HEALTH Volume 8 • No. 6
Dr. George Rapier: Quality and Prevention, p.6 Improved Outcomes with Engaged Patients, p.20 Healthy Employees, Healthy Business, p.28
November/December 2014
Confidence. The feeling you have when you are affiliated with Hill Physicians. Ernesto Quinto, D.O.
Hill Physicians provider since 2011. Uses Ascender preventive care reminders, Hill inSite to review eClaims and eligibility and Hill EHR for a comprehensive solution to patient care, practice management and ePrescribing.
At Hill Physicians, we continue to improve upon coordinated care, with remarkable results. We provide the tools and support that practices need to be financially successful and improve the coordinated care experience for their patients. Our advantages include: • Fast, accurate claims payments • Free eReferrals, ePrescribing and online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,800 independent primary care physicians, specialists and healthcare professionals have joined Hill. Feel confident in the future of your practice and your patients by affiliating with Hill Physicians Medical Group.
For more about the advantages of affiliating, visit HillPhysicians.com/JoinUs.
Hill Physicians’ 3,800 healthcare providers accept HMOs and many PPOs from Aetna, Anthem Blue Cross, Blue Shield, CIGNA, Easy Choice, Health Net, Humana, SCAN, United Healthcare WEST and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.
VITAS Is The ACO Partner You Need For Success Having a hospice and palliative care partner in place is critical to the success of any ACO. Since 1978, VITAS Healthcare has held itself to the standards of today’s ACO. Skilled, appropriate and timely hospice and palliative care reduce unnecessary admissions by relying on VITAS’s evidence-based care protocols, transition processes and ancillary resources. To discuss a specialized program or speak with a VITAS representative, please call 800.873.5198
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TABLE OF CONTENTS
ON THE COVER
6
Dr. George Rapier: Focusing on Quality and Prevention for Healthier Seniors DEPARTMENTS
FEATURES
Publisher
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Editor-in-Chief
Notes from the President
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HEALTH Valerie Okunami Don Crane
Managing Editor
Lura Hawkins, MBA Editor
Daryn Kobata
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Editorial Assistant
Federal Legislative Update
Nelson Maldonado Contributing Writers
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Bill Barcellona Emily Bernadon Amy Bucher, PhD Clayton Chau, MD, PhD Don Crane Emma Hoo Janelle Howe Somi Kim Mara McDermott Raphaela O’Day, PhD Jeremy Rich, MD Jay Thomas, MD Kimberly Whelan CAPG Health Magazine is published by
Valerie Okunami Media PO Box 674, Sloughhouse, CA 95683 Phone 916.761.1853
capghealth.org Please send press releases and editorial inquiries to capghealth@capg.org and/or c/o CAPG Health, 915 Wilshire Blvd., Suite 1620, Los Angeles, CA 90017
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Names in the News
Improved Outcomes Start with Engaging the Patient
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24
Upcoming Events
Working Together to Save Money and Improve Health
16 CAPG Member List
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18
End-of-Life Conversations: Updated POLST Form Improves Decision Making
State Legislative Update
For advertising, please send email to vokunami@netscape.com Subscription rates: $32 per year; $58 two years; $3.00 single copy. Advertising rates on request. Bulk third class mail paid in Jefferson City, MO Every precaution is taken to ensure the accuracy of the articles published in CAPG Health Magazine. Opinions expressed or facts supplied by its authors are not the responsibility of CAPG Health Magazine. Š 2014, CAPG Health Magazine. All rights reserved. Reproduction in whole or in part without written permission is strictly prohibited.
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The Benefits of Integrating Behavioral Health into Coordinated Care Systems
November/December 2014
28 Workplace Population Health: Healthy Employees, Healthy Business
From the President A M ES S AG E F R O M D O N A L D C R A N E , P R ES I D E N T A N D C EO , C A P G
CAPG Members and Friends: This month, CAPG Health looks at ways in which employers can support worker health and well being, including a proven, well-established employee wellness program and tools that can enhance these programs, such as behavioral health services and patient engagement. We think you’ll find valuable information in all of these articles. The National Accountable Care Conference (NACC), held this month in Los Angeles, Donald Crane, is one of three national conferences presented or co-presented by CAPG this year. All CAPG President and CEO three were designed to help our growing membership move forward with confidence in the midst of endless change. More than 1,600 individuals participated in our annual CAPG Healthcare Conference in June. Hundreds more benefited from October’s Colloquium on Medicare Advantage and will do so at the November NACC, which is co-sponsored by the Integrated Healthcare Association, a frequent supporter of CAPG events. It’s exciting to see the enthusiasm of our participants, who want to learn more, know more, and be more successful in bringing high-quality accountable care to their patients. I’m so proud of their willingness to seek and find what they need to be the best of the best. My personal thanks go to our sponsors, speakers, and supporters for their valuable contributions. We have another important member program underway that you’ll be hearing more about in the near future. CAPG has agreed to partner with TransforMED, the renowned nonprofit subsidiary of the American Academy of Family Physicians, to provide our members with a wide variety of customized management resources. As a member, you will have access to a complete and individualized plan for practice transformation, or you can choose those parts that most meet your needs, such as assessment and analysis, practice planning, on-site coaching, and implementation. We believe this offers an unprecedented opportunity for CAPG members to reach new heights of leadership in building innovative and effective primary care practices. When you see the options, we’re certain you’ll agree. o
CAPG HEALTHCARE CONFERENCE
2015
June 11-14, 2015 Manchester Grand Hyatt, San Diego, California
SAVE THE DATE November/December 2014
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ON THE COVER
Focusing on Quality, Prevention, and Improvement for Healthier Seniors On the eve of the 1990s, Dr. George Rapier was more than a little frustrated. The primary care physician had been practicing for nearly a decade and saw a healthcare system badly in need of repair. “The entire focus was on fixing what was broken,” Dr. Rapier said. “There was essentially no focus on prevention, and there was really no focus on helping people live better lives.” With a single vision—to change the face of healthcare delivery for seniors—and $1 million in seed money provided by Pacificare, Dr. Rapier founded WellMed Medical Management in 1990 with a single clinic in San Antonio, Texas. Today, WellMed has grown into a diversified company that serves more than 133,000 patients and is expected to grow to 100 clinics in Texas and Florida by January 2015. Nearly 300 employed providers—PCPs and specialists including cardiologists, rheumatologists, podiatrists, and hospitalists—deliver the company’s brand of healthcare to a largely Medicare-eligible population of seniors. Additional providers contract with WellMed to provide support services such as health coaches and disease management. With a focus on quality and preventive health, the WellMed Care Model has gained national recognition for serving a population of patients that many other doctors are turning away due to declining Medicare reimbursement rates. Photos: Al Rendon Photography
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An independent, federally funded study of WellMed seniors in Texas found that the WellMed Care Model is proven to help patients live a better quality of life, and live longer than their Lone Star State peers. WellMed does it by aligning the interests of the physician, payer and patient to make healthcare work.
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An independent, federally funded study of WellMed seniors in Texas found that the WellMed Care Model is proven to help patients live a better quality of life, and live longer than their Lone Star State peers.”
