Accountable Care, population health

Accountable Care, Population Health and the Social Determinants of Health

by Fred Goldstein, M.S.

Recently I took part in the Florida Trail Association (FTA) Annual Conference. The FTA develops, maintains, protects, and promotes a network of hiking trails throughout the state, including the unique Florida National Scenic Trail (FNST). This event celebrated the 50th Anniversary of FTA founding.

A Brief History

The National Scenic Trails were authorized under the National Trails System Act of 1968 that began with the naming of the Appalachian Trail (AT) and Pacific Crest Trail (PCT) as the first National Scenic Trails. The AT was originally founded by Benton MacKaye and completed in 1937. It’s over 2,000 miles long. Earl Shaffer was the first person to do a complete single thru-hike of the AT  in 1948. Earl was a soldier returning from World War II who said he was going to “walk off the war”.  More on this and its relevance to current day later.

Jim and Fred at the unveiling of the sign

The Florida National Scenic Trail another of the eleven National Scenic Trails is about 1,300 miles long and has its own originator, Jim Kern. The weekend was a well-earned celebration of Jim’s vision to establish the Florida Trail 50 years ago.  Jim is also a co-founder of the American Hiking Society, and founder of Big City Mountaineers which takes under-served urban youth through wilderness mentoring expeditions.

Jim has become a friend and I am now assisting him as a Board Member of  yet another organization he founded, Friends of the Florida Trail. Most people are not aware that the only National Scenic Trail that is complete from end to end is the Appalachian Trail.  All of the other trails have hundreds of miles of gaps which require hikers to walk along roads and highways, limits access to sections, has access that can be withdrawn at any time and trail routes are constantly changing as a result. Friends of the Florida Trail is working to find a way to complete the Florida Trail.

Hiking and Population Health

Fran Mainella while working at the NPS

So how does my interest in the Florida Trail and getting outdoors relate to my work in Population Health? Well its really quite simple and in fact the guest speaker, Fran Mainella addressed it in her presentation.  Fran was the 16th Director of the National Parks Service under President George W. Bush and before that she was director of the award-winning Florida State Parks for 11 years.

As she said said and I am paraphrasing:

“At the same time that outdoor places and trails seem see to be becoming less relevant to our youth with the advent of new technologies, the internet, online gaming, Facebook, Snapchat and messaging, we have become more aware that getting outdoors, walking and hiking have incredible health benefits.”

We have both seen the link that needs to be created between the healthcare system and these outdoor locations and activities to improve the health of our country. The healthcare system and the trail associations can come together in a mutually beneficial way. It’s a golden opportunity for health plans, hospitals and other providers to promote and create health in their populations while supporting a great cause, the awareness, use and protection of these outdoor assets.

img_6072Our long distance trails provide  even more reason to be supported and this was clearly expressed in what I felt was the best presentation of the entire event. The presentation was given by two recent veterans who discussed Warrior Expeditions and Warrior Hike. As mentioned above, Earl Shaffer thru-hiked the AT after WW II to “walk off the war”. Many of the men and women returning from Afghanistan, Iraq and other places, come back suffering from PTSD and other stress related issues. Warrior Hike, working with Georgia Southern University and other sponsors provides these returning veterans with the opportunity to thru-hike many of the National Scenic Trails to “decompress from their military service and come to terms with their wartime experiences”  or as one speaker said “deal with these demons.”

This year, six veterans began a thru-hike of the the Florida Trail and five completed it. The veterans told incredible stories of their journeys on the Florida Trail and how these long distance hikes positively changed their lives’, providing them with some healing from the trauma they faced.

All of the National Scenic Trails are amazing places, not just because of their beauty, but because of their ability to impact our health, both physical and mental; they are more than just a “walk in the woods” they are about Well-being for us and future generations. We should do all we can to protect and complete them.

A Few More Conference Highlights

There are two other things I’ll mention about the conference.

Ben Montgomery author of  Grandma Gatewood’s Walk gave an engaging presentation. This book, a Pulitzer Prize Finalist is worth a buy. It’s a great story about an amazing woman Grandma Gatewood, who was the first woman and just the 6th person overall to thru-hike the AT in 1955 at 67 years of age. How she did it was unbelievable and why she did it was something we as a society must work to eradicate. Having just completed the book, there’s much more to this story, but I won’t spill the beans.

Kara Montgomery Store Manager of the Jacksonville, FL REI with their award.

