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Didn’t Take Long! Meet Essence Group Holdings Corporation an ‘ACO/PPMC 2.0′

Not long after the post ‘Waiting on ACOcor‘ did I learn of the company Essence Group Holdings Corporation via a Tweet on Thursday, July 2oth, 2011 by @KHNews:

Leading Venture Capitalists Place A Bet On #ACOs including EGHC

One of the ‘leading VC’s’ referenced in this case happens to include ‘In Search of the Next Big Idea’, Kleiner Perkins via John Doerr, Partner, and EGHC Board Member, whose credits include: Silicon Compilers, @Home, Google, & Amazon to name a few, fellow board member Denis Cortese, MD, Chairman and CEO Emeritus, Mayo Clinic, and Director, Healthcare Delivery Policy Program, Arizona State University, as well as Michael Long, Chairman and CEO of EGHC. Long’s involvment completes the loop back to Michael Lewis’ ‘The New, New Thing‘. Anyone remember Jim Clark’s ambitious, on point but before its time ‘Healtheon‘, re-skined into the B2C play WebMD, and further differentiated into the current iteration of B2B Emdeon?

So what is one to make of this no so ‘stealth’ re-emergence of entrepreneurial engagement in ‘health reform’, ‘accountable care’, or ‘ACO transformational interest’ from a tea leaf interpretation POV?

While many healthcare stakeholders continue to register their dissatisfaction with CMS and more specifically the NPRM on the table relative to ACO formation, many are seeing the handwriting on the wall and positioning to lead the transformational imperative of the change resistant ‘whack-a-mole’ healthcare borg.

My guess is we’re witnessing tangible indicia of round 2.0 in the PPMC (physician practice management company) phenomenon, this time focused on enabling accountable care, whether at the organizational, enterprise or virtual network level.

So if EGHC can be anointed the first ‘PPMC 2.0’ in this race as the defacto ‘ACOcor‘, who will step up and into the ‘ACOPartners‘ slot?

Ladies and gentlemen…’let the games begin.’

Waiting for ‘ACOcor?’

Some of you with an event horizon a tad longer than the recent focus on social media, web 2.0 or health 2.0 energizing innovation in healthcare may recall the by-gone era of physician practice management companies, aka ‘PPMCs.’

The PPMC industry witnessed roughly a 10+ year run (circa 1990s – 2000s) with cheerleaders on Wall Street championing the likes of MedPartners (the carcass of which still exists today albeit in the form of the PBM, CVS/CareMark), FPA Medical, and PhyCor.

Due to some of its business practices and value proposition claims, PhyCor garnered its dis-proportionate share of the notoriety as the ‘poster child’ for a failing if not fundamentally flawed (perhaps pyramid-like) business model.

Yet, many of the sales points to prospective medical groups and/or acquisition candidates sound familiar to [ACO] consolidation plays we’re hearing today, i.e., overhead reduction via operating economies of scale, leveraging group discounts, pooling managerial excellence and best practices, and higher quality net revenue via superior contracts with payors due to increased purchasing leverage and better geographic dispersion/service area coverage.

All of the above are tangible and valid reasons why the PPMC pitch made so much sense. Yet few if any seemed to realize the operating benefits in any consistent way ergo the blood bath that followed. We might mention one survivor of that period, then known as ‘Physician Reliance Corp’, who was recently acquired by McKesson albeit as the rebranded nameplate of US Oncology.

So what’s the relevance today, and what is meant by the spirit of an ‘ACOcor’ entity?

Many of you will no doubt be familiar with the buzz associated with the March release of the notice of proposed rule-making relative to accountable care organizations (ACOs). Many of the usual (AHIP, AHA, etc.) and even not so usual suspects (AMGA) have gone on record with their displeasure with specific provisions of the NPRM.

Reading the ACO tea leaves is like relying on a weather forecast, don’t bank the farm on it. Yet, if most if not all of the objecting providers sit on the sidelines v. embrace the opportunity to transform their current business models and mindsets, the door will be thrown wide open for enterprising third parties who see wisdom in the tapestry of CMS, HITECH and ONC as dots connecting a rather purposeful re-engineering of the dysfunctional US sick care non-system.

Perhaps the era of PPMC 2.0 is here, and an enterprising successor to PhyCor is in the works as we speak albeit in ‘stealth or semi-stealth’ mode?

