuring success in lag metric terms. The medical directors looked for opportunities to recognize successes (i.e., “saves”) by following some of the teachings outlined in Daniel Pink’s book DRiVE. Specifically, they made concerted efforts to appeal to physicians’ intrinsic behavioral motivators (autonomy, mastery, and purpose), such as improving their personal performance, the patient and family experience, and clinical care outcomes, as well as reducing unnecessary care. They also ensured alignment and visibility to extrinsic motivators in the form of comparative performance and achieving incentive compensation thresholds.

ENCOURAGING RESULTS We experienced broad improvements in reducing readmissions, with an overall reduction in hospital admissions per thousand and ER visits per thousand. We also experienced reductions in the total cost of care. To illustrate our 2017 results, I will use the metrics from our PTG groups in Fort Worth, Texas (one market with 6,500 Medicare Advantage patients and 22 PCPs). We saw great improvement in the lead measures for the providers in this group and subsequent improvement in the lag measures. See the tables below:

We strategically chose our WIG as “reducing the readmission rate of high-risk transition patients in our contracted network.” We then aligned four evidence-based clinical interventions with the 4DX process to improve Fort Worth PTG, Lead Indicator Improvement care team engagement and utilization. Each of these interventions has been proven to reduce unnecessary 17-Jul17-Jul 17-Dec17-Dec admissions, either in published literature or in WellMed’s 3-Day 3-Day 54% 54% 76% 76% proprietary experience: 7-Day 7-Day 8% 8% 52% 52% 1. Early contact with patients, defined as “three-day Med Rec 46% 46% 71% 71% Med Rec telephonic contact.” Cont. Cont. Plan Plan 23% 23% 86% 86% 2. A seven-day follow-up visit with a patient’s PCP. 3. Medication reconciliation.

Fort Worth PTG, Lag Indicator Improvement

4. The creation of an individualized contingency plan. We then identified target groups most likely to benefit from our increased management effort. We selected groups with a critical threshold of patients (>100 full-risk Medicare Advantage), significantly aberrant utilization metrics (>25 percent worse than market average), and enough PCP engagement to meet with mentoring medical directors and

Admits/K ReAdmits/K ER Visits/K

Ft Worth PTG 2016 2017 299 239 41 36 383 361 continued on page 63

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ORGANIZATIONAL MEMBERS Advanced Medical Management, Inc.

Kathy Hegstrom, President Access Medical Group • Community Care IPA • MediChoice IPA • Seoul Medical Group

Advantage Medical Group, LLC

M E M B E R S

Arcilio Alvarado, MD, President Maria Melendez, VP of Operations

Adventist Health Physicians Network IPA

Arby Nahapetian, MD, CMO Jim Agronick, VP – IPA Operations

Affinity Medical Group

Richard Sankary, MD, President Scott Ptacnik, COO

Christopher Crow, MD, President Jeffrey Lawrence, Executive Director

Catholic Health Initiatives *

Robert Weil, MD, Chief Medical Officer Don Lovasz, President, Clinically Integrated Network Architrave Health • Arkansas Health Network • Colorado Health Neighborhoods • KentuckyOne Health Partners • Mercy Health Network • Mission HealthCare Network • PrimeCare Select • St. Luke’s Health Network • TriHealth • UniNet

Cedars-Sinai Medical Group *

Stephen C. Deutsch, MD, CMO John Jenrette, MD, Executive VP, Medical Network

Agilon Health

Central Ohio Primary Care Physicians Inc. *

Alameda Health Partners

Central Oregon Independent Practice Association

Nicholas Pirnia, MD, President Santos Veera, Executive Director

Divya Sharma, MD, Medical Director Kim Bangerter, Executive Director

AllCare IPA

Children’s Physicians Medical Group

Stuart Levine, MD, Chief Innovation Officer and CMO Liz Hernandez, Project Manager

J. William Wulf, MD, CEO Larry Blosser, MD, Corporate Medical Director

Dignity Health Medical Network-Santa Cruz Marvin Labrie CEO

DuPage Medical Group Paul Merrick, MD, President Mike Kasper, CEO

East Coast Medical Services, Inc. Ismary Gonzalez, MD, President

East Hawaii Independent Physicians Association Kevin Kurohara, MD, President Susan Mochizuki, Administrator

Edinger Medical Group

Denise McCourt, COO Matthew C. Boone, MD, Executive Medical Director

El Paso Integral Care, IPA

Rafael Armendariz, DO, President Tony Martinez, Administrator

Equality Health – Q Point

Pedro Rodriguez, HMA Board Member Mark Hillard, President

Facey Medical Foundation *

David Mast, Chief Executive, Medical Group Foundations Erik Davydov, MD, Medical Director

Matt Coury, CEO Randy Winter, MD, President

Leonard Kornreich, MD, President and CEO

Allied Physicians of California

George Liu, MD, President and CEO Peggy Sheng, COO

Golden Empire Managed Care, Inc.

Chinese Community Health Care Association

Golden Shore Medical Group

Choice Medical Group

Good Samaritan Medical Practice Association

Thomas Lam, MD, CEO Kenneth Sim, MD, CFO

Allina Health System

Rod Christensen, MD, VP of Medical Operations Brian Rice, MD, VP Network/ACO Integration

AltaMed Health Services Corporation *

Castulo de la Rocha, JD, President & CEO Alex Chen, MD, CMO

AppleCare Medical Group, Inc. Trish Baesemann, President George Christides, MD, CMO

Chinese American IPA

John M. Williams, PharmD, CEO Polly Chen, Director of Operations Manmohan Nayyar, MD, President Marie Langley, IPA Administrator

Cigna Medical Group Kevin Ellis, DO, CMO

Citrus Valley Independent Physicians

Arizona Health Advantage, Inc.

Gurjeet Kalkat, MD, Executive Medical Director Martin Kleinbart, DPM, Chief Strategy Officer

Ascension Medical Group

Colorado Permanente Medical Group, P.C.

Amish Purohit, MD, CMO

Joseph Cacchione, MD, FACC, President Mark Whalen, VP Business Development

Austin Regional Clinic *

Norman Chenven, MD, CEO and Founder Anas Daghestani, MD, President and CEO

Bakersfield Family Medical Center

A P G

Catalyst Health Network

Carol L. Sorrell, RN, COO Ju Hwan Lee, MD, Medical Director

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

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

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

Canopy Health

Joel A. Criste, CEO Margaret Durbin, MD, CMO

CareMore Medical Group

Sachin Jain, CEO Tom Tancredi, Director of Practice Operations

CareMount Medical, P.C.

Margaret Ferguson, MD, President and Executive Medical Director Claire Tamo, CFO and VP, Business Operations

Comprehensive Geriatric Care of San Juan

Maria Elena Narvaez, MD, CEO Milagros I Silva, IPA Operations Administrator

Conifer Health Solutions Megan North, CEO

AltaMed Health Services • 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

DaVita HealthCare Partners *

Don Rebhun, MD, Corporate Medical Director Jim Rechtin, SVP Corporate Strategy ABQ Health Partners, Division of DaVita HealthCare Partners (NM) • Colorado Springs Health Partners (CO) • HealthCare Partners (CA) • HealthCare Partners Nevada (NV) • HealthCare Partners South Florida (FL) • JSA Medical Group, Division of DaVita HealthCare Partners (FL) • The Everett Clinic (WA)

DFW HealthCare Partners LLC Osehotue Okojie, MD, Chairwoman Josh Cook, President

Dignity Health Medical Foundation Bruce Swartz, SVP, Physician Integration

Scott D. Hayworth, MD, President and CEO Kevin J. Conroy, CFO and Chief Population Health Officer

34 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

Michael Myers, CEO

J. Mario Molina, MD, President Keith Wilson, MD, CMO

Nupar Kumar, MD, Medical Director

Greater Newport Physicians Medical Group, Inc. * Diane Laird, CEO Adam Solomon, MD, CMO

Guthrie Medical Group, Inc. *

Joseph A. Scopelliti, MD, President and CEO Frederick J. Bloom, MD, President

Hawaii Pacific Health

Kenneth B. Robbins, MD, CMO Maureen Flannery, VP, Clinic Operations

Hawaii Permanente Medical Group, Inc. Geoffrey Sewell, MD, Executive Medical Director Daryl Kurozawa, MD, Associate Medical Director

HealthCare Partners, IPA

Joseph Cervia, MD, AAHIVS Regional Medical Director Edward Mirzabegian, Chief Operating Officer

Heritage Provider Network * Richard Merkin, MD, President Richard Lipeles, COO

Affiliated Doctors of Orange County • Arizona Priority Care Plus • Bakersfield Family Medical Group • California Coastal Physician Network • California Desert IPA • Coastal Communities Physician Network • Desert Oasis Healthcare • Greater Covina Medical Group • HealthCare Partners, IPA, AZ & NY • Heritage Physician Network • Heritage Victor Valley Medical Group • High Desert Medical Group • Lakeside Community Healthcare • Lakeside Medical Group • Regal Medical Group • Sierra Medical Group

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

Innovare Health Advocates

Charles Willey, MD, President and CEO Paul Beuttenmuller, CFO

In Salud, Inc.

Armando Riega, President Carmen Ramos, CPA, Executive Director

Spring 2018

Iora Health Inc.

Rushika Fernandopulle, MD, MPP, CEO Dave Fielding, CFO

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

Jefferson Health

Anne Docimo, MD, EVP, Enterprise CMO Richard Kwei, SVP, Value Based Care and Network Performance

John Muir Physician Network * Lee Huskins, President and CAO Ravi Hundal, MD, CFO

Key Medical Group, Inc.

Steve Beargeon, CEO Onsy Said, MD, Medical Director

Lakewood IPA

Varsha Desai, COO Alamitos IPA • St. Mary IPA • Brookshire IPA

Landmark Medical, PC

Adam Boehler, CEO Michael H. Le, MD, President

Leon Medical Centers, Inc. Rafael Mas, MD, SVP and 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

Marshfield Clinic, Inc.

Susan Turney, MD, CEO 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

Accountable Health Care IPA • Bella Vista Medical Group IPA • Centinela Valley IPA • El Proyecto Del Barrio, Inc. • Global Care Medical Group • HealthCare LA, IPA • Jewish Home for the Aging IPA • Pioneer Provider Network, A Medical Group, Inc. • Premier Physicians Network • Prospect Medical Group, Inc. • Redwood Community Health Network • Watts Healthcare Corporation

MemorialCare Medical Group *

Mark Schafer, MD, CEO Laurie Sicaeros, Chief Operating Officer, VP of Physician Alignment

Mercy Health Physicians Michele Montague, COO

Meritage Medical Network

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

Methodist LeBonheur

Molina Medical Centers *

Keith Wilson, MD, Vice President of Clinical Services Carrie Harris-Muller, SVP Care Delivery & Strategic Partnerships

Monarch HealthCare *

Bart Asner, MD, CEO Ray Chicoine, President and COO

Monterey Bay Independent Physician Association

James N. Gilbert, MD Michele Wadsworth, Network Management Associate

Mount Sinai Health Partners *

Niyum Gandhi, EVP and Chief Population Health Officer

MSO of Puerto Rico *

Richard Shinto, MD, CEO Raul Montalvo, MD, President

Muir Medical Group, IPA Ute Burness, RN, CEO Steve Kaplan, MD, President

PHM MultiSalud, LLC

Roberto L. Bengoa Lopez, President Lynnette Ortiz, MD, Medical Director 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 Choice Medical Group of San Luis Obispo

NAMM California *

John Okerblom, MD, President Barbara Cheever, Executive Director

Leigh Hutchins, CEO Verni Jogaratnam, MD, CMO Coachella Valley Physicians of PrimeCare, Inc. • 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 • Redlands Family Practice Medical Group, Inc.

Physicians Choice Medical Group of Santa Maria John Okerblom, MD, President Barbara Cheever, Executive Director

Physicians DataTrust

Lisa Serratore, COO Kathi Toliver, VP of IPA Administration Greater Tri-Cities IPA • Noble AMA IPA • St. Vincent IPA

Physicians of Southwest Washington, LLC

New England Quality Care Alliance Joseph Frolkis, MD, President & CEO Meg Costello, COO

Melanie Matthews, CEO Gary R. Goin, MD, President

New West Physicians, P.C. *

PIH Health Physicians

Ruth Benton, CEO Ken Cohen, MD, CMO

Rosalio J. Lopez, MD, SVP and CMO Andrew Zwers, VP of Group Operations

Northwest Physicians Network of Washington, LLC

Pioneer Medical Group, Inc. * Tom Mahowald, CEO Jerry Floro, MD, President

Rick MacCornack, CEO Scott Kronlund, MD, CMO

Oak Street Health

Preferred IPA of California

OhioHealth

Primary Care of St. Louis, LLC

Ohio Integrated Care Providers

PrimeCare Managers

Mark Amico, MD, Medical Director Zahra Movaghar, Administrator

Terry Olsen, MD, SVP, Accountable Care Drew Crenshaw, VP, Population Health

Bruce J. Berwald, MD, President Joy Strathman

David Applegate, MD, VP Medical Affairs Carmela Hartline, Director Clinical Services Cindy M. Baker, CEO Patrick Goggin, MD, Quality Improvement Medical Director

Omnicare Medical Group One Medical Group

Pacific Medical Administrative Group Donna Mah, MD, President Michael Chang, Executive Director

Pediatric Associates Peter Shulman, MD, CEO Scott Farr, COO

Peoples Health Network

Warren Murrell, President and CEO Brent Wallis, MD, Medical Director

Spring 2018

PriMed Physicians

Privia Medical Group LLC

Tom Lee, MD, Founder and CEO Brendhan Green, VP Contracting and Reimbursement Strategy

OptumCare Network of Connecticut

John D. Ford, CEO Ted Trimble, MD

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

Toni Chavis, MD, President Ashok Raheja, MD, Medical Director

Mid-Atlantic Permanente Medical Group, P.C.

Jan Buffa, CEO Greg Fraser, MD, CMO

Stephen Parodi, MD, Associate Executive Director Traci R. Perry, Director, TPMG, Advocacy and Political Affairs

Stephen Rosenthal, SVP

William Breen, SVP, Physician Alignment

Mid-Valley IPA, Inc.

