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

The Journal of

COVER STORY: Letting Doctors Focus on Medicine, p.10 Engage Physicians by Building Trust, p.36 Regional Focus: Northwest, p.23

Volume 12 • No. 2 • Summer 2018

Working continuously to balance the

SCALES OF JUSTICE. We’re taking the mal out of malpractice insurance. As a relentless champion for the practice of good medicine, we continually track, review, and influence federal and state bills on your behalf. All for one reason: when you can tip the scales in favor of the practice of good medicine, you get malpractice insurance without the mal. Find out more at thedoctors.com The nation’s largest physician-owned insurer is now expanding in New York.

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5/23/18 9:22 AM

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Improve the experience of care with fewer transitions

Enhance quality and in many instances, quantity of life1

Help relieve the burden associated with expensive attempts to stop the inevitable course of terminal illness

Maximize healthcare provider satisfaction by delivering optimal care at home for patients nearing the end of life Pyenson, B, et al. Medicare cost in matched hospice and non-hospice cohorts. J Pain Symptom Manage. 2004;28:200–210.

Contact us to learn how a partnership with VITAS can help you effectively manage the health of your high- and rising risk patient populations.

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TABLE OF CONTENTS

ON THE COVER

Don Crane and June Simmons Letting Doctors Focus on What They Love Best: Medicine The Journal of

Publisher

DEPARTMENTS

FEATURES

From the President

Valerie Okunami Editor-in-Chief

Don Crane

Editorial Advisory Board

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

Lura Hawkins, MBA Editorial Assistant

David L. Allen

Contributing Writers

Bill Ahrens Bill Barcellona Kenneth Cohen, MD, FACP Don Crane Scott W. Disch, MPH Paige Frederick, RN John Kitzhaber, MD Jeffrey Lasker, MD, MMM Melanie Matthews Tom Mone David Parry Margaret Peterson June Simmons 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.

News and Events

Building a New, Evidence-Based Model of Spine Care

Cybersecurity: Board Members Hold the Keys

Federal Policy Update 2018 Midterms and the Impact of the Election Cycle

Policy Briefing Single-Payer Vs. Universal Coverage: The New Debate

Organ Donation: A Physician-Patient Conversation Worth Having

A Strategic Operational Roadmap for Entering Downside Risk

APG Member List

REGIONAL FOCUS: NORTHWEST

APG Member Spotlight Portland Coordinated Care Association: A Partnership in Quality

Integrating Physical, Dental, and Behavioral Health in the Oregon Health Plan

APG Consultant Corner To Engage Physicians, Build Your Trust Equation

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.

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Harnessing the Value of Innovation in Post-Acute Care

Independent and Supported That’s what it means to be a Hill Physicians provider. As the largest IPA in Northern California, our physicians provide care to over 350,000 patients. We give you the support you need so you can remain independent and focus on what matters most: high-quality patient care. A leader in the industry, Hill Physicians offers: • A 30-year history of fiscal strength under the leadership of an all-physician Board of Directors. • A strong commitment to making technological investments, including a subsidized EHR, high performance claims system and patient registry. • Dedicated and exceptional support for you and your practice staff. • Health programs to support you such as case management, diabetes education, nutritional counseling and pharmacy consultations. • Fast, accurate claims payments. • Competitive reimbursement and meaningful performance bonuses.

Learn more at www.HillPhysicians.com/JoinUs

From the President A M ES S AG E F R O M D O N 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, When I think of summer, I think of the season when things tend to slow down for most of us. We take vacations or even “staycations.” We dust off our bicycles, golf clubs, and tennis rackets for some weekend fun (or weekday if we can sneak it in). We watch our gardens closely for the first sign of a tomato or green beans. And some of us hit the road for college tours.

Don Crane, America’s Physician Groups President and CEO

Yet even during these slower summer months, things at America’s Physician Groups couldn’t be hotter! After another very successful Annual Conference, we took a short, deep breath and then jumped right back into the issues that matter most to our members. It’s no secret that our Medicare Trust Fund is quickly approaching bankruptcy. With that in mind, we’re busy educating members of Congress and other health leaders in Washington, DC, about the savings that can be achieved by bringing risk-based, integrated, and capitated care to original Medicare. Known as our Third Option, this physician-led payment model aligns incentives for physicians to provide the best care in the right setting to improve the health of entire populations. And folks are taking notice. Earlier this summer, we received positive press from Modern Healthcare and Politico after submitting a comment letter to the Centers for Medicare & Medicaid Services (CMS) on the issue of direct provider contracting (DPC). But our work doesn’t end there. With the fifth-largest economy in the world, California faces a unique set of challenges— including finding a way to care for its three million uninsured residents. And that’s where you’ll also find us hard at work this summer. For years, our members in California have been practicing our model of coordinated, patient-centered care that offers the highest quality and greatest value for the patients and communities they serve. In fact, if we deployed our budget-responsible healthcare delivery model across the Golden State, there would be more than enough savings to cover all Californians! Our staff in Sacramento continues to fight for the implementation of capitated, coordinated care in California. Finally, we’re putting the finishing touches on what will be another can’t miss conference—America’s Physician Groups Colloquium 2018: The Essentials of Value-Based Care. Set for October 10-12 in our nation’s capital, the Colloquium will include the outstanding speakers, invaluable content, and unsurpassed networking you’ve come to expect from our events. So how can you keep up with all that’s going on at America’s Physician Groups? You can visit our website for the latest news, events, and calls to action. Make sure you follow us on Facebook and Twitter. And if you haven’t registered for our Colloquium 2018, I encourage you to do so today. Here’s wishing you a safe and enjoyable summer, and I hope to see you at our Colloquium in October. o

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ARE YOU CARRYING EXCESS RISK DUE TO INADEQUATE LIVER DIAGNOSIS?

In recent studies, up to 79% of patients with NAFLD had normal aminotransferase levels1

FibroScan® is recognized in the EASL NAFLD/NASH Guidelines and the new AASLD Fatty Liver Guidance.

Are you missing NAFLD in your patients? • NAFLD affects over 80% of obese adults and nearly 50% of patients with Type 2 Diabetes1 • Patients with Type 2 Diabetes and NAFLD have a 2x higher risk of all-cause mortality than diabetics without NAFLD1 Imagine being able to non-invasively identify and track the growing segment of your population at risk for NASH/NAFLD and other complications of liver disease. The dual-function technology of FibroScan® (VCTE™ and CAP™)* offers insights that may not be captured by traditional methods alone.

(one of several available models)

FibroScan®, as part of an overall workup of the liver, is FDA-cleared to quantitatively measure liver stiffness and approximate liver fat—providing information to support your diagnosis and monitoring of patients across the spectrum of liver diseases.

FibroScan® is supported by nearly 1800 peer-reviewed publications. To learn more about VCTE™ and CAP™, and access our clinical library, visit us at www.echosens.us *VCTE™ (Vibration-Controlled Transient Elastography) and CAP™ (Controlled Attenuation Parameter) are trademarks of Echosens, LLC. 1

Epidemiology of non-alcoholic fatty liver disease: Bellentani etal. Digestive Diseases 2010;28(1):155-61.

The FibroScan® Family of Products (Models: 502 Touch, 530 Compact, and 430 Mini+) is intended to provide 50Hz shear wave speed measurements and estimates of tissue stiffness as well as 3.5 MHz ultrasound coefficient of attenuation (CAP: Controlled Attenuation Parameter) in internal structures of the body. FibroScan® Family of Products (Models: 502 Touch, 530 Compact, and 430 Mini+) is indicated for noninvasive measurement in the liver of 50 Hz shear wave speed and estimates of stiffness as well as 3.5 MHz ultrasound coefficient of attenuation (CAP: Controlled Attenuation Parameter). The shear wave speed and stiffness, and CAP may be used as an aid to diagnosis and monitoring of adult patients with liver disease, as part of an overall assessment of the liver. Shear wave speed and stiffness may be used as an aid to clinical management of pediatric patients with liver disease.

News and Events APG COLLOQUIUM

APM COMMITTEE

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

September 25 WebEx

GENERAL MEMBERSHIP MEETING September 26 Los Angeles

GOVERNING BOARD August 1 Los Angeles

HUMAN RESOURCES COMMITTEE September 26 Los Angeles

CONTRACTS COMMITTEE August 9 Los Angeles

PHARMACEUTICAL CARE COMMITTEE August 22 Los Angeles

CALIFORNIA POLICY COMMITTEE August 23 Los Angeles

COLORADO REGIONAL MEETING August 30 Denver

EXECUTIVE COMMITTEE September 6 WebEx

STATE GOVERNMENT PROGRAMS COMMITTEE September 11 Sacramento, CA

INLAND EMPIRE REGIONAL MEETING September 18 Riverside, CA

SAN DIEGO REGIONAL MEETING September 19 San Diego

NORTHWEST REGIONAL MEETING September 25 Portland, OR

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NORTHERN CALIFORNIA REGIONAL MEETING September 27 Oakland, CA

SonoSculpt vs. Lumbar Fusion. ®

With the cost of healthcare accounting for nearly 18% of our GDP price matters. The reduction of these expenses improve our premiums, community health, and resource efficiency.

COST COMPARISON Surgical Procedure Option

SonoSculpt® (non-fusion)

$29k

Lower Lumbar Fusion - TLIF

$77k +**

RECOVERY TIME

888.95.SPINE

| sonospinesurgery.com

Expected recovery and therapy times with SonoSculpt® are much shorter than a traditional fusion procedure. SonoSculpt® offers a quicker path to getting back to life and work reducing lost wages etc… making an even greater long term financial impact than the initial surgical care cost!

You Have The Right To Choose Your Care! The cost of surgical services may vary widely among different providers and surgical facilities in different area. As a service to our patients, we have identified a cost model and facilities in the regions we believe to be the highest-value options, meaning they provide excellent patient service at an affordable price. Please note: We encourage you to get multiple opinions and take conservative options before surgery and please confirm pricing for services no matter your decision. Estimates are based on published peer reviewed articles, insurance claim information and PPO contracted facility cost rates. This information will be updated from time to time and may result in variation of cost listed. The information is not applicable for Medicare or Medicaid members or otherwise where your health plan is not the primary payer. Actual cost may vary by insurance product, location, facility, and the type or level of services received.

** Cost based on Spine Patients Outcome Research Trial (SPORT) study of TLIF procedures and resulting outcomes. Initial prices can be much higher with a hospital stay over 1.92 days.

ON THE COVER

Letting Doctors Focus on What They Love Best: Medicine BY JUNE SIMMONS

The recent American College of Physicians position paper addressing social determinants of health (SDOH) begins by quoting the World Health Organization’s definition of SDOH as “the conditions in which people are born, grow, work, live, age, and the wider set of forces and systems shaping the conditions of daily life.”1

“

Addressing social determinants of health eliminates the nonmedical barriers preventing your patient from getting the most out of your treatment plan.”