“I chose WellMed because I believe that healthcare in America is changing from fee-for-service—where the more you see the more you get paid—to a quality-based service where better outcomes get rewarded,” said Dr. Son Nguyen, who recently joined the company as a primary care provider. “WellMed is a leader in the focus on prevention and identification of diseases earlier to avoid future complications.” Dr. Rapier, a Dallas native, earned his medical degree from the University of Florida College of Medicine. He interned and completed his residency at the University of Texas
Health Science Center at San Antonio. His focus on prevention goes back to what he sees as a “Dr. Marcus Welby” approach to medicine. “We really do have to bring back the old-time primary care doctor who cared about you, who was concerned about you, who was part of your family, and you were part of their family,” Dr. Rapier said. “It’s a primary care physician that knows all about you. “So if you need a specialist, they know the best specialist to send you to. If you need to go in the hospital, they make sure you get the appropriate care in the hospital. They are your coordinator of care. And that’s really the concept of a medical home.” For patients like Annette and Ed Reus, WellMed has definitely made a difference. “We have seen an abundance of doctors, from the cancer doctors to the dermatologist, gastroenterologist, the blood doctor, the heart specialist—Ed has gone through it all,” said Annette, whose husband has Crohn’s disease and was once was considered terminally ill. “And they’ve all been coordinated by his primary care doctor. I’ve been to other doctors outside of WellMed and you don’t get the feeling they are communicating like this.” Today, the Reuses are looking forward to celebrating Ed’s 80th birthday in the new year. Building a stable, growing company didn’t come without bumps. WellMed expanded in the 1990s to Dallas and Houston, but began experiencing tremendous strain. Changing market conditions, dramatic reductions in reimbursement, the wrong healthcare partner in Dallas and, Dr. Rapier
admits, “some stupidity on our own part” resulted in near disaster in 1999 and 2000. The company retracted to its San Antonio roots to regroup. During this time, every provider organization in the state except WellMed disappeared, and the company started to gain ground. “It was a difficult lesson, an expensive lesson, but those are sometimes the best lessons,” Dr. Rapier said. “We began to expand again throughout Texas and started our own health plan in 2006 called Physicians Health Choice, with the same philosophy of providing the best practice environment for primary care doctors, fair reimbursement for all providers, and the best care for patients and their families. And that’s been our mission ever since.” After Physicians Health Choice grew to more than 40,000 members, WellMed sold the plan to UnitedHealth Group in 2011. WellMed also entered a partnership with Optum, a UnitedHealth division, with Dr. Rapier maintaining full ownership of the WellMed Medical Group professional association and the 501-A contracting organization. The transaction enabled WellMed to grow quickly and enter new markets. Now well established in Texas and Florida, the company is considering expansion in a number of other areas. With growth has come the ability to give back. Dr. Rapier founded the WellMed Charitable Foundation in 2006 to support the company’s vision. Today, the Foundation operates several senior centers in Texas and caregiver programs including six Caregiver SOS resource centers and the Caregiver Teleconnection educational program (www.CaregiverSOS.org). Yet Dr. Rapier readily acknowledges more work needs to be done. In a recent address to employees, he pushed for transformational change to help WellMed achieve its goals. “Now is the time for us all to step up,” Dr. Rapier said. “Now is the time to start our transformation to a deliberately developmental organization—an organization that can and will grow and change and evolve at the speed we need while we continually improve.” o
CAPG November/December HEALTH September/October 2014 CAPG HEALTH 2014 l 7 l7
Federal Legislative Update Medicare’s Accountable Care Organizations: What’s Next? BY MARA MCDERMOTT, DIRECTOR OF FEDERAL AFFAIRS, CAPG
Beginning this summer, Medicare’s Accountable Care Organizations (ACOs) have garnered a lot of attention. First, there was news that Sharp was exiting the Pioneer ACO program. Sharp was the tenth Pioneer of the original 32 to pull out of the program. By the end of September, three more Pioneers would drop out, creating a lot of buzz about whether the Pioneer program had a viable financial model. In mid-September, the Centers for Medicare & Medicaid Services (CMS) released results on quality improvement and financial performance for the second year of the Pioneer program and the first year of the Shared Savings Program. To summarize, the results showed that the ACOs are, in general, improving quality for Medicare beneficiaries and that some program participants are achieving shared savings. PIONEER RESULTS AT A GLANCE Pioneer ACOs, which were considered to be more advanced organizations in the ACO model from the outset, generated $96 million in savings in the second year (compared to $87 million in the first year). Eleven of the 23 program participants successfully lowered spending to achieve shared savings payments totaling $68 million. Six Pioneers had neutral performance. Six Pioneers generated losses, and of those, three organizations had losses significant enough that they had to pay money back to the federal government. All 23 Pioneers successfully reported quality measures and the mean quality scores increased in 2013. Pioneers also improved average scores for patient and caregiver experience on six out of seven measures. MSSP RESULTS AT A GLANCE Of the 220 MSSP ACOs that started in 2012 or 2013, 53 (about one-quarter) reduced spending enough to qualify for shared savings. Another 52 reduced spending against their benchmarks, but not enough to achieve shared savings. One ACO, Dean Clinic and St. Mary’s Hospital, overspent the benchmark by $10 million and owed shared savings of $4 million. As a whole, MSSPs saved the Medicare Trust Fund $345 million (including repayment of ACO losses). MSSPs improved quality scores on 30 of 33 quality measures. MSSP ACOs are also posting higher CAHPS patient experience survey scores than traditional fee-for-service Medicare. WHAT COMES NEXT? IMPROVEMENTS TO MEDICARE ACO PROGRAMS The CMS results received mixed reviews. While the response to the quality improvement was generally positive, stakeholders and observers expressed concerns about whether the financial results were strong enough to sustain the program in the future. 8 l CAPG HEALTH
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CAPG looks forward to continuing to work with lawmakers and regulators to improve the ACO program for our members, including testing global capitation.”
Some observers, including John Gorman of the Gorman Health Group, cautioned ACO participants that it was time to start planning for an ACO exit strategy. Gorman set out three choices for ACOs: return to fee-forservice; contract with existing Medicare Advantage (MA) plans; or form their own MA plans and “move up the food chain.” Others joined Gorman, predicting that the ACO movement would ultimately fuel more participation in provider-led MA products. But for those not yet ready to abandon the ACO program, it seems clear that there are some muchneeded legal and regulatory program changes. Providers participating in ACOs, including CAPG members, have identified various barriers to the program’s success, including a lack of beneficiary engagement, insufficient incentives for beneficiary participation, and barriers to beneficiary communication. From CAPG’s perspective, perhaps the biggest missing element has been the testing of the capitated payment model—an aspect of the program that was anticipated to be part of the Pioneer program but has yet to truly materialize. Earlier this year, CMS sent a proposed rule to the Office of Management and Budget for review. The
HEALTH Reach 180 physician groups in 29 states and Puerto Rico, top employers, public policymakers, and other influential healthcare leaders.
rule, which was to be released at the beginning of the summer, reportedly contained substantial proposed changes to the ACO program—perhaps addressing some of the flaws described above. However, as of this writing, the rule had not been released. Absent rulemaking to alleviate some of the problems with the ACO program, Representatives Peter Welch (D-VT) and Diane Black (R-TN) introduced legislation to address some stakeholder concerns. Notably for CAPG members, the legislation would require CMS to test a globally capitated ACO. CAPG looks forward to continuing to work with lawmakers and regulators to improve the ACO program for our members, including testing global capitation. We anticipate a long road ahead, with a fair share of bumps, but we also know that CAPG members have the expertise and experience to improve the program. We look forward to bringing that knowledge and expertise to Congress and the Administration. CAPG members interested in joining CAPG’s ACO committee to take a closer look at legislative, regulatory, and clinical ACO issues should contact Francine Moskowitz or Mara McDermott. o
Q1 HR, Finance, and Operations: The Business of Healthcare Deadline for Editorial: Friday, December 12, 2014 Deadline for Advertising: Monday, December 15, 2014 NEW IN 2015: • E-Version For Increased Circulation • Medical Profiles Sponsored Articles • Credit Cards Accepted
Contact Valerie Okunami at 916-761-1853 or capghealth@gmail.com
November/December 2014
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The Benefits of Integrating Behavioral Health into Coordinated Care Systems BY CLAYTON CHAU, M D , PhD , M E D I C A L D I R E C TO R , B E H AV I O R A L H E A LT H D E PA R T M E N T, L . A . C A R E H E A LT H PLAN
One of the unfortunate consequences of siloed healthcare services is the lack of communication between physicians, specialists, and other providers. A key reason for the rise of coordinated care systems across the U.S. is the need for better communication to benefit physicians and patients alike. California’s Coordinated Care Initiative (CCI) created one such system called Cal MediConnect, which is designed to improve the way the state delivers healthcare to low-income seniors and people with disabilities. Dual eligible patients (those who qualify for both Medicare and Medi-Cal) now have the option to enroll in Cal MediConnect, and receive all of their benefits through a single, complete, and coordinated system of care under one health plan.
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For physicians who treat dual eligible patients, behavioral health coordination can be an indispensable resource in effectively managing challenging patients...”
