“We’re see­ing busi­ness mod­els pred­i­cated on build­ing value”

Modern Healthcare - - Q & A -

Dr. Farzad Mostashari helped shape the elec­tronic health record land­scape from 2011 to 2013 as head of the Of­fice of the Na­tional Co­or­di­na­tor for Health In­for­ma­tion Tech­nol­ogy. To­day, he is CEO of Aledade, a Bethesda, Md.-based startup with 150 em­ploy­ees that man­ages physi­cian-led ac­count­able care or­ga­ni­za­tions. Ed­i­tor Mer­rill Goozner re­cently spoke with Mostashari about how the com­ing reg­u­la­tory and po­lit­i­cal changes will af­fect his busi­ness, which man­ages ACOs for over 1,000 pri­mary-care doc­tors in 15 states. The fol­low­ing is an edited ex­cerpt.

Mod­ern Health­care: Let’s start with MACRA (the Medi­care Ac­cess and CHIP Reau­tho­riza­tion Act). Will the new rules af­fect docs’ will­ing­ness to get in­volved in ACOs?

Dr. Farzad Mostashari: I was at a meet­ing re­cently where they went through the re­quire­ments and the scor­ing sys­tem un­der MIPS (the Merit-based In­cen­tive Pay­ment Sys­tem). Ev­ery­one’s eyes were glazed and in shock ex­cept our docs, who were giv­ing each other smiles and thumbs up. Why? Be­cause they’re pre­pared. We’re go­ing to help them do well in this en­vi­ron­ment.

A lot of in­de­pen­dent prac­tices will not by them­selves be able to han­dle the added com­plex­ity. They will be look­ing for con­sul­tants; some may look to sell to hos­pi­tals. And a lot of others will be look­ing to join to­gether through their vir­tual groups, through ACOS or in other ways to come to­gether to take these chal­lenges on so they can give them­selves a thumbs up in­stead of be­ing in fear.

MH: What is the like­li­hood that MACRA re­quire­ments will stay in place?

Mostashari: MACRA was passed with over­whelm­ing bi­cam­eral and bi­par­ti­san sup­port. I’ve talked to peo­ple on the Hill who were in­stru­men­tal in get­ting it passed. They are very com­mit­ted in get­ting MACRA im­ple­mented.

I’ve heard a lot of praise from law­mak­ers and their staff and doc groups that CMS re­ally lis­tened. The fi­nal rule is a pretty good start­ing point.

Ev­ery rule will have its it­er­a­tions. They ex­cluded a bunch of folks who don’t have much Medi­care busi­ness. They pro­vided ex­tra flex­i­bil­ity.

There is a deeper sense among physi­cians— how­ever easy you make it, and it won’t be easy— that they’d rather be fo­cused on out­comes than on check-the-box mea­sures. What we’ll also see is they’ll make it eas­ier to move on to ad­vanced pay­ment mod­els.

MH: Do you still see re­luc­tance among com­mer­cial in­sur­ers to get in­volved in ACO con­tracts?

Mostashari: I see clear re­cep­tiv­ity among all pay­ers to the idea of pay­ing more for value and en­gag­ing pri­ma­rycare doc­tors as be­ing the stew­ards of the pre­mium dol­lar. The de­gree to which pay­ers are pre­pared to work with physi­cians in these new kinds of ar­range­ments, which is a cul­tural as well as con­trac­tual change, dif­fers.

This is mov­ing to­ward col­lab­o­ra­tion. That is a very trans­for­ma­tive change and there are some pay­ers who are more pre­pared than others to make that shift.

“More rev­enue for pri­mary care … means fewer (hos­pi­tal) ad­mis­sions and fewer pro­ce­dures. They face de­mand de­struc­tion.”

“Many hos­pi­tals are block­ing (EHR in­ter­op­er­abil­ity) … We still have to de­cide as a coun­try if that’s OK.”

MH: What is dis­cour­ag­ing the lag­gards?

Mostashari: A lack of fa­mil­iar­ity with the model. We’re see­ing in the last two years a much greater com­fort with risk con­tracts. We had to help them write their first con­tracts. They didn’t know what to in­clude or ex­clude to make it work. Ex­pe­ri­ence is re­ally im­por­tant.

But there is grow­ing recog­ni­tion on the part of in­sur­ers that they’d rather keep these pri­mary-care prac­tices in­de­pen­dent than join a con­sol­i­dat­ing sys­tem. It’s the pri­mary-care physi­cian’s job to man­age the re­fer­rals.

MH: Are hos­pi­tal sys­tem physi­cian prac­tices re­cep­tive to your model?

