Part­ner­ing for pop­u­la­tion health man­age­ment and value-based care

Modern Healthcare - - News -

As value re­places vol­ume in the health­care in­dus­try, hos­pi­tals are look­ing for part­ners to be­come more ef­fi­cient and nim­ble un­der new care de­liv­ery mod­els and pay­ment ar­range­ments. But these part­ner­ships re­quire clear ob­jec­tives, agree­ments and align­ment to achieve suc­cess. In a dis­cus­sion about Michael Kasper, lessons learned, moder­a­tor CEO of the Ben­jamin Breier, DuPage Med­i­cal Group, talked with Lloyd Dean, CEO of Kin­dred Health­care; CEO of Dig­nity Dr. Farzad Mostashari, Health; and for­mer U.S. na­tional co­or­di­na­tor for health IT and cur­rently CEO and founder of Aledade, which op­er­ates physi­cian-led ACOs in 20 states.

What does pop­u­la­tion health and val­ue­based care mean to your or­ga­ni­za­tions?

Mostashari:

It means align­ment, and that we must do what’s good for the pa­tient and the doc­tor, but also for so­ci­ety. It’s not un­til you get that align­ment, fi­nan­cially and philo­soph­i­cally, that it re­ally starts to take off.

Dean: We come at this from the per­spec­tive of mak­ing sure that we have the right struc­ture in place to en­sure that pa­tients, con­sumers, have the re­sources to im­prove their health. As providers, we can’t do that in si­los. That means we’re de­liv­er­ing the right ser­vice at the right place at the right time. We have to pro­vide value and de­liver the clin­i­cal out­comes that pa­tients seek.

Breier: I think those of us who look at high costs, we know that a lot of the spend is com­ing later in life with lat­estage care. There is how­ever, a lack of trans­parency and co­or­di­na­tion. And in our view, the way to take waste out of the sys­tem is to form part­ner­ships.

How do you deal with is­sues of con­trol?

Dean: The first thing we do is as­sess if our mis­sions are aligned. That’s half of the equa­tion to suc­cess. We’ve also learned that just be­cause we may be the larger of the two en­ti­ties, we don’t have to con­trol the part­ner­ship, there is a lot of tal­ent and com­pa­nies that have ex­per­tise that we can use for the bet­ter­ment of our com­mu­ni­ties.

Breier: I’ll give you a per­fect ex­am­ple with Lloyd sit­ting here next to me. We have a joint ven­ture in Phoenix. We are happy to have Dig­nity’s name all over this beau­ti­ful re­ha­bil­i­ta­tion hos­pi­tal, and Lloyd and his team are happy to al­low our ex­per­tise in man­ag­ing the fa­cil­ity. Those are the kinds of part­ner­ships that work, be­cause ev­ery­body can’t be ev­ery­where all at once.

Mostashari: We are in a joint ven­ture for Medi­care Ad­van­tage, and the ques­tion was: If they have a ser­vice that goes to peo­ple’s homes and does an as­sess­ment—who is in con­trol of call­ing that ser­vice for a pa­tient? Is it the plan or the pri­mary-care doc? We’ve had con­tracts where the payer was like, “No, this is just what we do. You’ll be lucky if we tell you we went there.” But in this case they said, “You’re in charge of the clin­i­cal in­ter­ac­tions with the pa­tient, so you should call,” and that worked be­cause from the be­gin­ning we were crys­tal clear on who’s ac­count­able for what.

Dean: We find that cul­ture is­sues are very dif­fi­cult to over­come. When I first came to what was then called Catholic Health­care West, one of our at­ti­tudes was that if we didn’t build it—we didn’t own it—we didn’t con­trol it—it just couldn’t be good. So, part of our lead­er­ship

jour­ney was to check our egos at the door. When it comes to value, we need the ex­per­tise, the in­no­va­tion, the cre­ativ­ity of oth­ers.

How do you split the dol­lar?

Mostashari:

One way is try to get to some un­der­stand­ing of who brought what value to the ta­ble. The other is who’s got more power in the re­la­tion­ship? And all too of­ten, par­tic­u­larly when you’re deal­ing with lack of com­pe­ti­tion, it be­comes the lat­ter. So, the cure for, “I’m big­ger, there­fore you take my terms,” is, “Well, I’ll go work with some­one else.” There was one payer who we spent 18 months ne­go­ti­at­ing with and they said, “Well, take it or leave it,” and we said, “OK, bye,” and they were shocked. But we knew we had other op­tions.