Patients who enroll in Cal MediConnect will enjoy the support of a care manager to help them navigate and coordinate the full range of medical, pharmacy, longterm care (home and community-based), and behavioral health services. SUPPORT FOR PHYSICIANS According to a 2012 Kaiser Family Foundation report, 34% of dual eligibles nationwide suffer from chronic behavioral health issues, such as schizophrenia, bipolar disorder, depression and post-traumatic stress disorder (PTSD), along with other chronic medical conditions. Unfortunately, there is a lack of knowledge among this population regarding what mental health benefits are available to them. According to a recent field poll commissioned by the California HealthCare Foundation, only 54% of Medicare beneficiaries and 47% of MediCal beneficiaries believe their health plan provides mental health care benefits. For physicians who treat dual eligible patients, behavioral health coordination can be an indispensable resource to effectively managing these challenging patients, and can help support the practicing physician during this time of increased demand and decreased time. As a primary care physician operating in a strictly fee-for-service universe, if you encounter a patient with high behavioral health needs, the best you can do is recommend that he or she visit a mental health specialist. But what happens then? You may never hear back from the patient or the specialist, despite your best efforts. But if you are participating in a Cal MediConnect health plan, a care manager handles the follow up and care coordination for you—easing your administrative burden and significantly increasing the likelihood that your patient receives the care needed. Another recurring problem that is greatly reduced by this coordination is the challenge of medication interactions. Many psychiatric medications have a high drug-to-drug interaction profile when combined with medications prescribed for
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other chronic physical health conditions, which might render the patient at risk for complicated outcomes. Furthermore, antipsychotic agents put patients at increased risk for medical conditions such as obesity, hypertension, diabetes, and heart disease. A coordinated system provides a wealth of information to help physicians avoid prescribing contraindicated medications, as well as better monitor a patient’s chronic health conditions. BETTER HEALTH OUTCOMES FOR PATIENTS The improved communication provided by the integration of behavioral health services can have a positive effect on all aspects of a patient’s care. For individuals struggling with chronic conditions such as heart disease and high blood pressure, co-related behavioral health issues like depression may prevent them from achieving full adherence with their treatment regimens. A Cal MediConnect care manager can help dual eligible patients access the behavioral health treatment they need to better manage other chronic conditions. Dual eligible patients attempting to navigate a fee-for-service environment on their own often encounter unnecessary roadblocks. For example, a patient who regularly visits a psychiatrist or other behavioral health specialist may have an untreated heart condition that is impacting their mental health. However, the psychiatrist can only suggest that
the patient see a heart specialist. But if the patient is enrolled in a coordinated care system, a care manager could facilitate vital communication between the patient, primary care physician, cardiologist, and psychiatrist, conducting the necessary follow-up to ensure that treatment is pursued and received. HOW IT WORKS If you are new to coordinated systems of care, you may have questions about how patients’ behavioral health needs are identified and how information is transmitted between physicians, specialists, and the plan. Generally, physicians have the option to refer patients to specialists that belong to a plan’s provider network, after which a plan representative follows up with the patient to facilitate the next steps. Moreover, Cal MediConnect health plans are required upon enrollment to conduct a health risk assessment (HRA)—a unique service of coordinated care. The additional benefit may be early identification of potential behavioral health issues leading to earlier intervention and better patient outcomes. Integrating behavioral health services into coordinated care plans offers a number of benefits for both physicians and patients. It is part of a growing movement to address the lack of communication resulting from siloed services and to create a more holistic—and effective—approach to healthcare. o
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Names in the News UCLA RESEARCHER RECEIVES NIH NEW INNOVATOR AWARD UCLA Jonsson Comprehensive Cancer Center member Dr. Lili Yang has received a National Institutes of Health (NIH) Director’s New Innovator Award of $2.3 million, recognizing her breakthrough research on new ways to attack cancer tumors. Dr. Yang is developing ways to model how human blood stem cells can be genetically programmed to become iNKT cells, which are able to respond immediately and powerfully to disease when activated. Such models may provide a roadmap for future therapies to increase the number of blood iNKT cells—thus increasing the body’s ability to fight off cancer. “The potential for [this] gene therapy is very exciting…[it] could have universal application, treating many types of cancer and a large group of patients no matter what types of tumor they have,” said Dr. Yang. “It holds tremendous promise for the future.” ANTHEM BLUE CROSS, SEVEN SOUTHERN CALIFORNIA HEALTH SYSTEMS LAUNCH VIVITY Anthem Blue Cross and seven hospital systems have partnered to offer Anthem Blue Cross Vivity, an integrated health system in Los Angeles and Orange counties. This partnership is the first in the U.S. between an insurer and seven competing hospital systems that will align to benefit all Vivity members and also share financial risk and gain. The systems, all with hospitals ranked in the top 30 in the two counties by U.S. News & World Report, are CedarsSinai, Good Samaritan Hospital, Huntington Memorial Hospital, MemorialCare Health System, PIH Health, Torrance Memorial Medical Center, and UCLA Health System. Vivity continues the trend of moving away from traditional fee-for-service reimbursements toward a structure that financially rewards activities to keep patients healthy. PROMINENT ORTHOPAEDIC AND SPORTS MEDICINE GROUPS JOIN CEDARS-SINAI Cedars-Sinai Health System has finalized an agreement with the Institute for Sports Sciences to become formally affiliated with Kerlan-Jobe Orthopaedic Clinic and Santa Monica Orthopaedic and 12 l CAPG HEALTH
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Sports Medicine Group. The collaboration between the two orthopedic groups—well known for their care of professional sports teams and athletes—and the nationally renowned orthopedic physicians and staff at Cedars-Sinai creates the framework for a new model of patient-centered care integrating the latest research and treatment options. The affiliation expands the partners’ geographic reach, enhancing the community’s access, and will enhance patient care by facilitating collaborations among the entities such as expanded clinical trials and research, patient access to Cedars-Sinai, and collaborations on complex cases. PEDIATRICIAN JOINS BAY VALLEY MEDICAL GROUP Justin Sweder, MD, FAAP has joined Bay Valley Medical Group’s Hayward, California, office, working with Carolyn Hudson, MD, and Lilia Oceguera, MD. Board certified in pediatrics, Dr. Sweder has extensive experience working with children with developmental needs and is bilingual in English and Spanish. He earned his BA from Yale University and his medical degree at George Washington University School of Medicine, and completed his residency at the Children’s Hospital and Research Center in Oakland, California. LA BIOMED AWARDED NIH GRANT TO STUDY VACCINE FOR HOSPITAL-ACQUIRED INFECTIONS The National Institute of Allergy and Infectious Diseases of the National Institutes of Health (NIH) recently awarded the first year of a four-year, $1.3 million grant to Los Angeles Biomedical Research Institute researchers John E. Edwards, MD, and Ashraf S. Ibrahim, PhD. The grant will fund their work to develop a vaccine to protect patients from the healthcare-related infections Candida and Methicillincontinued on page 22
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E V E N T S
CAPG/IHA FIFTH NATIONAL ACCOUNTABLE CARE CONGRESS November 10–12, 2014 Hyatt Regency Century Plaza, Los Angeles, CA www.acocongress.com The trend toward accountable, coordinated care has taken hold in every region of the U.S. At the Accountable Care Congress, leading experts including policymakers, executives, and those on the front lines of ACO implementation and operations will offer high-level insights and hands-on knowledge of this influential sector.
SOUTHERN CALIFORNIA HIMSS 7TH ANNUAL CIO FORUM November 18, 2014 Richard Nixon Library, Yorba Linda, CA http://socal.himsschapters.rd.net/Events/ The 2014 CIO Forum will feature a keynote by Barry Arbuckle, PhD, President and CEO of MemorialCare Health System, and other distinguished leaders on “Taking Electronic Records to the Next Level.” Presenters will share organizational visions and strategic initiatives for ambulatory EMRs, genomics, informatics, and population health.
U P C O M I N G
INDUSTRY COLLABORATION EFFORT (ICE) ANNUAL CONFERENCE December 11–12, 2014 Hyatt Regency, San Francisco, CA www.iceforhealth.org ICE is partnering with the Centers for Medicare and Medicaid Services to present this event focusing on healthcare industry developments and operational improvements that offer opportunities to health plans, physician organizations, and industry administrators for efficiencies and standardization.
CAPG GENERAL MEMBERSHIP (SO CAL) November 4, 2014 Los Angeles, CAPG Office*
CAPG PHARMACEUTICAL CARE COMMITTEE November 5, 2014 Los Angeles, Hilton Los Angeles Airport*
CAPG STATE GOVERNMENT PROGRAMS COMMITTEE November 18, 2014 Los Angeles, CAPG Office*
CAPG GENERAL MEMBERSHIP (NO CAL) November 20, 2014 Oakland, CA*
*For more information contact CAPG at (213) 642-CAPG. If you have an event to submit for this column, please do so at CAPGHealth@CAPG.org. Please include the name of the event, date, location and where to get additional information.
