Consumer Engagement Structures and Mechanisms: Current Patient Involvement in Organizational Governance Among Providers Pursuing Value

The Health Care Transformation Task Force conducted an environmental scan and survey to identify consumer engagement structures and mechanisms utilized by provider organizations in the design and governance of value-based payment programs. The Task Force interviewed senior decisions-makers involved in consumer-engagement related activities and efforts within their respective organizations and found the following:

• Consumer engagement is important at every level of value-based care delivery, not only in direct patient-care but also in the design and oversight of new payment and delivery models;

• Health care providers are committed but struggling to recruit, train, and actively involve consumers in organizational governance; and,

• Organizations with long-standing regulatory requirements regarding board composition and patient involvement -- like Federally Qualified Health Centers -- can offer key lessons for other providers.

Read the full report.

Read the press release.

HCTTF CHRONIC Care Act Statement for the Record

The recent passage of the Senate’s Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017 (S. 870), which passed under a unanimous consent agreement, is a strong indicator of widespread bipartisan support for measures that can improve the quality of care while lowering costs. Specifically, provisions such as an expanded Value-Based Insurance Design model, improvements to Medicare Advantage special needs plans, broader telehealth access, and flexibility in Accountable Care Organization (ACO) beneficiary assignment, have the potential to greatly improve care delivery.

We strongly encourage the House to expeditiously move the components of this important legislation forward, either through existing individual component bills or through a single bill that serves as a complement to S. 870. We acknowledge that these bills are in various stages of review, and commend committee leadership for continuing to advance these critical issues. The Task Force has identified areas for further enhancement in the pending legislation, described below.

Read the full letter here

Economic Investment and the Journey to Health Care Value

Value-based payment and care has left a powerful and indelible footprint on the U.S. economy. Widescale provider and payer investment in IT infrastructure and personnel to support alternative payment models, an infusion of venture capital support into new technology-based third-party partners, and innovative employer arrangements with providers, are tangibly shifting the axis of healthcare spending and improving the lives of millions of Americans.

The Health Care Transformation Task Force has partnered with NEJM Catalyst to offer an unprecedented look at how value-based care has positively disrupted the U.S. health care economy. Below you’ll find a series of reports on how value has impacted patients, providers, payers, purchasers, and partner organizations.

Click on each of the links below to access the full text reports:

• Introduction
• Patients
• Partners

Click on each of the links below to access the summary and visit the NEJM Catalyst article:

• Providers
• Payers
• Purchasers

(PDF version of the Economic Engine infographic)

Introduction

As the nation continues to face uncertainties on health care policy reform, concerns about the long-term sustainability of the sector are prompting some organizations to sound a note of caution on major investments. The prior administration’s “let a thousand flowers bloom” approach to novel payment and delivery models is being pruned and mandatory participation requirements relaxed. To an outside observer, these signs could point to a slowing of the movement toward value.  But is that really the case?

Value-based payment and care delivery is an imperative that should remain front and center in the push toward a better system. One major driver is the Medicare Quality Payment Program (QPP), authorized under the 2015 MACRA legislation, which adjusts how doctors are reimbursed for services based on quality and cost. The QPP program went into effect in 2017 and encourages providers to pursue alternative payment models that require them to assume financial risk over care for their patient populations. Commercial payers will also continue to push for better value from providers through risk-based payment structures.

Value-based payment and care delivery have already left an indelible footprint on the US economy. Many providers have made major investments in infrastructure to support alternative payment models and better care delivery, including wide-scale implementation of electronic health records and workforce retooling to support care integration. Commercial insurers continue to roll out new value-based contracts and join forces with providers through accountable care arrangements and joint venture partnerships; they have also made internal investments in staff and IT to measure and support value efforts. Employers, or purchasers, are investing in creative alternatives to traditional health plan contracting and finding new ways to control spending that saves millions, such as establishing “centers of excellence” for routine elective surgeries. Finally, a host of new technology-based third-party partners are emerging through venture capital channels, drawing billions of investment dollars and spawning dramatic population health innovations.

These industry-wide initiatives have tangibly impacted patient lives. Providers and payers are succeeding in reducing deaths, avoiding hospitalizations and readmissions, and improving quality of care. Employers are better meeting the needs of employees with complex health conditions, and incentivizing individuals to stay healthy. Partner organizations are helping health systems make the changes they need to deliver care more efficiently and effectively, and to provide much-needed coordination for patients, providers, and caregivers.