In addition to the great presentations, in attendance was  REI and Kara Montgomery.  When REI came to Florida, they located their first store in Jacksonville. Since then I have been able to meet Kara and the excellent staff, purchase many items and introduce them to the FTA. REI has become a strong supporter of the Florida Trail including providing grants in 2014 and 2015.  At this years annual conference they had a booth, provided classes on map and compass and received the Florida National Scenic Trail Volunteer Partner Group of the Year award. Congratulations to REI and Kara and thanks for all of the support you provide to the FTA and other organizations around the country.


Post originally published at Accountable Health, LLC.

Accountable Care, Affordable Care Act, health insurance reform

CMS Quality Measure Development Plan: A DRAFT

by Gregg A. Masters, MPH

An inspirational leader and ‘disruptive‘ politician taken down well ahead of his time once opined:

“Ask not what your country can do for you, ask what you can do for your country…” John Fitzgerald Kennedy

Fast forward some 55+ years and season such an invitation with the relentless drone of 24/7/365 faux patriotism, hate mongering, intolerance, and emotive ‘hell no‘ sound-bytes proferred by those who self righteously claim title to the ‘take back our country’ narrative and you may ask yourself how did we get from there (the Peace Corps) to here (carpet bomb em)?

Yet, in our unique strain of American democracy even through studies empirically demonstrate a consistent disconnect between what Americans want and what their representatives codify via policy with a capital ‘P’, the bottom line is look in the mirror ‘we are the government’.

CMS_quality_development_planWhether it’s the creation and passage of what merged into the ‘Affordable Care Act‘ (ACA) or how the ‘public’ participates in both the legislative process and its implementation via the rule making process initiated aka the ‘notice of proposed rule making’ (NPRM), we are presented with both the opportunity and as it turns out obligation to engage in and thus granularly shape (via a dialectical bottoms up vs. top down exchange) the ground rules which in turn govern our economy and the conduct of its constituent industry stakeholders.

In the quest to advance the efficacy of quality initiatives (garbage in garbage out) one recent effort is the DRAFT release of the ‘CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models‘.  

As an industry we are process oriented sometimes to a fault. Moreover the ‘check the box’ or drop down nature of many of these measures lends itself to the argument that the state of the industry to actually measure, document and report healthcare quality is at best a crude representation of what is actually going on. Clearly there is more work to be done if this industry is to matter.

To help readers of this blog, the introduction of the executive summary is pasted below:

I. Executive Summary


A transformation of the U.S. healthcare delivery system gained momentum in 2010 with the passage of the Patient Protection and Affordable Care Act (Affordable Care Act).1

The law established the Health Insurance Marketplace to extend consumer access to affordable care through private payers and provided strong incentives in publicly financed healthcare programs to connect provider payment to quality of care and efficiency. 

Building on the principles and foundation of the Affordable Care Act, the Administration announced a clear timeline for targeting 30 percent of Medicare payments tied to quality or value through alternative payment models by the end of 2016 and 50 percent by the end of 2018.
These are measurable goals to move the Medicare program and our healthcare system at large toward paying providers based on quality, rather than quantity, of care.2

The passage of the Medicare Access and Children’s Health Insurance Program (CHIP)
Reauthorization Act of 2015 (MACRA)3 supports the ongoing transformation of healthcare delivery by furthering the development of new Medicare payment and delivery models for physicians and other clinicians. Section 102 of MACRA4,i requires that the Secretary of Health and Human Services develop and post on the website “a draft plan for the development of quality measures” by January 1, 2016, for application under certain applicable provisions related to the new Medicare Merit-based Incentive Payment System (MIPS) and to certain Medicare alternative payment models (APMs).

The law provides both a mandate and an opportunity for the Centers for Medicare & Medicaid Services (CMS) to leverage quality measure development as a key driver to further the aims of the CMS Quality Strategy:

• Better Care,
• Smarter Spending, and
• Healthier People. 5

Measure Development Plan Purpose
The purpose of the CMS Quality Measure Development Plan (MDP) is to meet the requirements of the statute and serve as a strategic framework for the future of clinician quality measure development to support MIPS and APMs. CMS welcomes comments on this draft plan from the public, including healthcare providers, payers, consumers, and other stakeholders, through March 1, 2016.ii The final MDP, taking into account public comments on this draft plan, will be posted on the website by May 1, 2016, followed by updates annually or as otherwise appropriate.i

So here it is… have at it. Perhaps your input will in fact shape the substance and steward the glide-path of how the transformation from volume to value can be realized. Certainly it’s worth your consideration. Afterall, another attributed Kennedy quote with biblical DNA may apply here:

“We are not here to curse the darkness, but to light a candle that can guide us through the darkness to a safe and sure future. For the world is changing. The old era is ending. The old ways will not do.