The paper’s opening paragraph goes on to state, “Evidence gathered over the past 30 years supports the substantial effect of nonmedical factors on overall physical and mental health.” 2 It continues with quantifiable impact: “An analysis of studies measuring adult deaths attributable to social factors found that, in 2000, approximately…162,000 deaths were due to low social support, 133,000 were due to individual-level poverty, and 119,000 to income inequality.” 3

In comparison, the paper states, “The number of annual deaths attributable to low social support was similar to the number from lung cancer (n=155,521).” 4

CMS LEADS THE WAY Recognition of the impact these conditions have on medical outcomes has led to policy changes at the Centers for Medicare & Medicaid Services (CMS)— allowing Medicare Advantage plans to provide enrollees with benefits and services that improve their quality of life and health outcomes through such services as home modifications/renovations, transportation, nutrition programs, care management, and evidencebased health promotion and disease prevention programs. 10 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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June Simmons with APG President and CEO Don Crane

With CMS leading the way in payment for SDOH services, it might be time for medical groups to think of communitybased organizations as new specialists in their toolbox. These organizations rely on evidence-based tools to improve person-centered care and advance population health through: • Patient activation and motivation • Access to evidence-based health-promoting services • Access to home- and community-based services that address activities of daily living (ADLs) and instrumental activities of daily living (IADLs) and compensate for patients’ functional limitations and/or cognitive impairment

COMMUNITY-BASED ORGANIZATIONS ARE KEY Community-based organizations have worked in homes and social settings for years toward improvements in an individual’s health and functioning. As local entities, they have the trust and support of their community’s residents. They know the lay of the land, where and how quality services can be obtained, and they often provide crucial services themselves. Additionally, their employees are part of the community, overcoming drawbacks to the call center approach to interventions. Another advantage that community-based organizations bring to the table is their mobility and flexibility. They can usually dispatch trained individuals to a setting far faster than a distant care manager. And since the staff come from a patient’s community, they are culturally and linguistically a match for those they are serving. For the past 20 years, the Partners in Care Foundation has seen how effective addressing SDOH can be in the lives of medical patients. It has developed a network of community-based organizations and services that address the many dimensions making up social determinants of health. In this way, the organization has made it easy for physicians, their practices, hospitals, health systems, and health plans to implement an effective and farreaching web of services on behalf of their patients and members. Furthermore, in partnership with those physicians, medical practices, hospitals, health systems, and health plans, the Partners network has been responsible for: • Reducing hospital readmissions • Preventing nursing home admissions • Improving quality measures (HEDIS, Medicare Star, MACRA) • Improving clinical outcomes • Enhancing the patient experience—achieving Net Promoter Scores of 80-85 • Keeping people in their homes and communities, reducing costly institutional care All of the above lead to both enhanced patient satisfaction and reductions in the cost of care. In our experience, addressing SDOH also offers significant opportunity to improve a medical practice’s revenue. Patient activation, timely follow-up visits, completion of preventive and chronic condition screenings, and support for outreach and wellness campaigns are care dimensions that react positively to SDOH services.

Partners in Care Foundation and other community-based organizations use a wide range of activities to address social determinants of health (SDOH).

THE PARTNERS APPROACH The Partners in Care Foundation approach uses an alternative workforce consisting of social workers, health coaches, and community health workers. This team supports the work of medical caregivers, resulting in whole-person care for the patient. The team also serves as the eyes and ears of a medical practice in a patient’s home environment, providing additional information about living conditions and other circumstances that may impact the efficacy of medical treatment plans. Community-based organizations within the Partners in Care Foundation network are HIPAA-compliant, and they focus on gathering data and information typically not shared by patients in a medical setting or encounter. This information includes: • Comprehensive psychosocial and functional assessment • Home safety and fall-risk evaluation • Medication issues—linked with evidence-based interventions • Advance directives Many of these assessment domains feed directly into Star ratings, particularly for older adults. Partners completes an assessment and medication inventory, which the physician reviews with the patient during a medical visit. (Partners helps the patient schedule this visit.) Once the visit is completed, the physician has sufficient information to document fall risk assessment and continued on page 35 Summer 2018

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Federal Policy Update 2018 Midterms and the Impact of the Election Cycle BY MARGARET PETERSON, DIRECTOR, FEDERAL AFFAIRS, AMERICA’S PHYSICIAN GROUPS

It’s summer in our nation’s capital, and the District is as swampy as ever. As you know, every two years all 435 seats in the House of Representatives and one-third of the Senate’s 100 seats are up for re-election. These elections play an incredibly significant role in shaping the legislative agenda (ahem, or lack thereof) for Congress. While regular, free, and fair elections are critical to the success of any democracy—and allow constituents to hold elected officials accountable for promises made—they also tend to throw a wrench into the regular working order of Congress. 2018 is no different. With the November 6 elections just around the corner, members of Congress have been turning much of their attention back to their home states and districts as they campaign for themselves and their colleagues.

LEGISLATIVE PRIORITIES In the House, the imminent retirement of Speaker Paul Ryan (R-Wis.) and uncertainty as to his replacement—as well as the potential for Republicans to lose the chamber in November—are playing a large role in shaping the chamber’s legislative priorities. On the Senate side, Majority Leader Mitch McConnell (R-Ky.) is determined not to allow the upcoming elections to be a distraction. He canceled the annual monthlong August recess to ensure that senators continue to move through their agenda. Specifically, McConnell noted that the Senate must focus its work on judicial and executive nominee confirmations and make further progress on the fiscal year 2019 budget—as it lags far behind the House on appropriations work. Historically, midterm elections are an impediment to controversial legislation moving through the chambers, or even being proposed at all. Moderates in both parties are hesitant to reach across the aisle, as such a move may threaten the security of their base electorate. In an already polarized Congress, this brings the advancement of most legislation of consequence to a screeching halt. It is doubtful that any work on healthcare issues, including Affordable Care Act (ACA) market stabilization or anything remotely related to the ACA, will gain traction until after November, if at all this year. Despite the distractions that come with an election year, Congress has remained committed to advancing an overarching opioid legislative package to address this epidemic facing our nation. The numbers on this front are truly staggering. In 2016 alone, 42,249 U.S. drug fatalities involved opioids. That’s over a thousand more than the 41,070 Americans who die from breast cancer every year. Young Americans are particularly impacted—opioids now account for 1 of every 5 deaths of Americans ages 25 to 34. While it remains unclear what legislative path an opioid package will take to reach the President’s desk, this issue is one that Congress cannot and will not punt to 2019. continued on page 37 12 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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the election “While cycle will continue to influence the timing of federal policy events, our advocacy work remains steadfast.”

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

Colloquium 2018

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

Aneesh Chopra President, CareJourney and the first U.S. Chief Technology Officer under former President Obama

Kavita Patel, MD, Senior Fellow, Brookings Institution

Paige Winfield Cunningham Reporter, The Washington Post

Michael F. Cannon Director of Health Policy Studies, Cato Institute

CAPG HEALTH l 13

Policy Briefing Single-Payer Vs. Universal Coverage: The New Debate BY BILL BARCELLONA, SENIOR VP FOR GOVERNMENT AFFAIRS, AMERICA’S PHYSICIAN GROUPS

As Congressional Republicans, red states, and the Trump administration continue to seek the end of the Affordable Care Act (“Obamacare”), Democrats, labor unions, and physician organizations have rallied to argue for the adoption of “single-payer” healthcare systems. Where that effort has stalled, advocates have called for the adoption of “universal coverage” systems as an alternative. But what do advocates mean by the terms “single-payer” and “universal coverage”? Many of the proposals are vague, and the terms are often interchangeable.

TYPES OF HEALTHCARE SYSTEMS

“

So far, no state has found a way to fund the wholesale conversion of its healthcare system under a single-payer model, or to plug the gaps through a more modest universal coverage expansion.”

There are many types of single-payer healthcare systems around the world and within the United States. The most common attribute is that one entity is responsible for organizing, managing, and paying for the healthcare of beneficiaries. Many liken the term “single-payer” to a national healthcare model in which a country provides care to all its citizens under a single system. So-called “Beveridge” models, such as Britain’s National Health System, typically provide care through governmentowned-and-run facilities with an employed healthcare workforce. Other nations use insurance models. For example, Germany’s “Bismarck” system features governmental oversight of a robust not-for-profit health insurance system. Under this model, everyone must enroll in coverage, but the delivery system is private and contracts with “sickness fund” payers. This arrangement is more commonly referred to as universal coverage. In the United States, both single-payer and universal coverage models coexist, depending on factors like age, income, and health status. Many working adults and families receive health insurance from their employers. Others purchase it directly from the insurance market. The elderly and some disabled individuals are eligible for Medicare, a single-payer model adopted in the mid-1960s that is similar to the Canadian system (which is also called “Medicare”). Medicaid eligibility, meanwhile, is based on income, not age or disability—although some individuals in a family, such as male working adults, may not be eligible. In states that chose to accept the Medicaid expansion under Obamacare, several million people obtained access to healthcare benefits under Medicaid. Finally, active-duty military personnel and veterans can receive healthcare from the military. In all, about 4 out of 10 people in America get their healthcare through a single-payer system.

MANDATES AND UNIVERSAL COVERAGE A single-payer system may or may not employ the delivery system and workforce, and it may or may not utilize an insurance coverage model. But more recently, we in the United States often refer to a model that uses a mandate to purchase health insurance as a universal coverage system, to distinguish it from a classic single-payer model. 14 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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The mandate may take the form of an individual requirement to purchase health insurance, but it can also include an employer mandate to provide coverage to employees. Massachusetts was the first to adopt such a model in the mid-2000s. California attempted to adopt a very similar system but failed. Then, in 2010, Congress adopted the Affordable Care Act. In a modern universal coverage model, three characteristics are common: 1. All citizens are guaranteed access to “affordable” healthcare insurance, regardless of their health status. 2. A system of subsidies is established to allow everyone to purchase health coverage, regardless of ability to pay. 3. In exchange for guaranteed access, a system of individual and employer mandates to purchase insurance is required. Universal coverage models were conceived to reform the health insurance marketplace for individuals who were not eligible for any of the single-payer systems. The models are complex and not readily understood by most people because they are designed to regulate how these individuals can access healthcare.

coverage in order to obtain guaranteed access to purchase insurance regardless of health status. In place of subsidies, people should have the ability to use advance tax credits against the cost of coverage. On the other hand, liberals have returned to their original position—after a slight detour during the pendency of Obamacare—that the nation should adopt a universal coverage model that features a single-payer system run by the government. Some refer to it as “Medicare for all,” but more recently, many are calling for “Medicaid for all.” The nuances are lost on the public, but essentially, the distinction lies in the richer benefit design of Medicaid over Medicare. Medicare only offers an 80 percent subsidization of healthcare costs for seniors, but Medicaid has little if any individual cost-sharing. This makes it a costlier program than Medicare, but it also provides far greater access to a spectrum of health and social services.

