Meet Redwood Community Care Coalition: A Health Center Nested ACO

By Gregg A. Masters, MPH

Wrapped in the ‘population health’ angle but clearly a unique play in the ACO space – at least from the participation point of view of Federally Qualified Health Centers (FQHC), former CEO Steve Ramsland (a 10% allocated FTE) addresses the audience about their market, approach to ACOs and the deployed healthIT spine (they use cClinical Works CCMR).

More information on Redwood Community Health is available here and via 2012 Annual Report. The ACO is an interesting construction of member entities up to and including ‘a doc in private practice’.Redwood Community Care Coalition ACO HealthIT

In the article noticing the Ramsland resignation – which is interesting on it’s face in terms of back-story if any, the service area for the FQHC includes:

…health centers in Marin, Sonoma, Napa and Yolo counties, including some of the largest FQHCs such as Petaluma Health Center, Marin Community Clinics, Clinic Ole in Napa and West County Health Centers in Sonoma County, among others.

The Redwood Community Care Coalition ACO is NOT aligned with a hospital partner, it is solely sponsored by its founding members.

Atul Gawande Opines on Post ACA Agenda

By Gregg A. Masters, MPH

‘The debate about whether to provide coverage for healthcare is over…’ Atul Gawande

I had a front row seat for this one at the 5th Annual (and last) ‘Health Datapalooza‘, a label affectionately coined by the former ‘athenista’ though always energetic and singularly determined Todd Park, U.S. Chief Technology Officer and Assistant to the President. Some pretty amazing insights from this public health sensitized and Harvard trained surgeon who’s simple proscription for checklists in hospital surgical suites has no doubt served the interests of many patients who may have otherwise been subject to an unacceptable pool of recurrent adverse hospital events, see: The Checklist Manifesto’.  

‘Fear and Trembling’ or Simply ‘Lonely in’ Seattle?

By Gregg A. Masters, MPH

The old is new again…

I’ve been writing and tweeting about this theme for some time now. It was aptly offered as contextual insight via Nicole Bradberry of MZI Healthcare /Orange Solutions and CEO of the Florida Association of ACOs.

Many have similarly echoed this ‘deja vu’ theme when discussing the roll-out of ACOs including functional similarities and key differentiators with HMOs and previous managed care initiatives circa the 1980 – 2000 vintage.

One such old is new again effort is ‘direct contracting’, where the employer deals directly with the provider community without a health plan as third party intermediary. An army of TPAs (third party administrators) stepped up to offer ‘administrative services only’ (ASO) typically to larger employers who self fund their benefit plans to carve out the middleman, i.e., Aetna, United, the Blues, etc., and exercise greater flexibility with their provider community. Seeing the handwriting on the wall, many traditional insurance carriers promptly positioned themselves to compete in the TPA space via acquisition or internal accommodations.

I suppose the novelty and efficacy of direct contracting (vs. traditionally orchestrated health plan based managed care) was somewhat muted by the overall failure of the managed care industry writ large to effectively restrain the rapacious appetite of a volume fueled delivery system; see: ‘Direct Contracting: Why It Hasn’t Grown’.   

Fast forward a decade plus and we read about innovation in the Seattle market where competing health systems have internally launched ACOs and in turn are direct contracting with Boeing, see: ‘Seattle Health Systems Launch New Accountable Care Organizations for Employer’.

While the cited ‘InterStudy’ report (the think tank founded by progenitor of the ‘SuperMed’ concept and the acknowledged father of HMOs Paul Ellwood, MD) is behind a pay-wall, the report highlights are as follows [Note: for details on Boeing direct contracting see: 'Narrow Networks in Today’s Health Care Climate]:

  • Aviation giant Boeing is the first large employer in the market to sign on for both ACO networks, which will be offered to non-union members and select unionized employees. Other employers are expected to contract with the health systems prior to January 2015.
  • The UW Medicine Accountable Care Network features a mix of hospitals within the Seattle market and in surrounding communities. The network includes Seattle Children’s Hospital and Seattle Cancer Care Alliance, both of which were left off the networks for most health insurance exchange policies.
  • The state’s exchange plans prominently featured narrow networks. After outcry from affected stakeholders, state Insurance Commissioner Mike Kreidler introduced new regulations requiring the submission of provider networks for approval, and the networks must include adequate access to specialists and community care providers. Insurers warn the regulations could lead to higher premiums, while hospitals argue that the new rule does not goes far enough to protect consumers.

