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49 posts categorized "Accountable Care Organization"

April 11, 2013

PQRS: Alphabet soup with little meaning

Bartolomeu_Velho_1568I'm quoted in the current issue of Medical Economics, on the subject of the Medicare PQRS: Physician Quality Reporting System. I'm not a big fan of PQRS, since it rewards reporting of process measures, not outcomes, and the amounts at stake (up to a 2% bonus or, soon, penalty) have not been enough to move most docs to bother.

Here are my 5 PQRS tips, as reported in the article:

1. EHRs will help with data collection and processing. “You just have to keep your records properly. It’s a little bit of easy money for collecting information you should be collecting anyway,” Harlow says.  

2. The PQRS is a way to keep track of a set of measures that the Medicare program has deemed important. “Personally, I would prefer they would focus on six that would be the most predictive of outcomes,” he says, suggesting that the program could be a little bit more focused so that, after 5 or 10 years, it could be determined what measures are most predictive of good outcomes. “The danger is, physicians could focus on just the things that are being measured and the other things fall off the table.” 

3. A greater “bang for the buck” will occur as the private sector jumps on board, he says. Practices could make significantly more money on the private-payer side for reporting these measures. The more people get comfortable with reporting on and meeting these measures now, the easier it will be to incorporate doing so later.

4. “It’s not just about collecting the data, but to focus on [improvement] from one year to the next,” he says. “The focus on tracking [data trends] will enable you to take the next step.”

5. It’s better for providers to be ready for the shift to pay-for-performance sooner rather than later. Being able to show you aren’t just collecting data, but that you also are using those data to improve outcomes from year-to-year, will be increasingly important.

Bottom line: Look to the future, to reimbursement and care systems that leave behind FFS and all its add-ons like PQRS, like the ACO model (Accountable Care Organizations) and other innovations

The old system, with all of its adjustments and recalibrations, looks more and more like pre-Copernican astronomy, with the outrageous adjustments to a geocentric model that had to be made to explain behavior of a heliocentric solar system. I think we're all ready for a breath of fresh air.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting  

December 19, 2012

HealthCare SocialMedia Review No. 19 - Festivals of Lights Edition

Welcome to the final edition of HealthCare SocialMedia Review for 2012. HCSM Review is a biweekly compendium of the best of the #HCSM blogosphere.

Given the plethora of holidays with themes of light that fall around this time of year -- Diwali, Eid al-Adha, Christmas, Kwanzaa and Hanukkah (well, some of them are on different calendars, so they sometimes fall around this time of year), this edition of the Review will attempt to incorporate the theme of lights into the roundup.

2012-12-10 17.10.39

(I had occasion to celebrate Hanukkah at the Massachusetts State House -- the photo to the left shows the Senate President, Chabad rabbi, Speaker of the House and Governor Patrick on a scissors lift, lighting the giant menorah.)

Fard Johnmar sheds some light into dark corners, debunking some common myths about online and social media health content at digihealth pulse.

2012-12-02 17.02.16Kathy Nieder is getting ready to flip the switch and turn on an online physician community for herself and fellow docs at her system. As they begin using this system, they will be in good company; a new survey coauthored by (among others) fellow tweeps and bloggers Brian McGowan and Bryan Vartabedian finds that one in four docs uses social media daily.  

(I captured the unusual set of lights shown here to the right after a friend of mine flipped the switch on his bid for a more ecumenical approach to holiday lights in his neighborhood.)  

Looking back on 2012 and peering into the future, Kevin Campbell offers some illuminating thoughts about social media, mHealth and medicine. He tips his hat to Doc Tom and the e-patient movement, medblogger Westby Fisher and others, but notes that health care providers are using social media in basic ways, just scratching the surface. It's important to match the tool to the job at hand. (Everyone's darling these days seems to be Pinterest, so here's the latest Pinterest post from the HL7 Standards blog.) And let's not forget: it's important to measure the value of your social media efforts.

I recently spoke with Barbara Ficarra about clinicians lighting up online; check out her post on the subject.

The story about physicians on twitter has jumped the shark -- it's not on a blog; it's in the LA Times, but it contains a boatload of references back to the blogerati and twitterati of health care, so I suppose it merits a link. Physicians who have not yet caught on to the many uses of social media should at least remember Dan Hinmon's advice on The One Thing You Should Not Do if a Patient Posts Negative Online Reviews. And a ll health care providers should remember not to fear patient negativity on social media.

Hospital use of social media is the subject of a Hospital Impact post, which draws in part on Reed Smith's study of Facebook use by thirteen hospital systems (check out the infographic at the link).

These days, when we think about hospitals and physicians, we often think of Accountable Care Organizations. Gregg Masters blogged about the role of social media in ACO development after hosting the #HITsm tweetchat where the issue came up.  

Patient communities on twitter are the subject of a series of posts on the Symplur blog, including this one on network centrality analysis, focusing on Kelly Young (aka @rawarrior) and other key nodes (or points of light) in the RA network. 

To balance this last post, here is a more basic primer on social media as a means to patient empowerment.