The Health Care Transformation Task Force (HCTTF) has developed a series of reports that illustrate the widespread impact of value-based payment and care delivery on the US economy.  These reports make the case for the critical importance of continuing these efforts in an era of uncertainty and concern, and individually highlight the economic impact of value through providers, payers, purchasers, and partners. HCTTF members believe that while the current political and policy environment is focused on the next generation of health reform, the marketplace continues to see meaningful strides forward in pursuit of value-based care. That forward momentum should continue to produce patient-centered, high quality care at a lower cost.

Patients

In the vastly complex and increasingly politicized U.S. health care environment, the patient voice is often overlooked or given only superficial consideration. National economic debate on the rising cost of care, combined with a narrative focused on the changing health care business environment, often neglect to include consumers. Yet, patients form the beating heart of the health care system, generating demand that directly impacts how organizations deliver and pay for care. Understanding the patient impact is imperative to understanding the broader economic forces shaping the industry, and highlights the very personal importance of improving value in health care.

The cost-quality disconnect

As total health care expenditures in the U.S. continue to rise, so do patient out-of-pocket costs. Average annual health care costs for an individual reached $10,372 in 2016; adjusted for inflation, that equates to an approximately nine-fold increase since 1960.[1],[2] Rising patient costs are also reflected at the national level. Total national health expenditures were projected to reach $3.4 trillion in 2016, an increase of 4.8 percent from 2015.[3] Although the U.S. health care expenditures are a little above two and a half times that of other OECD countries with similar incomes, U.S. patients have decidedly worse outcomes than their international peers.[4]

While high health care costs may be partially attributed to various uncontrollable factors such as aging of the population, other factors such as cost and quality of services contribute to higher health care spend and lower life expectancy. Between 2011 and 2014, Americans had a 17 percent readmission rate for heart attacks and pneumonia.[5] A recent study from researchers at Johns Hopkins estimated that more than 250,000 Americans die from medical errors, ranking third in overall deaths behind heart disease and cancer.[6]

The Importance of Value

Though the U.S. health care system remains strongly rooted in volume-driven fee-for-service payments, value initiatives are becoming increasingly prevalent and important as patient costs continue to rise, access to affordable care is threatened, and life expectancy remains low relative to other developed countries. Now more than ever, efforts that focus on increasing value in health care will prove to be the best hope for improving patient and consumer lives. Early initiatives have shown promising results to save lives and control costs. For example, a government-led initiative to reduce hospital acquired conditions resulted in 87,000 lives saved and $19.8 billion in financial savings between 2010 and 2014.[7]

Value-based programs that improve care coordination, strengthen the doctor-patient relationship, and hold providers accountable for the quality and cost of the care they deliver will be critical to improving patient lives. Though many different types of value-based care and payment models are currently being tested, not all have resulted in dramatic improvements. Both government and the private sector must continue to drive toward value for the benefit of patients and the broader U.S. economy. Taking the foot off the gas pedal and allowing the value momentum to wither from benign neglect would threaten the sustainability of the U.S. health care system and harm the patients who depend upon it.

Providers

Many providers have and continue to actively embrace value-based payment and care delivery reform, even amidst political and market uncertainties. Major investments in infrastructure to support accountable care organizations, episodes of care, and other value initiatives are reflected in areas such as new IT/data analytics infrastructure and expanded workforces. The Task Force examines the broader economic impact of these investments in the first part of a new series, produced in partnership with NEJM Catalyst.

Read the full article at NEJM Catalyst.

Payers

Many private health insurers, often following the lead of CMS in its push toward alternative payment models, have already invested broadly in value-based payment programs. Now payers are streamlining their efforts, positioning their businesses on value-based arrangements that have shown success in reducing costs and improving outcomes. In the second part of its collaboration with NEJM Catalyst, the Task Force identifies significant shifts to value by insurers and highlights tangible impacts on cost and the patient experience.

Read the full article at NEJM Catalyst.