Breier:

How many years ago did we start talk­ing about value-based care and pop­u­la­tion health and tak­ing bun­dles and tak­ing risk? We’ve made a lot of progress, but we still have a lot of work ahead of us. We still live in a pre­dom­i­nantly fee-for-ser­vice en­vi­ron­ment. And I would ar­gue that the big, large-scale na­tional pay­ers are not yet will­ing to give up the ghost, if you will. They like the con­trol.

Dean:

We can pre­vent some of the con­trol is­sues with due dili­gence up­front. We’ve found that by set­ting up trans­parency and hon­esty in the be­gin­ning that it al­lows for more room to op­er­ate. In some cases we deter­mined that no mat­ter what we said at the be­gin­ning, we were just not aligned and we walked away. And some­times we’ve de­cided that when we look at what we’re try­ing to achieve for the com­mu­nity, what our ul­ti­mate goals are, that we might take a 49% stake. But that has to be when a lot of other things are in place to en­sure that our value propo­si­tion for the com­mu­nity is stronger un­der that sce­nario. But to be clear, we don’t make a prac­tice of tak­ing the lesser po­si­tion.

How are you cre­at­ing part­ner­ships that pass the reg­u­la­tory sniff test?

Mostashari:

I used to be a reg­u­la­tor. And what I like to say is, if the fi­nal rule comes out and ev­ery­one says, “It’s ex­actly what we thought it was go­ing to be,” then we won. You have to lis­ten to the stake­hold­ers in a very pub­lic way, not re­quir­ing peo­ple to have very ex­pen­sive lob­by­ists. Now, I’m look­ing at the reg­u­la­tors and I’m think­ing, “What do they want? What are they wor­ried about?” So it’s in­cum­bent on you to of­fer reg­u­la­tors ways they can achieve their goals, be­cause they know what they want but they don’t have per­fect knowl­edge, par­tic­u­larly knowl­edge from the field.

There was one payer who we spent 18 months ne­go­ti­at­ing with, and they said, “Well, take it or leave it,” and we said, “OK, bye,” and they were shocked. But we knew we had other op­tions.

Dr. Farzad Mostashari

Dean:

Reg­u­la­tions can lead to stan­dard­iza­tion of best prac­tices. But even if there is reg­u­la­tion that on pa­per looks good, real world dy­nam­ics ne­ces­si­tate change and that can be, as we have all ex­pe­ri­enced, a long and te­dious pro­cesses. In the mean­time, pa­tients are still com­ing through our doors. My grow­ing con­cern is that pol­icy and reg­u­la­tions are be­com­ing more driven by in­ter­ests out­side of health care. I think the more we can do to ad­dress reg­u­la­tion pol­icy on be­half of our pa­tients, the stronger we will be as a na­tion and the more we will ul­ti­mately be able to achieve in the health­care sec­tor for our com­mu­ni­ties.

Is there re­ally a re­turn on in­vest­ment on value-based care, and can the push come from the pri­vate sec­tor?

Breier:

Yes, but I don’t be­lieve, quite frankly, that you can get there through the govern­ment telling you what you have to do. I thought maybe a hy­brid of show­ing us the path and let­ting the pri­vate sec­tor try to get it right was prob­a­bly more the right way. That has ob­vi­ously shifted with the changes in the Cen­ter for Medi­care and Med­i­caid In­no­va­tion, but I think, yes, and it has to.

Dean:

Yes, I agree with my col­leagues be­cause right now we are ser­vic­ing, col­lec­tively in this room, mil­lions of in­di­vid­u­als. We don’t have the lux­ury of tak­ing a time­out. I think that we have to con­tinue to talk to each other, whether it’s providers to pay­ers or vice versa, we’re in it now. We have to make it work.

Mostashari:

I think that the way out of the un­cer­tainty around the de­tails is to think about the low-re­gret ac­tions. It’s un­likely that there’s go­ing to be a fu­ture where be­ing able to de­liver gen­uinely bet­ter care at gen­uinely lower cost isn’t go­ing to be good for your or­ga­ni­za­tion.

Dr. Farzad Mostashari

Lloyd Dean

Ben­jamin Breier

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