Permanente Medical Group, Inc.*

Montefiore Medical Center/IPA

Karen Gee, SVP & COO Robert Wenick, MD, VP and Medical Officer

Bernadette Loftus, MD, Associate Executive Director for MAS Jessica Locke, Special Assistant

Health Prime, L.L.C. • Independent Physician Association of New Orleans, Inc. • Memorial Independent Physician Association, Inc. • North Shore Independent Physician Association, Inc. • Pontchartrain IPA, Inc. • South Louisiana Independent Physician Association • University Medical Group, L.L.C.

Clay Ackerly with Keith Fernandez, MD, National Chief Clinical Officer Graham Glaka, VP, New Product Development

ProHealth Physicians, Inc.

Jack Reed, President & CEO Rich Guerriere, MD, SVP & CMO

Prospect Medical Group *

Jeereddi Prasad, MD, President/Acting CMO AMVI/Prospect Medical Group • Genesis Healthcare of Southern California, Inc., a Medical Group • Nuestra Familia Medical Group, Inc. • Pomona Valley Medical Group, Inc. • Prospect Health Source 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

JOURNAL OF AMERICA’S PHYSICIAN GROUPS

l 35

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

M E M B E R S

Providence Health & Services Groups: in Alaska, California, Montana, Oregon, Washington Providence Medical Management Services Phil Jackson, Chief Integration and Transformation Officer

Korean American Medical Group • Providence Care Network

Reliant Medical Group, Inc.

Michael Sheehy, MD, Chief of Population Health and Analytics Betsy Hampton, VP of Population Health

Renaissance Physician Organization Clare Hawkins, MD, IPA Board Chair Whitney Horak, President

River City Medical Group, Inc.

Kendrick T. Que, COO Keith Andrews, MD, Medical Director

Kevin Spencer, MD, CEO and President Mat King, CFO

The Southeast Permanente Medical Group, Inc.

Michael Doherty, MD, Executive Medical Director and Chief of Staff

Southern California Permanente Medical Group *

Diana Shiba, MD, Director of Government Relations Veronica Dela Rosa, Assistant Medical Group Administrator

Southwest Medical Associates

Robert B. McBeath, MD, President and CEO Greg Griffin, COO

Starling Physicians, PC (formerly Connecticut Multispecialty Group) Jarrod Post, MD, CEO Tracy King, Chief Administrative Officer

Steward Health Care Network, Inc.

Kevin Manemann, President and CEO David Kim, MD, Medical Director

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

San Bernardino Medical Group James Malin, CEO Thomas Hellwig, MD, President

Sansum Clinic *

Larry deGhetaldi, MD, Division President, Palo Alto Medical Foundation Kelvin Lam, MD, MBA, CMO, Sutter Health Bay Central Valley Medical Group • East Bay Physicians Medical Group • Gould Medical Group • Marin Headlands Medical Group • Mills-Peninsula Medical Group • Palo Alto Foundation Medical Group • Palo Alto Medical Foundation • Peninsula Medical Clinic • Physician Foundation Medical Associates • Sutter East Bay Medical Foundation • Sutter Gould Medical Foundation • Sutter Independent Physicians • Sutter Medical Foundation • Sutter Medical Group • Sutter Medical Group of the Redwoods • Sutter North Medical Group • Sutter Pacific Medical Foundation

Swedish Medical Group

Kurt Ransohoff, MD, CEO and CMO Chad Hine, COO

Meena Mital, MD, Medical Director Bela Biro, Administrative Director, Accountable Care Services

Santa Clara County IPA (SCCIPA)

Synergy HealthCare, LLC

Santé Health System, Inc.

Scott B. Wells, CEO Daniel Bluestone, MD, Medical Director

SeaView IPA

Lynn Haas, CEO Kooros Samadzadeh, DO, Medical Director

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

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

Sharp Community Medical Group *

James Jones, MD, Chairman Austin Burrows, Sr. Administrator, CareAllies

Tandigm Health, LLC

James Jones, MD, Chairman of the Board Austin Burrows, Sr. Administrator, CareAllies

The Everett Clinic, PLLC*

Al Fisk, MD, CMO Adrianne Wagner, Associate Admin. For Quality Improvement

The Portland Clinic

Michael Doherty, MD, Executive Medical Director and Chief of Staff

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

Paul Durr, CEO Christopher McGlone, COO

Torrance Hospital IPA

Graybill Medical Group • Arch Health Partners

Tri Valley Internal Medicine Group

Sharp Rees-Stealy Medical Group *

Jonathan H. Dinh, MD, CEO; Kaila T. Pollock, COO

Stacey Hrountas, CEO Alan Bier, MD, President

Signature Partners Network * Matthew Poffenroth, MD Anne Rieger, COO

Norman Panitch, MD, President

Triad HealthCare Network, LLC* Steve Norr, VP, Executive Director

UC Davis Health

Michael Hooper, Medical Director, Care Services & Innovation Ann Boynton, Director, Care Services & Innovation

* Indicates 2017–2018 Board Members

36 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

Sam Skootsky, MD, CMO Kit Song, MD, Medical Director

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

Valley Care IPA

Sonya Araiza, CEO Michael Swartout, MD, Medical Director

Valley Organized Physicians

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

Verity Medical Foundation Eric Marton, CEO Dean M. Didech, MD, CMO

Washington Permanente Medical Group

WellMed Medical Group, P.A.

Sutter Health Foundations & Affiliated Groups *

St. Joseph Heritage Healthcare *

UCLA Medical Group *

Summit Medical Group, PA *

Riverside Physician Network Howard Saner, CEO Paul Snowden, CFO

Manuel Porto, MD, President & CEO Natalie Maton, Executive Director of Operations

Steve Tarnoff, MD, President and Executive Medical Director David Kauff, MD, Medical Director

Jeffrey Le Benger, MD, Chairman and CEO Jamie Reedy, MD, VP of Population Health and Quality

Judy Carpenter, President and COO Steven Larson, MD, Chairman

UC Irvine Health

Mark Girard, MD, President Douglas Costa, COO

Riverside Medical Clinic

J. Kersten Kraft, MD, President of the Board Janet Doherty Pulliam, CFO

A P G

South Austin Family Practice, LLP dba Premier Family Physicians

Spring 2018

George M. Rapier III, MD, Chairman and CEO Carlos O. Hernandez, MD, President

CORPORATE PARTNERS AbbVie Anthem Blue Cross of California Continuum Health Evolent Health Humana, Inc. Merck & Co. Nestle Health Science Novartis Pharmaceuticals Novo Nordisk Patient-Centered Primary Care Collaborative Pfizer, Inc. Sanofi, US SCAN Health Plan

ASSOCIATE PARTNERS Arkray Astellas Pharma US, Inc. Avanir Pharmaceuticals, Inc. Bristol-Myers-Squibb Easy Choice Health Plan, Inc. Genentech, Inc. HealthAxis Group, LLC Incyte Corporation Johnson & Johnson Family of Companies Kaufman, Hall & Associates Kindred Healthcare, Inc. Lumara Health Mazars USA, LLP Natera, Inc. Ralphs Grocery Company Relypsa, Inc. Soleo Health Inc. Sunovion Pharmaceuticals Inc. The Doctors Company

AFFILIATE PARTNERS Acurus Solutions Inc. Alignment Healthcare Altura Children’s Hospital Los Angeles Medical Group CVHCare Financial Recovery Group Inc. (FRG) Manifest MedEx Mills Peninsula Medical Group Nifty after Fifty Monarch LLC Partners in Care Foundation Pharmacyclics, Inc. Redlands Community Hospital SullivanLuallin Group Synergy Pharmaceuticals U.S. Advisors, Inc. Ventegra, LLC

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37 CAPG HEALTH ll 37

A New Model of High-Impact, RelationshipBased Primary Care for Seniors BY RUSHIKA FERNANDOPULLE, MD, MPP

Despite spending a huge portion of our national income on healthcare ($3.3 trillion and rising in 2016—over $10,300 per person1), the US healthcare system is not giving us the health we deserve. Our outcomes are worse than almost every other industrialized nation,2 and for the second year in a row, our life expectancy is actually dropping.3 While there are many deep social factors at play, it is clearly our responsibility to do something to improve America’s health. While many look to Washington, large health plans, conglomerate health systems, or Apple to address these problems, we believe the solutions lie much closer to everyday people—consumers—with a redesigned and robust care delivery system. Primary care is the best lever to truly improve health and to help patients navigate the rest of the healthcare system when they need more advanced care. Unfortunately, traditional primary care is not equipped to do this. The fee-for-service payment model encourages fragmented, reactive, transactional care. The system is geared to do more to patients, not to improve their health. Even the best-intentioned practices have less and less time to spend with their patients, and they spend more and more of their effort on checkboxes and other bureaucratic efforts—which may make care worse.

FOCUS ON MEDICARE ADVANTAGE Seven years ago, I founded Iora Health to build a fundamentally different model—one based not on transactions but on relationships—and to restore humanity to healthcare and actually improve health. Our proposition is that there is a new and much better way to take responsibility for people’s health: through totally redesigned, high-impact, relationship-based care practices. Because this is so different than current practice, we simply start from scratch and build new practices based on our unique model. While Iora has, at various times in our history, served retail customers through direct primary care practices and served self-insured employers through near-site clinics, our focus today is on seniors through Medicare Advantage. Older Americans particularly need our help—66 percent of Medicare beneficiaries have three or more chronic conditions, 27 percent report fair or poor health, and 31 percent have cognitive or mental impairment.4 The Medicare Advantage framework allows providers to move beyond fee-for-service and take responsibility for the entire healthcare costs of patients through global capitation arrangements with health plans. These arrangements allow us to think of our job not as doing what someone else says we get paid for, but doing whatever it takes to improve the health of our patients.

THE IORA CARE MODEL With this payment model, we can then build a wholly different delivery model to improve health. We hire care teams who are great at their jobs and have a deep empathy for their teammates and patients. We add health coaches who are hired for 38 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

Spring 2018

believe “Weengagement is key to helping our patients gain self-efficacy and improve their health.”

After at least three months of engagement with an Iora care team, patients’ hypertension control improved from a baseline of 59 percent to 74 percent. Quality performance on HEDIS is also high in patients with at least three months’ tenure with Iora, as we achieve 5-star ratings in the Medicare Stars program for medication adherence in hypertension, diabetes, and lipid treatments.

their compassion and empathy, behavioral health specialists for an integrated approach to care, and more team members to create a new approach. The team spends time together and with their patients, caring for those who come in and— often more importantly—those who don’t. We interact through email, text, and video, as well as in person, hold many groups where patients can engage and learn from each other, proactively check up on patients, and help remove social barriers to health (for instance, by providing transportation for patients who need it). In addition, we help our patients navigate the rest of the system through curbside e-consults and active co-management with a curated group of specialists and hospitalists. We also started from scratch with technology. Current electronic health records (EHRs) were built, not surprisingly, for the old world of billing and coding, so we built our own, called “Chirp” (an Iora is a bird). More customer relationship manager (CRM) than EHR, Chirp is a collaborative care platform that allows us to engage patients in their health, deeply embed population management into workflow, and track and improve performance. Most importantly, we started from scratch on the culture. We have learned from other great service companies like Zappos and Disney that our teams and customers (our patients) come first, and we focus on providing a great care experience for both. This is not just fluff; we believe engagement is key to helping our patients gain self-efficacy and improve their health.

Results from a cohort of 1,176 Iora Medicare enrollees over an 18-month period showed that patients saw dramatic changes in downstream utilization after one to two years, as teams built trust with patients and began to stabilize poorly controlled chronic conditions. Inpatient hospital admissions decreased by 50 percent over 18 months, and at the end of the study period, they were 54 percent lower than Medicare benchmarks. In addition, emergency department visits decreased by 20 percent, while the total medical spend declined by 12 percent.

WE CAN DO BETTER These results are not flukes. We now have 24 practices in eight different markets from coast to coast, and we are seeing similar results in each practice and market. As physicians, we believe we have a responsibility to improve health, but this requires having the courage to rethink our payment and delivery models, technology platforms, and culture. Only by doing this will we truly be able to serve the public. o Rushika Fernandopulle, MD, MPP, is Co-Founder and CEO of Iora Health. He can be reached at rushika@iorahealth.com. References https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-andreports/nationalhealthexpenddata/nhe-fact-sheet.html 1

http://www.commonwealthfund.org/publications/in-brief/2017/jul/last-to-firstcould-us-health-system-become-best-in-world 2

https://www.cdc.gov/nchs/data/databriefs/db293.pdf

Kaiser Family Foundation. (2016, April). An Overview of Medicare. Retrieved from http://www.kff.org/medicare/issuebrief/an-overview-of-medicare/ 4

Zuehlke, E. & Advisory Board. (2015 September). Is it fair to compare physicians’ Net Promoter Score to Apple’s? Retrieved from https://www.advisory.com/research/ market-innovation-center/the-growth-channel/2015/09/pcp-consumer-loyalty-survey 5

RELATIONSHIPS DRIVE RESULTS Satisfaction with Iora practices is high. Practices receive an average Net Promoter Score (NPS) of 86 on a -100 to 100 scale. The score represents patients’ willingness to recommend the practice to a friend or colleague, and it is far higher than the industry average.5 We have CAHPS scores that are the highest in our markets and open enrollment retention rates over 94 percent, and we have doubled the number of Medicare patients we serve in each of the last three years. Spring 2018

JOURNAL OF AMERICA’S PHYSICIAN GROUPS l 39

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IMPORTANT SAFETY INFORMATION WARNINGS AND PRECAUTIONS Hemorrhage: Fatal bleeding events have occurred in patients treated with IMBRUVICA®. Grade 3 or higher bleeding events (intracranial hemorrhage [including subdural hematoma], gastrointestinal bleeding, hematuria, and post-procedural hemorrhage) have occurred in up to 6% of patients. Bleeding events of any grade, including bruising and petechiae, occurred in approximately half of patients treated with IMBRUVICA®. The mechanism for the bleeding events is not well understood. IMBRUVICA® may increase the risk of hemorrhage in patients receiving antiplatelet or anticoagulant therapies and patients should be monitored for signs of bleeding. Consider the benefit-risk of withholding IMBRUVICA® for at least 3 to 7 days pre and post-surgery depending upon the type of surgery and the risk of bleeding. Infections: Fatal and non-fatal infections (including bacterial, viral, or fungal) have occurred with IMBRUVICA® therapy. Grade 3 or greater infections occurred in 14% to 29% of patients. Cases of progressive multifocal leukoencephalopathy (PML) and Pneumocystis jirovecii pneumonia (PJP) have occurred in patients treated with IMBRUVICA®. Consider prophylaxis according to standard of care in patients who are at increased risk for opportunistic infections. Monitor and evaluate patients for fever and infections and treat appropriately. Cytopenias: Treatment-emergent Grade 3 or 4 cytopenias including neutropenia (range, 13 to 29%), thrombocytopenia (range, 5 to 17%), and anemia (range, 0 to 13%) based on laboratory measurements occurred in patients with B-cell malignancies treated with single agent IMBRUVICA®. Monitor complete blood counts monthly.