CMS: Pioneer ACO Special Open Door Forum Conference Call

Moderator: Barbara Cebuhar, June 7, 2011, 12:00PM, Eastern Time

Operator: Good afternoon, ladies and gentlemen, my name is (Shawn) and I will be your conference operator today. At this time, I would like to welcome everyone to the Pioneer ACO Special Open Door Forum Conference Call. All lines have been placed on mute to prevent any background noise. After the speaker’s remarks, there will be a question-and-answer session. If you would like to ask a question during this time, simply press star then the number one on your telephone keypad. To withdraw your question, you may press the pound key. Thank you.

Ms. Barbara Cebuhar of CBS, CMS, excuse me. You may begin your conference call.

Barbara Cebuhar: Good afternoon, everyone. My name is Barbara Cebuhar. I’m with the CMS Office of Public Engagement. Thank you for everyone being with us on the call today.

We’re here to discuss some exciting new options for a whole range of providers across the health care spectrums that are considering being a part of accountable care organizations. Accountable care organizations are one of the most innovative tools provided by the Affordable Care Act that will help us create a health care delivery system that is sustainable over the long term.

Today, we’re discussing a new initiative from the CMS Innovation Center, the Pioneer ACO Model. I’m joined by Dr. Mai Pham and Dr. Mandy Cohen from the Innovation Center to provide us overview and answer your questions about the Pioneer ACO model.

I just want to make sure that folks know that this is not a press call. This is for stakeholders only and also that the Encore recording of this call will be available about three or four hours after the conclusion of this call. So, that means about 5:30 Eastern Time. And you can access it by dialing 1-800-642-1687 and asking for call number 70961782. If you have questions after this call ends, you may send them to pioneeraco@cms.hhs.gov. That’s pioneeraco@cms.hhs.gov.

I’ll now turn the call over to Dr. Pham and Dr. Cohen.

Mandy Cohen: OK. Thank you, Barb. Hi, everyone. My name is Dr. Mandy Cohen. I’m the director of Stakeholder Engagement for the Innovation Center. And we just wanted to welcome you all to the call today and thank you for taking the time and of your busy schedule to join us.

We’re going to be reviewing the Innovation Center’s new Pioneer ACO model, the request for applications that was announced just few weeks ago, and go through any questions you might have. I think we all know that the path towards a sustainable health care system can’t be through cutting care or slitting down coverage. It has to be through improving care. And we can achieve better care, better health, and lower cost by putting patients at the center of our health care system. And we believe Accountable Care Organizations or ACO‟s is the perfect example of how we can get there.

About two months ago, CMS published its initial proposed rules on how to implement ACO. And the public comment period for that rule, the Medicare Shared Savings Program closed yesterday. This call will not be addressing the Medicare Shared Savings Program; rather, it’s to discuss the Innovation Center’s new model, the Pioneer ACO model.

This model will offer an accelerated pathway performing an ACO to providers, who are already ahead of the pack in terms of coordinating care even before those new regulations for the Medicare Shared Savings Program go into effect. So, again, we’ll only be focusing our comments today on the

Pioneer ACO model and answering questions about that request for (read complete transcript here).

Clearer Thinking on ACOs and Healthcare Delivery Polarization

By Gunter Wessels, Partner, TIGI

Delivering advisory services to healthcare organizations across the vertical in the US and internationally has focused our analysis of the proposed ACO rule in a bit of a different way. We’re looking at the practical commercialization implications of an array of potential and likely outcomes of ACO-based healthcare delivery transformation. The healthcare reform debate is rife with non ACO relevant topics like reducing duplicative tests and assessments, fraud and abuse, and other important but unrelated delivery system improvements. These emotional issues have clouded the discussion in our opinion. The way we see it, whatever shape the final ACO rule takes, it will have to do a few things to deliver on it’s intent. These outcomes are simple but consequential.

[Editors note: Gunter is my guest on ACO Watch: A Mid-Week Review, Wednesday, July 6th, 2011 at 11AM Pacific/2PM Eastern. To listen live or via archived replay, click here.]

To achieve needed savings and the platform for expansion ACO rule for CMS must:

1. Reduce utilization in a few key disease states

The US, and a few international systems are primarily burdened by Chronic Kidney disease (including End-stage-renal disease and dialysis), Heart Failure, and Diabetes. Managing these three disease states consumes nearly 70% of medicare spending according to the USRDS. All three diseases are handily managed in the outpatient setting, but when care management is poor, inpatient utilization is increased along with cost.