The problems are not all solved and the battles are not all won and we stand today on the edge of a New Frontier – a frontier of unknown opportunities and perils, a frontier of unfulfilled hopes and threats.

It has been a long road to this crowded convention city. Now begins another long journey, taking me into your cities and towns and homes all over America.

Give me your help. Give me your hand, your voice and your vote.”

John Fitzgerald Kennedy

Accountable Care, ACO, Affordable Care Act

The Medicare Shared (ACO) Savings Program – A Tale of Transition

By Gregg A. Masters, MPH

In pursuit of the no longer optional ‘triple aim‘ and as once suggested by industry innovator Richard Merkin, MD the founder and CEO of Heritage Provider Network, the ‘gold’ in the ACA may be the programs and outreach of the CMMI. But we’re not obsessed with acronym’s in healthcare, right? So for clarity, the ‘ACA’ is the Patient Protection and Affordable Care Act, while the ‘CMMI’ is the Center for Medicare and Medicaid Innovation in the ‘CMS’ – the ‘Centers for Medicare and Medicaid‘.

While health policy and politics are energetically if not occasionally often toxically entwined, the release of NPRM (the notice of proposed rule making) is the current reflection of a feedback loop inherent in our public/private system of ‘partnership governance’. Since we’re coming up on three years in the implementation of the ACA including its principal dog in the hunt of a sustainable healthcare economy (ACOs and their derivative entities) the delivery of these insights have been eagerly anticipated.

For context, the initial reviews of the ACO NPRM (see: The ACO Proposed Rule: A [Skeptical] View From ‘The Street’‘, and ‘Proposed vs. Final ACO Rule’) logged upwards of 1,300+ comments many of which telegraphed the concerns now recognized in the proposed rule ‘Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations‘. The summary notes the intent of the filed NPRM as follows:

This proposed rule addresses changes to the Medicare Shared Savings Program (Shared Savings Program), including provisions relating to the payment of Accountable Care Organizations (ACOs) participating in the Shared Savings Program. Under the Shared Savings Program, providers of services and suppliers that participate in an ACO continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements.

Since issued, many have chimed in including analyses from Mark McCllelan, MD et al at Brookings (see summary below), the ACO management company founded by former National Coordinator for HealthIT Farzad Mostashari, MD AledadeThe National Law Review, HealthLeaders via ‘Proposed MSSP Changes Don’t Go Far Enough, Providers Say‘ and Rob Lazerow at The Advisory Board.

Proposed Updates to the Medicare Shared Savings Program

Risk Assumption, Attribution and Rebasing Savings Baselines

The good news is CMS took provider feedback to heart and addressed the issues above in a meaningful way. The retrospective attribution issue was perhaps the ACO ‘achilles heel’, while a three (3) year contract year extension to upside only participation (Track One) formula recognizes the immature state of many of the ACOs in the MSSP, and the need for additional runway to implement a value based healthcare delivery culture. Finally, the remaining Pioneer class were rather vocal about the dis-incentive of a progressively lowered baseline from which savings (or losses) are calculated.


We’re clearly in an innovation inspired learning mode thanks to the principle mission of CMMI which is to test:

innovative payment and service delivery models to reduce program expenditures …while preserving or enhancing the quality of care” for those individuals who receive Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) benefits.   

So amidst this toxic health policy and ‘politics of what’s possible’ health reform environment we find ourselves with some cause for optimism as many of the key drivers of ACA begin to take hold in a very difficult to restrain volume driven healthcare ecosystem.

The jury is and will remain out until the ACA is fully implemented and the accountable care industry writ large (including ACOs, PCMHs and derivative plays both commercial and public market) post the results of their efforts to improve user experience (outcomes), quality and lower per capita healthcare costs.

Accountable Care, ACO, Affordable Care Act

IPA 2.0 the Preferred ACO Chassis?

By Gregg A. Masters, MPH

Earlier his morning I received an email from a colleague watching the ACO space for one of his clients. He wanted to draw my attention to an announcement by a Northern Virginia based company that supports physicians in independent practice. He also offered his client as commentator on the significance of this announcement for the emerging accountable care industry.