Cardiac Arrhythmias: Fatal and serious cardiac arrhythmias have occurred with IMBRUVICA® therapy. Grade 3 or greater ventricular tachyarrhythmias occurred in 0 to 1% of patients, and Grade 3 or greater atrial fibrillation and atrial flutter occurred in 0 to 6% of patients. These events have occurred particularly in patients with cardiac risk factors, hypertension, acute infections, and a previous history of cardiac arrhythmias. Periodically monitor patients clinically for cardiac arrhythmias. Obtain an ECG for patients who develop arrhythmic symptoms (e.g., palpitations, lightheadedness, syncope, chest pain) or new onset dyspnea. Manage cardiac arrhythmias appropriately, and if it persists, consider the risks and benefits of IMBRUVICA® treatment and follow dose modification guidelines. Hypertension: Hypertension (range, 6 to 17%) has occurred in patients treated with IMBRUVICA® with a median time to onset of 4.6 months (range, 0.03 to 22 months). Monitor patients for new onset hypertension or hypertension that is not adequately controlled after starting IMBRUVICA®. Adjust existing anti-hypertensive medications and/or initiate anti-hypertensive treatment as appropriate. Second Primary Malignancies: Other malignancies (range, 3 to 16%) including non-skin carcinomas (range, 1 to 4%) have occurred in patients treated with IMBRUVICA®. The most frequent second primary malignancy was non-melanoma skin cancer (range, 2 to 13%). Tumor Lysis Syndrome: Tumor lysis syndrome has been infrequently reported with IMBRUVICA® therapy. Assess the baseline risk (e.g., high tumor burden) and take appropriate precautions. Monitor patients closely and treat as appropriate.

RESONATETM-2 FRONTLINE DATA

RESONATE -2 was a multicenter, randomized 1:1, open-label, Phase 3 trial of IMBRUVICA® vs chlorambucil in frontline CLL/SLL patients ≥65 years (N=269)2,3 Patients with 17p deletion were excluded3 TM

PROLONGED PROGRESSION-FREE SURVIVAL2,3

EXTENDED OVERALL SURVIVAL2

PRIMARY ENDPOINT: PFS IMBRUVICA® vs CHLORAMBUCIL

SECONDARY ENDPOINT: OS IMBRUVICA® vs CHLORAMBUCIL

84% statistically significant reduction in risk of progression or death2,3

Reduced risk of death by more than half

Estimated PFS at 18 months

90% IMBRUVICA®

100

56%

Estimated survival rates at 24 months

90 80 70

IMBRUVICA®

(95% CI: 89, 97)

95%

PFS (%)

Statistically significant reduction in risk of death HR=0.44 (95% CI: 0.21, 0.92)

60 50 40 30

41%

of patients crossed over to IMBRUVICA® upon disease progression

chlorambucil (95% CI: 77, 90)

84%

Estimated PFS at 18 months

52% Chlorambucil

HR=0.16 (95% CI: 0.09, 0.28); P<0.0001

0 0

• Median follow-up was 28 months2 • Fewer deaths with IMBRUVICA® were observed; 11 (8.1%) in the IMBRUVICA® arm vs 21 (15.8%) in the chlorambucil arm2

RESONATE™-2 Adverse Reactions ≥15%

• Diarrhea (42%) • Musculoskeletal pain (36%) • Cough (22%)

ADVERSE REACTIONS The most common adverse reactions (≥20%) in patients with B-cell malignancies (MCL, CLL/SLL, WM and MZL) were thrombocytopenia (62%)*, neutropenia (61%)*, diarrhea (43%), anemia (41%)*, musculoskeletal pain (30%), bruising (30%), rash (30%), fatigue (29%), nausea (29%), hemorrhage (22%), and pyrexia (21%). The most common Grade 3 or 4 adverse reactions (≥5%) in patients with B-cell malignancies (MCL, CLL/SLL, WM and MZL) were neutropenia (39%)*, thrombocytopenia (16%)*, and pneumonia (10%). Approximately 6% of patients discontinued IMBRUVICA® due to adverse reactions. Adverse reactions leading to discontinuation included hemorrhage (1.3%), pneumonia (1.1%), atrial fibrillation (0.8%), neutropenia (0.7%)*, rash (0.7%), diarrhea (0.6%), bruising (0.2%), interstitial lung disease (0.2%), and thrombocytopenia (0.2%)*. Seven percent of patients had a dose reduction due to adverse reactions. *Treatment-emergent decreases (all grades) were based on laboratory measurements and adverse reactions.

To learn more, visit

IMBRUVICAHCP.com © Pharmacyclics LLC 2018 © Janssen Biotech, Inc. 2018 03/18 PRC-03942

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CLB

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• Median follow-up was 18 months3 • With IMBRUVICA®, median PFS was not reached vs 18.9 months (95% CI: 14.1, 22.0) with chlorambucil2 • PFS and ORR (CR and PR) were assessed by an IRC according to the revised 2008 iwCLL criteria3

• Rash (21%) • Bruising (19%) • Peripheral edema (19%)

Embryo-Fetal Toxicity: Based on findings in animals, IMBRUVICA® can cause fetal harm when administered to a pregnant woman. Advise women to avoid becoming pregnant while taking IMBRUVICA® and for 1 month after cessation of therapy. If this drug is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to a fetus. Advise men to avoid fathering a child during the same time period.

Months

N at risk

• Pyrexia (17%) • Dry eye (17%) • Arthralgia (16%)

• Skin infection (15%)

DRUG INTERACTIONS CYP3A Inhibitors: Dose adjustments may be recommended. CYP3A Inducers: Avoid coadministration with strong CYP3A inducers. SPECIFIC POPULATIONS Hepatic Impairment (based on Child-Pugh criteria): Avoid use of IMBRUVICA® in patients with severe baseline hepatic impairment. In patients with mild or moderate impairment, reduce IMBRUVICA® dose. Please see the Brief Summary on the following pages.

CI=confidence interval, CLL=chronic lymphocytic leukemia, HR=hazard ratio, IRC=Independent Review Committee, iwCLL=International Workshop on CLL, OS=overall survival, PFS=progression-free survival, SLL=small lymphocytic lymphoma.

References: 1. Data on file. Pharmacyclics LLC. 2. IMBRUVICA® (ibrutinib) Prescribing Information. Pharmacyclics LLC 2018. 3. Burger JA, Tedeschi A, Barr PM, et al; for the RESONATE-2 Investigators. Ibrutinib as initial therapy for patients with chronic lymphocytic leukemia. N Engl J Med. 2015;373(25):2425-2437.

Brief Summary of Prescribing Information for IMBRUVICA® (ibrutinib) IMBRUVICA® (ibrutinib) capsules, for oral use IMBRUVICA® (ibrutinib) tablets, for oral use See package insert for Full Prescribing Information INDICATIONS AND USAGE Mantle Cell Lymphoma: IMBRUVICA is indicated for the treatment of adult patients with mantle cell lymphoma (MCL) who have received at least one prior therapy. Accelerated approval was granted for this indication based on overall response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial [see Clinical Studies (14.1) in Full Prescribing Information]. Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma: IMBRUVICA is indicated for the treatment of adult patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma with 17p deletion: IMBRUVICA is indicated for the treatment of adult patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) with 17p deletion. Waldenström’s Macroglobulinemia: IMBRUVICA is indicated for the treatment of adult patients with Waldenström’s macroglobulinemia (WM). Marginal Zone Lymphoma: IMBRUVICA is indicated for the treatment of adult patients with marginal zone lymphoma (MZL) who require systemic therapy and have received at least one prior anti-CD20-based therapy. Accelerated approval was granted for this indication based on overall response rate [see Clinical Studies (14.4) in Full Prescribing Information]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial. Chronic Graft versus Host Disease: IMBRUVICA is indicated for the treatment of adult patients with chronic graft-versus-host disease (cGVHD) after failure of one or more lines of systemic therapy. CONTRAINDICATIONS None WARNINGS AND PRECAUTIONS Hemorrhage: Fatal bleeding events have occurred in patients treated with IMBRUVICA. Grade 3 or higher bleeding events (intracranial hemorrhage [including subdural hematoma], gastrointestinal bleeding, hematuria, and post procedural hemorrhage) have occurred in up to 6% of patients. Bleeding events of any grade, including bruising and petechiae, occurred in approximately half of patients treated with IMBRUVICA. The mechanism for the bleeding events is not well understood. IMBRUVICA may increase the risk of hemorrhage in patients receiving antiplatelet or anticoagulant therapies and patients should be monitored for signs of bleeding. Consider the benefit-risk of withholding IMBRUVICA for at least 3 to 7 days pre and post-surgery depending upon the type of surgery and the risk of bleeding [see Clinical Studies (14) in Full Prescribing Information]. Infections: Fatal and non-fatal infections (including bacterial, viral, or fungal) have occurred with IMBRUVICA therapy. Grade 3 or greater infections occurred in 14% to 29% of patients [see Adverse Reactions]. Cases of progressive multifocal leukoencephalopathy (PML) and Pneumocystis jirovecii pneumonia (PJP) have occurred in patients treated with IMBRUVICA. Consider prophylaxis according to standard of care in patients who are at increased risk for opportunistic infections. Monitor and evaluate patients for fever and infections and treat appropriately. Cytopenias: Treatment-emergent Grade 3 or 4 cytopenias including neutropenia (range, 13 to 29%), thrombocytopenia (range, 5 to 17%), and anemia (range, 0 to 13%) based on laboratory measurements occurred in patients with B-cell malignancies treated with single agent IMBRUVICA. Monitor complete blood counts monthly. Cardiac Arrhythmias: Fatal and serious cardiac arrhythmias have occurred with IMBRUVICA therapy. Grade 3 or greater ventricular tachyarrhythmias occurred in 0 to 1% of patients, and Grade 3 or greater atrial fibrillation and atrial flutter occurred in 0 to 6% of patients. These events have occurred particularly in patients with cardiac risk factors, hypertension, acute infections, and a previous history of cardiac arrhythmias. Periodically monitor patients clinically for cardiac arrhythmias. Obtain an ECG for patients who develop arrhythmic symptoms (e.g., palpitations, lightheadedness, syncope, chest pain) or new onset dyspnea. Manage cardiac arrhythmias appropriately, and if it persists, consider the risks and benefits of IMBRUVICA treatment and follow dose modification guidelines [see Dosage and Administration (2.3) in Full Prescribing Information]. Hypertension: Hypertension (range, 6 to 17%) has occurred in patients treated with IMBRUVICA with a median time to onset of 4.6 months (range, 0.03 to 22 months). Monitor patients for new onset hypertension or hypertension that is not adequately controlled after starting IMBRUVICA. Adjust existing anti-hypertensive medications and/or initiate anti-hypertensive treatment as appropriate. Second Primary Malignancies: Other malignancies (range, 3 to 16%) including non-skin carcinomas (range, 1 to 4%) have occurred in patients treated with IMBRUVICA. The most frequent second primary malignancy was nonmelanoma skin cancer (range, 2 to 13%).

IMBRUVICA® (ibrutinib) capsules Tumor Lysis Syndrome: Tumor lysis syndrome has been infrequently reported with IMBRUVICA therapy. Assess the baseline risk (e.g., high tumor burden) and take appropriate precautions. Monitor patients closely and treat as appropriate. Embryo-Fetal Toxicity: Based on findings in animals, IMBRUVICA can cause fetal harm when administered to a pregnant woman. Administration of ibrutinib to pregnant rats and rabbits during the period of organogenesis caused embryo-fetal toxicity including malformations at exposures that were 2-20 times higher than those reported in patients with hematologic malignancies. Advise women to avoid becoming pregnant while taking IMBRUVICA and for 1 month after cessation of therapy. If this drug is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to a fetus [see Use in Specific Populations]. ADVERSE REACTIONS The following adverse reactions are discussed in more detail in other sections of the labeling: • Hemorrhage [see Warnings and Precautions] • Infections [see Warnings and Precautions] • Cytopenias [see Warnings and Precautions] • Cardiac Arrhythmias [see Warnings and Precautions] • Hypertension [see Warnings and Precautions] • Second Primary Malignancies [see Warnings and Precautions] • Tumor Lysis Syndrome [see Warnings and Precautions] Clinical Trials Experience: Because clinical trials are conducted under widely variable conditions, adverse event rates observed in clinical trials of a drug cannot be directly compared with rates of clinical trials of another drug and may not reflect the rates observed in practice. Mantle Cell Lymphoma: The data described below reflect exposure to IMBRUVICA in a clinical trial (Study 1104) that included 111 patients with previously treated MCL treated with 560 mg daily with a median treatment duration of 8.3 months. The most commonly occurring adverse reactions (≥ 20%) were thrombocytopenia, diarrhea, neutropenia, anemia, fatigue, musculoskeletal pain, peripheral edema, upper respiratory tract infection, nausea, bruising, dyspnea, constipation, rash, abdominal pain, vomiting and decreased appetite (see Tables 1 and 2). The most common Grade 3 or 4 non-hematological adverse reactions (≥ 5%) were pneumonia, abdominal pain, atrial fibrillation, diarrhea, fatigue, and skin infections. Fatal and serious cases of renal failure have occurred with IMBRUVICA therapy. Increases in creatinine 1.5 to 3 times the upper limit of normal occurred in 9% of patients. Adverse reactions from the MCL trial (N=111) using single agent IMBRUVICA 560 mg daily occurring at a rate of ≥ 10% are presented in Table 1. Table 1: Non-Hematologic Adverse Reactions in ≥ 10% of Patients with MCL (N=111) All Grade 3 Grades or 4 Body System Adverse Reaction (%) (%) Gastrointestinal Diarrhea 51 5 disorders Nausea 31 0 Constipation 25 0 Abdominal pain 24 5 Vomiting 23 0 Stomatitis 17 1 Dyspepsia 11 0 Infections and Upper respiratory tract infestations infection 34 0 Urinary tract infection 14 3 Pneumonia 14 7 Skin infections 14 5 Sinusitis 13 1 General disorders Fatigue 41 5 and administration Peripheral edema 35 3 site conditions Pyrexia 18 1 Asthenia 14 3 Skin and Bruising 30 0 subcutaneous tissue Rash 25 3 disorders Petechiae 11 0 Musculoskeletal and Musculoskeletal pain 37 1 connective tissue Muscle spasms 14 0 disorders Arthralgia 11 0 Respiratory, thoracic Dyspnea 27 4 and mediastinal Cough 19 0 disorders Epistaxis 11 0 Metabolism and Decreased appetite 21 2 nutrition disorders Dehydration 12 4