THE DEBATE IN THE STATES

So is the Affordable Care Act a single-payer or universal coverage model? It’s a bit of both.

Single-payer advocates now aspire to provide “universal” healthcare access to everyone in a state through a simpler system of eligibility based on residency. New York has run a single-payer bill for the past four years that would completely reform access to healthcare, without premiums or copays. California and Vermont have also run similar bills.

The Affordable Care Act did not cover everyone, but Congress aspired to extend access to coverage to nearly 50 million uninsured Americans. It did this through a complex system of subsidies, coverage exchanges, insurance reforms, and expansion of existing single-payer systems (like Medicaid). Did it work? Well, sort of.

Canadian-style single-payer proposals are expensive. California estimated that it would cost $400 billion. Vermont passed the legislation but found it too expensive to implement. And New York has passed the legislation in the state Assembly for the past four years, only to see it stall in the more conservative state Senate.

The number of uninsured definitely decreased. But the individual mandate was very unpopular, and the cost of coverage was very expensive in some areas of the country. In some areas, there was also very little choice of health plans and providers on the exchanges. The system has been a work in progress. Perhaps it has been most successful where it has expanded eligibility to Medicaid, a single-payer model, and in states with robust coverage exchanges.

Where single-payer efforts have failed, advocates have turned to an alternative proposal to fund subsidized individual coverage and expanded Medicaid for the remaining uninsured in their states. This is the “universal coverage” alternative.

WHERE ARE WE NOW? This leads us to the current debate. Both the “red” and “blue” sides appear to agree that the complex system of insurance market rules under the universal coverage side of Obamacare is costly, cumbersome, and problematic. Conservatives argue that the individual mandate is an unwarranted governmental intrusion into personal freedom. They also argue that the furthest extent of any individual mandate should be a requirement to maintain continuous

It’s arguably more fiscally conservative to fund coverage for the remaining uninsured. In California, the price tag would be about $20 billion to provide healthcare access to the remaining three million uninsured. While it’s cheaper, a state-level universal coverage expansion proposal depends on a reformed tax scheme: Someone has to pay for the remaining uninsured to obtain access. Most voters are reluctant to do that if it doesn’t benefit them directly. The efforts to “plug the gaps” for the remaining uninsured are complicated by the potential loss of existing Obamacare funding. In its recent tax reform bill, Congress removed the tax penalty for the individual mandate. The mandate still continued on page 37 Summer 2018

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Building a New, Evidence-Based Model of Spine Care BY KENNETH COHEN, MD, FACP

What if we designed an evidence-based model of spine care? Our group has spent close to a decade evolving a new spine care model—and we’re seeing marked reductions in opioid utilization and significant reductions in invasive procedures, while providing patients with alternatives to the existing model. The existing model of spine care in this country is seriously broken. Spine care commonly relies on non-evidence-based therapies, including medications that don’t work, epidural steroid injections (ESI) that don’t work, and often, surgery that doesn’t work. As a result, a large portion of patients receive unnecessary care that does not provide adequate clinical outcomes. Moreover, the current “passive system” of spine care does not actively engage most patients in rehabilitation and psychological support to help assure long-term success. Many services provided to patients with spine disorders do not have a high-quality evidence base to support their use. These interventions include overreliance on: • MRI and subsequent invasive therapies, including ESI, facet injections, vertebroplasty, and kyphoplasty • Pharmacotherapy, including opioids, muscle relaxants, tricyclic antidepressants, and benzodiazepines • Surgery, particularly lumbar fusion

A PROGRESSIVE MODEL OF SPINE CARE New West Physicians began building a new model of spine care in 1999, and this model has continued to evolve over the past two decades. After joining OptumCare in 2017, we are now working to scale the program nationally with the other OptumCare medical groups. Our program began with a philosophical underpinning grounded in evidence-based medicine. First and foremost, it involves actively engaging patients in various rehabilitative modalities to move them away from the passive-dependent model of care toward a model of active participation. The goals are to improve core strength and flexibility and reduce pain. Patient therapy begins with supervised physical therapy and then transitions to nonsupervised maintenance therapy. Patients and clinicians can select from a variety of modalities, including yoga, Pilates, and strength training. Other modalities with an evidence base to support their use include chiropractic care, mindfulness meditation, guided imagery, and acupuncture. Additionally, the program includes ergonomic adaptions at both work and home. For patients with chronic back pain, working with a pain psychologist is important, as patients need to understand that they will not be completely free of pain. It is pivotal to define the individual blocks preventing improvement, which may include depression, substance dependence, secondary gain, etc. 16 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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“Many services

provided to patients with spine disorders do not have a highquality evidence base to support their use.”

FINDING A PLACE FOR PHARMACOTHERAPY, PROCEDURES, AND IMAGING In this new model, there is a place for imaging, pharmacotherapy, and procedures, but these therapies are adjunctive and need to be chosen carefully to achieve benefit in the correct subset of patients. With respect to pharmacotherapy, there is no panacea. No therapy is markedly effective, but some are modestly so. Opioids have a very limited role, if any, in the management of chronic spine pain. No evidence base supports improvement in outcomes with chronic opioid therapy, and the problems with this therapy are well-documented and often devastating. Medications with data supporting their use include nonsteroidal anti-inflammatories, duloxetine, and possibly pregabalin and gabapentin—although recent studies have questioned whether pregabalin and gabapentin offer any benefit. The data are conflicting; however, short courses of glucocorticoids for flares of radicular pain are well-tolerated and may be of benefit. Although no strong data support the use of ESI, limited data support a benefit in cases of acute severe radiculopathy due to disc herniation or extrusion of a disc fragment. Welldone randomized trials have not shown a benefit in patients with spinal stenosis with or without radiculopathy. However, we occasionally use ESI in the setting of degenerative disc disease with foraminal stenosis and radiculopathy to achieve short-term pain relief; this allows patients to begin a rehabilitation program.

RECOMMENDING SURGERY: ADDING PHYSIATRY TO THE MIX Choosing which patients may benefit from spine surgery can be very difficult. There is a sixfold variability in the per-capita use of spine surgery across the country, and the areas with the lowest utilization do not appear to have inferior outcomes when compared with the highest-utilization areas. As with other specialties, utilization correlates closely with the density of spine surgeons in a given region. The evidence base supporting spine surgery is strongest for two conditions: • Acute lumbar disc herniation refractory to conservative therapy • Spinal stenosis refractory to conservative therapy, particularly in the setting of pseudoclaudication due to spinal cord compression Many primary care providers do not feel they have the expertise to choose optimal surgical candidates. Given this conundrum, our spine program has enlisted the expertise of our physiatrists to help with decision-making.

Because physiatrists are experts in the nonsurgical management of spine disorders, they are uniquely qualified to not only guide the rehabilitation process, but also to help determine who may most likely benefit from surgery. Therefore, in the absence of red flag signs and symptoms, when we are faced with patients who have not had an adequate response to rehabilitative modalities, our referrals go to physiatry and not spine surgery. This protocol not only affords patients additional expertise in noninvasive management, but also allows us to feel comfortable that physiatry will recommend a surgical evaluation when appropriate.

IS TOO MUCH CARE AS DANGEROUS AS NOT ENOUGH CARE? One could take the nihilistic position that truncating the use of drugs, procedures, and surgery leaves few options for treating this patient population. However, we are learning that too much care—particularly when it is the wrong care—is as dangerous as not enough care. We have all seen the continued on page 38 Summer 2018

JOURNAL OF AMERICA’S PHYSICIAN GROUPS l 17

Cybersecurity: Board Members Hold the Keys BY BILL AHRENS AND DAVID PARRY

Healthcare board members and corporate officers have a fiduciary responsibility to ensure that their organization is properly managed, financially sound, committed to achieving the corporate mission, and in compliance with laws and regulations. Among their many requisites is a thorough understanding of the organization’s environment and risks. One of these risks—data breaches—is a significant threat that cannot be ignored. If cybersecurity is not a current corporate priority, board and executive team members must immediately begin to work together to establish the appropriate board oversight and management operational systems for an effective cybersecurity program.

WHAT A DATA BREACH COSTS Bill Ahrens

According to IBM Security and Ponemon Institute, the average cost of a data breach for an organization reached a new high in 2017 at $7.35 million—an average of $225 per stolen record. The healthcare industry’s cost was even more severe, coming in at an average of $380 per record. The IBM and Ponemon report also highlighted the importance of being prepared to identify and respond to a data breach. On average, companies took 206 days to detect that an incident occurred and then 55 days to contain the incident. When the mean time to identify (MTTI) a breach was less than 100 days, the average cost was $5.99 million; when it exceeded 100 days, the average cost rose significantly to $8.7 million.

David Parry

“The average cost

of a data breach for an organization reached a new high in 2017 at $7.35 million.”

Similar correlations were found in the mean time to contain (MTTC) breaches. When the MTTC was less than 30 days, the average cost was $5.87 million. But when it exceeded 30 days, the cost rose to $8.83 million.1 Elevated levels of healthcare cyberattacks are expected to continue as an increasing number of diverse systems (including biomedical devices) become connected to the main corporate network, and intrusion methods become more sophisticated.

THE ROLE OF BOARDS AND MANAGEMENT Laws and regulations require healthcare organizations to implement appropriate security measures and substantiate them through documentation and audits. In 2016, the U.S. Department of Health and Human Services Office for Civil Rights (OCR) issued an updated audit protocol with expanded administrative, physical, and technical safeguard requirements. It also launched its Phase 2 HIPAA Audit Program. Organizations should use these updated audit rules as an opportunity to understand and remediate their security shortcomings, even if they are not among the healthcare entities being audited under the program. While OCR’s future audit plans are not fully known, the persistently high levels of cyberattacks—coupled with the need for HIPAA compliance—point to an increasing number of OCR breach investigations and compliance audits in 2018 and beyond.

18 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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1. Maintain security policies and procedures, with mandatory ongoing user education and awareness training. Osterman Research found that organizations that provide security awareness training more than once per year experienced four times fewer exploits than organizations with less frequent training.2

The need for cybersecurity to be a corporate priority continues to increase. Board members and corporate officers who do not provide reasonable fiduciary oversight for cybersecurity are exposing the organization—and perhaps even themselves—to significant risks and potential liabilities.

2. Apply secure, baseline builds using only approved devices and software, and stay current on patches and releases.

Management must apply the same level of direction, expertise, and structure regarding cybersecurity as it has historically given to such critical areas as the corporate mission and finances. A cybersecurity update should be a standing board agenda item. In addition, board members should assess their knowledge and expertise on cybersecurity. If appropriate, boards should obtain additional education or supplemental consulting or add a member with security expertise.