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REGISTRATION NOW OPEN
THE FIFTH NATIONAL
ACCOUNTABLE CARE CONGRESS NOVEMBER 10–12, 2014
HYATT REGENCY CENTURY PLAZA, LOS ANGELES
www.acocongress.com In Person or Via Webcast
KEYNOTE SPEAKERS: • Elliott S. Fisher, MD, MPH, Director, The Dartmouth Institute for Health Policy and Clinical Practice • Samuel W. Ho, MD, Executive VP and CMO, UnitedHealthcare; President, UnitedHealthcare Clinical Services • Jonathan S. Bush, MBA, Cofounder, CEO, and President, athenahealth • Hoangmai H. Pham, MD, MPH, Acting Director, Seamless Care Models Group, Center for Medicare and Medicaid Innovation, CMS • Farzad Mostashari, MD, Founder and CEO, Aledade, Inc.; Visiting Fellow, Engelberg Center for Health Care Reform, Brookings Institution • And more
FEATURED SESSIONS: • CMS Accountable Care Update • Health Plan Perspectives: Commercial ACO Arrangements • Hospital Perspectives: Role of Hospitals in Accountable Care • Physician Group Perspectives: Leading Accountable Care • Mobilizing Team Based Care Towards Patient Engagement and Population Health • Lessons Learned in Launching a Commercial ACO • Risky Business: California's Delegated Model in Critical Condition • Accountable Care and Government Programs
SPONSORSHIP AND EXHIBIT INFORMATION: Lura Hawkins, 213.239.5046 or lhawkins@capg.org
PRODUCED BY:
MEDIA PARTNERS:
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ORGANIZATIONAL MEMBERS
C A P G
M E M B E R S
Accountable Health Care IPA George M. Jayatilaka, MD, CEO Druvi Jayatilaka, Vice President Advanced Medical Management, Inc. Kathy Hegstrom, President • Access Medical Group/Access Santa Monica • Community Care IPA • Future Care IPA • MediChoice IPA • Pacific Healthcare IPA • Premier Care IPA • Seoul Medical Group • Affinity Medical Group Richard Sankary, MD, President Scott Ptacnik, COO AllCare IPA* Randy Winter, MD, President Matt Coury, CEO All Care Medical Group Samuel Rotenberg, MD, Medical Director Craig Kaner, Administrator Allied Physicians of California Thomas Lam, MD, CEO Kenneth Sim, MD, CFO Alta Bates Medical Group* Richard L. Oken, MD, President and Chairman of the Board Evan Moore, Vice President, East Bay Region AltaMed Health Services Corporation* Martin Serota, MD, Chief Medical Officer Castulo de la Rocha, JD, President/CEO AppleCare Medical Group, Inc.* Surendra Jain, MD, Chief Medical Officer Vinod Jivrajka, MD, President/CEO Bakersfield Family Medical Center Ju Hwan Lee, MD, Medical Director Beaver Medical Group* Charles Payton, MD, VP Medical Administration/CMO John Goodman, President/CEO Brown & Toland Physicians* Andrew M. Snyder, MD, Chief Medical Officer Richard Fish, CEO California Pacific Physicians Medical Group, Inc. Dien V. Pham, MD, Chief Executive Officer Carol Houchins, Administrator CareMore Medical Group Tom Tancredi, Dir. of Practice Operations Catholic Health Initiatives* Clifford Deveny, MD, SVP, Physician Services and Clinical Integrations James Slaggert, VP Physician Practice Management Cedars-Sinai Medical Group* Stephen C. Deutsch, MD, Chief Medical Director Thomas D. Gordon, CEO Children’s Physicians Medical Group Leonard Kornreich, MD, President and CEO Chinese Community Health Care Association John M. Williams, PharmD., CEO Polly Chen, Director of Operations Choice Medical Group IPA Manmohan Nayyar, MD, President Marie Langley, IPA Administrator * Indicates 2013 - 2014 Board Members
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November/December 2014
Cigna Medical Group Kevin Ellis, DO, Chief Medical Officer Edward Kim, President and General Manager Conifer Health Solutions Megan North, CEO • AKM Medical Group • Amvi Medical Group • Exceptional Care Medical Group • Family Choice Medical Group • Family Health Alliance • Huntington Park Mission Medical Group • Medicina Familiar Medical Group • New Horizon Medical Group • Noble Community Medical Associates • OmniCare Medical Group • Premier Physician Network • United Care Medical Group • DCHS Medical Foundation Dean M. Didech, MD Chief Medical Officer Ernest Wallerstein, CEO Desert Oasis Healthcare* Marc Hoffing, MD, Medical Director Dan Frank, Chief Operating Officer Dignity Health Bruce Swartz, SVP, Physician Integration Edinger Medical Group Matthew C. Boone, MD, Executive Medical Director Denise McCourt, Chief Operating Officer Empire Physicians Medical Group* Steven Dorfman, MD, President Yvonne Sonnenberg, Executive Director Everett Clinic, P.S., The Adrianne Wagner, Quality Improvement Consultant Manager Shashank Kalokhe, Associate Administrator of Value-Based Contracting and Coordinated Care Facey Medical Foundation* Erik Davydov, MD, Medical Director Bill Gil, President/CEO Golden Empire Managed Care, Inc.* C. Vincent Phillips, MD, President Robert Severs, CEO Good Samaritan Medical Practice Association Nupar Kumar, MD, Medical Director Greater Newport Physicians Medical Group, Inc.* Diane Laird, CEO HealthCare Partners* Robert Margolis, MD, Co-Chairman of the Board, DaVita Heritage Provider Network* Richard Merkin, MD, President Richard Lipeles, Chief Operations Officer • Affiliated Doctors of Orange County • Bakersfield Family Medical Group • California Coastal Physician Network • California Desert IPA • Desert Oasis Healthcare • Greater Covina Medical Group • Heritage Physician Network • Heritage Victor Valley Medical Group • High Desert Medical Group • Regal Medical Group • Sierra Medical Group • High Desert Medical Group Charles Lim, MD, FACP, Medical Director Anthony Dulgeroff, MD, Assistant Medical Director Hill Physicians Medical Group, Inc.* Tom Long, MD, Chief Medical Officer Darryl Cardoza, CEO Independence Medical Group Armi Lynn Walker, MD, Medical Director Gary M. Bohamed, Executive Director
John Muir Physician Network Ravi Hundal, MD, Medical Director Lee Huskins, Interim CEO/SVP/COO Lakeside Community Healthcare Kerry Weiner, MD, Chief Medical Officer Jonathan Gluck, Counsel Lakeside Medical Group, Inc. Lakewood IPA Jean Shahdadpuri, MD, MBA, Chief Medical Officer Varsha Desai, Chief Operating Officer • Alamitos IPA • St. Mary IPA • Brookshire IPA • Loma Linda University Health Care J. Todd Martell, MD, Medical Director Maverick Medical Group Warren Hosseinion, MD, Chairman Mark C. Marten, CEO MED3000 Gary Proffett, MD, Medical Director Lynn Stratton Haas, CEO • SeaView IPA • Valley Care IPA • MedPoint Management Rick Powell, MD, Chief Medical Officer Kimberly Carey, President • Apollo Healthcare • 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 • Redwood Community Health Network • United Physicians International • Watts Healthcare Corporation • MemorialCare Medical Group* Mark Schafer, MD, CEO Jennifer Jackman, Chief Operating Officer Meritage Medical Network J. David Andrew, MD, Medical Director Joel Criste, CEO Molina Medical Centers Keith Wilson, MD, Vice President of Clinical Services Gloria Calderon, Vice President of Clinic Operations Monarch HealthCare* Bart Asner, MD, CEO Ray Chicoine, President and COO MSO of Puerto Rico Richard Shinto, MD, CEO Raul Montalvo, MD, President Muir Medical Group, IPA Steve Kaplan, MD, President Ute Burness, RN, CEO NAMM California* Leigh Hutchins, President, COO Elizabeth Haughton, Vice President, Legal Affairs • Coachella Valley Physicians of PrimeCare, Inc., • Mercy Physicians Medical Group • Primary Care Associated Medical Group, Inc. • PrimeCare Medical Group of Chino • PrimeCare of Citrus Valley • PrimeCare of Corona • PrimeCare of Hemet Valley Inc • PrimeCare of Inland Valley • PrimeCare of Moreno Valley • PrimeCare of Redlands • PrimeCare of Riverside • PrimeCare of San Bernardino • PrimeCare of Sun City • PrimeCare of Temecula • Redlands Family Practice Medical Group, Inc. •
Omnicare Medical Group Ashok Raheja, MD, Medical Director Toni Chavis, MD, President
San Bernardino Medical Group Thomas Hellwig, MD, President James Malin, CEO
Triad HealthCare Network, LLC Thomas C. Wall, MD, Executive Medical Director Steve Neorr, VP, Executive Director
The Permanente Medical Group, Inc. Oakland (North)* Sharon Levine, MD, Associate Executive Director Suketu Sanghvi, MD, Associate Executive Director
San Diego Physicians Medical Group James Cordell, MD, President Joyce Cook, CEO
U.C.L.A. Medical Group* Sam Skootsky, MD, Medical Director David Hartenbower, MD, COO
San Luis Obispo Select IPA Barbara Cheever, Executive Director
USC Care Medical Group, Inc. Donald Larsen, MD, Chief Medical Officer Keith Gran, CEO