Health care brands active online understand the need to engage with patients. Exhibit A: a post on the NPR Shots blog, Social Media Help Diabetes Patients (And Drugmakers) Connect. (Shout out to Kerri Sparling.)  A key element of using social media to reach people and have a positive effect on their health is the need to meet people where they are.  This point comes through loud and clear in a post by Ruchi Dass about fighting malnutrition in rural India. And it is emphasized further by Susannah Fox, a reliable source of illumination and clarity, in her post on SMS messaging for health, and the cavalcade of comments that her posts always elicit.

Thanks to Dan Dunlop for highlighting "The Germinator" -- a homegrown, soon-to-be-viral video focusing on hospital acquired conditions (HACs) coming to you from Crouse Hospital in Syracuse, NY.  

With any luck, this meta-blog-carnival link will not create an irreparable tear in the fabric of the universe: Hold onto your hats while I commend to your attention the Festival of Lights edition of the Health Wonk Review recently hosted by Hank Stern at InsureBlog.

Candle_2A jumble of greetings to everyone, some late and some early: Shubh Deepavali, Eid Mubarak, Merry Christmas, Habari Gani, Hanukkah Sameach, and a Happy New Year. Here's to balance, and to a step back from burning the candle at both ends.

HealthCare SocialMedia Review has information about the next edition’s host and instructions on how to submit your posts for review in future editions.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

December 05, 2012

David Harlow featured in Becker's ASC Review: 6 Steps for ASCs to Participate in New Payment Models

Here's an excerpt from a piece in Becker's ASC Review quoting me on the effect ACO development and other health reform environmental changes are likely to have on ambulatory surgery centers, and how ASCs can position themsleves for future success

Here are six steps for surgery centers to participate in new payment models.

1. Figure out how to participate in ACOs productively. ACOs are becoming more common in different healthcare markets across the country and ambulatory surgery centers need to figure out how they can most productively participate. First and foremost, they should leverage the relationships they have with hospitals and physician groups for a seat at the table during the ACO formation.

"There is clearly a place for physician led ACOs because we are talking about developing systems to control costs that are ultimately directed by physician order," says David Harlow, principal at The Harlow Group, a healthcare law and consulting firm. "There is an opportunity for physician-led ASCs to participate in ACOs and benefit from the payment incentives that are included in the program simply because of the ability to improve quality and reduce costs over a baseline period, and that could fall to the ASC's bottom line."

Integration will be easier if the ACO is physician-led. Hospital-led ACOs may focus on filling hospital ORs; however, surgery centers also have partnership options if the ACO is hospital-led.

Follow the link to read about the other five.

For related information, check out the 2013 Medicare rate regulation for ASCs and my recent post on accountable care organizations and health reform after the election.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


November 12, 2012

Health Reform After the Election: Accountable Care Organizations and Population Health

Much has been written and said about the effect of the election on the implementation of federal health reform initiatives.  The commentariat, including the blogerati and twitterati wings, have focused on the budget battles of the future to come from Capitol Hill, the flurry of regulations to come from HHS, and the last stand of the boys in red in certain state capitals around the country against implementation of health insurance exchanges and Medicaid expansion under the ACA.

I spoke recently about the importance of the Accountable Care Organization law and regulations, and related initiatives being undertaken by the Center for Medicare and Medicaid Innovation (CMMI) at CMS, and the ways in which these initiatives are likely to affect the next phase in the development of the health care system in this country.  I thought I'd share a few of the highlights here.

We have built a system of sick care in the USA, not health care, and the disruptive forces contained in the Affordable Care Act, including the ACO provisions, have the potential power to change our system to a system of health care – by changing the focus, by changing the incentives, by changing the behaviors of both patients and providers.

The goal for all of us in health care these days is to be better integrated with other parts of the system, so that we can do more with less in the future. We all know -- or should know by now -- that we will have to do more with less. The key to future success will be managing patients’ care and its attendant costs over the long term, managing an episode of care that extends beyond an inpatient surgery to encompass pre-admission and post-discharge services, managing a chronic condition with a multidisciplinary approach using medicine, nursing and even social media and game theory to motivate patient behavior modification. We need to move from reimbursement-based medicine to evidence-based medicine.

When the ACA was enacted, folks likened the ACO to the unicorn: Nobody's ever seen one, but everyone knows exactly what it looks like.  Once the ACO regulations were finalized, I called it as I saw it: the ACO is a camel -- a horse designed by committee. And now I see the ACO and related initiatives under the ACA as a camel with its nose in the tent: a disruptive force beginning to change the world as we know it.

When the final ACO rules came out about a year ago, CMS actuaries predicted that there would eventually be about 270 Medicare ACOs -- including large and small organizations and urban and rural organizations -- by the end of three years (we are less than one year in at this point), providing care to up to 2 million Medicare beneficiaries.  We're on track to get there and beyond, with over 150 Medicare ACOs already approved and several hundred more applications queued up for the future. (Keep in mind there are approximately 150 commercial ACOs out there as well – according to an inventory updated this spring by Leavitt Partners.) 

In addition to the estimated 270 Medicare ACOs, HHS estimates up to $1 billion in savings to Medicare over four years, and the Congressional Budget Office estimates $5 billion in savings over eight years.  At first blush, these look like impressive figures, until we recall that there are 6000 hospitals in the US, nearly 50 million Medicare beneficiaries, and that Medicare is a $500 billion line item in FFY 2013 alone. The ACO initiative is a drop in the bucket.