Purchasers

Employers are approaching value in increasingly creative and collaborative ways to pursue population health management and care delivery. Rising health care costs, political instability, and looming health plan taxes continue to elevate the importance of value-based care and payment; employers continue to pursue innovative channels such as centers of excellence, high-performance networks, and bundled payments, among others, to tamp down costs and improve employee health. In the third part of its collaboration with NEJM Catalyst, the Task Force analyzes the impact of these initiatives on the broader US economic landscape.

Read the full article at NEJM Catalyst.

Partners

Over the past seven years, the health care industry has witnessed monumental change in the way care is paid for and delivered. Spurred by wider availability of federal and commercial payment and care delivery models, new contracting approaches, and a large wave of newly insured consumers, health care organizations are joining forces with savvy entrepreneurs to accelerate the pace of transformation and modernization.

While these entrepreneurial partners offer services that vary greatly in scope and breadth, they share the same common goals to improve quality and access while lowering costs and removing other barriers to effective care, most often with an underlying innovative technology platform. Some partners provide data analytics and decision support tools, while others offer a full suite of digital health and care management services, including personnel with special training and skills, to help organizations overhaul their delivery systems.

The rapid growth of these new partners has engendered widespread interest from the financial community, resulting in billions of investment dollars and millions of impacted health care consumers. Though the long-term effectiveness of the new programs developed and implemented by these organizations remains to be seen, large-scale economic investments and early results provide a compelling case for the importance of continued focus on value.

Investments in health care partners

Investments in health care start-ups and partner organizations has grown dramatically in less than a decade, reflecting an unprecedented focus on overhauling the health sector:

• According to incubator Rock Health, from 2011 to 2016 venture funding in digital health saw a compound annual growth rate of 30 percent. In 2016 alone, total investments in digital health reached $4.2 billion. Analytics and big data, including data aggregations and analysis used to support health care cases, garnered a large chunk of the total funding for the year at $341 million. Not far behind it were telemedicine and population health management, at $287 million and $198 million, respectively.[8]

• As care moves beyond the four walls of the hospital, large investments are being made in companies and technologies that support patients in their social and medical needs. In 2016, almost $8 billion in venture capital was invested in companies that supported individuals in their daily essential activities, with ride-sharing company Uber a notable example. Care coordination raised over $800 million, with 50 separate contractual arrangements. Transition support garnered $168 million in venture funding and 28 deals.[9]

• The population health market is expected to continue its explosive growth over the next several years. Research firm MarketsandMarkets estimates that the population health market will reach $42.5 billion by 2020, with a compound annual growth rate of 25.2 percent. While these numbers reflect the global market, North America (primarily the U.S.) will account for the largest market share.[10]

• A recent survey of health care entrepreneurs from venture capital firm Venrock indicated that 45 percent believe analytics and big data will experience the highest growth over the next year, compared to other health care IT sub-sectors.[11]

Understanding the impact

As options for health care technologies and services abound, and as providers face increasing pressure from federal and commercial payers to modernize their care delivery systems, many organizations are increasingly engaging with partners. Though many of these companies are still early in their product development and roll-out, evidence points to their positive impacts:

• Organizations employing population health initiatives grew from 67 percent in 2015 to 76 percent in 2016.[12]

• Advanced electronic health technology implementation has been associated with fewer patients with prolonged length of hospital stay and seven-day readmissions.[13]

• IBM Watson Health, which offers a variety of population health management solutions to its clients, reported a 250 percent improvement in care management efficiency among one of its clients.[14]

• Remedy Partners, a technology firm focused on episodes of care and employed across 671 acute care hospitals, has generated $500 million in annual savings, along with a 6.1 percent reduction in hospital readmissions for its clients.[15]

• Technology and population health services firm Evolent Health, which serves over 30 markets across the U.S. and manages over 2 million lives, has helped drive millions in clinical and pharmacy savings for its provider clients.[16]

Many more examples of successful disruptive entrepreneurs exist; as these organizations continue to mature, collect additional data on outcomes and ROI, and refine their strategies to best meet the needs of health care organizations and consumers, their value in transforming the sector will become increasingly apparent.

Conclusion

Despite uncertainty over the future of U.S. health reform, a broad movement toward value-based care models continues and investments in data-driven, value-based health care solutions are essential to that evolution. Third-party partners are critical to help drive industry transformation because they enable smarter data use, encourage new methods of reaching consumers, and serve as external change agents for health systems and plans that do not have the internal technology or ability to transform on their own. These partners have already had a significant impact on the U.S. financial landscape, and are poised to continue their expansion and influence over the next decade.