Physicians DataTrust Anthony Ausband, President Lisa Serratore, Chief Operations Officer • Greater Tri-Cities IPA • Noble AMA IPA • St. Vincent IPA • Physicians Medical Group of Santa Cruz County* Nancy Greenstreet, MD, Medical Director Marvin Labrie, CEO Physicians Medical Group of Santa Maria John Okerblom, MD, President Barbara Cheever, Executive Director Physicians of Southwest Washington, LLC Gary R. Goin, MD, President Mariella Cummings, CEO PIH Health Physicians Deeling Teng, MD, Sr. Medical Director, Group Operations Ramona Pratt, RN, Chief Operating Officer, Group Operations Pioneer Medical Group, Inc.* Jerry Floro, MD, President John Kirk, CEO Preferred IPA of California Mark Amico, MD, Medical Director Zahra Movaghar, Administrator Prospect Medical Group Prasad Jeereddi, MD, Chairman Mitchell Lew, MD, CEO • AMVI/Prospect Health Network • Gateway Medical Group • Genesis Healthcare • Nuestra Familia Medical Group • Prospect Corona • Prospect HealthSource • Prospect Huntington Beach • Prospect Northwest Orange County • Prospect Orange County • Prospect Professional Care • Prospect Van Nuys • Providence Medical Management Services Bart Wald, MD, Physician Chief Executive Phil Jackson, Chief Integration and Transformation Officer • Korean American Medical Group • Providence Care Network • Providence Health & Services Bart Wald, MD, Physician Chief Executive Bill Gil, Chief Executive Medical Foundations River City Medical Group, Inc. Jose Abad, MD, President/Medical Director Loren Douglas, CEO Riverside Medical Clinic Steven Larson, MD, Chairman Judy Carpenter, President/COO Riverside Physician Network Paul Snowden, COO Howard Saner, CEO St. Joseph Heritage Healthcare Khaliq Siddiq, MD, Chief Medical Officer C.R. Burke, CEO • Hoag Medical Group • Mission Heritage Medical Group • St. Mary High Desert Medical Group •
Sansum Clinic* Kurt Ransohoff, MD, Medical Director/CEO Vince Jensen, COO Santa Clara County IPA (SCCIPA)* J. Kersten Kraft, MD, President of the Board Lori Vatcher, CEO
WellMed Medical Group, P.A. George M. Rapier III, MD, Director and VP Carlos O. Hernandez, MD, President CORPORATE PARTNERS
Santé Health System, Inc Daniel Bluestone, MD, Medical Director Scott B. Wells, CEO Scripps Coastal Medical Center* Louis Hogrefe, MD, APC, Chief Medical Officer Tracy Chu, Assistant Vice President of Operations Sharp Community Medical Group* John Jenrette, MD, CEO Christopher McGlone, Chief Operating Officer • Graybill Medical Group • Arch Health Partners • Sharp Rees-Stealy Medical Group* Donald C. Balfour, III, MD, Chief Medical Officer Stacey Hrountas, SVP and CEO
Anthem Blue Cross of California Athenahealth Bayer HealthCare Pharmaceuticals Boehringer Ingelheim Pharmaceuticals, Inc. Humana, Inc. Merck & Co. Novartis Pharmaceuticals Novo Nordisk Patient-Centered Primary Care Collaborative SCAN Health Plan ASSOCIATE PARTNERS
Southeast Permanente Medical Group, Inc., The Michael Doherty, MD, Executive Medical Director and Chief of Staff Southern California Permanente Medical Group* Vito Imbasciani, MD, Director of Government Relations James Malone, Medical Group Administrator Sutter Health Foundations & Affiliated Groups* Jeffrey Burnich, MD, SVP and Executive Officer, Sutter Medical Network Brian Roach, President, Mills Peninsula Division of PAMF • Brown & Toland Physicians • Central Valley Medical Group • East Bay Physicians Medical Group • Gould Medical Group • Marin Headlands Medical Group • Mills-Peninsula Medical Group • Palo Alto Foundation Medical Group • Palo Alto Medical Foundation • Peninsula Medical Clinic • Physician Foundation Medical Associates • Sutter East Bay Medical Foundation • Sutter Gould Medical Foundation • Sutter Independent Physicians • Sutter Medical Foundation • Sutter Medical Group • Sutter Medical Group of the Redwoods • Sutter North Medical Group • Sutter Pacific Medical Foundation • SynerMed* George Ma, MD, Medical Director James Mason, President and CEO • Alpha Care Medical Group • Angeles IPA • Crown City Medical Group • EHS Inland Valleys IPA • EHS Medical Group – Central Valley • EHS Medical Group – Los Angeles • EHS Medical Group – Sacramento • Employee Health Systems • MultiCultural IPA • Pacific Alliance Medical Center • Southern California Children’s Network •
abbvie Actavis Pharma, Inc. Arkray Astellas Pharma US, Inc. AstraZeneca Pharmaceuticals CVS Caremark, Corp. Daiichi Sankyo Eisai, Inc. GenPath Diagnostics Genomic Health Gilead Sciences Group Practice Forum Johnson & Johnson Family of Companies Kaufman, Hall & Associates Kindred Healthcare, Inc. Lilly USA, LLC Pfizer, Inc. Ralphs Grocery Company Sanofi Sunovion Pharmaceuticals Inc. The Doctors Company Vitas Healthcare Corporation of California AFFILIATE PARTNERS Altura Ascender Software, LLC Clarity Health Services Childrens Hospital Los Angeles Medical Group Mills Peninsula Medical Group MZI HealthCare, LLC Partners in Care Foundation Pharmacyclics, Inc. Redlands Community Hospital Saint Agnes Medical Group SullivanLuallin Group Ventegra, LLC
Talbert Medical Group* Pratibha A. Patel, MD, Market President Donald Rebhun, MD, Corporate Medical Director Torrance Hospital IPA Norman Panitch, MD, President Stephen J. Linesch, CEO November/December 2014
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State Legislative Update Provider Direct Capitated Contracting with Employer ERISA Plans BY B I L L B A R C E L LO N A , SENIOR VP, GOVERNMENT AFFAIRS, CAPG
Enrollment in commercial fully insured HMO coverage has been declining for over a decade. As enrollment declines, it is made up by growing enrollment in Medi-Cal managed care HMO coverage, which is a far less secure revenue source for risk-bearing physician groups that are paid under capitated arrangements and delegated for downstream claims payment. Recently, the California Department of Managed Health Care published a report indicating that nonKaiser enrollment between commercial HMO and Medi-Cal managed care had reached parity (figure 1). California risk-bearing groups now face a future in which there are fewer commercial enrollees than Medi-Cal beneficiaries. These groups need to find greater diversity of payer sources if fully insured commercial enrollment continues to erode, since the current MediCal capitation
rates can severely undermine the financial solvency of a risk-bearing group. Some posit that the Covered California SHOP exchange will provide increasing enrollment in small group coverage over the next several years. The history of the Massachusetts exchange indicates otherwise: Since its inception in 2007, small group employers have been slow to transfer their enrollment. There will be additional uncertainty if Proposition 45 passes in early November. Proposition 45 is a California ballot measure that would insert additional regulatory oversight into the individual and small group markets in Covered California by the Insurance Commissioner. It also empowers third-party interveners to sue over rate and benefit filings made by exchange qualified health plans with the Insurance Commissioner— likely delaying time to market and creating chaos in the annual open enrollment process if specific product filings are delayed.
Figure 1 Non-Kaiser enrollment between commercial HMO and Medi-Cal managed care reached parity in 2013.
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At the same time, ERISA employer plans1 continue to complain about problems with their fragmented, unaccountable provider networks, many of which are leased from PPO plans. Employers
dislike their inability to obtain useful performance metrics from provider networks. They have experimented with reference pricing, bundled payment, and other alternative payment models to incent greater transparency of cost and quality, but have failed to find an effective delivery system model to both control cost and improve quality of care in a measurable, demonstrable way. California has for some time prohibited risk-bearing contracting between ERISA employer plans and physician groups that are used to functioning under capitated payments. Under the Knox Keene Act, the Department of Managed Health Care has required a Knox Keene license in cases where risk-bearing payments are made. ERISA plans have been reluctant to obtain full Knox Keene licenses just to pay providers in risk-bearing arrangements; this requirement defeats the underlying purpose of establishing an ERISA plan. CAPG has proposed that the State of California authorize the use of a restricted Knox Keene HMO license obtained by a provider entity (either a capitated physician group or integrated delivery system of hospitals and physicians) to enable a risk-bearing delivery system to contract directly with the ERISA plan and receive capitated payment. By placing the restricted license with the provider rather than the ERISA plan, the plan is saved the expense and duplication of obtaining a Knox Keene license that it does not need to conduct business on behalf of its employees. The employer plan derives the benefit of contracting with a risk-bearing delivery system that can coordinate patient care across a multi-specialty network, gather and report performance metrics from among its providers, and deliver accountable care that is budgeted. Restricted licensees would likely be longstanding participants in the Integrated Healthcare Association’s Pay-for-Performance program, for example, able to gather and report performance measures to an employer. The current 1 The Employment Income Security ACT (ERISA) is a federal statute that governs employer-provided benefits for retirement and health care. An ERISA-covered group health plan is an employment-based plan that provides coverage for medical care, hospitalization, physician services, prescription drugs, vision or dental services. A group health plan can provide benefits by using funds in a plan trust, the purchase of insurance, or by self-funding benefits from the employer’s general assets.
leased PPO networks often used by ERISA plans are incapable of such activity. By contracting directly with the risk-bearing delivery system, the employer can directly realize the savings generated by the provider that would normally accrue only to the fully insured HMO that has served as the middleman for several years.