3. Use a multi-layered network with firewalls, artificial intelligence-based behavioral analysis tools, and segments/subnets to limit unauthorized or malicious content. 4. Perform frequent system backups that are stored offline and off-site, and test system restorations and recovery plans.

Management’s ownership and ability to administer the cybersecurity program—along with the required tools, processes, and policies—should be both enabled and confirmed by the board. Does management have the knowledge and resources to run an effective cybersecurity program? Is cybersecurity perceived and run as a corporatewide and multidisciplinary risk management program?

5. Regularly conduct risk assessments to validate that security and regulatory goals are being met. 6. Monitor network and system logs, perform penetration tests, and address unusual or unauthorized activities. 7. Restrict user access to work needs and use limited, segmented privileged accounts.

Cybersecurity is not just a technology issue; it must involve leadership from all corporate disciplines (e.g., finance, legal, clinical, human resources, information technology) and encompass activities throughout the organization.

8. Use encrypted, two-factor authentication and secure connections for remote and mobile devices.

10 TIPS FOR CYBERSECURITY

10. Create an incident response plan, do mock tests, and encourage employees to report both minor and major incidents.

Cybersecurity requires considerable work, and there is no simple, one-time solution. While technology solutions play an important role, the biggest impact will come from educating employees to always practice good security hygiene. The following 10 security steps can provide significant protection:

9. Ensure all data is encrypted and implement a policy for removable media (e.g., flash drives) that requires encryption and scans before uploads.

MANAGING RISKS A board-driven and management-led cybersecurity program will enable your organization to take the right steps to protect itself from data breaches or harmful events. Cybersecurity is about identifying, understanding, and effectively managing risks, but even the best cybersecurity programs cannot eliminate all risks. Board and management discussions should include identification of which risks to avoid, accept, mitigate, or transfer through insurance, as well as legal implications and specific plans associated with each approach. o Bill Ahrens and David Parry are Senior Managers for the Healthcare Group at Mazars USA. References 1

Ponemon Institute: 2017 Cost of Data Breach Summary, June 2017

Osterman Research: Best Practices for Dealing With Phishing and Ransomware, September 2016

Summer 2018

JOURNAL OF AMERICA’S PHYSICIAN GROUPS l 19

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

Dignity Health Medical Foundation

Catholic Health Initiatives *

Dignity Health Medical Network – Santa Cruz *

Christopher Crow, MD, President Jeffery Lawrence, Executive Director Robert Weil, MD, CMO Don Lovasz, President, Clinically Integrated Network

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

Architrave Health • Arkansas Health Network • CHI Franciscan Health • CHI St. Joseph Health • Colorado Health Neighborhoods • KentuckyOne Health Partners • Mercy Health Network • Mission HealthCare Network • PrimeCare Select • St. Luke’s Health Network • TriHealth • UniNet

Affinity Medical Group

Cedars-Sinai Medical Group *

Adventist Health Physicians Network IPA

Richard Sankary, MD, President Scott Ptacnik, COO

Agilon Health

Stuart Levine, MD, Chief Medical & Innovation Officer Liz Hernandez, Project Manager

Alameda Health Partners

Santos Vera, Executive Director Nicholas Pirnia, MD, President

AllCare IPA

Randy Winter, MD, President Matt Coury, CEO

Allied Physicians of California 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 * Alex Chen, MD, CMO Castulo de la Rocha, JD, President and CEO

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

Arizona Health Advantage, Inc. Amish Purohit, MD, CMO

Ascension Medical Group

Joseph Cacchione, President Mark Whalen, VP Business Development

Austin Regional Clinic *

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

Bayhealth Physician Alliance, LLC

A P G

Catalyst Health Network

Evan W. Polansky, JD, Executive Director Joseph M. Parise, DO, Medical Director

Beaver Medical Group *

Raymond Chan, MD, VP Medical Admin/CMO of Epic Health Plan John Goodman, President and CEO

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

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

Central Oregon Independent Practice Association

Chinese American IPA

George Liu, PhD, President & CEO Peggy Sheng, COO

Chinese Community Health Care Association Cathy Chan, Director of Operations

Choice Medical Group

Manmohan Nayyar, MD, President Marie Langley, IPA Administrator

Cigna Medical Group

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

20 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

East Hawaii IPA

Kevin Kurohara, MD, President Susan Mochizuki, Administrator

Edinger Medical Group

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

El Paso Integral Care, IPA

Rafael Armendariz, DO, President Tony Martinez, Administrator

Equality Health – Q Point

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

Golden Shore Medical Group J. Mario Molina, MD, President Keith Wilson, MD, CMO

Good Samaritan Medical Practice Association Nupar Kumar, MD, Medical Director

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

Citrus Valley Independent Physicians

Guthrie Medical Group, Inc. *

CHS Physician Partners IPA, LLC

Hawaii Pacific Health

Gurjeet Kalkat, MD, Executive Medical Director Martin Kleinbart, DPM, Chief Strategy Officer Patrick M. O’Shaughnessy, DO, EVP & Chief Clinical Officer Jonathan Goldstein, MBA, Executive Director

Colorado Permanente Medical Group, P.C.

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

Comprehensive Geriatric Care of San Juan

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

DaVita Medical Group – HealthCare Partners *

CareMount Medical, P.C.

Ismary Gonzalez, MD, President

Kevin Ellis, DO, CMO

Canopy Health

Tom Tancredi, Dir. of Practice Operations Sachin Jain, CEO

East Coast Medical Services, Inc.

Facey Medical Foundation *

Leonard Kornreich, MD, President and 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

CareMore Medical Group

Paul Merrick, MD, President Mike Kasper, CEO

Children’s Physicians Medical Group

California Pacific Physicians Medical Group, Inc.

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

DuPage Medical Group

Pedro Rodriguez, HMA Board Member Mark Hillard, President

Conifer Health Solutions

Dien V. Pham, MD, CEO Carol Houchins, Administrator

Marvin Labrie, CEO

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

Brown & Toland Physicians * Fiona Wilson, MD, CMO Kelly Robison, CEO

Bruce Swartz, SVP, Physician Integration

Megan North, CEO

Don Rebhun, MD, Corporate Medical Director Jim Rechtin, SVP Corporate Strategy DaVita Medical Group (CA) • DaVita Medical Group (CO) • DaVita Medical Group (FL) • DaVita Medical Group (NM) • DaVita Medical Group (NV) • DaVita Medical Group (WA)

DFW HealthCare Partners LLC Osehotue Okojie, IPA Chairman Josh Cook, President

Summer 2018

Joseph A. Scopelliti, MD, President & CEO Frederick J. Bloom, MD, President 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 – NY

Joseph Cervia, MD, AAHIVS Regional Medical Director Edward Mirzabegian, COO

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

Affiliated Doctors of Orange County • Arizona Health Advantage, Inc. • 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 • 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 & CEO Paul Beuttenmuller, CFO

In Salud, Inc.

Mid-Valley IPA, Inc.

Pediatric Associates

Iora Health, Inc.

Molina Medical Centers *

Peoples Health Network

Jade Health Care Medical Group, Inc.

Monarch HealthCare *

Jefferson Health

Montefiore Medical Center/IPA

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.

Armando Riega, President Carmen Ramos, CPA, Executive Director Rushika Fernandopulle, CEO Dave Fielding, CFO Edward Chow, MD, President & CEO Thomas Woo, Manager of Operations

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

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

Key Medical Group, Inc.

Onsy Said, MD, Medical Director Steve Beargeon, CEO

Lakewood IPA

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

Landmark Medical, PC

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

Leon Medical Centers, Inc. Rafael Mas, MD, SVP & CMO Julio G. Rebull, Jr., SVP

Loma Linda University Health Care J. Todd Martell, MD, Medical Director

Managed Care Management and Educational, LLC

Luis Deliz Varela, MD, Medical Director Guido Lugo Modesto, Esq., Administrator

Marshfield Clinic, Inc.

Narayana Murali, MD, EVP & CSO Susan Turney, MD, CEO

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

Adventist Health • Alpha Care Medical Group • Bella Vista Medical Group, IPA • Centinela Valley IPA • Crown City Medical Group • El Proyecto del Barrio, Inc. • Global Care Medical Group IPA • Health Care LA IPA • Integrated Health Partners of Southern California • Pioneer Provider Network • Premier Physician Network • Prospect Medical Group • Prudent Medical Group • Redwood Community Health Coalition • Watts Health Corporation

MemorialCare Medical Group *

Mark Schafer, MD, CEO Laurie Sicaeros, COO, VP of Physician Alignment

Mercy Health Physicians Michele Montague, COO

Meritage Medical Network

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

Methodist LeBonheur Healthcare

Peter Shulman, MD, CEO Scott Farr, COO

Greg Fraser, MD, CMIO Jan Buffa, CEO

Carrie Harris-Muller, SVP Care Delivery & Strategic Partnerships Bart Asner, MD, CEO Ray Chicoine, President and COO Stephen Rosenthal, SVP

Monterey Bay Independent Physician Association

PHM MultiSalud, LLC

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

Mount Sinai Health Partners *

Niyum Gandhi, EVP & Chief Population Health Officer

MSO of Puerto Rico *

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

Lynnette Ortiz, MD, Medical Director Roberto L. Bengoa Lopez, President 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 DataTrust

Muir Medical Group, IPA

Kathi Toliver, VP of IPA Administration Lisa Serratore, COO

Steve Kaplan, MD, President Ute Burness, RN, CEO

Greater Tri-Cities IPA • Noble AMA IPA • St. Vincent IPA

NAMM California *

Verni Jogaratnam, MD, CMO Leigh Hutchins, CEO

Physicians of Southwest Washington, LLC

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.

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

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

PIH Health Physicians

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

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

Preferred IPA of California

Mark Amico, MD, Medical Director Zahra Movaghar, Administrator

Premier Family Physicians

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

New West Physicians, P.C. * Ken Cohen, MD, CMO Ruth Benton, CEO

Primary Care of St. Louis, LLC Bruce J. Berwald, MD Joy Strathman, Executive Director

Northwest Physicians Network of Washington, LLC

Prime Care Managers

Scott Kronlund, MD, CMO Rick MacCornack, CEO

Ted Trimble, MD John Ford, CEO

Oak Street Health

PriMed Physicians

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

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

OhioHealth

Privia Medical Group LLC

David Applegate, MD, VP Medical Affairs Carmela Hartline, Director Clinical Services

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

Ohio Integrated Care Providers

Patrick Goggin, MD, Quality Improvement Medical Director Cindy M. Baker, CEO

Omnicare Medical Group

One Medical Group

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

OptumCare Network of Connecticut Rob Wenick, MD, VP & Medical Director Karen Gee, SVP & COO

Mid-Atlantic Permanente Medical Group, P.C.

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

Summer 2018

ProHealth Physicians, Inc.