The ACO initiative is generating a lot more interest than perhaps they should, based on these numbers – but this is legitimate, for a couple of reasons.  ACOs really form the conceptual building blocks for a new approach to achieving the Triple Aim – which is now the mission of CMMI: Better Healthcare, Better Health and Lower Costs Through Improvement. CMMI seeks to: "Encourage better health for entire populations by addressing underlying causes of poor health, such as physical inactivity, behavioral risk factors, lack of preventive care and poor nutrition."  It is using the levers of the ACO program to enlist ACOs in the execution of this element of its mission.

So, the camel’s nose is in the tent – we're at the leading edge of a significant disruption built around the Affordable Care Act’s provisions on ACOs and related initiatives: a sea change in the way health care is conceptualized, and radical change in delivery and payment systems.  We’re ahead of the curve on these issues in Massachusetts, with a law passed this summer that will move us into ACOs for all -- not just Medicare beneficiaries -- and away from fee-for-service medicine, and a local Blue Cross-Blue Shield plan known as the Alternative Quality Contract that has been working on this basis -- budgeted caps with quality kickers -- for several years already. It’s the latest form of pay for performance, or value-based payment.

An ACO has to have at least 5000 Medicare beneficiaries attributed to it, but the beneficiaries cannot be forced to enroll in a closed network. Because Congress sees elimination of choice of provider as a third rail of health care, ACOs do not know for certain which patients will have more than 50% of their primary care encounters with an ACO PCP in any given year and thereby be attributed to the ACO, Thus, in order to succeed, ACOs must be focused on population health, on prevention and wellness in a population, not just on individual encounters with patients.

CMMI is also using the power of the purse -- its $10 billion budget, to be spent over ten years on experiments with the health care system.  Nearly two dozen experiments are already under way, including three flavors of ACOs. While CMMI is experimenting with a wide variety of methods to incentivize health care providers to change the way they provide care (check out the CMMI "What We're Doing" page), the health care providers participating in these innovations should be laser-focused on the 10% of chronically ill Medicare beneficiaries whose health care expenses consume 50% of the Medicare dollar. If they change their approach to managing these patients' care through patient-centered medical homes or otherwise, there are great opportunities to achieve significant savings through avoiding preventable hospitalizations and the like.

The keys to success will be clinical integration -- not just in word but in deed -- and turning data into actionable intelligence.  Health care systems that can achieve these two interim goals will be well-positioned to achieve the broader goals of improving population health and quality of care while bending the cost curve -- and not just for Medicare beneficiaries attributed to Accountable Care Organizations.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

November 08, 2012

David Harlow is keynote speaker at Louisiana Hospital Association 2012 Health Law Symposium

This morning I am in Baton Rouge, at the Louisiana Hospital Association conference center, sharing my perspectives on ACOs and the broad range of innovation in health care delivery and financing being ushered in under the Affordable Care Act.

I am also speaking about the use of health care social media in the face of concerns from legal, compliance and regulatory departments.

October 05, 2012

Upcoming Speaking Engagements - Fall 2012

This conference season has already been a busy one: I organized HealthCamp Boston 2012, which was an exciting one-day unconference that took place right before Medicine 2.0, where I spoke.  I hope that local HealthCamp attendees can keep in touch, and maybe this time around we won't wait three years for the next HealthCamp Boston.  Unfortunately, I couldn't make it to Medicine X or Health 2.0 on the left coast this year, but I hope to see some of you in Boston at the Connected Health Symposium later in October.

Here are some of my upcoming speaking engagements:

The Effect of ACOs on the Health Care and HIT Ecosystems
Let's Talk HIT Speaker Series
Scratch Marketing + Media
Cambridge, MA
October 18, 2012
An informal presentation and discussion - join us if you are local.

Health Care Social Media: The Lawyers Don't Always Say "No"
MGMA 2012 - Medical Group Management Association Annual Conference
San Antonio, TX
October 21-24, 2012

Keynote Speaker on Health Care Social Media and on Accountable Care Organizations
Louisiana Hospital Association
23rd Annual Health Law Symposium
Baton Rouge, LA
November 7-8, 2012

Moderator of Legal Panel Discussion
Healthcare IT News and HIMSS
The Privacy and Security Forum
Boston, MA
December 13-14, 2012

I hope to see some of you at these events - please let me know if you'll be attending.

If you'd like to learn more about my speaking, keynoting and retreat facilitation, please start with this page about my speaking.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting 

September 05, 2012

CO-OPs - The Stealth Public Option Under the ACA?

362px-Minute_Man_Statue_Lexington_Massachusetts_croppedLast week, the Massachusetts CO-OP was approved by the federales under a provision of the Affordable Care Act that was key to the Act's passage, yet not widely known. The Consumer Operated and Oriented Plan, known as the Minuteman Health Initiative, secured a startup loan as part of the approval, intended to cover operational expenses as well as state-mandated reserves. Here's an excerpt from the Minuteman presser, as published by CommonHealth:

Tufts Medical Center, its New England Quality Care Alliance (NEQCA) physicians network and Vanguard Health Systems (NYSE: VHS) are proud to sponsor the Minuteman Health Initiative, which has received an $88.5 million loan from the Centers for Medicare and Medicaid Services (CMS). This new member-governed, non-profit health insurance option for Massachusetts residents intends to offer consumers and employers lower-cost, high-quality care with unprecedented transparency, as well as increased efficiency and satisfaction for physicians, patients and employers alike. Plan members will ultimately govern this health plan via Minuteman’s unique ownership structure.