Comments from report author include:

  • “The introduction of direct-contract ACOs in the Seattle market is surprising, as the market has only begun fully embracing ACOs in the last year. Traditionally, Seattle health systems have shied away from bearing risk, so the market is now entering into a more advanced model of care. Franciscan Health, which was not included in a direct-contract ACO network, may feel pressure to form one to remain competitive in the market.”
  • “Boeing’s willingness to offer the new ACOs, as well as its traditional health plans, allows employees to select the coverage and network they prefer. UW Medicine may have a bigger draw as its ACO network includes providers that have been excluded from insurance networks.”

Meanwhile, per ‘Employer Direct Contracting‘ via Knowledge Source:

According to a recent National Business Group on Health survey, 11% of the large employers are using direct contracting with designated surgical centers of excellence or patient-centered medical homes. Such direct contracting is likely to increase because another roughly 20% of such employers are considering such provider agreements.

Large employers are using reference pricing, where self-insured companies offer to pay only the median price in certain geographic areas for some medical services and require employees to pay the difference at more expensive providers.

So yes, the old is new again. The question is: will it or can it be different this time? Or will we witness another round of ‘me too’ cookie cutter strategies followed by a risk push-back bloodbath, and ‘return to core operations’ by health systems who can’t manage risk, or the acquired physician practices they are so busy swallowing or health plans who can’t manage delivery systems.

Perhaps more on point with the headline of the post is: Will the health plan and institutional health system communities and their advocacy partners respond in kind to another Søren Kierkegaard ‘fear and trembling’ moment with wisdom and clarity? Or will the collective industry ignore the lessons learned from prior well intended but misguided strategic initiative?  

Times have indeed changed, and the horse is out of the barn. Healthcare reform and its required re-engineering is no longer contained behind the closed doors of board rooms of health systems or health plans. Achieving the triple aim is a ‘all hands on deck’ responsibility of all stakeholders in the healthcare ecosystem. But people are people, so we shall see!

 

Catching Up with Farzad Mostashari, MD: An Aledade Preview at HiMSS 2014?

By Gregg A. Masters, MPH

The HealthInnovation Media footprint was again on the ground at Health Information Management Systems Society (HIMSS) 2014 in Orlando, Florida. One of the privileges I enjoy as producer and creator of all digital content generated is I get to tag interesting people to put in front of the camera including suitable hosts for each interview segment.

In this shoot we meet with former Director of the Office of the National Coordinator for HealthIT and now Founder and CEO of ACO management company Aledade, Farzad Mostashari, MD.

The interview was masterfully handled by industry veteran and colleague Neil Versel.

Enjoy!

Meet Aledade An ACO Management Company Putting Docs at the Head of The Table

By Gregg A Masters, MPH

farzad mostashari MDWhen Farzad Mostashari, MD not too long ago sported a Federal business card his principal mission was to stimulate and evangelize the adoption of electronic health records (EHR) in his capacity as the lead official for the Office of the National Coordinator for HealthIT (ONC). This important market transformational role was enabled by the American Recovery and Reinvestment Act (ARRA), and in particular the provisions to ‘HITECH‘, the Health Information Technology for Economic and Clinical Health Act signed into law on February 17, 2009:

‘to promote the adoption and meaningful use of health information technology.’

Amidst ‘silo-ed medicine’ the enabling role of health information technology and specifically EHRs to the care management, care coordination and generally the principal upside of the ‘managed care’ vision has been recognized for quite some time. In fact, ‘clinical integration‘, i.e., a network wide EHR platform, shared by independent physicians who were otherwise competitors in a specific market (absent legal integration) was one of the exceptions if not ‘safe harbors’ to antitrust vulnerability.  In other words, a ‘shared healthIT spine’ of sorts allowed physicians to collaborate with each other without getting ‘married’ – if you will.