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

Prospect Medical Group *

Jeereddi Prasad, MD, President/Acting CMO

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

William Breen, SVP, Physician Alignment

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

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

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 Medical Group, Inc. • Prospect NWOC Medical Group, Inc. • Prospect Professional Care Medical Group, Inc. • Prospect Provider Group RI, LLC • Prospect Provider Group CTE, LLC • Prospect Provider Group CTW, LLC • Prospect Provider Group NJ, LLC • Prospect Provider Group PA • Prospect Health Services TX, Inc. • StarCare Medical Group, Inc. • Upland Medical Group, a Professional Medical Corporation

JOURNAL OF AMERICA’S PHYSICIAN GROUPS

l 21

Providence Health & Services Alaska, California, Montana, Oregon, Washington

Providence Medical Management Services Phil Jackson, Chief Integration and Transformation Officer

Korean American Medical Group • Providence Care Network

M E M B E R S

Reliant Medical Group, Inc.

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

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

River City Medical Group, Inc.

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

Riverside Medical Clinic

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

Riverside Physician Network Paul Snowden, CFO Howard Saner, CEO

St. Joseph Heritage Healthcare * David Kim, MD, Medical Director Kevin Manemann, President and CEO

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 Thomas Hellwig, MD, President James Malin, CEO

Sansum Clinic *

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

Santa Clara County IPA (SCCIPA)

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

A P G

Santé Health System, Inc.

Southwest Medical Associates

UCLA Medical Group *

Starling Physicians, PC (formerly Connecticut Multispecialty Group)

UniPhy ACO, LLC

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

Jarrod Post, MD, CEO Tracy King, Chief Administrative Officer

Steward Health Care Network, Inc. Mark Girard, MD, MBA, President Douglas Costa, COO

Summit Medical Group, PA *

Jeffrey Le Benger, MD, Chairman & CEO Jamie Reedy, MD, Chief of Population Health

Sutter Health Foundations & Affiliated Groups *

Larry deGhetaldi, MD, Division President, Palo Alto Medical Foundation Kelvin Lam, MD, MBA, CMO, Sutter Health Bay Area 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

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

Synergy HealthCare, LLC

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

Tandigm Health, LLC

Kenneth Goldman, MD, FACP, CMO Patrick Adams, President & CEO

The Everett Clinic, PLLC *

Al Fisk, MD, CMO Adrianne Wagner, Associate Administrator for Quality Improvement

The Permanente Medical Group, Inc. *

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

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

SeaView IPA

The Portland Clinic

Kooros Samadzadeh, DO, Medical Director Lynn Haas, CEO

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

Scripps Physicians Medical Group

Jeffrey Cleven, MD, CMO Dick Clark, CEO

The Southeast Permanente Medical Group, Inc.

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

James Cordell, MD, Medical Director Joyce Cook, CEO

The Vancouver Clinic, Inc., P.S. *

Sharp Community Medical Group *

Torrance Hospital IPA

Christopher McGlone, COO Paul Durr, CEO

Graybill Medical Group • Arch Health Partners

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

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

Southern California Permanente Medical Group *

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

Mark Mantei, CEO

Norman Panitch, MD, President

Tri Valley Internal Medicine Group Jonathan H. Dinh, MD, CEO Kaila T. Pollock, COO

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

UC Irvine Health

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

* Indicates 2017–2018 Board Members

22 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

Summer 2018

Sam Skootsky, MD, CMO Kit Song, MD, Medical Director Maria Labarga, MD, CMO Rene J. Valverde, President & CEO

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

Valley Care IPA

Michael Swartout, MD, Medical Director Sonya Araiza, CEO

Valley Organized Physicians

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

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

Washington Permanente Medical Group

Steve Tarnoff, MD, President & Executive Medical Director David Kauff, MD, Medical Director George M. Rapier III, MD, Chairman and CEO Carlos O. Hernandez, MD, President

CORPORATE PARTNERS AbbVie Anthem Blue Cross of CA Continuum Health Evolent Health Humana, Inc. Merck & Co. Nestle Health Science 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 Kaufman, Hall & Associates Kindred Healthcare, Inc. Lumara Health Mazars USA, LLP Novartis Pharmaceuticals Ralphs Grocery Company Relypsa, Inc. Soleo Health, Inc. Sunovion Pharmaceuticals, Inc. The Doctors Company

AFFILIATE PARTNERS Acurus Solutions, Inc. Alignment Healthcare Altura ArborMetrix Children’s Hospital Los Angeles Medical Group CVHCare Financial Recovery Group, Inc. Mills Peninsula Medical Group Nifty after Fifty Monarch, LLC Partners in Care Foundation Pharmacyclics, Inc. Redlands Community Hospital SullivanLuallin Group Ventegra, LLC

Northwest

Fall 2017 2017 Summer

CAPG HEALTH HEALTH ll 23 23 CAPG

REGIONAL FOCUS | NORTHWEST

Integrating Physical, Dental, and Behavioral Health in the Oregon Health Plan BY JOHN KITZHABER, MD

In 2012, Oregon created a new care model—the Coordinated Care Organization (CCO)—for its Medicaid program, the Oregon Health Plan (OHP).1 Each of the state’s 15 CCOs has a local governance structure that includes both providers and members of the community; is required to coordinate and integrate care; operates within a global budget indexed to a sustainable rate of growth (3.4 percent per member per month); and must meet rigorous metrics around quality outcomes and patient satisfaction. During the first five-year waiver period (2012 – 2017), these CCOs: • Successfully operated within the constraints of the per capita growth cap

CCO model “The sought to move physical, dental, and behavioral health out of their traditionally rigid lanes into a coordinated arrangement that put patients in the center. ”

• Enrolled over 385,000 more people under the Affordable Care Act Medicaid expansion • Met the outcome and quality metrics stipulated under the waiver • Realized a cumulative total funds savings of over $1 billion While there are many interesting aspects of this care model worth exploring, I will focus here only on the challenges of care coordination, which helped the CCOs successfully meet the quality and outcome metrics while operating within the growth cap.

SWIMMING UPSTREAM Although the OHP has covered behavioral health services and dental benefits since its inception in 1994, that care had been delivered through a fragmented collection of individual autonomous managed care, dental care, and mental health organizations. The CCO model sought to move physical, dental, and behavioral health out of their traditionally rigid lanes into a coordinated arrangement that put patients in the center. This is more difficult than it sounds because our system was not designed for integration and coordination. It was built around silos, and most providers were not trained to think or operate outside their own silo. Primary care rarely considers the impact of mental health conditions on physical health, and behavioral health providers rarely consider how to intervene in chronic physical conditions. We were swimming upstream against decades of tradition and culture. To some extent, this integration was a “forced marriage” in the CCO model, which was required to enter into contractual relationships with all three disciplines. At the same time, it meant that they were all “under the same roof,” creating a space in which to build the trust between providers that is the foundation for transformational change. And because they were all sitting at the same table, the first few “learning years” also helped alleviate fears among providers about the extent to which they were going to have to change the way they practiced. In the end, the requirement for integration and coordination offered the opportunity to openly discuss the interrelationships between physical, dental, and behavioral health.

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THE IMPACT OF DENTAL HEALTH For example, dental problems are the second most common emergency department discharge diagnosis for young Oregonians between 20 and 39. Their treatment is almost always symptomatic rather than curative, and it is here that many are first exposed to opioid analgesics. Most children ages 0 to 3 see a pediatrician far earlier and more often than a dentist, and unless that pediatrician is doing an oral assessment, these children may well develop tooth decay at a very early age. Poor oral health is linked to chronic diseases, and vice versa. For example, people with diabetes are more likely to develop periodontal disease, and periodontal disease makes it more difficult to control diabetes. In addition, poor oral health during pregnancy can transmit pathogenic bacteria from mother to child. In general, it has been easier to integrate oral health than behavioral health, largely because both dental and medical providers focus primarily on physical health. The resistance has been more about the additional workload rather than any philosophical objection. For example, when some pediatric providers were approached about doing oral assessments and applying fluoride varnish, it was often viewed as just “one more thing” to do in an already busy practice. As a consequence, the OHP pays medical providers to do oral assessments for children under 6 if the provider has received appropriate training (from programs such as First Tooth).2

CHALLENGES OF BEHAVIORAL HEALTH INTEGRATION The experience with behavioral health integration has been more challenging, more complex, and embedded in stigma as well as cultural, organizational, and financial issues—and we still have a long way to go. Our current community mental health system is rooted in the federal Community Mental Health Act of 1963, which sought to move people with mental illness from institutional “warehousing” to community mental health centers, where they would receive not only medical treatment but also social support services.3 Thus, the behavioral health system is much more focused on social services than the physical health system. This creates a cultural challenge. Furthermore, although the Community Mental Health Act led to widespread deinstitutionalization, adequate funding did not follow it into the community. The behavioral health system has been chronically underfunded. Reimbursement for mental health is far lower than for physical health, and funding for substance abuse disorder treatment is even

lower than for mental health. This is reflected in a poorly paid, unstable behavioral health workforce with high turnover and low productivity. Despite these challenges, there is widespread recognition of the importance of integrating behavioral health with oral and physical health in the CCO model. First, mental health conditions and substance disorders aggravate many physical chronic conditions and interfere with their treatment, resulting in poorer outcomes. Second, opioid dependence is the single most expensive diagnostic code for many CCOs on a per member per month basis. Those with opioid abuse disorder use the emergency department at three times the rate of the general population, and they use primary and specialty care at twice the rate. This fragmented care not only makes it difficult to effectively treat the underlying substance abuse disorder, but it is also hugely expensive—straining the global budget. Furthermore, untreated mental health and substance abuse disorders waste human potential and are major contributors to avoidable cost and suffering in the criminal justice system and the child welfare system. Over two-thirds of children who end up in foster care are there because of parental substance abuse. Indeed, the presence of untreated mental illness and/or substance abuse disorder in a family is a potent adverse childhood experience that may lead to poor physical, mental, and behavioral outcomes later in life.4

A TOP PRIORITY Making better progress to integrate behavioral health is a top priority for CCOs during the current (second) five-year waiver period (2017 – 2022). This will involve a number of aspects, including: • Clarifying and agreeing on what should be treated in the physical health system versus the behavioral health system • Better care coordination and communication between the two systems, including improving interoperability of the electronic health record • Establishing reimbursement parity between behavioral health and physical health • Stabilizing the behavioral health workforce • Directly confronting the social stigma that persists around mental health and substance abuse disorders continued on page 38 Summer 2018

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REGIONAL FOCUS | NORTHWEST

Harnessing the Value of Innovation in Post-Acute Care BY MELANIE MATTHEWS

Today’s healthcare landscape demands strategic transformation, regardless of the role an individual or entity has in the healthcare continuum. As witnessed on a weekly basis, this transformation is taking place in dynamic fashion—crossing industries, setting new expectations, and fundamentally reshaping the future of healthcare. Physicians of Southwest Washington (PSW), an independent physician association based in Olympia, Washington, wrestled with the question of how to leverage this momentum of transformation into real change for its network—resulting in outcomes that would benefit patients, support physicians, and improve performance related to multiple Medicare Advantage (MA) plans and the Next Generation Accountable Care Organization (ACO).

nursing “Skilled facilities have not always received the recognition they deserve when it comes to their role in care delivery.”