Congressional proponents of "Medicare for All" (aka the public option) took their lumps when the ACA did not include such an animal -- in part, because it did include the CO-OP requirement: one CO-OP per state, to be a nonprofit founded by providers and run by consumers, whose margins are to be plowed back into premium reductions, improving benefits and improving quality of care. (Don't confuse the CO-OPs with co-ops, which are simply group purchasing cooperatives for health insurance that manage to eke out tiny group discounts. In Massachusetts, co-ops are limited in total enrollment to 85,000, a fraction of the small group and individual market population.) CO-OPs are supposed to be operational in every state, ready to enroll members (and therefore with provider networks already in place) by 2014, so they can get started on an equal footing with other health plans on state exchanges, on offer both to individuals and to employers (though 2/3 of enrollees must be from the individual and small group markets).  Founded by providers, they are required to transition to member control within a year of beginning member enrollment.

Did that political horse trade make sense? Do CO-OPs make sense?

The CO-OP in any state has the potential to become a serious competitor to existing health plans. Since there is a limit of one per state, the potential enrollment is high, and the attractiveness to providers and provider networks -- including a willingness to enter into pricing and contracting arrangements favorable to the CO-OP, such as global caps and ACOs -- is also high. In the Massachusetts example, seventeen non-founder hospitals have expressed interest in participating. (That's about 20% of the state's acute care hospitals interested in the CO-OP before it's even off the ground.) The only other insurance plan on offer statewide is Blue Cross Blue Shield, so if the CO-OP can build or rent a provider network quickly, and differentiate itself in the various markets statewide, it has the potential to become a real powerhouse.

On the downside, a CO-OP has to price its products without having historical claims data, which could be tricky, and it needs to scale up its administrative infrastructure before it has the membership base to support it (of course, it could contract for those services, and the loan from the federales is intended to cover such up-front costs). It's a big gamble: trying to break into a market dominated by a small handful of players is never easy, and trying to do so as a nonprofit that can have no ties to existing insurance companies may make it harder.  

The potential difficulties ahead of the CO-OPs explain why CMS reportedly anticipates a 35-40% default rate on the startup loans and may raise an eyebrow (after all, a billion here, and a billion there, and soon we're talking serious money).  Do we need CO-OPs to make the ACA work, or is this one of the throw-it-against-the-wall-and-see-what-sticks provisions?

The CO-OPs may well play out as the Medicare for All / Accountable Care Organizations for All sleeper cell of the ACA. A well-managed CO-OP in a state with the right market conditions could end up as a significant player. In Massacusetts, if Minuteman picked off half of the individual and small-group subscribers through its likely more attractive pricing, and the maximum number of larger-group subscribers to go along with them, it could be looking at 375,000 subscribers (and some multiple of that for covered lives) in not too long from now. Let's say, for argument's sake, 1 million covered lives in a state with a population of around 6.5 million. Not too shabby for a startup. While some may say that Massachusetts is a bad example as a poster child for this initiative, because the "big three" health insurers here are all nonprofits and we don't have a significant uninsurance problem thanks to state health reform, there is still room for improvement here -- nonprofits still have highly-paid execs and other elements of high-cost structures that may be different in a member-controlled CO-OP, and there are rural parts of the state that would benefit from the innovations that could be brought to bear by a high-functioning CO-OP partnering with ACOs and PCMHs. And if there's room for improvement here, I think there's room for improvement in most states.

The CO-OPs have the potential to be the tail that wags the dog -- larger insurance companies may well adopt the commercial market pricing and provider network contracting and benefits strategies of the CO-OPs in order to remain competetive. And in an era of legislated medical loss ratios (and the CEO of Aetna saying that he sees his company as a health information company rather than as an insurance company), that dog seems ready to be wagged.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

July 31, 2012

Massachusetts Health Reform Bill Tackles Cost Control and More

The Massachusetts legislature is voting today on "An Act improving the quality of health care and reducing costs through increased transparency, efficiency and innovation" reported out of conference committee at the eleventh hour, last night. (Update: The law was passed by both houses and sent to the Governor for signature this evening.) The headlines include:

1.    The health care cost growth rate may not exceed growth of the "gross state product" (GSP) for five years, and must be between the GSP and .5% below the GSP for the next five.

2.    Certification programs for Patient Centered Medical Homes and Accountable Care Organizations.

3.    Transparency and accountability for cost and quality.

4.    Investment in wellness and in community hospitals.

5.    Med-mal reform including a 6-month coooling off period and inadmissibility of medical apologies in court proceedings.

The full text of the bill, and a summary, are set forth below.  It's been a long haul, and this Part III of Massachsuetts health reform was kicked off by Governor Deval Patrick almost 18 months ago.

A return to central health planning?  Not quite, but certainly more heavily regulated than things are at the moment. Is that a bad thing?  Well, consider how the free-market approach has been working out: overall, we've seen a high-cost, low-quality experience (relatively speaking) that could use some help. Is this new law the panacea we need? Too soon to tell. But we surely cannot stick with the status quo.