Task Force responds to CMS Request for Information on Innovation Center New Direction

In a letter responding to CMS’ Request for Information (RFI) about new directions for the Center for Medicare & Medicaid Innovation (CMMI), the Health Care Transformation Task Force called on the Center for Medicare and Medicaid Services to continue refining existing alternative payment models that are showing genuine, long term promise as it reorients CMMI agenda to explore new alternatives to the prevailing fee-for-service payment system. The Task Force welcomes new ideas for innovation, noting that there are attractive private sector models that warrant consideration for use in Medicare and Medicaid. Still, the agency should not abandon promising current models, and instead focus on making improvements to these promising models as part of its refined agenda. 

Read the letter here

Read our Health Affairs blog

Press release

Levers of Successful ACOs

Webinar:

Featuring Marci Sindell, Chief Strategy Officer and Senior Vice President of External Affairs and Dr. Richard Lopez, Chief Medical Officer of VNA Care and Senior Vice President of Population Health at Atrius Health and Danielle Lloyd, Vice President of Policy and Advocacy at Premier, Inc.
View the Recording.
Download the slides.

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The Health Care Transformation Task Force interviewed high-performing Accountable Care Organizations (ACOs) to assess structures and strategies that led to their success. Although each organization had differing approaches and experiences, common themes emerged in three major categories: 1) Achieving High-Value Culture, 2) Proactive Population Health Management, and 3) Structures for Continuous Improvement.

Full Report

Press Release

Read the individual reports:

Part 1: Identifying the Levers of Successful ACOs

The Health Care Transformation Task Force (HCTTF) designed and conducted a qualitative study analyzing the elements of ACO success. The reports below detail that work, describing key findings across a number of domains, while this introductory report provides background, detailed methodology, and ACO selection criteria. The findings represent the experiences of select high-performing ACOs, including HCTTF and non-HCTTF members. The objective of this resource is to move beyond high-level themes to provide a tactical guide for understanding, prioritizing, and implementing the levers of ACO success.  The HCTTF recommends that ACOs and other health care stakeholders leverage these resources to:

• Evaluate proficiency across key activities;
• Educate organizations about the importance of these key activities; and
• Prioritize improvement efforts based on unique needs.

Part 2: Achieving a High-Value Culture

Perhaps the most elusive yet most important element for achieving long-term success is developing a culture conducive to value. Having a high-value culture means that all levels of the organization –particularly the leadership – demonstrate an internally-motivated commitment to excellent patient outcomes (quality) that are achieved at the lowest possible cost. This category represents the underlying current that drives all improvement efforts, by ensuring the ACO objectives are prioritized at every level of the organization.

As true with most other elements, approaches to developing and maintaining a strong culture will vary from organization to organization. Still, all studied ACOs have pursued similar channels for engaging individuals across the organization:

• Involvement by senior decision-makers (i.e., governance bodies) in ACO operations
• Physician and community practice engagement
• Expanded clinical partnerships

Part 3: Proactive Population Health Management

Unsurprisingly, common to all studied ACOs is a dedication to proactive population health management. Managing the health of a defined population across the continuum of care requires a complete paradigm shift for most providers, as well as the development of new systems and processes. While challenging to learn and implement, population health management is the cornerstone of all accountable care success. In addition to its foundational importance for accountable care, population health management and its various components were mentioned most frequently in the interviews, and were said to have the greatest impact on practice transformation. 

While population health approaches can take many forms, most ACOs studied had developed analogous operational elements. Those fundamentals – which are detailed in a separate report – include:

• Systems for identifying high-risk patients
• General care management functions
• Specific disease management programs

Part 4: Structure for Continuous Improvement

To be successful under any value-based payment model requires a strong supporting infrastructure, but this is especially true of ACOs. The nature of this care model, combined with the added complexity of multiple providers with disparate systems and multiple payers with different requirements, makes careful investments in infrastructure a principal strategic decision for organizations participating in ACOs. In combination with workforce resources, this is the backbone of all performance improvement. A successful ACO leverages its supporting structure to learn about its organization, its people, its performance, and its patients, and then uses that information to create feedback loops for continuous learning and system improvement. ACOs identified essential elements that support continuous improvement:

• Operational infrastructure for performance measurement
• Tying performance to compensation and network contracts
• Participation in shared learning opportunities

Project Background

Value-based payment models have proliferated over the past several years in an attempt to address the unsustainably high costs and variable outcomes of health care in the U.S., and to test innovative models to solve these particular challenges and promote high-quality, low-cost care. While there are several approaches to value-based payment, accountable care organizations (ACOs) have been the most popular vehicle for value-based payment model adoption to date, with over 923 ACOs covering approximately 32.4 million lives across the country in 2017. ACOs can take a variety of forms, differing by provider configuration, contracted payers, payment methods, and more. While approaches to ACO implementation vary, the principles of population health management remain the same. Now, several years into the accountable care movement, health care stakeholders are closely studying the structures and behaviors of existing ACOs to learn about the attributes of successful organizations.

Recognizing the importance of identifying and disseminating these success levers, the Health Care Transformation Task Force (HCTTF) designed and conducted a nearly 12-month qualitative study analyzing the elements of ACO success. This report details that work, outlining research methods and describing key findings across a number of domains. The information contained in this paper represents the experiences of select ACOs, including HCTTF and non-HCTTF members, and is supported by additional evidence found in the current literature.

Methodology

The HCTTF’s Accountable Care Work Group conducted a multi-step project which included, among other things, a series of in-depth interviews with leaders of successful ACOs to investigate the common structures and strategies that enable success.

It was determined that all interviewed ACOs must meet the following criteria:

• Shared savings rate ≥2%
• Quality score ≥90%
• Below-average baseline
• ≥5,000 ACO-covered lives
• More than one year under accountable care contract
• At least one commercial ACO contract (in addition to a Medicare ACO contract)
• Diverse geographic representation (preferred)

Using the PY 2015 Medicare ACO performance results and the Leavitt Partners ACO database, 21 Medicare Shared Savings Program (MSSP) and Pioneer ACOs were identified as meeting the criteria. The Work Group conducted interviews with 11 of the 21 ACOs, corresponding to over 10 hours of interviews. Within each ACO, the HCTTF interviewed senior decision-makers involved in designing and implementing accountable care-related activities across the ACO. To standardize the areas investigated, all ACOs were interviewed using the same interview guide. Interview transcripts were then coded to enable a thorough qualitative analysis. All quotes in this report draw from these interviews and written transcripts.

Acknowledgements

This is a product of the Health Care Transformation Task Force under the leadership of the Accountable Care Work Group. The Accountable Care Work Group is comprised of Task Force members and other organizations dedicated to improving the design and implementation of the ACO model in public and private payer programs. The Work Group addresses both internal operational challenges as well as public policy issues that challenge transformation efforts for health care organizations.

 In case you missed it: Gain insights from organizations at the vanguard of value in our Transformation to Value leadership guide and strategy framework.

Task Force Submits Recommendations on Consumer Priorities to CMS

The Task Force offers recommendations to CMS on addressing consumer priorities in value-based payment and care delivery. Through input from the Advisory Group for Consumer Priorities, the Task Force identified key areas where CMS can advance these consumer priorities and principles.

Read the letter here.

Task Force Provides Comments to CMS regarding EPM Cancellation and CJR Modifications

The Task Force has submitted comments to CMS on the proposed rule Cancellation of Advancing Care Coordination Through Episode Payment and Cardiac Rehabilitation Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement Payment Model (CMS-5524-P). The Task Force advocated that CMS introduce voluntary bundled payment models as soon as possible, and recognize proactive investments. Regarding the proposed modifications to CJR, the Task Force encouraged better synchronization with other Alternate Payment Models, a redefinition of the “low-volume” threshold and offered support for gainsharing and broadening the scope of the Affiliated Practitioners.

Read the comment letter here

Task Force statement for CMMI Behavioral Health Summit

The Task Force provided a statement to CMS in response to request for input for the Center for Medicare and Medicaid Innovation (CMMI) Behavioral Health Summit on September 8, 2017. Through recommendations from its Improving Cost to High Cost Patients Work Group, the Task Force identified key areas of focus for future CMMI behavioral health models.

Read the statement here.