One of the first ideas we identified was to focus on post-acute strategies. Based on my 20 years in post-acute care management, I realized that there was rich opportunity to successfully implement value-based models within this care setting. Skilled nursing facilities have not always received the recognition they deserve when it comes to their role in care delivery. I knew our institutional post-acute care partners had good reason to be actively engaged, as managed care compensation comprises more and more of their total reimbursement mix. They now have the opportunity to be proactive in shaping the changing care climate, rather than taking a reactive role.

THE CATALYST Transformation is coming from all directions. The Centers for Medicare & Medicaid Services (CMS), the Center for Medicare & Medicaid Innovation (CMMI), and managed care organizations continue to require greater accountability and to incentivize value-based care models that improve outcomes and control costs. PSW realized that success in these models would require physicians and facilities to have more “skin in the game”—spurring the development of several value-based incentive contracts. In early 2016, PSW developed a value-based incentive contract specific to skilled nursing facilities. The catalyst was to share the vision, gain buy-in, and strengthen engagement. From the start, we chose to partner with high-quality skilled nursing facilities—those who achieve Four-Star or Five-Star CMS quality ratings, demonstrate excellent outcomes, allow 24/7 admissions to ensure flexible intake from acute care hospitals, and have the staff and capabilities needed to improve outcomes and control costs. We chose facilities whose leaders expressed interest in being active players in leading the local transformation of healthcare and were eager to move to a valuebased model that aligns payment with care quality. The new contracts aligned payment incentives in a platform that allowed us to work more closely toward mutual goals—achieving the Triple Aim of improved clinical outcomes, better patient satisfaction, and lower cost.

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AN INNOVATIVE APPROACH PSW sought to work with our partners to find new ways to create personal, high-touch, coordinated care from the patient’s direct-admit to transition to home. The goal was to find the right intensity of care, at the right time, in the right setting, for every patient. We believed that increased utilization of post-acute care could help bridge the gap between hospital and home—ultimately reducing costs and improving long-term outcomes. Seeking an innovative approach that would maximize limited resources and meet the needs of all stakeholders, PSW assembled an interdisciplinary team composed of medical directors with skilled nursing facility experience, care navigators (non-nurse, highly trained engagement specialists), nursing home social workers, and an assessment nurse. The entire team—including the patient, family members, and the patient’s primary care provider—is engaged from the moment of transition, with a focus on discharge care and developing an appropriate long-term care plan from Day One. Eric Coleman’s care transitions intervention model is at the center of the team’s approach to support patient engagement, smooth transitions, and reduce rehospitalizations. A critical element of PSW’s model is the personal relationship at the bedside. A more meaningful relationship in the post-acute setting means improved patient care and outcomes, and front-line knowledge of patients’ needs puts us in a position to recognize potential downstream implications well in advance. To facilitate this goal for high-touch care, our navigators spend time on-site in the skilled nursing facility as often as weekly for care review meetings. During our patients’ time in transitional care, we work to bridge the gap between health needs, community support, and resources. Partnerships with identified high-quality skilled nursing facilities are well served by regular joint operating committee meetings that allow all parties to address gaps and opportunities.

to value-based care, program benefits, and how and when to effectively use skilled nursing facilities to benefit their patients.

RESULTS In January 2017, PSW launched NW Momentum Health Partners LLC (NWMHP), which was selected to participate in the CMS Next Generation ACO model. This opened the door to the skilled nursing facility direct waiver program— eliminating the need for the three-day hospital stay—which continued the work PSW initiated in support of its Medicare Advantage post-acute care strategies. In the two years since program implementation, NWMHP achieved a 20 percent decrease in average length of stay by working with facility and care navigators to ensure appropriate resources and discharge planning to the home/ family environment. Together, PSW and NWMHP noted a 50 percent increase in the number of direct admissions, concurrent with a 6 percent reduction in emergency department use and reduced inpatient stays. Throughout the process, skilled nursing partners have been committed to high patient outcomes and a collaborative partnership that has delivered a seamless process benefiting both patients and providers. PSW sees this as the first of many innovative strategies that will be implemented with home- and community-based providers.

MAINTAINING VALUE MOVING FORWARD Healthcare is a highly collaborative effort. Physicians, hospitals, and health plans must work together to collectively shape the future of how quality care will be delivered to the communities we all serve. It is the interdependence of these partners that serves PSW’s mission of supporting the physician-patient relationship in independent practice. o Melanie Matthews is CEO of Physicians of Southwest Washington, a member of America’s Physician Groups.

Physician engagement is essential. For example, feedback from early implementation efforts of the post-acute strategies clearly identified a communication gap between PSW and its physician network: Many physicians were not aware of the services that skilled nursing partners could provide or that direct-admit was an option. In response, PSW went on a road show, meeting with our physician network and physicians’ practice staff to educate them about the key levers for success in the movement Summer 2018

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APG Member Spotlight Portland Coordinated Care Association: A Partnership in Quality BY PAIGE FREDERICK, RN

When dedicated professionals work together, the opportunities for discovery are nearly limitless. That’s why The Portland Clinic—an independent, physician-owned medical group in Portland, Oregon—helped establish the Portland Coordinated Care Association (PCCA) in 2012. The venture has been deemed a success and was accomplished even without the support and resources of a larger hospital system. PCCA brings together Portland-area independent medical groups to explore innovative ways to reduce healthcare costs, improve quality outcomes, and enhance patient experience. The network now has more than 400 providers—130 of whom specialize in primary care—and 20 care facilities.

“PCCA member

groups support each other in efforts to improve the delivery of care to patients.”

Its six partner groups are Northwest (NW) Primary Care; South Tabor Family Physicians; Davies Clinic; The Portland Clinic, a multispecialty group; Compass Oncology, an independent cancer and hematology treatment practice; and Rose City Vein Center, an independent physician group treating venous insufficiency disease and associated complications. The groups participate in risk-based contracts with Regence, Aetna, Cigna, Moda, and CareOregon.

A COLLABORATIVE APPROACH Current PCCA efforts are focused on analyzing quality performance and cost-ofcare data. The network sponsors quarterly Metrics Committee meetings to review performance and share best practices. Members of community medical specialty groups also attend these meetings to dialogue about a collaborative approach to tackling rising cost and overutilization in healthcare. These conversations have been enlightening and productive and have led to stronger partnerships. Indeed, we have all benefited from regular contact and sharing among providers, administrators, IT professionals, and quality leaders from each of our partner groups. PCCA member groups support each other in efforts to improve the delivery of care to patients. For example, in 2016, NW Primary Care realized it was not capturing tests and exams performed at outside facilities, resulting in a drop in its quality performance. The team partnered with South Tabor Family Physicians, which years earlier had encountered the same problem and developed a solution. South Tabor shared its Quality Improvement Release Form, which allows staff to request specific reports such as mammograms, colonoscopies, and diabetic eye exams necessary to close gaps. NW Primary Care adapted this form to fit its own needs and within a few months saw a positive impact on quality performance. Similarly, South Tabor received guidance from NW Primary Care in 2014 to help its performance on diabetic foot exams. With no standard process for completing and capturing these exams, South Tabor had wide variation across providers, and its overall performance had room to improve. NW Primary Care already had a process in place, and it helped South Tabor develop its own internal diabetic foot exam workflow.

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Within a year, South Tabor showed marked improvement in its completion of diabetic foot exams, and it continues to improve every year. By mid-2017, South Tabor was exceeding the benchmark of 75 percent and had increased its diabetic foot exam completion rate from 9 percent in 2013 to 77 percent in 2017.

Accordingly, as we shift our focus to value-driven healthcare, we celebrate our successes and recognize the hard work our staff and providers put in every day. We know that our partners at South Tabor Family Physicians and NW Primary Care will be excellent resources for us as we continue to evolve.

SHARING PERFORMANCE AND COST DATA

WHAT’S NEXT

Transparency has also been critical to PCCA’s success, with groups sharing performance and cost data with each other. Several PCCA partner groups, including NW Primary Care and South Tabor, are fully transparent within their own organizations. This has helped their quality improvement efforts and encouraged friendly competition across care teams and providers. These groups make quality measure performance data at the provider level available to all staff and providers.

In 2018, measuring and tracking quality has continued to be a major focus for the PCCA. The network also plans to expand its focus to utilization and cost-of-care data, with the help of reporting tools such as PreManage. This system allows us to track Emergency Department (ED) and inpatient utilization in our patient population and identify specific cohorts of patients—such as those with high ED utilization, chronic conditions, or readmissions within 30 days of discharge.

At The Portland Clinic, we are striving to improve data transparency within our organization. Indeed, over the past few years, our involvement in value and risk-based contracting has helped our providers recognize the importance of transparency.

We are also working closely with the Oregon Health Care Quality Corporation to access more robust data on cost and service utilization—helping to better equip our groups to tackle the nation’s rising healthcare costs and service overutilization.

As The Portland Clinic approaches its centennial in 2021, we realize that change can be difficult in an organization with a deeply rooted culture that historically has not emphasized quality measurement, performance, and transparency.

We are excited to continue this important work and look forward to seeing what the future holds for the PCCA. o

THE

DATE!

Paige Frederick, RN, is Quality Improvement Manager for The Portland Clinic, a member of America’s Physician Groups.

AMERICA’S PHYSICIAN GROUPS

ANNUAL CONFERENCE 2019

APRIL 11-13, 2019 MANCHESTER GRAND HYATT SAN DIEGO, CALIFORNIA Summer 2018

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Organ Donation: A Physician-Patient Conversation Worth Having BY TOM MONE

Physicians—more than any other segment within the healthcare industry—have long been a trusted source of information, service, and compassion within their local communities. Building upon the special relationships they have with their patients, many physicians have stepped forward in recent years to discuss the most sensitive of all topics: death and dying. By not dodging this topic or passing it along to a surrogate, these physicians should be applauded for helping their patients confront dying on their own terms—with assurance that their wishes will be respected. It is now time for these same physicians to take the lead in facilitating a thoughtful conversation on another sensitive topic where patients’ wishes need to be respected. It’s a topic that far too few physicians presently discuss: organ, eye, and tissue donation.

day in the “Every United States, 22 people die unnecessarily while waiting for an organ transplant.”

It is a cold, hard fact that every day in the United States, 22 people die unnecessarily while waiting for an organ transplant. Currently, more than 115,000 of our fellow citizens are waiting to receive lifesaving hearts, livers, lungs, kidneys, and pancreases—but there are simply not enough donors to meet the growing demand. For physicians concerned with saving and preserving life, these numbers should be unacceptable.