MA Health Care Reform Bill - Summary


MA Health Care Reform Bill S 2400 7 30 2012

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

March 08, 2012

HealthCare SocialMedia Review - A New Blog Carnival - To Launch In April

While the HealthBlawger is generally loath to republish press releases, the source for the presser reproduced below is, well, the HealthBlawger himself.  With such impeccable provenance, we need make no further apologies ....

HealthCare SocialMedia Review - A New Blog Carnival - To Launch In April

HealthcareSocialMediaReviewOn April 4, 2012, the inaugural edition of a new blog carnival, HealthCare SocialMedia Review, will be posted on HealthWorks Collective by HWC curator Joan Justice, one of the co-founders of HCSMR. “We were inspired by other blog carnivals, including Grand Rounds and Health Wonk Review, and decided it was time to bring the blog carnival treatment to the world of health care social media,” said Justice.

David Harlow (aka HealthBlawg), health care lawyer, HWC advisory panel member and the other co-founder of HCSMR, continued:

The #hcsm tweetchat moderated by Dana Lewis and the community built by Lee Aase through the Mayo Clinic Center for Social Media are two examples of the many ways in which those of us who are involved in health care social media are able to interact, share best practices and new developments, and learn from each other.  By adding a blog carnival to the mix, we hope to increase the sharing of long-form thoughts on the opportunities and challenges associated with health care social media.

Justice noted, “All are welcome to submit blog posts for consideration to each edition’s host.  HCSM will be posted every other week -- alternating weeks with Health Wonk Review.  And for the uninitiated: a blog carnival is an anthology, an on-line journal club for bloggers, hosted by a different blogger each time.”

Details on hosting, submission guidelines, Justice and Harlow bios and more are available on the HCSMR home page.

Connect with HCSMR on Facebook, Google+ and Twitter to keep up to date.

For further information contact:

Joan Justice joan AT or @healthcollectiv
David Harlow david AT or @healthblawg  

# # #

Health care social media is of consequence in its own right, but also as a tool to implement or leverage other initiatives, across the spectrum of health care innovation today, including participatory medicine, accountable care organizations, mHealth and others.  We look forward to your participation in the HealthCare SocialMedia Review blog carnival as contributors, hosts and engaged readers/commenters.  See you April 4, at the inaugural edition, on HealthWorks Collective.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

December 05, 2011

Deja Vu All Over Again: David Harlow speaks with Gene Lindsey, MD, President and CEO of Atrius Health and Harvard Vanguard Medical Associates


Recently, I had the opportunity to speak with Gene Lindsey, President and CEO of Atrius Health and Harvard Vanguard Medical Associates. Atrius is a 1000-physician allliance of six medical groups in eastern and central Massachusetts; Harvard Vanguard is the largest of those groups.  We discussed some current developments in the health care regulatory landscape and marketplace, and Atrius' approach to positioning itself for success -- as well as its definition of success -- in the current environment, in domains ranging from improvinmg medical education to achieving the Triple Aim. 

Gene is a student of the history of his organizations (he's been a part of their operations, and those of their predecessor, Harvard Community Health Plan, since the 1970s), and he traces current discussions about health care quality and cost back to the thinking and writing of HCHP's founder, Dr. Richard Ebert. He described delving into Ebert's papers in "the bowels" of Countway Library at Harvard Medical School (Ebert was Dean there when he founded HCHP) and is clearly committed to the framework of collaborative, physician-led efforts to manage health care and control costs. He's taking his organization through a Lean process of cost-cutting, and is working to further Atrius's early successes under the proto-ACO Blue Cross Blue Shield of Massachsuetts Alternative Quality Contract (AQC).  Atrius Health's first year's results under the AQC look promising, though researchers writing in the New England Journal of Medicine concluded that further study is needed.  Gene says he has another two years' data, and the results continue to look good.

The audio file of my interview with Gene Lindsey is available for download/podcast.  It runs about 25 minutes. A full transcript is at the end of this post (and in the linked Gene Lindsey, CEO, Atrius Health, interview transcript).

In thinking about how to create a high-performing health care system, Gene observed: "as Atul Gawande says, the issue is that we’re not without knowledge, we’re just inept in applying that knowledge."  He predicts that the next several decades will be devoted to figuring out how to apply the knowledge we already have.  

He wrapped up our coversation by tying his work at Atrius to the IOM's six domains of quality, making a strong statement about his organization's commitment to patient-centeredness:

We have constructed our organizational activities around what the IOM called the six domains of quality, the most important of which is patient-centricity.  We need to design the system to be a benefit to the people who come to us for care - they are our reason for existence. That’s not been true in the past. In the past we’ve designed it for a lot of other reasons, but not always and specifically to benefit the care of people.  Sometimes it’s for the convenience of physicians, sometimes it’s for the perpetuation of august institutions - whatever it’s been, but it’s not always been that the patient’s been at the center of it.  Lucian Leape, whose name you introduced earlier, focused us on safety. The other issues . . . care needs to be timely if it’s going to be safe and patient-centered, it needs to be efficient and effective if we’re going to have a society that continues to exist, and the last and most important of the domains is it’s got to be equitably delivered -- and probably that has been the biggest conundrum for our country.  How do we get the last 15% of our citizens covered in a fashion that doesn’t destroy the economics for the rest of us? [T]hat in and of itself is the most compelling reason to look hard at why and how we waste resources.  