Since the passage of the Affordable Care Act (ACA), the ‘urge to merge’ is strong particularly at the hospital or institutional health system level, with many corporate parents acquiring medical practices at a pace unwitnessed during the prior ‘integration generation’ circa the 1980 – 2000 vertical integration and subsequent turbulent unwinding timeline.

Inside the ACA the majority of the ‘chop wood and carry water’ provisions of the anticipated transformation or ‘disruption’ are clearly laid at the doorstep of ACOs and the broader ‘accountable care’ framework it has set into motion via both Government and derivative private sector initiative.

Inside this market shift and not un-noticed by many healthcare ecosystem stakeholders (both pre and post passage of the ACA), many argued for the modulation if not regulation of the institutional ‘integration impulse’. Absent restraint, many provider mergers would amount to de-facto ‘too big to sail’ (i.e., more costly) enterprises via asset concentration for anti-competitive pricing leverage. Against this ‘unintended consequence of the law’ (more costly vs. less) some have stepped  up to lend support to physicians as the principal organizers and aggregators of clinical delivery (if not financing) assets. The theory goes, un-beholden to costly hospital infrastructure, physicians are the ‘free and informed agents’ to competitively purchase and allocate needed clinical assets across the care delivery continuum.Aledade ACO

Clearly the wildcard in this formula is an ‘empowered network of physician aggregators.’ Since most physicians are NOT infrastructure nor business savvy per se, a third party enabler to harmonize performance around this ‘triple aim’ (better care, better outcomes, lower costs) fueled vision is essential.  In other words, build and support the crosswalk from volume value where care is not incentivized by unit volume to support incomes and lifestyles but what’s right for the patient.

Enter ‘ACOcor’ (see: ‘Waiting for ACOcor?‘) as in Aledade, the new vision and initiative of Farzad Mostashari, MD and his capital partners at Venrock, specifically ACA advisor Bob Kocher.

Today on ‘This Week in Health Innovation‘ with my co-host Dr. Phil Marshall, we chat with Dr. Mostashari about his vision at Aledade.

 

The 5th Annual ACO Summit

By Gregg A. Masters, MPH

Can’t make the annual gathering in DC? Why not follow the conference via Twitter?

ACO Summit 5th Annual MeetingIn years past, I registered the ACO Summit as a conference with the healthcare hashtags registrar @Symplur.

While the dashboard has not been updated with current information (the program description dates back to 2012), the conference hashtag remains #ACOsummit.

So check out the twitter stream, pull real time analytics including ‘reach’, impressions’ and tweet frequency here.

 

Former ONC Director Farzad Mostashari, MD Launches @AledadeACO

By Gregg A. Masters, MPH

Aledade ACOOn July 8th 2011 I penned a blog post titled: Waiting for ACOcor? pondering the question of whether this time will be different in the managed competition positioning dynamics we’re likely to witness post roll-out of the Affordable Care Act. Afterall, the ‘chassis’ on which to graft if not build an ACO can be found in iterations of prior physician led vehicles including IPAs, medical group Medicare Advantage contractors and even PHOs (Physician Hospital Organizations) where the ‘institutional partner’ (ie, the ‘H’ hospital) serves as a limited partner to the medical group or IPA which operated the PHO as ‘the general’.

Today we learned that the former Director of the Office of the National Coordinator for Health Information Technology, Farzard Mostashari, MD has launched – with an infusion of $4.5 of investment capital from Venrock and Bob Kocher, MD taking the lead – an ‘ACOcor’ of sorts tagged ‘Aledade‘.

Mostahari outlines his rationale and reasoning pathway to this ACO consulting and turnkey management company as follows:

Today, I’m launching a new company, called Aledade.

Aledade partners with independent primary care physicians to make it easy and inexpensive for them to form and join Accountable Care Organizations (ACO) in which doctors are paid to deliver the best care, not the most care.

This is good for patients who will find that their trusted primary care doctors are more available and better informed than ever before. It’s good for doctors who want to practice the best medicine possible, the way they always wanted to. It’s good for businesses and health plans looking for healthcare partners that deliver the highest possible value and outcomes. And it’s good for the country as higher quality, lower cost care will help lessen the strain on our budget and our economy.