“
The restricted HMO license does not We believe that enable the provider employers can entity licensee to sell coverage directly to benefit greatly the public. To do so, from the inclusion a full Knox Keene license must be of risk-bearing obtained. In this way, delivery systems restricted licensees can continue in capitated in their overall arrangements with fully ERISA plan provider insured commercial networks.” HMO plans; further, in light of increasing underpaid Medi-Cal managed care enrollment, they can also diversify and strengthen their financial solvency by adding capitated ERISA plan enrollees within their network. CAPG has prepared a draft version of a Knox Keene Title 28 regulation and submitted it to the Department of Managed Health Care. The DMHC is evaluating whether to proceed with the adoption of such a regulation. If it does, the Administrative Procedures Act requires the Department to post the regulation for public review and to obtain written comment from the public under a prescribed time period, usually 45 days. We believe that employers can benefit greatly from the inclusion of risk-bearing delivery systems in their overall ERISA plan provider networks. A restricted licensee could even receive global capitation from the plan—both hospital and professional fee capitation. The potential has never been greater for the alignment of incentives between the employer ERISA plan and its contracted, risk-bearing provider network under this kind of arrangement. o
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Improved Outcomes Start with Engaging the Patient BY A M Y B U C H E R , P h D , R A P H A E L A O ’ D AY, P h D , K I M B E R LY W H E L A N , E M I LY B E N A D O N , A N D S O M I K I M , J O H N S O N & J O H N S O N
PATIENT ENGAGEMENT IS A BURNING ISSUE FOR HEALTHCARE PROVIDERS BUT NOT NECESSARILY FOR PATIENTS. The Affordable Care Act (ACA) has heightened the focus on optimizing patient outcomes, whether that means maximizing biometric outcomes or minimizing hospital readmission rates. The fact is that good care doesn’t just come from inside the health system. Many, if not most, of the factors that predict patient outcomes are patient behaviors. For the best possible outcomes, patients must be engaged in their own health. Unfortunately, even as we recognize the growing need for an engaged patient population, research suggests that patient attitudes are moving in the wrong direction. In 2012, Deloitte published a report that found one out of three healthcare consumers self-identify as disengaged, see little need for preventative care, and have low interest in health education1. In fact, a lack of understanding of what is required to be healthy is associated with poor health outcomes. People who lack the skills, ability, and willingness to engage in their own health may incur healthcare costs up to 21% higher than other people2. SO, HOW DO YOU GET PATIENTS INVESTED IN THEIR OWN HEALTH? Johnson & Johnson Health Care Systems created a cross-functional team with representatives from behavioral psychology in our Wellness & Prevention team, Global Strategic Design Office, Market Research Insights, and many other functional teams to address that question. Together, we leveraged behavioral science theory, design market research insights, and case studies of successful interventions to develop seven principles for sustained engagement that can be used to enhance any interaction a healthcare organization might have with its members. The data support that the engaged patient is one who takes ownership of his or her own health, and works in collaboration with providers and supporters to achieve the best possible outcomes. We have defined this network of individuals as the ecosystem or community of care. In order for patients to be actively engaged, their values, beliefs, and behaviors must be taken into consideration; they must be encouraged to participate and engage, and to help build a community of care. The seven principles of sustained engagement that we’ve created are organized on a framework based in motivational psychology3. There is a deep body of research that shows people share fundamental psychological needs, and that a motivating experience is one that helps fulfill those needs in some way. The three most basic needs that form the hub of our framework are connection, confidence, and ownership. Patients must have some sense of control over their health experience, believe in their ability to feel understood and accepted, and take action. 5 l20 CAPG HEALTH 2014 HEALTHJuly/August November/December 2014 l CAPG
As our definition of sustained engagement suggests, we believe that engagement happens both within the patient and within the patient’s system of care. Many parties have critical roles to play in the collaboration that leads to improved outcomes. When all individuals within the system of care are able to use the principles of engagement effectively in interactions with patients, those patients will be more motivated to follow through on the behaviors to support their health in their daily lives. Here are some of the ways that the community of care surrounding patients, including the healthcare providers, can support each of the three basic psychological needs for their patients: CONNECTION: People who feel connected to others not only feel like part of a community or social group, they also feel recognized and understood. They can reach out to others for support in a way that advances their goals. Connection is the basic need where interpersonal dynamics between provider and patient are most critical. Strong, empathic, and active listening skills can help a patient feel engaged. Using language that is meaningful to the patient and reflects back the patient’s goals is an important aspect of creating the supportive relationship. Because being able to rely on friends, family, or community members while coping with a health issue is also critical to motivation and self-care, another principle urges the inclusion of supporters in patient care when possible. Offer tools, resources, and information when available to the people who matter in the patient’s life, so that they can be more effective in
supporting the patient’s behavior change. CONFIDENCE: People feel a sense of confidence when they experience success. When they are not successful, they can still feel confident if they receive clear and encouraging feedback on how to improve performance. A confident and competent patient is armed with a set of skills that can be applied in a challenge, while a supportive provider stands ready to offer appropriate and helpful evaluations. The guidelines that support confidence include tailoring instructions into digestible pieces to help a patient receive the right combination of skills without becoming overwhelmed, and timing feedback to arrive when the patient is able to take action. In addition, we suggest providing positive feedback—often overlooked in an environment that emphasizes correcting mistakes—and prioritizing behavior changes that will set the patient up for success. OWNERSHIP: When people take ownership of their health, they take action not because they believe they should or have to, but because they want to. Even though many health behaviors, including modifying diets and adhering to medications, may not hold inherent appeal, when patients see them as instrumental to a personal goal, then they will develop a sense of ownership. Our engagement guidelines related to ownership emphasize understanding patients’ habits and rituals, and helping them to fit care behaviors into existing structures when possible. We also recommend as much transparency as possible around both shortand long-term expectations, so that patients feel informed about their care journey. This framework offers a way for providers and continued on next page November/December 2014
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Improved Outcomes...continued from page 21
health systems to collaborate more effectively with patients to optimize outcomes. Importantly, the principles of engagement can be applied to any touch point with the patient, including faceto-face, telephonic outreach, digital interventions, print communications, and smartphone apps. These principles, when implemented appropriately and consistently, can help providers create a supportive and encouraging voice to the patient. Additionally, applying these principles within one’s own organization can support a leading culture to deliver on commitments in a more engaged and collaborative way. Our research suggests that implementing the principles also inspires patients to take action in managing their own health, leading to the shared goal of enhanced outcomes. For more information, contact Michele Cappel at MCappel@its.jnj.com or Eric Swelland at ESwella1@its.jnj.com.
Names in the News...continued from page 12
resistant Staphylococcus aureus (MRSA). Candida is the fourth leading cause of bloodstream infections among U.S. hospital patients. MRSA is caused by a strain of antibiotic-resistant staph bacteria, and infections are more likely to occur in healthcare settings such as hospitals and nursing homes. WESTERVELT NAMED SVP/COO OF NEWYORKPRESBYTERIAN HEALTHCARE SYSTEM Karen Westervelt has been appointed senior vice president and chief operating officer of the NewYorkPresbyterian Healthcare System. Succeeding Wayne Osten, who is retiring, Ms. Westervelt will report to Dr. Laura Forese, president, and will oversee a system of hospitals, physician practices and ambulatory care sites serving approximately one in five inpatients in the New York metro area. Most recently, Ms. Westervelt was president and CEO of the William F. Ryan Community Health Network. She previously served as executive director of the Ryan/Chelsea5 l22 CAPG HEALTH 2014 HEALTHJuly/August November/December 2014 l CAPG
Amy Bucher, PhD, Associate Director, Behavioral Science, and Raphaela O’Day, PhD, Behavioral Scientist, Health & Wellness Solutions, apply behavioral and psychological science insights to enhance engagement and sustained behavior change. Kimberly Whelan, Senior Director, Strategic Customer Marketing, oversees development of strategies that support market access and reimbursement for key strategic customers. Emily Benadon, Marketing Director, leads strategies and tactics for the Strategic Customer Group within Johnson & Johnson Health Care Systems Inc. Somi Kim, Global Creative Director, Global Strategic Design Office, collaborates with partners across Johnson & Johnson to develop and implement people-centered experience design solutions. o References: 1 Deloitte Center for Health Solutions (2012). The U.S. Health Care Market: A Strategic View of Consumer Segmentation, 3. 2 Hibbard J., Greene J., and Overton V. (2013). Patient Activation and Health Care Costs: Do More Activated Patients Have Lower Costs? Health Affairs. 32 (2): 216-222. 3 Ryan, R. M., and Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development and well-being. American Psychologist, 55, 68-78.
Clinton Community Health Center and as deputy commissioner of the Office of Primary Care and Health Systems Management in the New York State Department of Health. PHYSICIANS FOR PEACE RECOGNIZES LOCAL CHAMPIONS AND GLOBAL HEALTH ADVOCATES Old Dominion University and Eastern Virginia Medical School have received the 2014 Physicians for Peace (PFP) President’s Award for their commitment to advancing global health. In addition, the Charles E. Horton Humanitarian Award is being presented to Merck and Co., Inc. for the Richard T. Clark Fellowship for World Health and for the assistance the company provides to humanitarian organizations working worldwide. Physicians for Peace, an international nonprofit based in Norfolk, Virginia, offers medical training and support to local healthcare teams in developing countries and has operated in more than 60 countries over the past 25 years. o
When you practice medicine at Providence, you’re in good company Providence Health & Services, Southern California
If you believe in practicing medicine that changes lives and creates healthier communities, we invite you to consider partnering with Providence Health & Services, Southern California. Our goal is to provide flexibility for physicians to practice in a model that suits each physician’s needs. Available today or in active development are practice models including: Multi-Specialty Group models Specialty Group and Institute models Independent Physician Association models Medical groups like Affiliates in Medical Specialties, Axminster, Facey and Providence Medical Group have all made Providence their home for the support they need and the compassionate, quality care for their patients. With Providence, you’re aligning yourself with California’s first and only health system to have our eligible hospitals recognized with the Healthgrades’ Distinguished Hospital Award for Clinical Excellence.
1-888-HEALING (432-5464) california.providence.org Providence Affiliated Medical Groups Affiliates in Medical Specialties Axminster Medical Group Facey Medical Group Providence Medical Group Providence Holy Cross Medical Center Providence Little Company of Mary Medical Center San Pedro
At Providence, you can practice medicine the way that’s best for you and your patients.
Providence Little Company of Mary Medical Center Torrance
For more information about Providence Health & Services, visit us online at california.providence.org or call 1-888-HEALING (432-5464).
Providence Saint John’s Health Center Providence Saint Joseph Medical Center Providence Tarzana Medical Center Providence TrinityCare Hospice
*Based on risk adjusted, in-hospital data. Providence Little Company of Mary Medical Center San Pedro was not eligible for consideration for this award.