IMBRUVICA® (ibrutinib) capsules Table 1: Non-Hematologic Adverse Reactions in ≥ 10% of Patients with MCL (N=111) (continued) Grade 3 All or 4 Grades (%) (%) Body System Adverse Reaction Nervous system Dizziness 14 0 disorders Headache 13 0 Table 2: Treatment-Emergent* Hematologic Laboratory Abnormalities in Patients with MCL (N=111) Percent of Patients (N=111) All Grades Grade 3 or 4 (%) (%) Platelets Decreased 57 17 Neutrophils Decreased 47 29 Hemoglobin Decreased 41 9 * Based on laboratory measurements and adverse reactions Ten patients (9%) discontinued treatment due to adverse reactions in the trial (N=111). The most frequent adverse reaction leading to treatment discontinuation was subdural hematoma (1.8%). Adverse reactions leading to dose reduction occurred in 14% of patients. Patients with MCL who develop lymphocytosis greater than 400,000/mcL have developed intracranial hemorrhage, lethargy, gait instability, and headache. However, some of these cases were in the setting of disease progression. Forty percent of patients had elevated uric acid levels on study including 13% with values above 10 mg/dL. Adverse reaction of hyperuricemia was reported for 15% of patients. Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma: The data described below reflect exposure in one single-arm, open-label clinical trial (Study 1102) and three randomized controlled clinical trials (RESONATE, RESONATE-2, and HELIOS) in patients with CLL/SLL (n=1278 total and n=668 patients exposed to IMBRUVICA). Study 1102 included 51 patients with previously treated CLL/SLL, RESONATE included 391 randomized patients with previously treated CLL or SLL who received single agent IMBRUVICA or ofatumumab, RESONATE-2 included 269 randomized patients 65 years or older with treatment naïve-CLL or SLL who received single agent IMBRUVICA or chlorambucil, and HELIOS included 578 randomized patients with previously treated CLL or SLL who received IMBRUVICA in combination with bendamustine and rituximab or placebo in combination with bendamustine and rituximab. The most commonly occurring adverse reactions in Studies 1102, RESONATE, RESONATE-2, and HELIOS in patients with CLL/SLL receiving IMBRUVICA (≥ 20%) were neutropenia, thrombocytopenia, anemia, diarrhea, musculoskeletal pain, nausea, rash, bruising, fatigue, pyrexia and hemorrhage. Four to 10 percent of patients receiving IMBRUVICA in Studies 1102, RESONATE, RESONATE-2, and HELIOS discontinued treatment due to adverse reactions. These included pneumonia, hemorrhage, atrial fibrillation, rash and neutropenia (1% each). Adverse reactions leading to dose reduction occurred in approximately 6% of patients. Study 1102: Adverse reactions and laboratory abnormalities from the CLL/ SLL trial (N=51) using single agent IMBRUVICA 420 mg daily in patients with previously treated CLL/SLL occurring at a rate of ≥ 10% with a median duration of treatment of 15.6 months are presented in Tables 3 and 4. Table 3: Non-Hematologic Adverse Reactions in ≥ 10% of Patients with CLL/SLL (N=51) in Study 1102 All Grade 3 Grades or 4 Body System Adverse Reaction (%) (%) Gastrointestinal Diarrhea 59 4 disorders Constipation 22 2 Nausea 20 2 Stomatitis 20 0 Vomiting 18 2 Abdominal pain 14 0 Dyspepsia 12 0 Infections and Upper respiratory infestations tract infection 47 2 Sinusitis 22 6 Skin infection 16 6 Pneumonia 12 10 Urinary tract infection 12 2

IMBRUVICA® (ibrutinib) capsules Table 3: Non-Hematologic Adverse Reactions in ≥ 10% of Patients with CLL/SLL (N=51) in Study 1102 (continued) All Grade 3 Grades or 4 Body System Adverse Reaction (%) (%) General disorders and Fatigue 33 6 administration site Pyrexia 24 2 conditions Peripheral edema 22 0 Asthenia 14 6 Chills 12 0 Skin and subcutaneous Bruising 51 2 tissue disorders Rash 25 0 Petechiae 16 0 Respiratory, thoracic Cough 22 0 and mediastinal Oropharyngeal pain 14 0 disorders Dyspnea 12 0 Musculoskeletal and Musculoskeletal connective tissue pain 25 6 disorders Arthralgia 24 0 Muscle spasms 18 2 Nervous system Dizziness 20 0 disorders Headache 18 2 Metabolism and Decreased appetite 16 2 nutrition disorders Neoplasms benign, Second 12* 0 malignant, unspecified malignancies* Vascular disorders Hypertension 16 8 * One patient death due to histiocytic sarcoma. Table 4: Treatment-Emergent* Hematologic Laboratory Abnormalities in Patients with CLL/SLL (N=51) in Study 1102 Percent of Patients (N=51) All Grades (%) Grade 3 or 4 (%) Platelets Decreased 69 12 Neutrophils Decreased 53 26 Hemoglobin Decreased 43 0 * Based on laboratory measurements per IWCLL criteria and adverse reactions. RESONATE: Adverse reactions and laboratory abnormalities described below in Tables 5 and 6 reflect exposure to IMBRUVICA with a median duration of 8.6 months and exposure to ofatumumab with a median of 5.3 months in RESONATE in patients with previously treated CLL/SLL. Table 5: Adverse Reactions Reported in ≥ 10% of Patients and at Least 2% Greater in the IMBRUVICA Treated Arm in Patients with CLL/SLL in RESONATE IMBRUVICA Ofatumumab (N=195) (N=191) Body System All Grades Grade 3 or 4 All Grades Grade 3 or 4 Adverse Reaction (%) (%) (%) (%) Gastrointestinal disorders Diarrhea 48 4 18 2 Nausea 26 2 18 0 Stomatitis* 17 1 6 1 Constipation 15 0 9 0 Vomiting 14 0 6 1 General disorders and administration site conditions Pyrexia 24 2 15 1 Infections and infestations Upper respiratory tract infection 16 1 11 2 Pneumonia* 15 10 13 9 Sinusitis* 11 1 6 0 Urinary tract infection 10 4 5 1 Skin and subcutaneous tissue disorders Rash* 24 3 13 0 Petechiae 14 0 1 0 Bruising* 12 0 1 0

IMBRUVICA® (ibrutinib) capsules Table 5: Adverse Reactions Reported in ≥ 10% of Patients and at Least 2% Greater in the IMBRUVICA Treated Arm in Patients with CLL/SLL in RESONATE (continued) IMBRUVICA Ofatumumab (N=195) (N=191) All Grades Grade 3 or 4 All Grades Grade 3 or 4 Body System (%) (%) (%) (%) Adverse Reaction Musculoskeletal and connective tissue disorders Musculoskeletal 28 2 18 1 pain* Arthralgia 17 1 7 0 Nervous system disorders Headache 14 1 6 0 Dizziness 11 0 5 0 Injury, poisoning and procedural complications Contusion 11 0 3 0 Eye disorders Vision blurred 10 0 3 0 Subjects with multiple events for a given ADR term are counted once only for each ADR term. The body system and individual ADR terms are sorted in descending frequency order in the IMBRUVICA arm. * Includes multiple ADR terms Table 6: Treatment-Emergent Hematologic Laboratory Abnormalities in Patients with CLL/SLL in RESONATE IMBRUVICA Ofatumumab (N=195) (N=191) Grade 3 All Grade 3 All or 4 Grades or 4 Grades (%) (%) (%) (%) Neutrophils Decreased 51 23 57 26 Platelets Decreased 52 5 45 10 Hemoglobin Decreased 36 0 21 0

IMBRUVICA® (ibrutinib) capsules Table 7: Adverse Reactions Reported in ≥ 10% of Patients and at Least 2% Greater in the IMBRUVICA Treated Arm in Patients with CLL/SLL in RESONATE-2 (continued) IMBRUVICA Chlorambucil (N=135) (N=132) Grade 3 All Grade 3 All or 4 Grades or 4 Grades Body System (%) (%) (%) (%) Adverse Reaction Skin and subcutaneous tissue disorders Rash* 21 4 12 2 Bruising* 19 0 7 0 Infections and infestations Skin infection* 15 2 3 1 Pneumonia* 14 8 7 4 Urinary tract 10 1 8 1 infections Respiratory, thoracic and mediastinal disorders Cough 22 0 15 0 General disorders and administration site conditions Peripheral edema 19 1 9 0 Pyrexia 17 0 14 2 Vascular disorders Hypertension* 14 4 1 0 Nervous system disorders Headache 12 1 10 2 Subjects with multiple events for a given ADR term are counted once only for each ADR term. The body system and individual ADR terms are sorted in descending frequency order in the IMBRUVICA arm. * Includes multiple ADR terms

RESONATE-2: Adverse reactions described below in Table 7 reflect exposure to IMBRUVICA with a median duration of 17.4 months. The median exposure to chlorambucil was 7.1 months in RESONATE-2.

HELIOS: Adverse reactions described below in Table 8 reflect exposure to IMBRUVICA + BR with a median duration of 14.7 months and exposure to placebo + BR with a median of 12.8 months in HELIOS in patients with previously treated CLL/SLL.

Table 7: Adverse Reactions Reported in ≥ 10% of Patients and at Least 2% Greater in the IMBRUVICA Treated Arm in Patients with CLL/SLL in RESONATE-2 IMBRUVICA Chlorambucil (N=135) (N=132) All Grade 3 All Grade 3 Body System Grades or 4 Grades or 4 Adverse Reaction (%) (%) (%) (%) Gastrointestinal disorders Diarrhea 42 4 17 0 Stomatitis* 14 1 4 1 Musculoskeletal and connective tissue disorders Musculoskeletal 36 4 20 0 pain* Arthralgia 16 1 7 1 Muscle spasms 11 0 5 0 Eye disorders Dry eye 17 0 5 0 Lacrimation 13 0 6 0 increased Vision blurred 13 0 8 0 Visual acuity 11 0 2 0 reduced

Table 8: Adverse Reactions Reported in at Least 10% of Patients and at Least 2% Greater in the IMBRUVICA Arm in Patients with CLL/SLL in HELIOS Ibrutinib + BR Placebo + BR (N=287) (N=287) All Grades Grade 3 or 4 All Grades Grade 3 or 4 Body System (%) (%) (%) (%) Adverse Reaction Blood and lymphatic system disorders Neutropenia* 66 61 60 55 Thrombocytopenia* 34 16 26 16 Skin and subcutaneous tissue disorders Rash* 32 4 25 1 Bruising* 20 <1 8 <1 Gastrointestinal disorders Diarrhea 36 2 23 1 Abdominal pain 12 1 8 <1 Musculoskeletal and connective tissue disorders Musculoskeletal 29 2 20 0 pain* Muscle spasms 12 <1 5 0

IMBRUVICA® (ibrutinib) capsules

Table 8: Adverse Reactions Reported in at Least 10% of Patients and at Least 2% Greater in the IMBRUVICA Arm in Patients with CLL/SLL in HELIOS (continued) Ibrutinib + BR Placebo + BR (N=287) (N=287) All Grades Grade 3 or 4 All Grades Grade 3 or 4 Body System (%) (%) (%) (%) Adverse Reaction General disorders and administration site conditions Pyrexia 25 4 22 2 Vascular disorders Hemorrhage* 19 2 9 1 Hypertension* 11 5 5 2 Infections and infestations Bronchitis 13 2 10 3 Skin infection* 10 3 6 2 Metabolism and nutrition disorders Hyperuricemia 10 2 6 0 The body system and individual ADR terms are sorted in descending frequency order in the IMBRUVICA arm. * Includes multiple ADR terms <1 used for frequency above 0 and below 0.5%

Table 9: Non-Hematologic Adverse Reactions in ≥ 10% in Patients with WM in Study 1118 (N=63) (continued) Grade 3 Body System Adverse All or 4 Reaction Grades (%) (%) Respiratory, thoracic and Epistaxis 19 0 mediastinal disorders Cough 13 0 Nervous system Dizziness 14 0 disorders Headache 13 0 Neoplasms benign, Skin cancer* 11 0 malignant, and unspecified (including cysts and polyps) The body system and individual ADR preferred terms are sorted in descending frequency order. * Includes multiple ADR terms.