2. Increase non-acute care delivery

Non-acute care is less expensive, and a more conservative option for treatment of the cost drivers in medicare, i.e. chronic disease states.

3. Improve transitions of care

Care management and care coordination are critical in handling chronic disease. Affected patients are high consumers of healthcare goods and services; devices, testing modalities, pharmaceuticals, and education services. They require explicit and detailed direction, are sometimes easily confused, and are sometimes prone to making poor choices. These patients need care and attention, but case managers, and care managers are few and often overworked.

4. Reward participants

Payment for not doing something is much more difficult than payment for doing something. There are complex considerations in structuring incentives that aim to reward the right provider behavior when monitoring is expensive or untenable. The CMS will have its hands full crafting the right incentive package for ACO participants. The right package will need to balance the inability to monitor with perverse incentives like denying access or rationing care. Fortunately, core measures, and other quality metrics are now a bigger part of the healthcare system, and these create a useful platform.

The picture changes when the requirements for providers are considered. To be a profitable ACO, big things are required. These are:

1. Strong, effective, and agile medical policy

We call this the “Dr. Bieber” effect. A “rock-star” medical policy maker and influential and informed medical policy staff will be required to update care-pathways, develop and implement new standards of care, and champion patient communication and quality initiatives.

2. Powerful IT infrastructure

ACO IT needs to be able to process claims, collect information from disparate systems including paper based records, transmit quality data, create alerts, dashboards and financial controls, as well as adapt to medical policy changes and clinical decision support tools. The system needs to be mobile, and easy to use. In other words, it will be very expensive and require many support resources etc.

3. Robust care coordination infrastructure

The name of the game in reducing unnecessary cost is coordination. Care coordinators are required as the human extension of the elaborate IT infrastructure. These coordinators will be charged with educating, communicating, as well as care triage. Without coordinators that can act in time, patients could stumble around the system and inadvertently interfere with the ACO’s ability to reduce cost and improve outcomes.

4. Significant financial resources

High cost and difficulty in forming and operating an ACO needs to balanced against the prospect of financial gain in the program. A quick calculation shows that the economics are just not there in most cases. Therefore, providers venturing down the ACO path are doubling down, and sponsoring private insurance backed plans as well. If the ACO can enjoy the underwriting profit, i.e. collect more in insurance premium than it spends, the economics work out much better. However, launching an insurance company or renting part of one requires additional human and capital resources.

The ACO rule

The ACO rule is in our view an important beginning to a new polarization in healthcare delivery. Providers can opt in, or opt out at their choosing. We are noticing that many are contemplating opting out, but this action is not risk-less. By having ACOs in the delivery ecosystem a cascade of changes is set in motion. Providers that can reduce utilization and effectively manage chronic disease will likely be more adroit at managing acute disease. Hence these ACOs will be powerful players in their local markets. However, being a good ACO should not require owning the whole continuum of care. Rather, affecting patient flow within the continuum through care management can be done from the primary care level.

Therefore, on one pole the ACOs will exist and on the other pole the highly capable and differentiated speciality or tertiary care providers will exist as a procedure hub. As the hubs, these organizations will require the services of a large proportion of specialists and expensive equipment. Hub providers that can demonstrate overall care improvement and outcomes benefit through the use of sophisticated new diagnostic and treatment modalities should enjoy a bright future when partnering with ACOs. Radio-surgery, high-volume/dynamic volume imaging, molecular diagnostics, and robotic surgery all have positive outcomes profiles that could benefit the ACO, and the non-ACO provider partner. We see the need for expensive and difficult intervention capabilities in the future, but the mission of these organizations will be an evolution over the current state. Hub organizations will be paid a premium to deliver highly effective complex care.

In between these poles, the undifferentiated and moderately capable provider will struggle, especially in competitive and highly populated markets. The “mid” market will devolve in urban areas, and struggle in rural markets where volumes are mixed, and population mobility expands the competitive reach of hub-providers.

As the healthcare system evolves, new players will likely emerge, but we foresee these new actors as focused and operationally competent. In an ACO world, specialization and network affiliation will carry more weight than regional presence. Having a clearly defined value proposition, investing in clinical capabilities that create operational efficiencies will grant sustainable financial outcomes. In the end, a more modern and capable health system can be expected in the near future.