TALKING ABOUT DONATION—NOW Far too often, the question of organ donation doesn’t arise until a catastrophic circumstance has occurred. By then, if individuals have not previously registered as donors, it is too late for them to express their intent. Instead, it rests upon the next of kin to guess what their loved one would have wanted. Physicians can be of great value by suggesting to their patients that they have a meaningful conversation with a donation specialist and make their organ donation decision known. Physicians are also uniquely positioned and charged with helping patients address their end-of-life planning. This planning should include becoming comfortable with the idea of donation and seeing it as an opportunity to give greater meaning to their loved ones or their own lives. This is especially true and valuable for patients whose cultural backgrounds and places of birth never exposed them to donation and transplantation. Just as physicians routinely ask their patients about their health and lifestyle habits, they should also take the time to ask patients if they are registered to be organ or tissue donors. This unexpected question may trigger some curious looks, but the connection will become clear when it is explained that a single organ donor can save the lives of up to eight people—and improve the lives of up to 75 more through cornea and tissue donation. Saving and improving lives whenever possible is what medicine is all about.

ADDRESSING PATIENTS’ CONCERNS Be prepared to explain that there is no inherent conflict between saving lives and using organs for transplant. Patients need to understand that the doctors who work to save a patient’s life are not the same doctors involved with organ donation. continued on page 38 30 l JOURNAL OF AMERICA’S PHYSICIAN GROUPS

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916.565.6130

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A Strategic Operational Roadmap for Entering Downside Risk BY SCOTT W. DISCH, MPH

When providers first embark on their journey for deeper financial risk performance with government and commercial payers, there needs to be institutional change and education for all stakeholders. This needs to happen well ahead of implementing operational tactics, systems, and interventions. Ideally, when providers understand what bearing risk means, how it will have to be underwritten, and what new approaches it will require to manage their patients, they will adopt the behavioral changes and team-based approach needed to build clinical offerings to engage their patients.

PLANNED APPROACH TO YOUR END GAME Medical groups, practices, and ACOs need to define what their overall finished operational product will look like within the relationship to larger financial risk and expectations with insurance carriers. Additionally, within select markets or populations, operational tactics need to be in place sooner to capture necessary data, meet underserved needs, develop efficiencies within the practice, and engage the patient in greater responsibility and self-management. There is well-documented financial reward for providers and payers when they are both aligned and heading down the road of true patient utilization and measurement of clinical outcomes.

FUTURE OPERATIONAL NEEDS FOR MEDICAL GROUPS AND NETWORKS Each provider group may be at different phases of risk with a payer or patient population. But the key areas of meaningful impact are still the same; it is just a matter of when certain elements get layered into the network and at what intensity. Social determinants and population illness burdens will dictate what services are necessary ahead of providers bearing more financial risk. These services should be recognized early in a group’s strategy. As the provider network matures toward more financial risk, delegation will be shifted, and you will need a more concentrated focus on patient self-management of their disease, engagement in the home, and reduction of unnecessary utilization across all healthcare domains.

FROM FEE-FOR-SERVICE TO FULL CAPITATION: KEY OPERATIONAL AREAS Payer What do you need? Strengthened network relationships with key payer partners. This will allow you to either design a wrap-around network through an exchange product for their consumers or develop a clear roadmap on how to move into deeper risk-sharing models of professional capitation, full capitation, and delegated services that payers will turn over to providers based on historical success.

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“

There is welldocumented financial reward for providers and payers when they are both aligned and heading down the road of true patient utilization and measurement of clinical outcomes.”

What partnership can be obtained? Provider groups must have well-documented proof points of their operational success for network steerage, quality outcome measures, and provider engagement to support clinical decision-making and reduce inappropriate utilization.

Key Directive: Analyze data together monthly or quarterly to strengthen mutual understanding of the market dynamics to help with contracting decisions. Network What do you need? Engaged specialists, scalable post-acute partners across your designated market, and innovative medical neighborhood partners that deliver care to the patient in ways and locations your group cannot. What partnership can be obtained? Examples include clinical pathways, specialist compacts, bundled arrangements, preferred partnerships, centralized services like referral management, financial arrangements for comprehensive services, and episodes of care management.

Key Directive: To move to more lucrative arrangements with payers, you need a network that can shift and move care toward value services. Having a solid established network that works well across the continuum is ideal. If you have multiple markets, you should have scalable resources to quickly set up an engaged market that is aligned under risk. Data What do you need? Real-time data. A three- to fourmonth lag time in data means it arrives too late to allow you to be reactive. It also results in limited visibility into progress. Complete data should encompass social and behavioral elements and allow patients to access it and provide feedback about their perspective of care and illness burden. Comprehensive data sets should also include the payer, ancillary providers such as lab results, and electronic health record (EHR) data that reflects patient decisions and coordination of care activities. What partnership can be obtained? Patient data is now available in all forms of wearable technology; it also can be self-reported or come from census data, surveys, or inferred relationships between data. This is beneficial to medical decision-making to understand patients’ holistic needs. In fact, in the U.S., social determinants of health were estimated to account for 70 percent of avoidable mortality. Therefore, it makes the most sense to move from data

registry and canned reporting to intelligent analysis and individualized recommendations for your population. Seek “at the provider” workflow solutions, not aggregated trends that are difficult to deploy.

Key Directive: Understand your population, who’s healthy, who’s moving in and out, and what risk pools might be best for specific patients and providers. Don’t be afraid to pilot operational needs, but keep the pilots short, and make a “go versus no-go” decision on how you scale it out to the provider network. Physician Engagement What do you need? A progression of compensation models that support the transition from fee-for-service to value-based arrangements for providers, their staff, and advanced practitioners. Rewarding providers for key tactics met within a performance year can be more valuable than fee-forservice visits. You must recognize the provider’s time and build in administrative reimbursement for care team involvement, population reviews, and advisory roles. Outside of the direct compensation arrangement, entities should have a roadmap for a progressive funds flow model designed to reward the highest performers and hold low performers accountable. What partnership can be obtained? Providers should have a compact or coordination of care agreement to ensure that agreed-upon initiatives and guideposts are established. Agreements should define a rubric for selecting new providers for the group and should contain language allowing for corrective action to be taken on the group’s poorer performers.

Key Directive: Be selective within your group, be transparent, be fair in compensation, and reward work done outside of the normal fee-for-service mechanism. Patient Engagement What do you need? With the birth of social ACOs, providers need to encompass all patient factors in improving the patient’s responsibility for healthy self-management of their lives. Engagement is not just pestering patients to close process care gaps. Rather, it’s about developing trust, reliability, and relationships so patients can better absorb treatment recommendations from providers. What partnership can be obtained? Historically, payers have done a poor job engaging patients in their care. Over the past five years, providers have bothered continued on next page Summer 2018

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Strategic Operational Roadmap...continued from page 33

patients to complete multiple hoops in quality measures so they can get better rankings and payment. Now, patients are in the driver’s seat relative to paying providers (i.e., Concierge, Direct Primary Care arrangements, and the Value-Based Insurance Design model). It’s critical to find the correct solution for patients with plan design and incentives that align improved behavior, choice, and trust.

Key Directive: Consider adding an in-house ability to help patient migration through open enrollment time periods instead of using an outsourced partner. In addition, diversify your reimbursement portfolio with patient direct-pay options. Workflow What do you need? Providers need more than just evidence-based medicine protocols and encounter plans. They need real-time data that support medical decisionmaking and teams built around them that are focused on delivering efficiency through empathy, listening to the patient, and relating to patients in a way that inspires connectedness. Workflow needs to be more focused on

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the integration of provider and patient needs, as well as the alignment of goals and objectives. What partnership can be obtained? Teambased care management can take on various forms and relationships. Providers moving into risk should evaluate companies that can support the full complement of services—such as chronic care management, transitional care management, annual wellness visits, advance directives, behavioral health, disease education, and counseling—that they may not have time to complete for their entire population.

Key Directive: Give providers the most appropriate data and teams to help elevate everyone to working at the top of their license. Let providers “orchestrate” the best course of treatment necessary with the robust team of resources at their disposal. o Scott W. Disch, MPH, has held leadership positions with physician organizations such as Privia Health, Vanguard Health Systems, Catholic Health East, and other independent entities. Currently, he is President and CEO of SolveMed Consulting, LLC, focused on helping providers, payers, and population health partners define their strategy and achieve success under risk performance contracts.

Letting Doctors Focus on Medicine...continued from page 11

interventions, pain assessment, functional status assessment, and possibly reductions in the use of highrisk medications and completion of advance directives.

The program’s outcomes were impressive. Compared to baseline, after 12 months: • Self-rated health good or excellent: 60 percent vs. 32 percent at baseline • BMI i 1 point

Following the initial assessments, a health coach works with patients and families to develop a person-centered plan that includes:

• A1C i 1 point • Systolic blood pressure i 11 points

• Coordination of services such as home-delivered meals, personal assistance, home modifications, and transportation

• Depression score i from 5.8 at baseline to 3.2 • Pain i from 3.2/10 to 2.0/10 • Aerobic exercise h from 51 to 75 minutes per week

• Connection to benefits and discounts

• Stretching/strength exercise h from 21 to 35 minutes per week

• Medication regimen or adherence recommendations by the pharmacist • Attention to caregivers—including education/training, support, and respite • Evidence-based health self-management and fallprevention workshops The needs of the patient, coupled with the concerns of the medical practice, drive the skill mix and approach of the Partners team as it is applied to each patient’s unique circumstance. This involves coordination of resources— such as medication management, home modifications and services, meal delivery, and health coaching. It can also include limited case management or communitybased adult services assessments. A key to Partners’ successful approach is local knowledge and cultural sensitivity. A patient with limited transportation options is likely to find it difficult to get to the doctor’s office. Solving that problem requires an understanding of all the available transportation options and how they will fit that patient’s specific circumstances. For example, it isn’t possible to set up an Uber ride if the person has no means to pay the driver. Equally important is knowing cultural sensitivities and limitations. Will a female patient ride in a car with an unrelated man? Does an elderly patient understand English, or is a translator necessary?

STUDIES SUPPORT SDOH INTERVENTION Partners recently participated in an outcomes study as part of Stanford’s Chronic Disease Self-Management Program. The study population consisted of 571 union members with chronic conditions in a managed care organization. The intervention involved implementing three items: the Stanford Chronic Disease Self-Management Program, monthly meetings, and targeted incentives.

In a recent California CMS Demonstration Project, Partners helped participating hospitals achieve between 28 to 41 percent reductions in readmission rates for all conditions.