Atrial fibrillation of any grade occurred in 7% of patients treated with IMBRUVICA + BR and 2% of patients treated with placebo + BR. The frequency of Grade 3 and 4 atrial fibrillation was 3% in patients treated with IMBRUVICA + BR and 1% in patients treated with placebo +BR. Waldenström’s Macroglobulinemia and Marginal Zone Lymphoma: The data described below reflect exposure to IMBRUVICA in open-label clinical trials that included 63 patients with previously treated WM (Study 1118) and 63 patients with previously treated MZL (Study 1121). The most commonly occurring adverse reactions in Studies 1118 and 1121 (≥ 20%) were thrombocytopenia, diarrhea, neutropenia, fatigue, bruising, hemorrhage, anemia, rash, musculoskeletal pain, and nausea. Nine percent of patients receiving IMBRUVICA across Studies 1118 and 1121 discontinued treatment due to adverse reactions. The most common adverse reactions leading to discontinuation were interstitial lung disease, diarrhea and rash. Adverse reactions leading to dose reduction occurred in 10% of patients. Study 1118: Adverse reactions and laboratory abnormalities described below in Tables 9 and 10 reflect exposure to IMBRUVICA with a median duration of 11.7 months in Study 1118. Table 9: Non-Hematologic Adverse Reactions in ≥ 10% in Patients with WM in Study 1118 (N=63) Grade 3 Body System Adverse All or 4 Reaction Grades (%) (%) Gastrointestinal Diarrhea 37 0 disorders Nausea 21 0 Stomatitis* 16 0 Gastroesophageal reflux disease 13 0 Skin and subcutaneous Rash* 22 0 tissue disorders Bruising* 16 0 Pruritus 11 0 General disorders and Fatigue 21 0 administrative site conditions Musculoskeletal and Muscle spasms 21 0 connective tissue Arthropathy 13 0 disorders Infections and Upper infestations respiratory tract infection 19 0 Sinusitis 19 0 Pneumonia* 14 6 Skin infection* 14 2

Table 10: Treatment-Emergent Hematologic Laboratory Abnormalities in Patients with WM in Study 1118 (N=63) Percent of Patients (N=63) All Grades (%) Grade 3 or 4 (%) Platelets Decreased 43 13 Neutrophils Decreased 44 19 Hemoglobin Decreased 13 8 Study 1121: Adverse reactions and laboratory abnormalities described below in Tables 11 and 12 reflect exposure to IMBRUVICA with a median duration of 11.6 months in Study 1121. Table 11: Non-Hematologic Adverse Reactions in ≥ 10% in Patients with MZL in Study 1121 (N=63) Body System Adverse Reaction All Grade 3 Grades or 4 (%) (%) 43 5 Gastrointestinal Diarrhea 25 0 disorders Nausea 19 0 Dyspepsia Stomatitis* 17 2 Abdominal pain 16 2 Constipation 14 0 Abdominal pain upper 13 0 Vomiting 11 2 General disorders Fatigue 44 6 and administrative Peripheral edema 24 2 site conditions Pyrexia 17 2 Skin and Bruising * 41 0 subcutaneous tissue Rash* 29 5 disorders Pruritus 14 0 Musculoskeletal and Musculoskeletal connective tissue pain* 40 3 disorders Arthralgia 24 2 Muscle spasms 19 3 Infections and Upper respiratory infestations tract infection 21 0 Sinusitis* 19 0 Bronchitis 11 0 Pneumonia* 11 10 Metabolism and Decreased appetite 16 2 nutrition disorders Hyperuricemia 16 0 Hypoalbuminemia 14 0 Hypokalemia 13 0 Vascular disorders Hemorrhage* 30 0 Hypertension* 14 5 Respiratory, thoracic Cough 22 2 and mediastinal Dyspnea 21 2 disorders Nervous system Dizziness 19 0 disorders Headache 13 0 Psychiatric disorders Anxiety 16 2 The body system and individual ADR preferred terms are sorted in descending frequency order. * Includes multiple ADR terms.

IMBRUVICA® (ibrutinib) capsules

Table 12: Treatment-Emergent Hematologic Laboratory Abnormalities in Patients with MZL in Study 1121 (N=63) Percent of Patients (N=63) Platelets Decreased Hemoglobin Decreased Neutrophils Decreased

All Grades (%) 49 43 22

Grade 3 or 4 (%) 6 13 13

Chronic Graft versus Host Disease: The data described below reflect exposure to IMBRUVICA in an open-label clinical trial (Study 1129) that included 42 patients with cGVHD after failure of first line corticosteroid therapy and required additional therapy. The most commonly occurring adverse reactions in the cGVHD trial (≥ 20%) were fatigue, bruising, diarrhea, thrombocytopenia, stomatitis, muscle spasms, nausea, hemorrhage, anemia, and pneumonia. Atrial fibrillation occurred in one patient (2%) which was Grade 3. Twenty-four percent of patients receiving IMBRUVICA in the cGVHD trial discontinued treatment due to adverse reactions. The most common adverse reactions leading to discontinuation were fatigue and pneumonia. Adverse reactions leading to dose reduction occurred in 26% of patients. Adverse reactions and laboratory abnormalities described below in Tables 13 and 14 reflect exposure to IMBRUVICA with a median duration of 4.4 months in the cGVHD trial. Table 13: Non-Hematologic Adverse Reactions in ≥ 10% of Patients with cGVHD (N=42) All Grade 3 Grades or 4 Body System Adverse Reaction (%) (%) General disorders Fatigue 57 12 and administration Pyrexia 17 5 site conditions Edema peripheral 12 0 Skin and Bruising* 40 0 subcutaneous tissue Rash* 12 0 disorders Gastrointestinal Diarrhea 36 10 disorders Stomatitis* 29 2 Nausea 26 0 Constipation 12 0 Musculoskeletal and Muscle spasms 29 2 connective tissue Musculoskeletal disorders pain* 14 5 Vascular disorders Hemorrhage* 26 0 Infections and Pneumonia* 21 10 infestations Upper respiratory tract infection 19 0 Sepsis* 10 10 Nervous system Headache 17 5 disorders Injury, poisoning Fall 17 0 and procedural complications Respiratory, thoracic Cough 14 0 and mediastinal Dyspnea 12 2 disorders Metabolism and Hypokalemia 12 7 nutrition disorders The system organ class and individual ADR preferred terms are sorted in descending frequency order. * Includes multiple ADR terms. Table 14: Treatment-Emergent Hematologic Laboratory Abnormalities in Patients with cGVHD (N=42)

Platelets Decreased Neutrophils Decreased Hemoglobin Decreased

Percent of Patients (N=42) All Grades (%) Grade 3 or 4 (%) 33 0 10 10 24 2

Additional Important Adverse Reactions: Cardiac Arrhythmias: In randomized controlled trials (n=1227; median treatment duration of 13.1 months for patients treated with IMBRUVICA and 9.0 months for patients in the control arm), the incidence of ventricular tachyarrhythmias (ventricular extrasystoles, ventricular arrhythmias, ventricular fibrillation, ventricular flutter, and ventricular tachycardia) of any grade was 1.0% versus 0.2% and of Grade 3

or greater was 0.2% versus 0% in patients treated with IMBRUVICA compared to patients in the control arm. In addition, the incidence of atrial fibrillation and atrial flutter of any grade was 7% versus 1.5% and for Grade 3 or greater was 2.8% versus 0.3% in patients treated with IMBRUVICA compared to patients in the control arm. Diarrhea: Diarrhea of any grade occurred at a rate of 43% (range, 36% to 59%) of patients treated with IMBRUVICA. Grade 2 diarrhea occurred in 9% (range, 3% to 14%) and Grade 3 in 3% (range, 0 to 5%) of patients treated with IMBRUVICA. The median time to first onset of any grade diarrhea was 10 days (range, 0 to 627), of Grade 2 was 39 days (range, 1 to 719) and of Grade 3 was 74 days (range, 3 to 627). Of the patients who reported diarrhea, 82% had complete resolution, 1% had partial improvement and 17% had no reported improvement at time of analysis. The median time from onset to resolution or improvement of any grade diarrhea was 5 days (range, 1 to 418), and was similar for Grades 2 and 3. Less than 1% of patients discontinued IMBRUVICA due to diarrhea. Visual Disturbance: Blurred vision and decreased visual acuity of any grade occurred in 10% of patients treated with IMBRUVICA (9% Grade 1, 2% Grade 2). The median time to first onset was 85 days (range, 1 to 414 days). Of the patients with visual disturbance, 61% had complete resolution and 38% had no reported improvement at time of analysis. The median time from onset to resolution or improvement was 29 days (range, 1 to 335 days). Postmarketing Experience: The following adverse reactions have been identified during post-approval use of IMBRUVICA. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. • Hepatobiliary disorders: hepatic failure • Respiratory disorders: interstitial lung disease • Metabolic and nutrition disorders: tumor lysis syndrome [see Warnings & Precautions] • Immune system disorders: anaphylactic shock, angioedema, urticaria • Skin and subcutaneous tissue disorders: Stevens-Johnson Syndrome (SJS), onychoclasis • Infections: hepatitis B reactivation DRUG INTERACTIONS Effect of CYP3A Inhibitors on Ibrutinib: The coadministration of IMBRUVICA with a strong or moderate CYP3A inhibitor may increase ibrutinib plasma concentrations [see Clinical Pharmacology (12.3) in Full Prescribing Information]. Increased ibrutinib concentrations may increase the risk of drug-related toxicity. Dose modifications of IMBRUVICA are recommended when used concomitantly with posaconazole, voriconazole and moderate CYP3A inhibitors [see Dosage and Administration (2.4) in Full Prescribing Information]. Avoid concomitant use of other strong CYP3A inhibitors. Interrupt IMBRUVICA if these inhibitors will be used short-term (such as antiinfectives for seven days or less) [see Dosage and Administration (2.4) in Full Prescribing Information]. Avoid grapefruit and Seville oranges during IMBRUVICA treatment, as these contain strong or moderate inhibitors of CYP3A. Effect of CYP3A Inducers on Ibrutinib: The coadministration of IMBRUVICA with strong CYP3A inducers may decrease ibrutinib concentrations. Avoid coadministration with strong CYP3A inducers [see Clinical Pharmacology (12.3) in Full Prescribing Information]. USE IN SPECIFIC POPULATIONS Pregnancy: Risk Summary: IMBRUVICA, a kinase inhibitor, can cause fetal harm based on findings from animal studies. There are no available data on IMBRUVICA use in pregnant women to inform a drug-associated risk of major birth defects and miscarriage. In animal reproduction studies, administration of ibrutinib to pregnant rats and rabbits during the period of organogenesis at exposures up to 2-20 times the clinical doses of 420-560 mg daily produced embryofetal toxicity including structural abnormalities (see Animal Data). If IMBRUVICA is used during pregnancy or if the patient becomes pregnant while taking IMBRUVICA, the patient should be apprised of the potential hazard to the fetus. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively. Animal Data: Ibrutinib was administered orally to pregnant rats during the period of organogenesis at doses of 10, 40 and 80 mg/kg/day. Ibrutinib at a dose of 80 mg/kg/day was associated with visceral malformations (heart and major vessels) and increased resorptions and post-implantation loss. The dose of 80 mg/kg/day in rats is approximately 14 times the exposure (AUC) in

IMBRUVICA® (ibrutinib) capsules

patients with MCL or MZL and 20 times the exposure in patients with CLL/SLL or WM administered the dose of 560 mg daily and 420 mg daily, respectively. Ibrutinib at doses of 40 mg/kg/day or greater was associated with decreased fetal weights. The dose of 40 mg/kg/day in rats is approximately 6 times the exposure (AUC) in patients with MCL administered the dose of 560 mg daily. Ibrutinib was also administered orally to pregnant rabbits during the period of organogenesis at doses of 5, 15, and 45 mg/kg/day. Ibrutinib at a dose of 15 mg/kg/day or greater was associated with skeletal variations (fused sternebrae) and ibrutinib at a dose of 45 mg/kg/day was associated with increased resorptions and post-implantation loss. The dose of 15 mg/kg/day in rabbits is approximately 2.0 times the exposure (AUC) in patients with MCL and 2.8 times the exposure in patients with CLL/SLL or WM administered the dose of 560 and 420 mg daily, respectively. Lactation: Risk Summary: There is no information regarding the presence of ibrutinib or its metabolites in human milk, the effects on the breastfed infant, or the effects on milk production. The development and health benefits of breastfeeding should be considered along with the mother’s clinical need for IMBRUVICA and any potential adverse effects on the breastfed child from IMBRUVICA or from the underlying maternal condition. Females and Males of Reproductive Potential: Pregnancy Testing: Verify the pregnancy status of females of reproductive potential prior to initiating IMBRUVICA therapy. Contraception Females: Advise females of reproductive potential to avoid pregnancy while taking IMBRUVICA and for up to 1 month after ending treatment. If this drug is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be informed of the potential hazard to a fetus. Males: Advise men to avoid fathering a child while receiving IMBRUVICA, and for 1 month following the last dose of IMBRUVICA. Pediatric Use: The safety and effectiveness of IMBRUVICA in pediatric patients has not been established. Geriatric Use: Of the 905 patients in clinical studies of IMBRUVICA, 62% were ≥ 65 years of age, while 21% were ≥75 years of age. No overall differences in effectiveness were observed between younger and older patients. Anemia (all grades) and Grade 3 or higher pneumonia occurred more frequently among older patients treated with IMBRUVICA. Hepatic Impairment: Avoid use of IMBRUVICA in patients with severe hepatic impairment (Child-Pugh class C). The safety of IMBRUVICA has not been evaluated in patients with mild to severe hepatic impairment by Child-Pugh criteria. Dose modifications of IMBRUVICA are recommended in patients with mild or moderate hepatic impairment (Child-Pugh class A and B). Monitor patients for adverse reactions of IMBRUVICA closely [see Dosage and Administration (2.5) and Clinical Pharmacology (12.3) in Full Prescribing Information]. Plasmapheresis: Management of hyperviscosity in WM patients may include plasmapheresis before and during treatment with IMBRUVICA. Modifications to IMBRUVICA dosing are not required. PATIENT COUNSELING INFORMATION Advise the patient to read the FDA-approved patient labeling (Patient Information). • Hemorrhage: Inform patients of the possibility of bleeding, and to report any signs or symptoms (severe headache, blood in stools or urine, prolonged or uncontrolled bleeding). Inform the patient that IMBRUVICA may need to be interrupted for medical or dental procedures [see Warnings and Precautions]. • Infections: Inform patients of the possibility of serious infection, and to report any signs or symptoms (fever, chills, weakness, confusion) suggestive of infection [see Warnings and Precautions]. • Cardiac Arrhythmias: Counsel patients to report any signs of palpitations, lightheadedness, dizziness, fainting, shortness of breath, and chest discomfort [see Warnings and Precautions]. • Hypertension: Inform patients that high blood pressure has occurred in patients taking IMBRUVICA, which may require treatment with antihypertensive therapy [see Warnings and Precautions]. • Second primary malignancies: Inform patients that other malignancies have occurred in patients who have been treated with IMBRUVICA, including skin cancers and other carcinomas [see Warnings and Precautions]. • Tumor lysis syndrome: Inform patients of the potential risk of tumor lysis syndrome and to report any signs and symptoms associated with this event to their healthcare provider for evaluation [see Warnings and Precautions].