The world of start-ups may not be the usual path for those leaving a senior federal post, but it’s the right decision.

For me, Health IT was never the “ends,” but a “means” to better health and better care, and I continue to believe that better data and technology is the key to a successful transformation of health care. And it is why the attempts to do so now can succeed, where they have failed before.

Empowering doctors on the frontlines of medicine with cutting edge technology that helps them understand and improve the health of all their patients- that is the mission of our new company, and one that has animated my entire career.

During the seven years I spent working for Tom Frieden and Mike Bloomberg in NYC, it was exhilarating to be able to push the frontier in what was possible — to innovate at the edge.

Working with my team, we were able to: invent new statistical methods for outbreak detection , develop new data visualization methods, create visibility into population health down to the neighborhood level, bring decision support and rapid diagnostics to the point of care, automate electronic quality measurement, and implement novel financial incentives and hands-on technical assistance to support care transformation in small independent primary care practices. It was exhilarating.

When I moved to HHS in 2009, the transition to federal service also meant a change in perspective.

As the National Coordinator for Health IT, my key responsibility was now to ensure a minimum national “floor.” We had to push the country as a whole towards a common core set of data and capabilities. We applied creativity and grit to do what needed to be done, using the best tools available to us: encouraging the private sector; organizing and scaling state and local efforts like the inspiring work of the regional extension centers; and — yes — through the blunt instrument of regulations too.

I’m extremely proud of the work we did, and the foundation we put in place. The country is in a massively different place, and the age of data has finally come to healthcare. But in that role, I was also acutely aware of the compromises and incremental half-steps that have to be taken when the goal is to move an entire nation. I was inspired by those that pursued improvement not “compliance” and did not mistake the floor for a ceiling.

I’ve had the good fortune for the past nine months to be ensconced among some truly great thinkers at the Brookings Institution, and to go on a “walkabout” – talking to and visiting with leading practitioners throughout healthcare. I have come away with a rare stereoscopic view of the changes sweeping through health care — the anxiety of those with “one foot on their old business model’s grave and the other foot on their new business model’s banana peel”, mingled with the excitement of those who would disrupt the status quo.

And during this process, I have also found my cause.

It’s to help independent primary care doctors re-design their practices, and re-imagine their future. It’s to put primary care back in control of health care, with 21st century data analytics and technology tools. It’s to support them with people who will stand beside them, with no interests other than theirs in mind. It’s to promote new partnerships built on mutual respect, and business arrangements that will truly reward them for the value that they uniquely can bring- in better care coordination, management of chronic diseases, and preventing disease and suffering. It’s to achieve lower cost through better care and better health.

I believe in this. And this is the mission of our new company. And to realize it, we will be back at the vanguard, helping to lead this transformation in health care that has been underway for years but is quickening and coming faster than ever before.

This is clearly an idea who’s time has come – in fact, it’s been here a while. Yet the white water of health[care] ecosystem reform remains, witness: Universal American: A Sign of Things to Come?  The key strategic question is: can Aledade build upon and leverage the collective experience and insights of the past in the development of independent physician networks (IPAs) or their management companies (MSOs) to put physicians back in control via risk assumption at the population health level? In other words, can they succeed in tapping if not channeling the vital community physician leadership to deliver on the culture as well as the mission critical objectives (i.e., the triple aim) of the ACA levied principally on the ACO community writ large?

Clearly Mostashari’s work in building out the HealthIT infrastructure and population health connectivity that enables the vision if not spine of any ACO or accountable care initiative (better care, better outcomes & lower per capita costs) is mission critical insight. Improvements in healthIT and reach of REC’s (Regional Extension Centers) is one big difference since the ambitious if not technologically ‘pre-mature’ launch of Healtheon and the associated rise and collapse of the PPMC (physician practice management company) industry. [Editor's Note: For additional PPMC context, see 'The ‘Medical Aggregators’: Are We Entering Round Deux?']

This one is worth watching very closely!