I promptly read and followed the hyperlink tree for backstory on the announcement and am now called to author this blog post.

Here is the seemingly superficially benign headline with considerably deeper dive significance grabbing the moment:

Arlington's Privia Health lands $400M to begin national expansion


Thus far the ACA rollout in general with all its misdirected and misinformed ideological representations in the media and ‘monkey courts’ in the Congress, and the ACO uptake chatter in particular has centered on major moves by nameplate operators in the space (hospitals, health systems and health insurers re-imagining their business models and market presence), with a smattering of regional or niche market players with interesting designs or claims on a novel path that might work.

Lost perhaps in the conversational exchange moving the health reform football forward is the net contribution to be realized via seasoned and risk savvy players who have demonstrated the value equation via their delivery systems albeit in the more familiar and perhaps safer turf of ‘Medicare Advantage’ and have chosen to sit on the sidelines or enter and exit the Pioneer program.

Simmering in the sea of competitive repositioning however in somewhat ‘semi-obscurity’ (perhaps stealth mode) are players who are emerging from the physician led, or preserving the independent practice of medicine model. Of late we’ve learned of the launch of Aledade, here and here, and today we witness the rather prominent bolstering via significant capital investment in Privia Health who’s ‘about’ content notes:

Privia builds and enables high-performance physician groups and clinically integrated provider networks – using technology, team-based care, and unique wellness programs to help leading doctors better manage the health of their populations.

So here we revisit the fundamentals of physician integration which is mission critical and the ultimate driver if the ACA is to work as envisioned. Physicians – traditionally averse to top down leadership especially when originated by health system or hospital executives – must aggregate into cohesive, seamless, coordinated nodes of care delivery to prudently purchase, deliver and thus restrain the ‘rapacious appetite’ of an institutionally driven healthcare [perhaps more aptly characterized as sick-care] industry drunk on a fee-for-volume paradigm.

When IPAs (independent practice associations) where first envisioned in the mid 70s and later amped up in the mid 80s to penetrate so-called mainstream medicine, the value prop was always to ‘preserve independent medicine’ while enabling participation in and thus positioning a ‘dog in the hunt’ for a market segment eagerly pursued by ‘bricks and sticks’ medical groups (primarily multi-specialty) who’s professional management correctly saw as a growing piece of the commercially insured (and later Medicare) pie.

The announcement by Privia Health today of a $400 million investment by ‘An investor group led by an affiliate of Goldman Sachs & Co.’ is in the words of an informed colleague aka @VinceKuraitis ‘could be a very BFD’.

As noted in the article above, Privia:

‘ itself as a platform for physicians to stay in private practice while becoming part of a larger network…’

Get to know these guys ASAP. We’ll be extending an invitation to their leadership to come tell the Privia Health story on ‘This Week in Accountable Care‘, and the details will be posted here upon confirmation.




ACO, Affordable Care Act, Triple Aim

This Week in Accountable Care with Aetna Strategist Charles Saunders MD

By Gregg A. Masters, MPH

On the broadcast I chat with Charles Saunders MD, CEO of Emerging Businesses at Aetna. Dr. Saunder’s seat in the house of healthcare innovation is a unique perch and his tenure in the business brings both depth and breadth to fundamental questions we face as a collective industry.

A fountain of information and insight we discuss the emergence of all strains of ACO’s from the Medicare Shared Savings Program to accountable care collaborations and their public/private hybrids and derivative strains. There is strong demand from the provider community to work with Aetna as an infrastructure and strategic partner.

We originally broadcast this episode on September 18th 2012 under the blog post: ‘I’m Absolutely Bullish on the Future of Healthcare!‘ The story remains an important one and if anything, the momentum has only accelerated since up to and including the recent announcement of the launch of the National Association of ACOs earlier this month. Do yourself a favor and spend some time with Dr. Saunders, it is well worth the listen.


CTE on the Accountable Care Agenda? Junior Seau it’s latest victim?

By Gregg A. Masters, MPH

On a day when another athlete dies from self inflicted wounds, and the acronym ‘CTE‘ (chronic traumatic encephalopathy) finds its way into the popular press, while perhaps opening a line of inquiry as to health consequences of repetitive brain injury, we may find the ante in and around the ‘accountable care’ conversation has just been raised a notch.