• Embryo-fetal toxicity: Advise women of the potential hazard to a fetus and to avoid becoming pregnant during treatment and for 1 month after the last dose of IMBRUVICA [see Warnings and Precautions]. • Inform patients to take IMBRUVICA orally once daily according to their physician’s instructions and that the oral dosage (capsules or tablets) should be swallowed whole with a glass of water without opening, breaking or chewing the capsules or cutting, crushing or chewing the tablets approximately the same time each day [see Dosage and Administration (2.1) in Full Prescribing Information]. • Advise patients that in the event of a missed daily dose of IMBRUVICA, it should be taken as soon as possible on the same day with a return to the normal schedule the following day. Patients should not take extra doses to make up the missed dose [see Dosage and Administration (2.6) in Full Prescribing Information]. • Advise patients of the common side effects associated with IMBRUVICA [see Adverse Reactions]. Direct the patient to a complete list of adverse drug reactions in PATIENT INFORMATION. • Advise patients to inform their health care providers of all concomitant medications, including prescription medicines, over-the-counter drugs, vitamins, and herbal products [see Drug Interactions]. • Advise patients that they may experience loose stools or diarrhea, and should contact their doctor if their diarrhea persists. Advise patients to maintain adequate hydration [see Adverse Reactions]. Active ingredient made in China. Distributed and Marketed by: Pharmacyclics LLC Sunnyvale, CA USA 94085 and Marketed by: Janssen Biotech, Inc. Horsham, PA USA 19044 Patent http://www.imbruvica.com IMBRUVICA® is a registered trademark owned by Pharmacyclics LLC © Pharmacyclics LLC 2018 © Janssen Biotech, Inc. 2018 PRC-03819

Expanding A1c Testing to Help Control Diabetes and Prediabetes BY CHAN CHUANG, MD, AND GLENN MELNICK, PHD

The Centers for Disease Control and Prevention reports that more than 100 million US adults are living with diabetes or prediabetes. In California, about 2.5 million adults—9 percent of the state’s adult population—are living with a diabetes diagnosis, while another 13 million adults—nearly half of all adults in the state— are estimated to have either prediabetes (metabolic syndrome) or undiagnosed diabetes. Between 2001 and 2012, the prevalence of diabetes among adult Californians increased by 35 percent. What can the healthcare system do to help reverse this trend? Proactive and focused population health management with healthcare delivery refinement is one answer. Chan Chuang, MD

DaVita HealthCare Partners (DHCP), a DaVita Medical Group with a large geographic presence in California, recognizes that the first step in proactive population management is better monitoring of patient health status. That’s why, in 2007, DHCP–California began a program to expand the number of members who routinely monitor their blood glucose levels using the hemoglobin A1c (A1c) test. The table below shows that DHCP has been very successful in this effort. Between 2007 and 2016, the number of members receiving A1c tests skyrocketed—from 49,314 to 229,673. DHCP A1c Testing, 2007 – 2016

Glenn Melnick, PhD

Year

Total A1c Tests

Total Members Tested

“

2007

81,864

49,314

2008

100,558

59,119

2009

144,773

86,203

2010

192,306

112,950

2011

241,623

137,345

2012

256,152

152,848

2013

293,108

179,044

2014

362,739

201,407

2015

509,067

224,778

2016

414,726

229,673

Total

2,596,916

1,432,681

We expanded testing beyond patients who were at the highest risk for diabetes to include those who may be prediabetic.”

Below, Chan Chuang, MD, Chief Clinical Officer of DHCP, describes this intervention and its key components in a conversation with Glenn Melnick, PhD, the Blue Cross of California Chair of Health Care Finance at the University of Southern California and a resident consultant at RAND.

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Dr. Melnick: Why did DHCP undertake such a large expansion of A1c testing? Dr. Chuang: Internally, we recognized the genuine value of glycemic control to minimize adverse health outcomes among diabetic patients, including loss of vision, kidney failure, infection, and amputation. There were also changes in clinical opinion. For example, in 2009, an international expert committee recommended using hemoglobin A1c tests to diagnose diabetes, and this was endorsed by the American Diabetes Association. Previously, A1c was not standardized and often yielded very different results. But accuracy improved with the National Glycohemoglobin Standardization Program (NGSP), facilitating acceptance and use by physicians and patients. And from a data perspective, there is now only one LOINC® (4548-4) being used to report A1c results in the US. As the NGSP notes, “A better A1c test means better diabetes care.” Not surprisingly, several A1c measures are now part of the current set of HEDIS indicators that form comprehensive diabetes care. From a population health and health policy perspective—one that encompasses health promotion and efficiency—DHCP sought to expand A1c testing for all atrisk members to allow us to clinically intervene earlier. Dr. Melnick: What are the key components that led to increasing the number of DHCP patients who received an A1c test? Dr. Chuang: This intervention was multifaceted, and it involved authentically changing both provider and patient behavior. We needed to increase testing among diagnosed diabetic patients, undiagnosed patients, and at-risk patients. While the Centers for Disease Control and Prevention estimates that about 9 percent of the US population has a diabetes diagnosis, it also estimates that another 3 percent are undiagnosed. The process began with outreach to physicians, including both informal and formal meetings and email messages.

We provided support, including follow-up phone calls to patients to ensure testing was done. Goals were set based on P4P and STAR measures. We expanded testing beyond patients who were at the highest risk for diabetes to include those who may be prediabetic. Physicians, nurse practitioners, and physician assistants may order the A1c test for a patient because of family history, patient request, ethnicity, or other factors such as being overweight. To encourage and support A1c testing, our site lead physicians and administrators receive regular clinical measures that can be easily reviewed at any time. We are transparent with performance within our various clinic sites and share our metrics between primary care physicians and lead physicians. Seeing the gains in real time provides immediate positive reinforcement. It also means physicians and other health professionals can respond quickly if they start to see a trend they don’t like. Physicians, nurses, diabetes educators, health coaches, behavioral health specialists, and patients need to be empowered to implement positive changes. Lastly, sites also have goals to meet regarding their patients with diabetes and their specific A1c goals (e.g., <9.0 percent, <8.0 percent). Testing is key to knowing whether patients have achieved glycemic control. If they have not, there are effective self-management education and support programs we can provide to help patients safely lower their A1c and avoid the potentially serious and debilitating complications that can remain silent for years. Dr. Melnick: Why is expanding A1c testing to the prediabetic population so important to population health management? Dr. Chuang: We need to screen patients for prediabetes with the A1c test so we can slow the rate of conversion to diabetes. Otherwise, diabetes is going to be an even bigger health problem than it is today. On the bright side, we have substantial evidence, such as the Diabetes Prevention Program, which shows lifestyle intervention can reduce the incidence of type 2 diabetes by 58 percent over three years. That knowledge provides hope to patients and is substantial motivation for all of us at DHCP. As our research shows, DHCP increased the number of tests administered by more than fivefold over the 10-year study period. This increase was largely due to expanding the number of individuals tested, rather than an increase in the number of tests per individual member. The number continued on page 66 Spring 2018

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Telehealth: It’s About Time BY PAUL BERNSTEIN, MD, FACS

1876. That’s right, it’s been 140 years since Alexander Graham Bell invented the basic device needed for telemedicine: the telephone. And it’s taken us almost that long to figure out how to transform patient care from a physician-centric model to a patient-centric one.

are “E-visits the streaming downloads of the modern medical world. The Netflix of medicine. And remember, the customer-driven approach always wins.”

Alexander Graham Bell with his telephone

The traditional care model where a patient takes a day off from work or school and drives to the physician office and waits—yes, waits to be seen—is no longer acceptable in our consumer‑ and convenience-driven world. Blockbuster Video learned that the hard way. Netflix, by putting the customer at the center of its business model, showed that the customer-driven approach always wins.

HEALTH EVERYWHERE Let’s first clarify the difference between telemedicine and telehealth. Simply put, telemedicine refers to the devices that allow us to provide telehealth—such as phones, video equipment, computers, wearables, etc. On the other hand, telehealth refers to a system of care known as “health everywhere”—namely, health where, when, and how the patient wants it. In other words, a patient-centric system of care. And we provide this care using Alexander Bell’s telephone, which has been transformed over the years into the smartphone, allowing us to do both voice and video consultations with our patients. In this summary of telehealth, we will look at the basics: where we’ve been, what we are currently doing, and where we will be going. We will use one example patient, Alexander Graham Bell, and an example doctor, Sidney Garfield, MD, the founder of Kaiser Permanente. Dr. Garfield was the brains behind the first large-scale, successful telehealth system in America, back in the 1960s. Alexander Graham Bell picks up his telephone and asks the operator to connect him to his doctor: “Dr. Ferguson’s office, how may I help you?” “This is Mr. Alexander Bell, and I’d like to see the doctor.” “Yes, Mr. Bell, the doctor has an appointment open next Thursday.” “I’m not feeling that well. Is there a way I can ask the doctor a question?” “I’m sorry, Mr. Bell, but the doctor needs to examine you and see you in person.” You get the point. The physician-centric care model provides no choice, no convenience, and at times, waits that can lead to care delays and quality issues. Now let’s go forward 100 years to the 1970s, when Dr. Garfield published his landmark article in the April 1970 issue of Scientific American on the logical pathways for preventive and comprehensive care. This article later led to the development of the electronic medical record.

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Dr. Garfield said, “Instead of waiting for the patient to get sick, we will use our microprocessor computers to know when to reach out to our patients to check on their diabetes, their high Sidney Garfield, MD blood pressure, and other ailments. We will call our patients with a new system of telehealth.” Dr. Garfield was one of the first physicians to use the word telehealth. In his program, known as Total Health, his doctors and nurses were able to make informed decisions on the phone by referring to their patients’ medical records. His system used early IBM computers and punch cards and was just accepted by the Smithsonian in Washington, DC, as part of an exhibit on the history of medicine.

A NEW ERA OF E-VISITS Where have we gone with this groundbreaking work? Into a new era of telehealth. Now, from the convenience of the patient’s home, not the doctor’s office, the patient is able to get valuable information and help for acute, nonemergency problems, follow-up care for chronic diseases, and even telederm advice to diagnose skin lesions remotely. These consultations can be done by a group of physicians, e.g., Teladoc, American Well, or a patient’s own healthcare team. At Kaiser Permanente, we call it KPNOW. A simple call, and the patient can talk to a doctor in less than an hour. The VA system has piloted telehealth care for veterans in rural areas. Patients no longer have to drive hours to see a doctor. This pioneering work has led to laws in most states allowing physicians to provide similar remote care. What type of telehealth has become widely used in 2018? Telephone and video visits are the norm. At Kaiser Permanente, we have done well over a million telehealth visits. Emailing your doctor has been widely used for years. But how can patients go online to find out the answer and get treatment for their acute symptoms? That’s where E-visits come in. Different organizations have come up with protocols that allow patients to define their symptoms through a questionnaire. A provider reviews this questionnaire and emails or texts the patient with treatment guidelines, including medications if indicated.

E-visits are the streaming downloads of the modern medical world. The Netflix of medicine. And remember, the customerdriven approach always wins. E-visits have allowed us to achieve the Quadruple Aim: improved patient satisfaction, quality, provider work-life, and cost. Here’s what a real patient wrote us about her E-visit: “Based on my symptoms, I obviously had a UTI. Why take a doctor’s time with that? It was so much easier to answer the questionnaire at midnight when the symptoms started and pick up meds in the morning.” Another system of immediate care utilizes not only talk to a doc, but “Chat with a Doc.” Kaiser Permanente Colorado has done pioneering work showing how this can improve patient satisfaction and timeliness and quality of care, while at the same time lowering costs.

DOES TELEHEALTH COST MORE? You may be familiar with the RAND study looking at CalPERS patients who were offered telehealth in addition to their own panel of providers. The study showed that although patient satisfaction improved, overall cost increased, as 88 percent of telehealth visits represented new use of medical services—people who wouldn’t have gone to the doctor otherwise. At Kaiser Permanente, after 500,000 KPNOW visits, we have a different outcome. In the system that Sidney Garfield described above (punch cards have now been replaced by server farms), every touchpoint of care can decrease overall visits to the doctor. In other words, telehealth in an integrated, comprehensive health plan can decrease utilization and improve affordability. With $1 out of every $5 in America being spent on healthcare, and with our quality outcome rankings 37th in the world, it’s time we transformed our system of “sick” care to a system of “health” care that every patient can easily access and afford.

WHAT’S NEXT? After just coming back from the Consumer Electronics Show in Las Vegas, telemedicine (again, I’m referring to the devices and hardware) is rapidly becoming a multibilliondollar market and an industry of its own. The future is one of wearables (diagnostic devices that will allow physicians to remotely monitor patients’ activity, vital signs, labs, etc.). In a recent study at KP, we remotely monitored patients with congestive heart failure by measuring their weight, blood pressure, and movement. continued on page 66 Spring 2018

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A Bipartisan Health Reform...continued from page 12

DELIVERY SYSTEM REFORM

One key component of this plan is to have states and the federal government champion value-based care through public programs such as Medicaid, Medicare, state employee benefits plans, the Federal Employee Health Benefits Program, and all federal agencies. The governors additionally urge public-private partnership and the adoption of reforms across both the public and private sector.

Finally, the governors note the need to fairly measure value and increase transparency, to support “an evolution of primary care,” and to hold providers accountable for costs and outcomes for episodes of care. The governors also want to empower consumers with new technologies and tools to encourage healthy lifestyles and value-based healthcare decisions.

The blueprint also takes direct aim at healthcare consolidation. The governors urge federal and state regulators to directly combat anti-competitive behavior, “particularly among local hospital systems, pharmacy benefits managers, and pharmaceutical companies,” and to address regulations that inhibit innovation and competition. The governors cite prescription drug import regulations as an example of a federal restriction that might inhibit competition.

LEADERSHIP IN UNCERTAIN TIMES

MODERNIZING THE STATE AND FEDERAL RELATIONSHIP The blueprint also includes a section on modernizing the relationship between the federal government and states. Recommendations include having the federal government act where a national approach is most efficient, such as regulating pharmaceuticals and air ambulances, but to otherwise give states broad independence, so long as they meet a minimum federal standard for health system quality and coverage.

T HE

DATE!