During our conversation, Gene jokingly called me an anarchist, due to my hyperbolic characterization of the Lucian Leape Institute's recommendations about re-inventing medical education in the US. The truth is, we need to put a little bit of the anarchist in each of us to work if we want to achieve meaningful change to our broken health care system.

Keep an eye on the man with the bowtie.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


HealthBlawg :: David Harlow’s Health Care Law Blog

Interview of Dr. Gene Lindsey, President and CEO of Atrius Health 

 and Harvard Vanguard Medical Associates

November 30, 2011

David Harlow:  Hello, this is David Harlow on HealthBlawg and I have with me today Dr. Gene Lindsey, President and CEO of Atrius Health, an alliance of 6 medical group practices in Eastern and Central Massachusetts with over 1000 physicians at 50 locations.  Dr. Lindsey also serves as President and CEO of Harvard Vanguard Medical Associates, the largest of the groups.  He started practicing at Harvard Vanguard’s predecessor, Harvard Community Health Plan, over 35 years ago and has held a variety of leadership positions in these and related entities through the years.  Gene, thank you for joining us today.

Gene Lindsey:  I’m glad to be here David, thank you very much for inviting me.

David Harlow:  My pleasure.  So you’ve had some firsthand experience practicing in the early days at one of the country’s leading HMOs - in fact, working with our soon-to-be-former CMS administrator Don Berwick. How are those days and that experience similar to the current environment where so many folks are focused on accountable care organizations and new payment systems?  Many have said these look a lot like capitation - though we’re not allowed to say capitation these days, and of course we have some new bells and whistles.  I wonder if you could speak to some of the similarities and differences and, since we didn’t fix the healthcare system for good back in the ’70s, what’s different this time around?

Gene Lindsey:  Well, that’s one of my favorite questions, David.  It is déjà vu all over again for me in many ways, in that there is certainly a sort of a pioneer spirit that’s associated with our organization now that feels very reminiscent of the spirit that existed when I joined the organization in 1975.  In fact, the term “capitation” was not a term that we used back then. Dr. Robert Ebert, who was the dean of the Harvard Medical School and through whose vision Harvard Community Health Plan evolved, used the phrase “prepayment” and it was his concept which we still share today: that fee-for-service medicine led to a fragmentation of care that was deleterious to the concept of wellness and to the preservation of health.  And so some of the terms that were popular at that time really focused more on health maintenance and so we call them HMOs, Health Maintenance Organizations - it’s too bad that these three-letter acronyms became four-letter words.  But I think that that was because of the fact that the larger market that wasn’t driven by Dr. Ebert’s vision of wellness but was more economically focused on institutional bottom lines sort of took the spirit of the process and diverted it in a different direction; but the early days of Harvard Community Health Plan included not only Don Berwick, but other people who have gone on and made huge contributions like Glenn Steele who was a surgeon here - he is now the CEO of Geisinger.  Glenn was a surgeon at Harvard Community Health Plan from the mid 70s through the late 80s.  There was Glenn Hackbarth, who is the current chair of MedPAC, who was one of my predecessors as the CEO of Harvard Vanguard.  So our organization has always been focused on the future and always been focused on what we can do in the moment to improve the health of the individuals who come to us for care.

David Harlow:  So you said the word “pioneer,” so I wanted to ask you about what you’re doing in the pioneer arena as we’re moving towards ACO development, and my understanding is that you’re moving in that direction on behalf of the organization.  I’d like to get your thoughts on the Pioneer ACO structure and how that relates to your present activities, or activities over the past year or so under the alternative quality contract with Blue Cross Blue Shield of Massachusetts.

Gene Lindsey:  Well I certainly am in support of the Affordable Care Act, in particular the part of the Affordable Care Act that’s looking at the development of new practice models through CMMI, and on various occasions we have had conversations with people at CMMI and CMS -  they’ve asked us for our input in how to create programs that will be potentially successful.  Their goal is obviously to simultaneously reduce the healthcare spend while improving the quality of the care that’s provided, and our organization literally has adopted as a major portion of its reason for existence the success of what the IHI has called the triple aim: better care for individuals and better care for communities at an affordable cost. 

The ACO movement, I believe, is the national extension of Dr. Ebert’s ideals.  We’ve been looking for an economic model that actually supports the fact that care that’s going to be most effective will probably be care that’s delivered in a variety of environments that are difficult to harness in a fee-for-service way.  I think that we have sort of gotten as far as we can get in terms of health improvement and efficiency paying for care only in a hospital or in an office, and the advantage that Dr. Ebert saw 42 years ago was prepayment, was that many programs that utilize time and energy of clinicians outside the office and hospital environment were going to be the fulcrum of what we could accomplish with patients.  Now in this moment that means trying to take care out of the office into the space where the patient lives, and our organization does that through things like a patient portal on our website that allows them to have direct communication with their physician or with other caregivers in our system. We’d like to have programs of wellness, behavior modification, things of that sort, that go beyond the scope of the 15-minute appointment, and actually often take our clinicians into the home for the homebound elderly in ways that are very difficult to support – again, if there’s a turnstile in front of the office that a patient has to walk through to economically support the system. 