Gunter Wessels, partner at TIGI joined the firm in 2006 after launching his own consultancy while completing a Ph.D. in Marketing. Gunter has consulted with numerous companies in the private sector, principally focused on the healthcare vertical market, but also including insurance and other industries. His expertise is in the domains of marketing and persuasion. In practice he most often consults in personal selling and sales management, but also develops go-to-market strategy, pricing, integrated marketing communication tactics, and value proposition tools.

2nd Annual National Accountable Care Organization Summit

Remarks as prepared for delivery by Secretary Sebelius on June 27th, 2011, Washington, DC.

Thank you, Mark, for that kind introduction. Few people have done as much to improve America’s health and health care as Mark has over the last decade. Every day, we build on the foundation he left at CMS. And I’m especially grateful to Mark and Brookings for their work on Accountable Care Organizations – a concept they helped invent and have done as much as anyone to develop and promote.

I also want to thank everyone who’s here today, especially the hospital and physician leaders. Having all of you here in this room is a powerful sign of how committed America’s health care providers are to improving care.

Finally, I want to acknowledge all those from the Health IT conference next door who are here for the opening session. It’s fitting that we’re here together this morning because electronic health records can play a key role in almost everything Accountable Care Organizations hope to accomplish, from measuring and improving quality to helping providers work together more effectively.

We’re gathered this morning at a time when two trends are converging. On the one hand, there is new urgency about rising health care costs.

It’s coming from working families who have had to give up raises in order to avoid health insurance cuts. It’s coming from small businesses that have had to choose between offering health coverage to their current employees and adding new ones. It’s coming from states where rising costs in Medicaid are crowding out investments in better schools and new roads. And it’s coming from Medicare where the program’s trustees recently found that, even with Affordable Care Act reforms that added eight years to the life of the trust fund, it is still on pace to become insolvent in 2024.

At the same time, we have a growing understanding of how to bring down costs by improving care. A recent study found that as many as one in three hospital patients are harmed by their care. But I’ve visited innovative hospitals across the country that are showing that much better results are possible. At Seton Medical System in Austin, they told me how they had reduced emergency room visits by a third and hospital stays by two thirds for a group of patients with asthma by providing better preventive care. At Henry Ford Health System in Detroit, they told me how they had cut major categories of harms by 25 percent by improving communication between providers. I’ve seen similar results everywhere from Norfolk to Denver to San Francisco.

Improving care is clearly the best approach to addressing rising costs – especially compared to recent proposals that would simply cut Medicare and Medicaid, without doing anything to address underlying growth in health care spending. But it’s also clear that we are not improving fast enough. So our challenge is to speed it up.

To do that, we need to change one of the unique facts about health care, which is that it’s a field in which innovators are actually punished financially. In a system where empty beds don’t generate revenue, a hospital that provides excellent follow-up care to keep a patient from being readmitted may actually lose money. In a system that primarily rewards procedures, there’s little reward for a physician practice that invests its time in helping its patients manage their diabetes. This doesn’t make sense, and that’s where the Affordable Care Act comes in

This is a law that has three simple goals: better care, better health, and lower costs. It achieves these goals in a variety of ways from strengthening our health insurance market to investing in prevention. But it also contains more than 80 tools to help providers reinvent health care to make it more effective and affordable. One of those exciting tools is Accountable Care Organizations.

The idea behind these organizations is very powerful. By giving hospitals and physician’s groups a share of the savings when they reduce costs by improving care, we can start to reward innovation just like other fields do. All of a sudden, there is a clear financial incentive to prioritize primary care and prevention. Innovative programs for providing follow-up care to discharged patients and helping people manage their chronic conditions are no longer money-losing luxuries. Patients can feel like they have active partners in getting and staying healthy, while still being able to see any doctor they choose.

Many of you know this already. But I repeat it now because I hope that as you have your discussions today, you will keep in mind both of the powerful urgency behind change and the enormous possibilities of a health care system in which payers, doctors, and patients all benefit when health improves.