Much in this consensus-driven proposal reiterates policies that have been advocated by America’s Physician Groups at both the state and federal levels, and it is encouraging that state-level chief executives are reaching across their borders to exercise leadership in uncertain times. It’s worth noting that less than one week after the blueprint was issued, 20 “red” states filed an action in federal district court to seek a ruling that the ACA is now unconstitutional. The lawsuit has drawn immediate skepticism over its legal basis, and it reveals the deep divide among the states over the continued validity of the universal coverage model. You can find the governors’ seven-page proposal through an easy Google search on the title: “A Bipartisan Blueprint for Improving Our Nation’s Health System Performance.” o

AMERICA’S PHYSICIAN GROUPS

ANNUAL CONFERENCE 2019

APR IL 11-13, 2019 MANCHESTER GRAND HYATT SAN DIEGO, CALIFORNIA

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Mazars USA Can Help Your Organization Manage the Business of Managed Care. Mazars USA’s Health Care Group is proud to support APG and its mission to assist medical groups, independent practice associations (IPAs) and risk-bearing organizations nationwide as they strive to improve the quality and value of healthcare provided to patients. Our experts can assist you in the following key areas: • Compliance • Contract Management & Analysis • Fraud, Waste & Abuse • Licensing & Certiﬁcation • Network Data Integrity & Survey Services • Organizational Assessments • Regulatory Audit Preparation …and much more. how Mazars can help optimize your Find out h organization’s performance. Gil Enos, Principal 916.656.6130 Gil.Enos@MazarsUSA.com MeetMazars.com

Fall 2017

CAPG HEALTH l 53

APG Advocates...continued from page 14

space. Moreover, APG Advocates provides a platform for members to directly contact their members of Congress and the Administration, both as individuals and as part of a larger movement. The program also connects like-minded individuals, allowing for networking and coalition-building across the membership and beyond. This includes providing APG Advocate members a way to influence the political process through the APG Political Action Committee (PAC). America’s Physician Groups uses the APG PAC to support members of Congress who are committed to advancing the value movement and improving our nation’s healthcare system.

THIS YEAR’S PRIORITIES For 2018, APG Advocates’ priorities include: • MACRA. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is central to the goal of moving away from our current fee-forservice reimbursement system toward a system that reimburses clinicians based on quality, efficiency, and patient outcomes. America’s Physician Groups is calling for timely MACRA implementation, with flexibility for expanded participation for a wide variety of clinicians at various stages of the transformation journey. • Medicare Advantage (MA). Our members recognize the importance of the care coordination tools MA provides both clinicians and patients. We have built an exceptional coalition of physician supporters for the program—now nearly 300 physician organizations strong. We successfully worked with clinicians, associations, beneficiary groups, health plans, and others to improve MA funding and strengthen the program. • Medicare Advantage APM. Congruent with our above priorities, the Centers for Medicare & Medicaid Services (CMS) announced its

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intent to create a Medicare Advantage advanced alternative payment model (APM) demonstration project, which will qualify as an advanced APM under the MACRA Quality Payment Program (QPP) in 2018. Previously, there was no path for MA to qualify as an advanced APM in 2018. In 2017, we laid out our specific model for CMS to test an MA APM, and we will continue to work closely with CMS and Innovation Center staff to design and implement an MA APM model for testing this year. • A Better ACO: The Third Option. In response to physicians’ need for additional advanced APM options—and to address the weaknesses of the fee-for-service accountable care organization (ACO) program—America’s Physician Groups designed a better ACO model, the Third Option. The Third Option features prospective, capitated payments; robust quality measurement; and active beneficiary engagement. In late 2017, we worked closely with members of Congress in both the House and Senate to submit a letter to CMS Administrator Seema Verma urging the agency to test a prospective, global payment ACO model that would qualify as an advanced APM under MACRA, on par with our Third Option model. o Not yet an APG Advocate member? Join us! Sign up at apgadvocates.org.

Are you in Alignment?

AT ALIGNMENT HEALTHCARE we believe nothing is more important than the relationship between DOCTORS and the COMMUNITIES they serve. That’s why we’ve carefully chosen dedicated local doctors and empowered them with some of the most innovative tools in the world. Together, we took a 3-star Medicare Advantage plan to an overall 4.5 star rating in 2018 – and 5 out of 5 stars for its Prescription Drug plan. alignmenthealthcare.com Fall 2017 CAPG HEALTH l 55

Advantage Medical Group Agilon Health Arizona Health Advantage, Inc. Ascension Medical Group Canopy Health

Catalyst Health Network Comprehensive Geriatric Care of San Juan DFW HealthCare Partners, LLC East Hawaii IPA Golden Shore Medical Group HealthCare Partners, IPA In Salud Jade Health Care Medical Group Jefferson Health Landmark Medical, PC Martin Luther King, Jr. Community Medical Group Montefiore Medical Center/IPA New England Quality Care Alliance (NEQCA) Oak Street Health Ohio Integrated Care Partners OhioHealth OptumCare Network of Connecticut Pacific Medical Administrative Group (PMAG) Peoples Health Network PHM MultiSalud, LLC Primary Care of St. Louis, LLC PrimeCare Managers PriMed Physicians ProHealth Physicians Reliant Medical Group TriValley Internal Medicine Group University of California, Davis WVP Health Authority/Mid-Valley IPA o

APG Member Spotlight...continued from page 21

AN ONGOING COMMITMENT

Within weeks, InnovaCare Health leadership arrived on 737s full of food and medical supplies to help with the initial relief effort. A group of providers from Saint Barnabas and Rutgers hospitals in New Jersey provided additional medical services and supplies. InnovaCare also partnered with CareOne Management to raise more than $4 million at a fundraiser within a month of the storm’s landfall.

Today, months after the primary impact of the hurricane, our walk together continues. Many of our beneficiaries are still struggling to access adequate transportation, nutrition, and housing. We treat a sizable percentage of Puerto Rico’s elderly population, some of whom are still without electricity and water, and our clinicians are seeing the storm’s secondary effects on residents’ health.

Importantly, InnovaCare’s digital platforms are housed in Atlanta, which meant our systems stayed up and running when the storm hit. Day to day, more than 90 percent of our physicians are connected to our proprietary health information exchange. They’re used to communicating this way, and they were able to log in and access their patients’ electronic records in the immediate aftermath of the storm.

Our commitment to our members and their communities didn’t start with the storm, and it certainly hasn’t ended with it. We know that part of our responsibility as a healthcare provider is to step up when the people we serve struggle to access care for whatever reason. Frankly, we’re honored that whenever there’s a healthcare challenge in Puerto Rico, we’re expected to be an integral part of the solution. o

This meant patients never experienced a gap in care— which can mean the difference between life and death for a patient population with multiple comorbidities and some of the highest rates of chronic disease in the country.

Richard Shinto, MD, CEO of MSO of Puerto Rico, and Raúl F. Montalvo, MD, President of MSO of Puerto Rico, serve on the America’s Physician Groups Board of Directors. They can be reached at rick.shinto@mmmhc.com and raul.montalvo@mso-pr.com.

News and Events...continued from page 8

from every region of the United States are represented— from Hawaii to Puerto Rico, from Connecticut to Texas, from Oregon to Louisiana.

The America’s Physician Groups family proudly welcomes our 2017 members:

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Proven Engagement Solutions

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1.9% reduction in visits $800k cost avoidance

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Social Determinants of Health 40% report having difficulty getting to the doctor’s office

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HRA participation

Contact HMS Eliza to Start the Conversation. Discover how Eliza engages and motivates healthcare consumers to take a more active role in their care.

eliza@hms.com

1.844.343.1441

Home Visit Program...continued from page 25

the appropriate risk stratification care intervention tier, which determines the amount and type of program visits that are needed. For members referred from a hospital at discharge, this visit represents a true transition-ofcare visit. Starting with the clinical plan, the team educates the patient and family on the patient’s conditions—including pathophysiology, predicted future course, symptoms present at steady state, and initial symptoms that signal an acute or chronic exacerbation—as well as home- and community-based services that are needed. The team also develops an action plan for the patient and family to follow when they notice exacerbation symptoms. Early action is encouraged, in the hopes that the lowest care level possible is needed, as well as appropriately sought out by the patient and caregivers in their time of need. Finally, to round out the clinical plan of care, a clinical pharmacist performs an in-person medication reconciliation and provides education and tools to ensure medication adherence. The team also develops a social and behavioral plan of care during those initial visits. This plan includes a home safety evaluation and a training needs assessment. Patients are also referred to a social worker for education on community resources, including financial counseling and behavioral healthcare. Last, but certainly not least, the team begins discussions on advance care planning, which hopefully leads to completion and documentation of advanced directives.

FOLLOW-UP AND TRANSITIONS Once these initial comprehensive visits are complete, patients either transition out of active status or remain active, with scheduled follow-up until or if stability is reached. For those relatively rare, stable patients, care returns to the PCP and our complex care management/disease management programs. If the patient is still very complex but does not meet criteria for primarily home visits, the team transfers care to the Comprehensive Care Center. If stability is not achieved following the initial visits, patients are scheduled for regular follow-up visits until it is possible to transition them to a Comprehensive Care Center or, rarely, back to the PCP. The average time for a patient in the Home Visit Program is approximately 58 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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nine months (with the exception of true transition-ofcare-only patients). About 5 percent of all senior patients will require extensive follow-up—including weekly or biweekly visits for the first three to six months of the program—before stabilization is achieved or they enroll in hospice. If a patient graduates out of active status or to a lower or higher level of care, he or she can always be placed back into active Home Visit Program status. The program schedule is designed to allow room for sameday add-on appointments as needed.

RESULTS AND MARKET DIFFERENCES Like most things in life, one size does not always fit all. The Home Visit Program at agilon health varies based on geography, patient population, patient and physician community, line of business, and risk contracting between the agilon risk-bearing entity and partner health plans. In California markets, the target population is 0.5 to 1 percent commercial membership, 1 to 2 percent Medi-Cal, 5 to 8 percent Medicare, and 7 to 10 percent dual-eligible members. In each market, the program impact is continually assessed. Patients who received care via the Home Visit Program reported greater satisfaction with services, as did their physicians, and significantly higher quality-of-care outcomes. Home Visit patients have fewer hospitalizations and emergency department (ED) visits. This results in reduced costs of care, compared with the costs before the program started, with a significant return on investment. While the program iterations have subtle differences in each market, given the shared goals and vision, similar success is expected outside of California. Altogether, the agilon health Home Visit Program is about bringing back the joy to medicine for both patients and doctors and achieving the Quadruple Aim: Higher quality care, lower total cost of care, better patient engagement, and higher physician satisfaction. Won’t you join us on this journey? o Stuart Levine, MD, MHA, is Chief Medical and Innovation Officer for agilon health, and Assistant Professor, Internal Medicine and Psychiatry, at the UCLA David Geffen School of Medicine and the Stanford University School of Medicine. The author gratefully acknowledges the following for their contributions: Amy Rhine, MD; Martha Jones; Laurence Blauser, MD; Khaliq Siddiq, MD; and Elizabeth Garcia.

The Journal of

RESERVE YOUR SPACE IN 2018 Issue

Theme

Summer

Coordinated Northwest Care (Washington/ Adapts Oregon)

Colloquium Healthcare Forecast/ Elections

Regional Focus

Northeast/ Mid-Atlantic

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JOURNAL OF AMERICAâ&#x20AC;&#x2122;S PHYSICIAN GROUPS

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Social Determinants of Health...continued from page 26

around fee-for-service revenue targets, we’re engineered to, as we say, keep patients “happy, healthy, and out of the hospital” by addressing sources of morbidity and mortality—regardless of whether they fall within traditional medical service delivery. Here are just a few examples: Social isolation. Every Oak Street center contains a staffed community center with a computer lab, library, and social space with daily events for education and social engagement. Food. Oak Street outreach teams regularly support local food pantries and soup kitchens, and we work with our health plan partners to ensure qualifying patients receive food benefits when transitioning from the hospital when available as a plan benefit. Transportation. Oak Street Health provides transportation to and from our centers for patients unable to travel otherwise. If our van service is insufficient due to patient circumstance, our Complex Care Team delivers care in the patient’s home. Physical environment. In a city that ranges from lows of minus 10 in the winter to 95 in the summer, our patients are often at risk of hypo- and hyperthermia. Our

centers are open to the public as both warming and cooling centers in extreme weather. It’s obvious from these examples that orientation around fee-for-service revenues does not support sustainable approaches to social determinants. Instead, it’s our commitment to health equity in the context of a valuebased economic model that allows for innovation. We hope our experience at Oak Street Health serves as an example to others interested in pursuing value-based models that support evidence-based medicine, health equity, and accountability in the delivery of care and in creating solutions for social determinants—the things that really matter to patients. o Griffin Myers, MD, is Chief Medical Officer and Co-Founder of Oak Street Health. References: Klinenberg, Eric. Heat Wave: A Social Autopsy of Disaster in Chicago. University of Chicago Press, 2005. https://www.weather.gov/lot/1995Jul13_heat https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1854989/ http://press.uchicago.edu/Misc/Chicago/443213in.html https://www.cdc.gov/climateandhealth/pubs/extreme-heat-guidebook.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380980/ https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinantsof-health http://www.nejm.org/doi/full/10.1056/NEJMsa073350?query=recirc_ curatedRelated_article

C.R. BURKE

MARIELLA CUMMINGS

BILL GIL

VINOD JIVRAJKA, MD

JOHN M. KIRK

MATTHEW MAZDYASNI

DONNA J. MILLS

CHARLES E. PAYTON, MD, MBA

ROBERT SEVERS

BART WALD, MD, MBA

AMERICA’S PHYSICIAN GROUPS

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One call does it all.

For coordinated services that address the social determinants of health. • • • • • •

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Medical Home Success...continued from page 31

3. NURSE NAVIGATION INVESTMENT We wouldn’t be able to achieve our quality goals without investing in nurse navigation. The numbers reflect this commitment. ARC’s nurse navigators assisted about 22,000 patients last year. Most recently, we added an emergency room nurse navigator who made 1,300 contacts in one year. ARC deploys four types of navigators: • Care transition, based at the central office. • Chronic care, based in clinics. • Hospital-based, at the primary medical center affiliate. • Diabetes, based at the central office. Routinely, nurse navigators sit in on patients’ physician visits to help clarify, advocate for, and coordinate care—ultimately playing an active role in more fully understanding and documenting each patient’s individual circumstances. Notably, navigators are trained in and regularly use motivational interview techniques to engage patients and encourage them to better care for themselves. More patients who need extraordinary care outside hospital settings are placed where they can get this care. Transitions to local home health and hospice facilities increased 62 percent, from 169 patients in January 2017 to 273 by the end of the year. These transitions benefited ARC financially via shared savings, of course, but it wasn’t cost-free. Moving 273 patients to home health or hospice is a hands-on endeavor, requiring hundreds of nurse navigator visits with patients and many hours of other work. But it is worth it.