So those ideas all feel to me like they’re exploratory and in that regard the concept of it being a pioneer effort seems very appropriate.  I think in the commercial area - you referred to the AQC, I believe - we’ve learned a lot over the last 3 years because what the AQC contract had as a very laudable direction was moving from volume-based reimbursement to value-based reimbursement.  And when it started for us we didn’t know for sure how to begin that journey but what we did quickly learn was – and I know that you have a prior relationship with Marc Bard – Marc preaches that the whole success will be on the basis of moving from a concept of individual effort to group effort.  He talks about moving from I to WE and that’s exactly what was necessary to be successful within the AQC - to begin to assemble groups of clinicians and healthcare professionals to look at rosters of patients, to look at results in a collective fashion, to put together programs that would allow outreach to people whose health needed particular attention in one area or another - congestive heart failure and diabetes have been certainly big areas of focus, we’re beginning to try to put together programs that help with mental health issues and also with the new epidemic of obesity.  So all of these programmatic approaches to problems that are shared by patients is what we refer to as population medicine and you can do more, and do more effectively, if you approach it in terms of programs - and those are all not possible to support very effectively in a fee-for-service system.  But if you can group the budgets from many patients together as a resource then in fact you can very efficiently fund programs that do promote wellness which, over a series of years, will reduce the total spend on healthcare because it’ll be avoiding a lot of long term complicated problems that are otherwise going to be an individual drain on the collective healthcare spend.  So we’re learning a lot - it’s a fun time - my only regret in this is that I’m old as I am and I don’t have that many more years left to go because I think the next 20 years of healthcare is going to be a really fantastic place to be.

David Harlow:  Yes, we are certainly in interesting times.  You said a couple of things I wanted to follow up on.  One is on the question of seeing results and system savings from the approach that you describe.  There was a recent piece in The New England Journal of Medicine looking at initial experience under the AQC which basically said, if I remember correctly, looks good, looks like we’re moving in the right direction, but further study is needed.  Is there any information that you could bring to bear on that observation from prior experience with Atrius, with Harvard Vanguard, with Harvard Community Health Plan, that would tend to support the idea that this is actually going to work?

Gene Lindsey:  Yes, in fact that article was based on just the very earliest results from the first year and I’m aware of the results of the next year already and almost two years’ more data, and the data has continued to improve.  We’ve learned a lot, our initial efforts for instance in the quality areas led to what I would say is the reproduction of a typical dose-response curve.  You had a sharp improvement that then began to plateau off, and that’s not a surprise because I think that each time you do something new it has an effect, and the effect will carry you so far towards the goal, but then you have to come up with what’s next that’ll get you a little further so it’s a very interesting concept of continuous improvement.  And in fact much of the results that we’ve achieved have been through the adoption of continuous improvement in the form of Lean process management so that the results that we’ve achieved so far are the results of a very fledgling organization with Lean and I’m very excited that as our process improvement skills increase, our ability to yield results within the AQC-type payment mechanisms will improve as well. 

What we’re really driving for is improved health. We talk about outcomes, and ultimately, to get the sort of outcomes we need and want, we have to go through a process of creating professionals who know how to affect behavior.  And then we have to have those skills connect with patients in such a fashion that the patients begin to be involved in improving their health.  And that is a series of adaptive changes that takes time and so I think that it’s a long climb, but we’re well on our way, and it is a good example of the phrase that you sometimes hear, which is “act your way into learning.” We really, every time we do something, whether it works or not, it clarifies to us what will lead to more success - and that’s really the adventure of it.  I think physicians by nature are heuristic, they like to solve problems, the people who work with us - our other healthcare professionals - have found that this adds a new meaning to their work; they all went into healthcare because they have strong empathetic tendencies, they want to see improvement, it’s been frustrating for them to be embedded in systems that don’t deliver results,  and the hope of being involved in something that actually approaches what they dreamed of when they went into healthcare - I think it’s been a personally regenerative sort of process for a lot of folks.  It’s sort of exciting to be around. 

David Harlow:  It sounds like it. I’m wondering as you’re talking a lot about retraining and redirecting and refocusing folks who have been practicing clinicians for a while, and earlier this year or last year the Lucian Leape Institute issued a recommendation to blow up medical education and start again, basically saying – look, we haven’t really addressed the issues of medical errors and cost and to do so we really need to reinvent medical education.  Do you see that as a reasonable approach? An organization like yours is of a size that can afford, in the scheme of things, to engage in this sort of reinvention, but most medicine is still practiced in smaller settings and folks can’t really do that.