Mostashari: Many hos­pi­tal sys­tems that have cre­ated clin­i­cally in­te­grated net­works are able to in­te­grate them into a co­he­sive unit with their dozen or so dif­fer­ent EHRs. Some have asked us to man­age them. But to date we have stuck to our knit­ting and worked only with physi­cian prac­tices that aren’t tied to sys­tems.

MH: Is the in­de­pen­dent prac­tice bet­ter po­si­tioned than a hos­pi­tal sys­tem to get into risk-based con­tracts?

Mostashari: Def­i­nitely. They have less of a cap­i­tal in­vest­ment that has to be fed by vol­ume. We need more pri­mary care, which means more rev­enue for pri­mary care. And for hos­pi­tals it means fewer ad­mis­sions and fewer pro­ce­dures. They face de­mand de­struc­tion. That’s a fun­da­men­tal chal­lenge to health sys­tems.

There are cer­tainly some who talk about the com­mit­ment they’ve made. They’re pre­pared to go through the tran­si­tion needed to turn the hos­pi­tal from a rev­enue cen­ter to a cost cen­ter. That is a very tough, high level of dif­fi­culty dive to pull off—to man­age that tran­si­tion well while main­tain­ing cash flow and bond rat­ings and com­mit­ments to depart­ment chairs and all the other stuff they have to deal with that pri­mary-care docs don’t.

MH: What’s the state of in­ter­op­er­abil­ity, es­pe­cially as it ap­plies to pro­mot­ing value-based re­im­burse­ment?

Mostashari: When I joined the govern­ment, there were no con­sis­tent vo­cab­u­lar­ies for things like med­i­ca­tion. Now we’ve stan­dard­ized ev­ery EHR on pre­scrip­tions. The same with di­ag­noses and pro­ce­dures.

Once you have that, it is rel­a­tively easy to have dif­fer­ent sys­tems in­gest data from other sys­tems. So a lot of progress has been made on the build­ing blocks for in­ter­op­er­abil­ity.

How­ever, it’s not all shiny. There are two is­sues we still strug­gle with. Many of the EHR ven­dors un­der­took the changes not be­cause they wanted to or be­cause they felt it was in their busi­ness in­ter­est to do so, but be­cause there was a cer­ti­fi­ca­tion re­quire­ment. So they made sure they could pass the test in the lab. But they didn’t re­ally push to in­cor­po­rate it into their prod­uct in the field or make it work well for their cus­tomers.

The sec­ond chal­lenge is it’s not clear the cus­tomer has de­manded in­ter­op­er­abil­ity, which would make it eas­ier for a pa­tient to move to an­other sys­tem. Many hos­pi­tals are block­ing that in­for­ma­tion, whether through var­i­ous ex­cuses, de­lays, pre­var­i­ca­tion or they flatout say, “Why should I share it with you be­cause it’s a com­pet­i­tive ad­van­tage.” We still have to de­cide as a coun­try if that’s OK.

MH: How would you de­scribe the en­vi­ron­ment for dis­rup­tive health tech­nolo­gies?

Mostashari: It’s a great time for new in­no­va­tive so­lu­tions that can make use of all this in­fra­struc­ture that’s been built on the health IT side. We build on top of the EHR. We con­nect to 49 dif­fer­ent EHRs. That’s painful and ex­pen­sive. But we couldn’t do what we do if we didn’t have that in­fra­struc­ture in place.

The pay­ment mod­els that were rooted in just fee-for-ser­vice doc­u­men­ta­tion and billing sti­fled in­no­va­tion and im­prove­ments in care. It didn’t mat­ter if you im­proved care or not. You still got paid. Now we’re see­ing busi­ness mod­els pred­i­cated on build­ing value.

MH: Will the change in ad­min­is­tra­tion de­rail that?

Mostashari: I don’t think so, but there is un­cer­tainty. There’s clearly a com­mit­ment on the part of Congress to con­tinue for­ward. But the ad­min­is­tra­tion may be dis­tracted with re­peal and re­place; with Medi­care vouch­ers; with Med­i­caid waivers and Med­i­caid re­form. The risk isn’t to roll back, but that the ad­min­is­tra­tion may be dis­tracted and won’t push.

The push will have to come from the pri­vate sec­tor. The fed­eral govern­ment won’t push it ahead. But I don’t think they’ll put it in re­verse.

MH: Yet in­com­ing HHS Sec­re­tary Tom Price wants to get rid of manda­tory bun­dled pay­ments.

Mostashari: Tom Price voted for MACRA. We’ll find out. What he re­ally ob­jected to was the manda­tory na­ture of the bun­dles. It should be the physi­cians’ choice. Thou­sands of physi­cians have made the choice to join the vol­un­tary pro­grams. I don’t think he’d be happy if that choice was taken away from them.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.