4. RELENTLESS OUTREACH Patients with apparent care gaps need to be identified and pursued. In 2017, we scheduled more than 11,000 ARC appointments with identified “gap” patients, a 12 percent increase over the previous year. Working with two Texas health insurance providers (Cigna and Superior), we established a dedicated team to schedule well child checks. Meanwhile, mailing reminders to ACO patients who were overdue for fecal occult blood tests (FOBTs) and colon cancer screenings helped us achieve a 67 percent screening rate. This exceeded the national average of 65 percent and was well above the Texas state average of 58 percent. 62 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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5. STRONG ANALYTICS AND IT DEVELOPMENT Our Analytics and IT teams (and staff assigned to EMR management and improvement) have made it possible to “re-architect” IT infrastructure and create a robust and easily accessible warehouse of EMR and health plan data to enable a comprehensive picture for each patient. This allows ARC to better measure and manage quality and financial performance, as well as identify patients’ complex, high-cost chronic problems. For example, our EMR group developed a “Healthy Planet” module, enabling staff to track and monitor patient tasks and goals in structured fields. Special disease-specific modules now prompt nurses to ask patients specific, relevant questions. These teams research, develop, and administer quality initiatives and measure financial impacts on an ongoing basis. Their behind-the-scenes work makes our clinical achievements possible.

6. HYPER FOCUS ON ACCESS TO CARE It is part of our group’s DNA to focus on access— from the way we design our schedule to investing in online tools and now building out our telemedicine infrastructure and services.

WHY DO WE DO IT? Like most every healthcare provider, we have a mission statement. Ours pledges “to provide coordinated, comprehensive, accessible healthcare to individuals and families in Central Texas, with sensitivity to the cost of that care.” Instituting and successfully operating a wide-ranging care management program has helped us prepare for an anticipated future of accepting increasing responsibility for both quality and cost of care. We are using what we’ve developed and learned to build an even stronger infrastructure that will allow us to move to a fully delegated, full-risk Medicare Advantage platform on January 1, 2019. Being early adopters for the Austin community has earned the respect of the payers that we deal with and has certainly provided a differentiator for us with medium and large employers in the community. o Anas Daghestani, MD, is Chief Executive Officer and Medical Director of Medical Home/Population Health & Clinical Quality for Austin Regional Clinic in Austin, Texas. He is also a practicing internal medicine physician.

Evidence-Based Management... continued from page 33

Similar results across the enterprise (215 PCPs and 55,000 patients) resulted in an overall enterprise reduction in admissions per thousand from 266 to 254. (See chart.) And although our overall ER visits per thousand increased, the providers engaged in the PTG process had a lower percentage increase than those who were not engaged in PTG. Enterprise-Wide Results Year

Admits Per K ER Visits Per K

2016

213

315

Non P TG

2017

214 0.1%

345 9.7%

2016

266

372

P TG

2017

254

386

-4.6%

3.9%

moving health care forward.

A WIN FOR PCPS AND PATIENTS We see these results and our experience as a win for everyone. PCPs were supported in their efforts to care for patients. Patients and families experienced less time in potentially risky hospital environments. And WellMed moved closer to its mission of changing the face of healthcare delivery for seniors. As a whole, we believe we are creating a system where providers have the tools they need to more effectively manage their patients, and where patients benefit from a more coordinated experience that intentionally works to reduce unnecessary care and improve outcomes. We are optimistic we will continue to see improved provider and patient engagement as we evolve our Practice Transformation Group methodology. o Richard Whittaker, MD, is Chief Medical Officer at WellMed Medical Management.

A50857-A_3-18.indd 1

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Enhancing The Triple Aim Through Patient Engagement ELLEN HARRISON, SENIOR VICE PRESIDENT OF MARKET STRATEGY & CONSULTING, HMS ELIZA

“Patient engagement is a critical component to health improvement and achieving The Triple Aim.”

Being patient-centric sounds good, but it is a complicated, costly business, especially for at-risk populations. Equally as important to provider groups are improving health and financial outcomes. The solution to improving those outcomes requires moving individual consumers to be engaged in their own healthcare. That’s where HMS® Eliza comes in. The leader in health engagement management, Eliza® uses multi-channel technology and healthcare communication best practices from over 90 million healthcare consumer interactions, supported by behavior-driven analytics, to close gaps in care and improve patient outcomes and experiences. Moving patients into more active roles in their own care can lead to improved health outcomes, better patient care and lower costs. As the only single vendor solution capable of delivering effective healthcare engagement at scale, Eliza achieves: • Improved patient experience of care (including quality and satisfaction) • Improved health of populations • Reduced per capita cost of health care Eliza has found that true engagement and behavior change requires empathy and an understanding of the barriers that patients within a population face. By incorporating that understanding into its engagement design, Eliza goes beyond one-way, one-channel communication methods to facilitate real conversations with consumers—developing a relationship – at enterprise scale. Whether it is retaining membership, driving appointment scheduling and medication adherence, or following up on post-hospital discharge plans, these intelligent interventions drive consumer healthcare actions that produce significant savings. This is why top healthcare organizations trust Eliza to help lead the voice of their brand. Eliza programs are designed to engage healthcare consumers and drive results that align with HEDIS and CMS measurements. Eliza works with clients to identify and activate specific members to drive utilization of quality improvement programs, which optimizes resources and results in positive ROI. Eliza clients have experienced a two to five percent year-over-year increase in HEDIS quality measures; and have increased the gap in care closure rate by as much as 32 percent. Other results delivered from an Eliza Health Engagement Management solution: Proactively reached out to patients recently discharged for a behavioral health event to assess health status and reduce admissions: Members who interacted with Eliza were 72 percent less likely to readmit than members who did not receive the outreach. Over 30 percent of members asked, accept a real-time transfer to a health

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coach for additional support. 40 percent of those asked requested that a coach call them back later. 57 percent of those asked agreed to offer their email address for further communication. Motivate individuals to adhere to their prescription regimens – Insight captured: 54 percent reported forgetting to take their medication as a main barrier to adherence. Client outcomes: 40 percent increase in member refill rates in targeted population, 25 percent increase in medication adherence with statin treatment, 26 percent increase in medication adherence rates for hypertension over a group that received no intervention. Diabetes testing improvements among Hispanic population - 8.5 percent higher HbA1c testing rate for those who chose to receive communications in Spanish, versus those who were not reached. Members retained to reduce Medicaid churn: $3.6 million in projected annual revenue retained. Dual eligible members were 50 percent more likely to renew after Eliza outreach, and Medicaid members were 25 percent more likely to renew. Increase utilization of health and wellness programs. Website registration and personal health record use increased by as much as 138 percent. Adding email CASE STUDY The Challenge: A large regional Medicaid managed care organization needed to quickly launch a comprehensive multi-channel member engagement strategy that would: • Close gaps in care, improve HEDIS rates and meet quality pay-for-performance goals • Improve brand loyalty and member retention • Prioritize the competing and diverse outreach needs of its members • Collect contact information and consents Enter Eliza. Over the course of a single year, Eliza launched over 20 programs and initiated 2.3 million multi-channel outreaches to almost a million members, resulting in the client achieving pay-for-performance goals. Other results included: 30-42 percent overall engagement rate; 12,877 gaps in care closed; 10 HEDIS measures improved and $15.6 million in revenue retained through member retention efforts.

and SMS to a call outreach results in highest site registration rate. Engage members in their preferred channel. 58 percent opted in to digital communications. 62 percent opted in to future text communications. The Medicaid population faces unique challenges that can make it appear difficult to reach and engage in health conversations. Healthcare providers across the country struggle with obtaining accurate contact information, breaking through cultural barriers and competing against real-life challenges that often take priority over health. Contact Eliza so we can start the conversation about how we can help you overcome these challenges engaging patients to enhance The Triple Aim. Ellen Harrison, 844.343.1441, eliza@hms.com, http://www.elizacorp.com Ellen Harrison brings over 20 years of experience in strategic planning, managed care operations and consulting experience with demonstrated results leading teams to build and redesign health care solutions, provider incentive systems and developing successful quality, cost and utilization improvement programs for commercial, government, and senior populations. Outcome: Over the past two years, these programs have continued to deliver measurable results. In fact, 72 percent of the programs continue to show improvement in year-over-year analysis. We started by launching select programs which were key to driving engagement and impacting HEDIS outcomes quickly. Our continued partnership and focus on aligning our client’s business imperatives with member engagement programs have strengthened the overall outcomes for our client. Member satisfaction rates are as high as 92 percent and our client continues to see improvement in member engagement and health outcomes, resulting in higher quality ratings, less member churn, and cost savings. In fact, the client was so pleased with these Medicaid outcomes that they chose to expand the program to other populations. Because Eliza has proven experience and data insights, we have a deeper understanding of consumer behavior. This gives Eliza the ability to design more effective conversations and ultimately the best outcomes for our clients. View this case study and more insights in the Eliza for Medicaid eBook: bit.ly/ElizaMedicaid1

Paid Sponsorship Spring 2018

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Expanding A1c Testing...continued from page 49

of new members tested in each year averaged 54,756 over the 10-year period. Dr. Melnick: Are there any plans to delve more deeply into this data and how it might be used to achieve the Triple Aim of a better patient experience, improved population health, and reducing the per person cost of healthcare? Dr. Chuang: We plan to study the data in much more detail to better understand how testing can be better targeted, and more importantly, how we can use test results to better manage the health of our members— including slowing down the progression from prediabetes to diabetes. We are very fortunate to have the HealthCare Partners Institute for Applied Research and Education, which collaborates with top researchers from several universities and healthcare delivery science organizations, to help us examine, document, and share lessons learned to strengthen the primary care system. This embedded research collaboration and partnership model is fairly unique and is critical to us—it’s at the heart of evidencebased medicine. It can help shape national health policy with integrity, reduce waste, and better engage patients and providers in care. o Chan Chuang, MD, is Chief Clinical Officer of DaVita HealthCare Partners, a DaVita Medical Group. Glenn

Telehealth...continued from page 51

These simple parameters can decrease readmission rates to the hospital and improve overall health significantly. And this is just the start. What about saving the lives of cardiac rehab patients? A simple exercise watch that monitors a patient’s activity along with his or her nurse manager improves overall quality of life and saves lives. When patients don’t have to drive to a cardiac rehab center and can do rehab from the convenience of their home, outcomes improve. Oh, and as Steve Jobs would say, “There’s one more thing.” The Holy Grail of remote diagnosis. What do I mean by that? Sure, we can do video visits now, but how do we listen to the patient’s heart and lungs and look at a patient’s ears, nose, throat, and skin? The answer, which initially involved large kiosks and expensive carts, can now be done with a consumer-based instrument for less than a few hundred dollars. 66 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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Melnick, PhD, is the Blue Cross of California Chair of Health Care Finance at the University of Southern California and a resident consultant at RAND in Santa Monica. He can be reached at gmelnick@usc.edu. The authors gratefully acknowledge Janelle Howe, Health Enhancement Senior Director; Carolina Hiranand, Quality Improvement Director; Christine Moore, Project Manager; and clinical leaders Christine Castano, MD, and Mohinderjit Neelam, MD, at DHCP for their input regarding implementation of mechanisms to increase hemoglobin A1c testing. Bibliography Babey SH, Wolstein J, Diamant AL, Goldstein H. “Prediabetes in California: Nearly Half of California Adults on Path to Diabetes.” Los Angeles, CA: UCLA Center for Health Policy Research and California Center for Public Health Advocacy, 2016. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2017. https://www.cdc.gov/media/releases/2017/ p0718-diabetes-report.html. Institute for Healthcare Improvement. http://www.ihi.org/Engage/Initiatives/ TripleAim/Pages/default.aspx. International Expert Committee. International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care 2009; 32:1327– 1334. Knowler WC, Fowler SE, Hamman RF, et al. Diabetes Prevention Program Research Group. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program. Outcomes Study. Lancet 2009; 374:1677–1686. Meng YY, Pickett MC, Babey SH, Davis AC, Goldstein H. “Diabetes Tied to a Third of California Hospital Stays, Driving Health Care Costs Higher.” 2014. Los Angeles, CA: UCLA Center for Health Policy Research and California Center for Public Health Advocacy. National Committee for Quality Assurance. http://www.ncqa.org/report-cards/ health-plans/state-of-health-care-quality/2016-table-of-contents/diabetes-care.

This means that patients, in their living rooms, can be remotely guided through a complete physical exam. The physicians, from the convenience of their home or office, can make an intelligent and informed diagnosis. This is the future. We are piloting this in a variety of settings: home, urgent care, and remote offices. This is just the beginning. So, thank you, Alexander Graham Bell. Thank you, Sidney Garfield. You have transformed medicine with telehealth. The future you envisioned is now. Our patients thank you. o Paul Bernstein, MD, FACS, is the Regional Coordinator for Telehealth for Southern California Permanente Medical Group, which serves over four million patients. He is a head and neck surgeon, the former Medical Director for KP San Diego, and Past President of the San Diego Academy of Head and Neck Surgery. He has been active in attending America’s Physician Groups meetings and supporting efforts to advance the principles of managed care. He can be reached at paul.e.bernstein@kp.org.

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Giving Our Doctors the Tools They Need to Succeed Brown & Toland Physicians and our network doctors are uniquely positioned to improve patient outcomes and reduce the total cost of care regardless of current payment models or future models yet to come. As a physician-led organization, we believe that physicians, along with their patients, are best suited for making healthcare decisions. Over the years we have succeeded in providing our patients with the right care at the right time while reducing healthcare costs and improving outcomes. We have achieved this through the use of technology, care management programs, as well as enhanced operations and incentives tied to outcomes and the risk-severity of care delivered to patient populations. This recipe has worked well. Brown & Toland participates in and has delivered results in numerous accountable care projects for HMO and PPO patients, delivering high quality, cost-effective care to hundreds of thousands of patients, regardless of the insurance they carry. As new payment models are implemented that tie to cost-savings, outcomes, and risk-severity of patient populations, Brown & Tolandâ&#x20AC;&#x2122;s successful accountable care track record will help our doctors navigate healthcare payment reform and continue to serve patients in the community. To learn more about Brown & Toland Physicians and our programs, visit brownandtoland.com.

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