Working Together to Save Money and Improve Health Aligning Provider and Workplace Engagement Strategies BY E M M A H O O , D I R E C TO R , PA C I F I C B U S I N E S S G R O U P O N H E A LT H
For every study that touts the impact of employer-based health promotion programs, there is an article that disputes the return on investment for these wellness programs. Yet most large employers invest resources for health improvement and risk reduction, in the belief that it will have a favorable impact on workforce productivity and healthcare costs associated with multiple chronic conditions. However, most of these wellness activities occur independently of health promotion activities offered through provider organizations. More than 70 percent of large employers offer health assessment and health risk reduction programs, with nearly 50 percent providing worksite biometric screening.1 In terms of employer priorities, improving health often far outranks changing cost-
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sharing or contribution strategies. Furthermore, over 65 percent rank their top desired healthcare outcomes as increases in health and wellness program participation and in participants’ awareness and decision making on health issues, while rating behavior change as the biggest challenge.2 Much as provider organizations recognize that psychosocial issues are key to unlocking barriers to health management and risk reduction, employers also are exploring holistic approaches to addressing employee stress and depression, as well as enhancing happiness, resiliency, and financial security. Recognition is growing that the home environment and socioeconomic status may have an even greater impact on sustaining behavior change and health status than does an individual’s interface with healthcare delivery. Additionally, some of the highest needs and costs are from dependents, who are typically beyond the reach of worksite wellness programs. Acknowledging the importance of social and community influences, employers are adopting social media tools to promote goalsetting and activating social networks to support behavior change in wellness programs. No single intervention, such as an incentive to complete a health assessment, does the trick. In many elements, employee activation has come to parallel the way provider organizations conduct identification and outreach, with engagement tactics that seek to meet members “where they are.” Sometimes the solutions can be simple, such as connecting someone with a local walking club to reduce social isolation and promote exercise, or offering cooking classes to
introduce healthier foods and ways to stretch a food budget. The growing practice of a wholeperson approach, including multiple ways of reaching and connecting with employees, creates opportunities for providers to align their patient outreach and engagement with employer-sponsored initiatives. The broad range of potential strategies could include connecting patients to community-based resources and supporting members across the full continuum of health—from prevention to advanced care needs. Emma Hoo is a Director at Pacific Business Group on Health (PBGH), focusing on care redesign and payment reform initiatives. o References: 1 2013 Mercer National Survey of EmployerSponsored Health Plans, firms with 500-4,999 employees. 2 Aon Hewitt 2014 Healthcare Survey. 3 Accessed at: http://www.myhss.org/downloads/ board/regular_meetings/2014/RM_081414_ WellnessPlanSponsorsDraft.pdf 4 Accessed at: http://www.calpers.ca.gov/ eip-docs/about/committee-meetings/agendas/ pension/201402/item-7-attach-2.pdf
PURCHASERS IN ACTION San Francisco Health Service System Wellness Plan.3 Through forming two accountable care organizations with its health plan, hospital, and medical group partners; flex-funding of its Blue Shield of California HMO; and plan design changes, the City of San Francisco substantially lowered workforce healthcare costs and redirected those monies to civic programs and toward reducing the City’s deficit. But business innovations alone cannot control costs in the long term, and a comprehensive employee wellness strategy is an important part of the plan. Improving the wellness of City employees will enhance quality of life, improve morale, reduce worker injuries, reduce absenteeism, and help contain healthcare costs. MUFG Union Bank’s Four Pillars of Wellness—eat, move, balance, and learn—includes an annual design challenge that creates camaraderie and engagement. A newsletter features employee submissions of favorite recipes for traditional foods prepared in a healthier way. Onsite biometric screenings are also popular among employees. Healthier U: California State Employee Workplace Wellness Pilot.4 A collaborative effort between Service Employees International Union (SEIU) Local 1000, the State Controller’s Office (SCO), the State Treasurer’s Office, California Department of Human Resources (CalHR), and California Public Employees’ Retirement System (CalPERS), this program seeks to create an evidence-based workplace wellness program with measureable health outcomes. One goal of the Healthier U project is to demonstrate that comprehensive workplace wellness programs developed in partnership with labor and management are a key factor in improving the health and wellness of state workers. Leadership worked together to identify and resolve structural and policy barriers in the workplace and promote a culture that supports a comprehensive vision of wellness.
Experts in Workplace Yoga Programs since 2009 • Turnkey Employer/Employee paid workplace programs • Certified & Insured Instructors • Chair & Traditional Yoga www.gotmobileyoga.com “It is fair to conclude that yoga can be beneficial in the prevention & cure of diseases.” - Pallav Senqupta Int J Prev Med v.3(7);2012 Jul; PubMed.gov Certified 200 hour yoga teacher training specializing in corporate, disabled senior chair, and personal transformative yoga.
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End-of-Life Conversations: Updated POLST Form Improves Decision Making BY J AY T H O M A S , M D , L E A D P H YS I C I A N , PA L L I AT I V E M E D I C I N E , H E A LT H C A R E PA R T N E R S
My parents have had an incredible journey together, but now that my father is 99 years old and my mother is 82, they are thinking about their wishes for the end of that journey. They want to make sure their loved ones and healthcare providers know exactly what they want. This is why they’ve each completed a POLST form. POLST, or the Physician Orders for Life-Sustaining Treatment, is a physician order signed by both a doctor and a patient that specifies the types of medical treatment the patient wishes to receive towards the end of life. My parents live at home with me and my wife, and copies of their POLST forms travel with us wherever we go. If something were ever to happen to them, we want to be ready to communicate their wishes, and my parents’ completed POLST forms are the best way to accomplish that. At this year’s CAPG and IHA National Accountable Care Congress, my colleagues will discuss the need to integrate palliative care into how we effectively care for patients at the end of life, and POLST will be an important part of that conversation. POLST is designed to help patients make more informed decisions and communicate their wishes clearly. As a result, POLST can prevent unwanted or medically ineffective treatment, reduce patient and family suffering, increase a patient’s comfort at the end of life, and help ensure patient wishes are followed. When I discuss end-of-life choices with seriously ill patients, I often reference my parents’ POLST forms and explain why they made the choices they made. These conversations provide an opportunity for my patients to start thinking about what a good quality of life means to them, and help them understand both the burdens and benefits of potential medical interventions. These discussions also offer an opportunity to communicate end-of-life decisions to loved ones—one of the most important gifts a patient can give. Communication is key to POLST’s effectiveness because it keeps family members from having to guess what the patient wanted, or from feeling guilty about the choices they made. Loved ones will have the comfort of knowing they are only carrying out the patient’s wishes. Now a new version of the POLST form, which will continue to be printed on bright pink paper, will improve these conversations. The updated POLST form, which went into effect October 1, includes goal statements for each potential treatment option so patients can better understand their choices.
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I’ve seen the benefits of POLST in both my personal life and professional life, and I encourage all medical staff to have end-of-life conversations with their seriously ill patients.”
The treatment options are listed more consistently in each section of the form (from most aggressive to least aggressive), so patients can better understand what these choices involve. Earlier this year, the Institute of Medicine released a report focusing on the need for improved end-oflife care. The report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, found that “improving the quality and availability of medical and social services for patients and their families could not only enhance quality of life through the end of life, but may also contribute to a more sustainable care system.” The report also highlighted the need for all states to develop POLST programs likes the ones that already exist in California and 16 other states. I know from personal experience that patients want end-of-life planning. When I’ve brought up the subject with patients, most have been eager to discuss it. And it doesn’t take a great deal of time. Though advance care planning is a process rather than a single event, I’ve found that patients often already have a good sense of the kind of end-of-life care they want and can begin to effectively express their wishes almost immediately. POLST hasn’t just become an important part of my practice; it has become a standard tool at HealthCare Partners for patients with serious illness and has gained broad acceptance throughout the state. By the beginning of 2012, nearly 95 percent of California hospitals had admitted a patient with a POLST, 65 percent had a formal POLST policy, 87 percent had blank forms available, and 84 percent had educated staff about POLST. Among California nursing home facilities, in 2012 66 percent had a formal POLST policy and 87 percent had educated their staffs about POLST. I’ve seen the benefits of POLST in both my personal life and professional life, and I encourage all medical staff to take the time to have end-oflife conversations with their seriously ill patients. Information on the new POLST form is available at capolst.org/2014polst, including translations in 12
languages and Braille. Physicians should only use the new version of the POLST form, but previous versions will continue to be honored. Healthcare professionals who would like to learn more about POLST can contact the Coalition for Compassionate Care of California (coalitionccc. org) with questions or to arrange training for their colleagues. The Coalition website also lists upcoming education opportunities and local POLST coalitions (coalitionccc.org/who-we-are/localcoalitions). o Please contact Dr. Thomas at JRThomas@ heathcarepartners.com with any questions. HealthCare Partners is a member of CAPG.