Gene Lindsey:  I think you’ve thrown me enough to talk about for maybe 3 hours right there, in that last little soliloquy. Let me just begin with a first thought.  The core of the reason for the formation of Harvard Community Health Plan was to do just that - to change medical education.  Dr. Ebert envisioned it as a teaching practice. I’m a student of history, in a way, and I’ve gone to the Countway library archives, with permission of his wife, and gone down into the bowels of the building where all of his papers are stored and actually read what he wrote back in the ‘60s.  And he imagined then that much of the problem lay in medical education, in the fragmentation of the education that residents and interns and medical students received, where they learned about the kidney and then they learned about the heart and then they learned about the lungs, but they never learned about the whole person.  And he didn’t believe it that was possible in a hospital environment, which is very artificial in a way and he felt that the education needed to move into the ambulatory environment where people could actually see their patients closer to where they lived and closer to where the behaviors that created disease actually occurred.  So that’s not a new thought, and I think it is true that we need to be continuously redesigning medical education - in fact I read recently that some of our medical schools across the country, the one that I remember reading about, Jefferson Medical School for instance in Philadelphia, I think, has a program where they actually admit medical students to the hospital overnight so they can have the experience of being in the hospital to understand what it’s like from the point of view of the patient.  And I think that there’s been a lot of activity towards trying to introduce into the lives of medical students how to assess readiness for behavioral change and things of that sort.  So the progress is slow but it’s not non-existent - I do believe that it needs to continue.  I can tell you that every medical student who graduates from Harvard Medical School now has some sort of experience within Harvard Vanguard.  So it’s not as if we’re at zero; we may not be up to full speed but there is progress towards the issue of retraining, and revamping medical education, and I think Dr. Leape’s Institute is correct that process needs to - I assume that they’re using a lot of hyperbole in their statement and trying to --.

David Harlow:  I don’t think they said they’re going to blow it up - that was me -

Gene Lindsey:  That was you, okay -

David Harlow:  That was me -

Gene Lindsey:  Okay, so you’re the anarchist, okay - but it does need to continuously improve, that’s for sure, in this direction.  So I think that’s also a part of what’s encouraging in the moment.  The term that I’ve really come back to again and again and again are the issues of adaptive change both for patients and also for healthcare professionals. The ways in which we have worked have created a lot of understanding scientifically and yet, as Atul Gawande says, the issue is that we’re not without knowledge, we’re just inept in applying that knowledge. So I see this period of time, over the next 20 years, as the way in which we develop the systems that actually bring the fruits of the bench science and the medical technology that’s developed over the last 30 years to the benefit of more and more people in a more and more efficient fashion.  And that’s about organization and that’s about teamwork and that’s about redeployment.  It’s certainly true that as in many other industries we’re still shackled by the fixed investments that we have and so it’s about a process of, as a society, moving away from nonperforming assets and all of that is difficult because there is a sense of loss that’s associated with it, and that’s got to be balanced by a continuous reminder to ourselves of what it is we’re trying to achieve because that’s the only way that you can find the emotional energy to do the hard things that are necessary to get to a better level.  I don’t believe you can do it for money; I think you have to do it because you believe that it will be better for the community - for the same reasons that you plant flowers around your home: because you want it to look better and to be aesthetically something that provides you a gratification that just a focus on finance can’t ever bring.

David Harlow:  Well, hopefully, it has some of these desired results because otherwise we’re going to bankrupt ourselves.  I heard an interesting figure last month, or earlier this month, where somebody said that in order to support our expanding healthcare spend at the federal level, by 2050 our marginal tax rate will have to be 93%.

Gene Lindsey:  Absolutely.

David Harlow:  So we do have to focus on costs.

Gene Lindsey:  I was in a conversation recently with Jay Gonzales who is the Secretary of Administration and Finance for our State, Massachusetts. Right now we’re spending 41 cents of every dollar that the state collects as taxes on healthcare. You don’t have to be an economist to know that that’s probably not a good idea; it doesn’t leave us much left over for roads, for public safety, for schools, for the cultural things that add meaning to our lives.  It pretty much just makes it about supporting a hospital-based system and that’s really -- I don’t think, I can’t think of anyone who would prefer to go to the hospital versus the symphony.  It’s just not right – now, so let me clarify something: all of the stuff that I’m talking about is not in my mind a sense of adding more dollars to the system, I think that I’m a total proponent of the concept that we have allocated enough of our economy to healthcare we’re just not spending it effectively and efficiently.  If there is any phrase that reverberates through my mind on a daily basis it’s efficient, effective, and that’s the thing that’s appealing to me and if you remember those are two of the six domains of quality.  We have constructed our organizational activities around what the IOM called the six domains of quality, the most important of which is patient-centricity.  We need to design the system to be a benefit to the people who come to us for care - they are our reason for existence. That’s not been true in the past. In the past we’ve designed it for a lot of other reasons, but not always and specifically to benefit the care of people.  Sometimes it’s for the convenience of physicians, sometimes it’s for the perpetuation of august institutions - whatever it’s been, but it’s not always been that the patient’s been at the center of it.  Lucian Leape, whose name you introduced earlier, focused us on safety. The other issues - just quickly -  care needs to be timely if it’s going to be safe and patient-centered, it needs to be efficient and effective if we’re going to have a society that continues to exist, and the last and most important of the domains is it’s got to be equitably delivered -- and probably that has been the biggest conundrum for our country.  How do we get the last 15% of our citizens covered in a fashion that doesn’t destroy the economics for the rest of us and that in and of itself is the most compelling reason to look hard at why and how we waste resources. 

David Harlow:  Well thank you Gene.  I think I’d like to end it there wrap it up there and you’ve given us a lot to think about today and again I thank you for joining me on HealthBlawg. 

Gene Lindsey:  Thank you David.  I really appreciate this opportunity.

David Harlow:  I’ve been speaking with Dr. Gene Lindsey, CEO and President of Atrius Health and Harvard Vanguard Medical Associates.  Thanks again, Gene.

Gene Lindsey:  Thank you David.