As you know, our department issued proposed rules to guide the creation of Accountable Care Organizations at the end of March. These rules were carefully written by our staff, led by Dr. Don Berwick who many of you know as our nation’s leading expert on health care improvement. He is the right leader in the right place at the right time, and in writing these proposed rules, he and his team carefully weighed the interests of hospitals, doctors, patients, and other stakeholders – but the emphasis here is on the word “proposed.” These rules were a first draft, and even as we were writing them, we were looking forward to receiving comments that we knew would make these rules even stronger.

Altogether, we received more than 1,200 comments on everything from… (read complete speech here).

ACO Summit AM Roundup

We always feel a tad behind the power curve here on the West coast when events begin in the ‘ET’ AM zone circa, in Todd Park’s vernacular, ‘…..at 0 dark hundred.’

Such is the case for the 2nd National ACO Summit which has convened in Washington DC today with many of the names we’ve come to associate with leadership (both thought and on the ground) in the ‘accountable care’ conversation with our without the ‘O’.

See the complete agenda here.

For a hashtag summary courtesy of our friends at the Fox Group, see the recap and Twitter scroller, here.

And the emerging ‘digital footprint’ can be view here.

We’ll stay on top of notable quotes and key themes as they unfold.

Meanwhile my key take away from the AM session is summarized by the following quote from Steve Hester, MD, MBA
Senior Vice President and Chief Medical Officer, Norton Healthcare, Louisville, KY:

‘Change is coming whether we all like it or not..’

Don Berwick’s preso at 1st Accelerated Development Learning Program

On June 20th through the 22nd, 2011 the Centers for Medicare & Medicaid Services (CMS) held the first of its ‘ACO Accelerated Development Learning Sessions (ADLS)’. The sessions are ‘to provide the executive leadership teams from existing or emerging ACO entities the opportunity to learn about essential ACO functions and ways to build capacity needed to achieve better care, better health, and lower costs through improvement.’

‘Four ADLSs will be offered in 2011. Each will offer a focused curriculum on core competencies for ACO development, such as improving care delivery to increase quality and reduce costs; effectively using health information technology and data resources; and building capacity to assume and manage financial risk.’

The goal of these sessions is to prepare participants to:

Understand their current readiness to become an ACO.
Identify organization-specific goals for achieving the three-part aim of improving care delivery, improving health, and reducing costs through improvement.
Begin to develop an action plan for establishing essential ACO functions.

To watch Dr. Berwick’s presentation, click here.

Continued Insigthts into ACO’s: 5 Key Findings

By Molly Gamble for Becker’s Hospital Review

1. Approximately 40 percent of healthcare administrators and physicians say physician-staffing alignment is the biggest challenge with accountable care organizations. A June survey based on 882 responses found 40 percent attributing delayed progress towards ACOs to alignment. After physician and staff alignment, 31.4 percent of respondents attributed the delay in ACO formation to a lack of capital and 26.2 percent cited a lack of integrated IT systems.

2. ACO start-up costs can peak to as much as $26.1 million. A May study projected the start-up costs of ACOs to be between $11.6 million and $26.1 million. These findings were significantly higher than the original estimate of $1.8 million by the Centers for Medicare & Medicaid Services in its proposed rule.

3. More than 70 percent of hospital executives have cynical view of ACOs. In a February survey, 74 percent of hospital executives said they are cynical of the effect of medical homes and ACOs will have on their bottom lines. Of that percentage, two-thirds of hospital executives said the new models will cause hospital margins to slide.

4. Nearly half of physicians do not know what an ACO is. In January, a survey found (for complete article, click here).

ACO Onramp or Sideline?

Listening in and tweeting about the CMS Days 1 & 2 (partial only) ‘Accelerated Learning Program’ yesterday and today, I am struck by the candor and willingness of CMS to both acknowledge & signal their intentions to work with the provider (both institutional and professional) and payor communities.

As noted today by Rick Gilfillan, MD, Acting Director, the Center for Medicare and Medicaid Innovation:

‘We can’t write the perfect [rule] model from Washington. You need tell us what works, why & how to structure it.’

I also sense a steady but open hand via the recurrent reminder, that this isn’t just about keeping provider and to a lesser degree those transaction processors (aka ‘health plans’) happy. This is first and foremost about patients: keeping them safer, healthier, and for less cost. The Medicare Trust fund outlays are not sustainable (nor are group or individual health insurance premiums for that matter, editors note). As one member of the audience commented, health care cost run rates are at $2.5 trillion currently, and expected to hit $4 trillion within 5 years….Ooops!