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Workplace Population Health: Healthy Employees, Healthy Business Introduction: In 2008, HealthCare Partners Affiliates Medical Group (HCP) launched its voluntary wellness program, Vitality, for the Southern California region, where approximately 4,500 employees are eligible to participate. Dr. Jeremy Rich, Director of the HealthCare Partners Institute for Applied Research and Education, interviewed Ms. Janelle Howe, Senior Director of Health Enhancement at HCP, regarding the reasoning for the program’s implementation . Jeremy Rich: What was the impetus behind HCP developing and implementing an employee wellness program? Janelle Howe: When we opted to become self-insured, launching a wellness program was a positive extension of that change. We felt that our message of preventive and coordinated care in addition to wellness was not only good for our patients, but also important for our employees.
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Dr. Rich: Were there senior-level leaders who promoted greater employee wellness engagement—“champions” who viscerally embraced these ideals? Ms. Howe: Drs. Robert Margolis and William Chin (former Chief Executive Officer and former Executive Medical Director, respectively), spearheaded the initiative. Ms. Catherine Crow (Senior VP, People Services) and I co-chaired the selection of a vendor, managed the launch, and have ongoing oversight for the program. Rather than hiring a dedicated wellness program staff associate, we recruited a group of initial champions for the launch, many from my department. Today we have over 150 “Champs,” and the number keeps growing. They embody the program and have a rapport with staff. Their words—and more importantly, their actions— resonate robustly with employees. Champs are a source of inspiration, motivation, and at times perspiration for fellow employees. Dr. Rich: What qualities did you look for in selecting an employee health and wellness vendor? Ms. Howe: We engaged in a formal RFP process and reviewed 15 separate wellness vendor offerings. We invited our top three to make live presentations and ultimately decided the Vitality Group offered the best value. With 70-plus group model offices, we needed an online system that would provide the same experience at each location, yet offer variety and flexibility for earning and using incentives. Additionally, we wanted to reward those just beginning their journey, and support individuals already in good health.
Dr. Pratibha Patel (left) and her husband ascended to the summit of Mount Kilimanjaro, Tanzania, at 19,341 feet. To prepare, Dr. Patel performed weight training and walked 10,000 steps per day, including on a treadmill at a 15% incline to simulate the hike. “When I joined HCP’s employee wellness program, I realized I could gain momentum to become physically fit,” she explained. “It made me more disciplined—it pushed me to be ready for Kilimanjaro by helping me reach my fitness goals.” Photo: Dr. Pratibha Patel
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Dr. Rich: What are the specific operational components of the wellness program? Ms. Howe: Overall, Vitality Group provides a webbased system to offer education, track activity, and support incentives for employees. Family members are also eligible to participate. • A Vitality Health Review initiates participation, identifies areas of wellness focus, and suggests goals for the employee. • The employee launches goals and selects activities to achieve those aims. • Employees earn points for both achieving goals and a host of wellness activities: preventive care, fitness, nutrition, mental well-being, and education, specifically managing stress.
fitness category called “Extraordinary Achievements” when she climbed Mount Kilimanjaro. Some staff conduct walking meetings, others had a relay swim team from Los Angeles to Catalina, and another led both patients and employees on a walk from Carlsbad to Seal Beach. Dr. Rich: HCP has a large and diverse workforce, with employees of various ethnicities and cultures, ages, CASE IN POINT Ms. Linda Sanfilippo, an HCP physician assistant, now speaks to patients and colleagues about weight loss from her own experience participating in the Vitality program. Her words are heartfelt and authentic, and resonate with patients and coworkers alike.
• All health activity is verified. We have tools and applications that transfer data directly to Vitality from the employee’s online wellness account. This includes partner gyms that forward attendance data. • Points convert to spendable dollars that can be used for online malls or discounted hotel and travel vouchers. • An annual Vitality Check is a key component and includes total cholesterol, blood pressure, BMI, and blood glucose readings. These values are tracked each year. • Local champions discover their communities’ wellness interests and spearhead group events: walks, swimming, education classes, yoga sessions, cooking, etc. We think this is one of the most successful components of the wellness program. Champs receive no additional compensation or incentives; they believe in wellness and want to encourage it among their teams. Dr. Rich: How was the program launched and how was/is it promoted? Ms. Howe: At the beginning of each year, we hold kickoff events across the organization to share the features and benefits of the program. Executives encourage local leaders, particularly clinic physicians, to support the program and to participate themselves. For example, Dr. Pratibha Patel, California Market President at HealthCare Partners, LLC, inspired a new
Employee wellness member Ms. Linda Sanfilippo before and after (at right), having lost 65 pounds. Photos: Linda Sanfilippo
lifestyles, family dynamics, and health conditions and needs. How does the wellness program reasonably accommodate these differences? Ms. Howe: That is the beauty of the program. It has a structure; however, there is an opportunity to submit additional activities tailored to individuals. Moreover, our Champs have contributed creative ideas for engaging coworkers. For example, • Our Healthy Selfies contests feature photographs of members’ healthy meals and/or recipes they created. • The Last One Standing contest: Members and their spouses who completed five verified continued on page 30 November/December 2014
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Workplace Health...continued from page 29
workouts per week over the course of three months (the holiday season, November through January) were eligible for a drawing to receive either a tablet computer or hotel voucher; currently, 60 members are eligible. • Participants share information, with photographs, on how they spent their points—from designer purses to trips. • Many members have chosen to share their personal health accomplishments for our “Vitality Realities” newsletter, often with before and after photos. Some of these unsolicited testimonials are quite moving, such as people with chronic conditions who have taken substantial steps to reclaim their health and wish to motivate others. • To further engage employees’ families, we have a children’s assessment to address nutrition, physical activity, and sleep patterns. • In 2013, we added a mental health component to help address psychological wellness. Dr. Rich: How does one measure and document the impact of a wellness program? What are the costs and benefits, and are there non-monetary ways to measure return on investment? Ms. Howe: We monitor and report participation, which has steadily increased (now over 50 percent of eligible employees), as well as total costs and spending on employee health, and compare these numbers to pre-program values. To maintain employee confidentiality, we do not have access to
Wellness Status Blue Bronze Silver Gold Platinum Silver and above
2010 2011 2012 2013 # Emp % # % # % # % 1651 98.6 1895 53.7 2015 53.9 1852 49.5 9 0.4 988 28.0 848 22.7 818 21.9 1 0 500 14.2 547 14.6 509 13.6 2 0 93 2.6 184 4.9 250 6.7 2 0 54 1.5 144 3.9 310 8.3 5 0 647 18.3 875 23.4 1069 28.6
This table presents numbers of employees and distribution (percentages) of wellness status from verified health achievements for the past four years. The data show increased numbers of employees earning higher wellness status since program inception as reflected in the shift from the lowest status (blue) to higher statuses (silver and above).
30 l30 CAPG HEALTH 2014 HEALTHNovember/December September/October 2014 l CAPG
This graph depicts a net improvement of 15.4% in the 11 risk factors for 938 participants when comparing the first laboratory measure to the last. Risk factors include total cholesterol, triglycerides, systolic and diastolic blood pressures, fasting blood glucose, BMI, stress, alcohol consumption, physical activity, tobacco use, and nutrition (fruit and vegetable consumption). Reprinted with permission, The Vitality Group, 2013.
individual employee results, nor to who is or is not participating. Costs vary according to the number of employees and the incentives they earn. We have documented reductions in overall health care costs and reductions in our medical loss ratio. In addition, 96 percent of all teammates agreed that the Vitality Wellness Program helped them to live a healthier life, according to the 2013 Employee Opinion Survey results. Dr. Rich: For organizations that are thinking about developing an employee wellness program, what is one key piece of operational advice? Ms. Howe: Choose a program with flexible incentives, and spend time to develop a strong communication strategy. Most important is to recruit creative and impassioned internal wellness champions, and provide an outlet for them to promote various health and wellness activities. While executive leadership and buy-in are important, “on the ground” Champs are key to motivating employees who want to get involved. They can help address facilitators and barriers for employee population health, and disseminate the wellness program by sharing lessons learned. Dr. Jeremy Rich is Director of the HealthCare Partners Institute for Applied Research and Education, a nonprofit organization in Torrance, CA. He can be reached at jrich@ healthcarepartners.com. We gratefully acknowledge the assistance of Dr. Janice Frates and Ms. Ifsha Buttitta with this article. o
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Value-Based Care: Today and Tomorrow The healthcare industry has been moving from “volume to value,” placing more emphasis on coordinating care and delivering better outcomes in the most appropriate and cost effective settings. That’s a good thing. Improving quality and reducing costs is not a trend at Brown & Toland Physicians. It’s part of our DNA. As one of the first medical groups in the country to implement electronic health records in our physicians’ offices, and develop system-wide population health management programs, we’ve learned that every population and every individual is not the same and does not require the same level of care. Taking a team approach, our professional care managers work closely with our physicians to develop successful programs and education for specific patient groups. These programs have helped improve preventive screening rates, reduced hospital stays, and have resulted in fewer hospital readmissions. Using predictive population health analytics, Brown & Toland Physicians has advanced care for patients in our Pioneer Medicare ACO and commercial ACOs. We will continue to provide proprietary solutions that help our physicians deliver value-based care, as this type of care is good for our patients today, as well as tomorrow. To learn more about Brown & Toland Physicians, please visit our website at www.brownandtoland.com.
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