According to the Center for Traumatic Encephalopathy at Boston University School of Medicine:

“Chronic Traumatic Encephalopathy (CTE) is a progressive degenerative disease of the brain found in athletes (and others) with a history of repetitive brain trauma, including symptomatic concussions as well as asymptomatic subconcussive hits to the head. CTE has been known to affect boxers since the 1920s. However, recent reports have been published of neuropathologically confirmed CTE in retired professional football players and other athletes who have a history of repetitive brain trauma. This trauma triggers progressive degeneration of the brain tissue, including the build-up of an abnormal protein called tau.  These changes in the brain can begin months, years, or even decades after the last brain trauma or end of active athletic involvement.  The brain degeneration is associated with memory loss, confusion, impaired judgment, impulse control problems, aggression, depression, and, eventually, progressive dementia.”

I learned of this tragedy via Twitter just past noon Pacific time via the headline: ‘NFL legend Junior Seau found dead at his California home‘.

In the public reaction department, The North County Times reported:

‘According to Former NFL player and 1968 Oceanside High graduate Willie Buchanon, who played with the Packers and Chargers from 1972-82, said he was stunned.’

My first reaction was why, Buchanan said. We lost an Oceanside Pirate, a San Diego Charger. He was on top of the world. To take his life like this, we don’t know what led him to this. Everyone in Oceanside looks up to Junior. He’s Oceanside.

Yet the LA Times begins to connect certain dots via:

Seau is the eighth member of the 1994 Chargers, who lost to the San Francisco 49ers in the Super Bowl, to die at a young age. Linebacker Lew Bush died of an apparent heart attack last December. Running back Rodney Culver died in a 1996 plane crash; linebacker Dave Griffs died in a 1995 car crash; linebacker Doug Miller was struck by lightning in 1998; center Curtis Whitley died of an overdose in 2008; defensive end Chris Mims died of an enlarged heart in 2008; and defensive tackle Shawn Lee died of cardiac arrest in 2010.

While on Twitter and Facebook the questions were fast and furious, including the inevitable speculation:

Addiction: Cunning, Baffling and Powerful. Hope you’ve finally found peace Mr. Seau. I will always remember you sitting in Jitters ukulele and telling me that I sang pretty at karaoke. RIP.

Followed by:

Wait, did he have an addiction problem?

So another one has fallen ‘before his time’ or was it his time and no-one noticed (or worse cared)?

Epidemiologists speak of the incidence and prevalence of disease (morbidity) in a given population to establish benchmarks of normative distribution, and to provide guidance as to specific nature, timing, and location of intervention.

Yet today we speak of the “triple aim’ and the related concepts of population health management vs. our traditional episodically focused sick care system. As we move to embrace expanded notions of community wellness and prevention, we’d better get clear as to the extent of morbidity that may exist in certain ‘demographic groups’ to recognize and effectively address the underlying pathology – including the associated social or economic determinants of dis-ease. Absent this nervous system, we’ll be blindsided by what may appear patently obvious – yet only in retrospect.

So welcome to another chapter in the accountable care conversation. Let the discussion of ‘CTE’, domestic violence, or as some may have suggested alcoholism, drug abuse or underlying depression begin in earnest given our lofty intentions to proactively manage identifiable health risks, including those sometimes ‘invisible’ yet tragic morbidities.


AMGA 2012: The complete ‘digital footprint’

By Gregg A. Masters, MPH

The synopsis tweeted is pasted below:

Final ‘digital footprint’ for #AMGA12: Reached 66,842 peeps via 273 tweets & an exposure of 638,735 impressions

The trade group arguably representing a majority of forward thinking and innovation oriented, in terms of the active exploration of what and how accountable care business models can be articulated, the AMGA held their annual conference in San Diego from March 7th, – 10th, 2012.

Courtesy of @ePatientDave who was tagged to deliver the closing keynote on Saturday, I had the good fortune to both ‘crash’ the preso, as well as monitor, tweet and re-tweet the action [there are many excellent preso’s which I will bring forward via future posts]. Editors Note: Compared to most other healthcare conferences I attend, the twitter volume was rather thin – much to my surprise, considering the relationship between technology, healthIT and social media.

None-the-less, a ‘digital footprint’ as we say emerged from the event via both the ‘happy fingers’ in the room as well as tweeps out of the room who collectively engaged in the AMGA’s conference proceedings.

For the complete ‘digital footprint’ report, click here.