Apparently in the room at this first CMS Accelerated Development Learning Program session where an eclectic mix of willing and ready representatives from the ‘Pioneer Model group’, as well as the intermediates and also the ‘newbie crowd’.

My sense is this event does not rise to the level of a ‘Rick Scott-esque’ staged attempt to show off CMS flag waving supporters and make a statement to the Mayo’s and Cleveland Clinics’ of the world (including the most visible trade group representing risk savvy medical groups, i.e., AMGA, who’ve signaled their displeasure with the NPRM, and intention to not participate in the ACO program). Yet I came away with the distinct sense that CMS was issuing the following appeal: ‘either walk the talk’ (i.e., collaborate with us), or ‘get out of the way’ (again, emphasis and interpretation are solely mine).

When I met Dr. Gilfillan in DC at the Healthcare Innovation Summit earlier this month and had the privilege of interviewing him (see his keynote here), I urged him and CMS via proxy, to stand firm and not lower the bar regardless of what may have amounted to some unexpected push back by certain mission oriented ‘friends’ (AMGA, et al). By lower the bar here I do not mean ignore some of the salient feedback offered by the industry as a whole, but crater to the repeal and unwind crowd cheerleading the opposition to a CMS lead innovation conversation and rule implementation process.

May we [continue] to live in interesting times….and indeed we do!

Day 2: Acquiring Core Competencies for ACO Success

8:00 – 8:15	Welcome to Day 2 – and Day 1 Summary
8:15 – 9:00	Remarks by CMS Leadership Don Berwick, MD, MPP, Administrator, Centers for Medicare & Medicaid Services Rick Gilfillan, MD, Acting Director, Center for Medicare and Medicaid Innovation, CMS
9:00 – 10:30	Overview of Core Competencies Essential to ACO Success Overview of Competencies Related to Organizing & Delivering Care James Rogers, MD, St. John’s Health System, Springfield, Missouri Overview of Competencies Related to Assuming & Managing Risk Mark Eustis, MHA, Chief Executive Officer, Fairview Health Services
10:30 – 10:45	Break
10:45 – 6:00	Learning Modules:The remainder of Day 2 will be structured as a series of break-out sessions each presenting a learning module related to one or more core competencies. One track of learning modules will address the competencies related to the delivery of care. These modules will be attended by clinician member(s) of each team. A second track of learning modules will address the competencies related to financial and risk management. These modules will be attended by the manager member(s) of each team. Within each track, participants will break into two smaller groups.
	Track 1: Clinicians	Track 2: Management/Operations
10:45 – 12:00	Module 1: Connecting providers (EHR/HIT)Glenn Loomis, MD, St. Elizabeth Physicians, Keith Hepp, HealthBridge, John Blair, MD, MedAllies, Susan Stuard, MBA, THINC	Module 6: Describing your population’s risk profile. David Knutson, MS, Department of Health and Human Services, David E. Kelleher, MS, HealthCare Options Inc.
12:00 – 12:45	Lunch Break	Lunch Break
12:45 – 2:00	Module 2: Describing your population’s clinical profile. Steve Bernstein, MD, University of Michigan, James Rogers, MD, St. John’s Health System	Module 7: Risk management. Shashank Kalokhe, PhD, Everett Clinic, Greger Vigen, FSA, Independent Actuary
2:00 – 3:15	Module 3: Coordinating care for high-risk patients, Steve Bernstein, MD, University of Michigan, Barbara Walters, MD, Dartmouth-Hitchcock Medical Center	Module 8: Financial modeling, Greger Vigen, FSA, Independent Actuary, Rob Parke, FSA, Milliman
3:15 – 3:30	Break	Break
3:30 – 4:45	Module 4: Primary care and specialist services, Rich Baron, MD, CMS, Jeff Schiff, MD, State of Minnesota Public Programs	Module 9: Capitalization Barbara Spivak, MD, Mount Auburn Cambridge Independent Practice Association, Matthew Mazdyasni, MS, HealthCare Partners
4:45 – 6:00	Module 5: Leading care process improvementChristine Sinsky, MD, Medical Associates Clinic and Health Plans, David Moen, MD, Fairview Physician Associates	Module 10: Incentive paymentsCraig Sammit, MDDean HealthBarbara Spivak, MD, Mount Auburn Cambridge Independent Practice Association