PARTNERING WITH APG Partners in Care Foundation recently became a group purchasing partner with America’s Physician Groups to provide SDOH services. When considering whether to buy versus build a network of community-based organizations (CBOs) for SDOH services, consider that Partners relies on a system-of-care approach, is NCQA-accredited, uses evidence-based interventions, relies on HIPAA-trained staff, and provides a diversity of language, culture, and skills. Technical considerations covered by the Partners CBO Provider Network include being well-insured, as well as a focus on network security and privacy (IT security standards: secure email, SFTP, etc.). Partners offers a 10 percent discount on SDOH services for APG members. Addressing social determinants of health eliminates the nonmedical barriers preventing your patient from getting the most out of your treatment plan. At Partners, we’re fond of saying our efforts let doctors focus on what they love best: medicine. o June Simmons is CEO and President of Partners in Care Foundation. To talk with Partners in Care Foundation about how addressing SDOH can help your practice and your patients, call 818-923-4135. References Hilary Daniel, BS; Sue S. Bornstein, MD; and Gregory C. Kane, MD; for the Health and Public Policy Committee of the American College of Physicians, “Addressing Social Determinants to Improve Patient Care and Promote Health Equity: An American College of Physicians Position Paper,” Annals of Internal Medicine, 2018;168:577-578. doi:10.7326/M17-2441 1

Ibid.

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APG Consultant Corner To Engage Physicians, Build Your Trust Equation BY JEFFREY LASKER, MD, MMM, APG CONSULTANT

Physician engagement is critical in driving improvement in healthcare organizations. Current demands require improvement in all areas of the Triple Aim: better patient care, better population health, and moderated cost. One of the key elements in engaging physicians is building an organization that physicians trust. In particular, physicians need to trust your organization’s leadership. Often left out of this trust-building is the importance of personal relationships. For example, in the 1,800-physician organization I ran—which became the highestperforming network in our region—I was on a first-name basis with close to 400 physicians. This helped build trust in very significant ways. Below is a commonly used “trust equation” that illustrates the importance of personal relationships: Reliability + Competence + Intimacy

= TRUST Self-Interest

If you assign up to 10 “points” to each of these variables, you get your “trust” value.

UNDERSTANDING THE TRUST EQUATION • Self-interest is a very important part of the equation. A strong governance process that involves physicians in all aspects of the organization’s oversight can mitigate this effect. Leaders who act in ways that promote the organization’s mission, vision, and values will be seen as having less “self” and more “organizational” interest. • Intimacy is just as important as reliability and competence. Think of your local auto repair shop, for example. You have known “Bill” for many years. He asks about your family while he checks out your car. Maybe he’s not as competent as the car dealer, but you trust him. • Your organization must be reliable. You must deliver services in a competent way. There will always be mistakes, oversights, bad years, etc., but trust can often be maintained by making sure your intimacy value is always high. Trust will help you get past the inevitable service failures all organizations have and keep your physicians engaged in improvement work. When there are problems, those who trust you as a leader will feel comfortable contacting you to express their concerns and frustrations. They will not be shy because they know that you will take their comments seriously. And if you have reasonable explanations, they will give you the benefit of the doubt and more. You just need to make sure you don’t make the same mistake again! o Jeffrey Lasker, MD, MMM, is a senior physician executive consultant with a track record of building and leading highly successful physician organizations. He has focused on value-based care over a wide range of community and academic practice settings.

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“One of the

key elements in engaging physicians is building an organization that physicians trust.”

Federal Policy Update: 2018 Midterms...continued from page 12

MEDICARE RULEMAKING AND FEE-SETTING Meanwhile, the focus this summer and fall for healthcare advocates remains on the administrative front. Staff at the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) continue to slog through the perennial Medicare rulemaking and feesetting process. Agencies publish proposed regulations in the Federal Register, which is part of the rulemaking process and explains an agency’s plan to issue new regulations or modify existing ones. Proposed rules include advance notices of proposed, petitioned, and negotiated rulemaking. Typically, they address current problems in the way the agency is running the Medicare program and introduce new goals for future years. Importantly, this process provides an opportunity for the administration to solicit public and stakeholder comments to improve the final rule. The fee schedule proposed rule is of particular importance to physician groups. It provides an avenue for the administration to fast-track certain changes to the Medicare program (within its jurisdiction) without having to rely on Congress. As mentioned, it also provides advocates with an opportunity to influence policymaking in a timelier fashion. Policy Briefing: The New Debate...continued from page 15

exists, but it is unenforceable. Funding for subsidies in the individual market was also curtailed. That’s two out of the three pillars of universal coverage.

A LAWSUIT AND THE COMING MIDTERMS Most recently, the Trump administration and certain red states, led by Texas, have sued to overturn the last remaining pillar of universal coverage: guaranteed issue. Arguably, this provision—which guarantees individuals the right to purchase health insurance regardless of pre-existing medical conditions—has been the most popular aspect of Obamacare with the public. Texas and the Trump administration argue that because Congress has nullified enforcement of the tax penalty for the individual mandate, the guaranteed issuance mandate is unconstitutional. This argument is based on Chief Justice John Roberts’ 2012 opinion—which held that congressional action to mandate the purchase of insurance was unconstitutional, but that using a tax penalty for failure to purchase insurance was a proper exercise of Congress’ authority. The plaintiffs argue that because the tax penalty has

Stakeholders like America’s Physician Groups use the rulemaking process to ask for the impact of proposed rules, promote specific priorities like APG’s Third Option direct contracting model, and fight suggested changes that could jeopardize care for the millions of people who depend on Medicare to get and stay healthy.

POST-ELECTION ACTION While the lame-duck period is typically slow, January 2019 will mark the first few months of the 116th Congress, and members—especially newly elected members—will be eager to quickly make their mark. Pre-election lethargy can lead to post-election action. The theme of coordinated care is an important one, as it is absolutely central to our model of care and represents one of the pillars of the volume-to-value movement. We are committed to using all available tools at our disposal, including our APG Advocate members, to ensure Congress and the administration understand the importance of coordinated care and how best to incorporate and promote it in the Medicare program and beyond. While the election cycle will continue to influence the timing of federal policy events, our advocacy work remains steadfast. o

been removed, the entire law is now relatively unenforceable. Accordingly, they believe the guaranteed issuance mandate should be stricken down as well. Some see this strategy as a long shot. Curiously, the Texas lawsuit does not go after the Medicaid expansion. So if the suit is successful, Obamacare would effectively be trimmed down to a single-payer expansion, shedding the other attributes of a universal coverage system. Congress tried to overturn Obamacare in its entirety but failed. It next sought to fatally wound the law through the budget process, starving it into failure. Now, red states (led by Texas) and the Trump administration are attempting to kill it off in the courts. But the midterm elections loom. If the lawsuit fails, and Congress changes hands (at least the House), we appear to be headed toward another two years of stalemate. The states will then have to innovate to maintain the coverage gains enjoyed during the brief history of Obamacare. So far, no state has found a way to fund the wholesale conversion of its healthcare system under a single-payer model, or to plug the gaps through a more modest universal coverage expansion. Stay tuned. o Summer 2018

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New Model of Spine Care...continued from page 17

Organ Donation...continued from page 30

direct result of inappropriate care in patients who have failed spine surgery and are worse off than they were preoperatively.

It is only after every attempt has been made to save a life that the appropriate medical professionals review the deceased’s medical and social history to determine if the individual is a candidate for donation. The bodies of donors are then treated with the dignity and respect they deserve.

While the options for evidence-based therapies may be limited, this reality should not result in the use of non-evidence-based therapies. Particularly because spine pain is so common, adhering to evidence-based treatment is crucial. The effects of following evidence-based protocols are clear in some key metrics. Chronic opioid utilization by patients of New West Physicians is one-sixth the national rate, at 0.5 percent of our patient population, and ESI utilization among our patients has been cut by 64 percent. Adoption of the above program allows for optimal success in the long-term management of these patients, while still allowing for the proper selection of the subset of patients who are likely to benefit from invasive management, including ESI and surgery. o Kenneth Cohen, MD, FACP, is a practicing internist who serves as the Chief Medical Officer for both New West Physicians and OptumCare Mountain West region. He serves on the Board of Directors of America’s Physician Groups. Oregon Health Plan...continued from page 25

Our experience has taught us that integrating and coordinating physical, oral, and behavioral health is essential to improve community health and bend down the unsustainable cost curve of the U.S. healthcare system. We have identified the barriers to such integration and have begun to address them. We have also learned that the requirement for CCOs to enter into contractual relationships with physical, oral, and behavior health providers is what created the space necessary for trust to grow—and to be translated into practical, collaborative solutions. o John Kitzhaber, MD, was governor of Oregon from 1995 to 2003 and from 2011 to 2015. He was the chief architect of Oregon’s Coordinated Care Organizations (CCOs). References 1

http://johnkitzhaber.com/taking-responsibility-for-americas-health/

https://www.orohc.org/first-tooth/

https://en.wikipedia.org/wiki/Community _Mental_Health_Act

https://www.samhsa.gov/capt/sites/default/files/resources/acesbehavioral-health-problems.pdf

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These donation conversations should take place with patients of all ages, not just with the sick or elderly or when palliative care is being discussed. And it should be explained that while most organ and tissue donations occur after the donor has died, some organs (including a kidney or part of a liver or lung) and tissues can be donated while patients are alive and well. Even for a donation that occurs after death, it is not about sadness and loss. In fact, donor families repeatedly say that for them, donation helps give greater meaning and fulfills the life of their loved one while keeping their memory alive. In short, donation is really about life. Many other questions will arise in this conversation, including: • What do religions say? The truth is that every major religion in the United States supports organ, eye, and tissue donation as one of the highest expressions of compassion and generosity. • Is there favoritism in selecting transplant recipients? No. When an organ becomes available, it is given to the best possible match based on blood type, body size, the recipient’s medical condition, and the length of time the recipient has been waiting. • How can I register? Individuals can register to be a donor at their local DMV. California residents can register online at https://register.donatelifecalifornia.org/register/ OneLegacy.

HEARTWARMING NUMBERS Nationwide, a record 34,772 organ transplants were performed in 2017, using organs from both deceased and living donors. That marked the fifth consecutive record-setting year for transplants in the United States. Millions more lives were healed through tissue and cornea transplantation. These heartwarming numbers tell us that the message is getting through. But there is still a lot of work left to be done in dispelling myths, building understanding, and spreading this message of hope. We urge physicians to help in this cause. o Tom Mone is CEO of Los Angeles-based OneLegacy, the nation’s largest organ, eye, and tissue recovery organization.

The Journal of

RESERVE YOUR SPACE IN 2018 Issue

Theme

Colloquium Healthcare Forecast/ Elections

Regional Focus Northeast/ Mid-Atlantic

For information on editorial contribution and advertising opportunities, contact Valerie Okunami at journalofapg@gmail.com or call 916-761-1853.

Spring 2018

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

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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.

Keeping the San Francisco Bay Area healthy for more than 25 years

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