19 October 2018
Dear Interested Readers,
“Systemness” as Nirvana
This week I have had the pleasure of attending the 5th Annual ATLAS conference in Boston. ATLAS is an acronym for Annual Thought Leadership on Access Symposium. It is the annual meeting of the current and potential customers of Kyruus, an innovative medical software company located in Boston. The co-founder of Kyruus is Graham Gardner, MD, MBA, who is a former resident and cardiology fellow at the Beth Israel Deaconess Medical Center. The theme of the conference was “SYSTEMNESS. IGNITED.” Last year I reviewed the 4th Annual ATLAS meeting in a post entitled “Patient Access, Patient Engagement, and the Triple Aim.”
I have had the interesting experience of being on the Clinical Advisory Board of Kyruus since I retired as the CEO of Atrius Health now almost five years ago and have attended all of the ATLAS conferences. I have really enjoyed watching the company evolve from a great idea to being a key resource for many of our largest and most prominent healthcare systems. This year’s conference drew 220 healthcare professionals from 65 health systems from across the country. I hope that what I write about the meeting will coincide with the experience of several “Interested Readers” who were also in attendance! The Chief Medical Officer of Kyruus and the principle force behind the ATLAS program is Erin Jospe, MD, whom I know to be an exceptional PCP because she was my colleague at Harvard Vanguard Medical Associates/Atrius Health.
It was once true that when people asked me what Kyruus did I would have a little difficulty answering the question. I would stammer around and talk about how its products facilitated matching patients with the right doctor for them considering the concern to be addressed on referral. The program helped to find the physician that best matched them in terms of their problem, their language, many personal preferences, and their location. That made Kyruus sound like some kind of medical eharmony or some other online dating service, or KAYAK, an online travel service. Kyruus does have the flexibility that those platforms offer to assist consumers in their effort to make the best decision when choice is an option, but it is also a strategic tool with many other benefits for the large networked delivery systems in healthcare which are the customers of Kyruus. If you clicked on the Kyruus link you learned that the banner on the website reads:
A BETTER MATCH MEANS BETTER CARE: Provider search, scheduling, and data management solutions that help health systems match patients with the right providers and enhance patient access, enterprise wide.
That’s a mouth full but it is getting closer to building a picture of the complexity of the tasks that Kyruus takes on as it attempts to improve the care that systems can offer their patients.
Sometimes an example helps. Imagine that your mother is an elderly Spanish speaking resident of a community near Houston, Texas. She is seen regularly for her many medical problems near her home in Conroe, Texas at the ambulatory practice that is part of the Houston Methodist system, one of the first and most experienced users of Kyruus. Her PCP has decided that she needs to see a cardiologist. His concern is that she may need an ablation to manage an increasingly debilitating arrhythmia. You live nearby and will be taking time off from work to be her driver because the 45 mile trip through Houston traffic to see the doctor would be too much for her to do alone. It would be nice to know that when you get there she will see the best person to address her needs. It would be great if that doctor also spoke Spanish and could effectively communicate with her.
Before Kyruus there was a real possibility she would be given an appointment with a cardiologist in Houston who did not speak Spanish, and was a cardiologist, but did not do EP studies or ablations. The cardiologist might agree that an EP study seemed indicated, but his interest was managing patients with cardiomyopathies. At the end of the appointment you would be given another appointment with an electrophysiologist which would mean another day off from work for you and another midday ninety mile round trip drive through Houston traffic. That’s annoying. It’s also a waste of medical resources. Comparing the experience to the six domains of quality it is a disaster. It is not patient centered. It may not be safe since it is also not timely because care is delayed. It fails most dramatically in terms of being manifestly inefficient. Since the objective was not achieved it was not effective. Finally, it may not be equitable since it could represent a differential burden on patients whose care is publically funded. It is not an example of effective “systemness.” Your satisfaction is a big zero, and you are left wondering why someone did not care enough to make sure that your mother’s needs were met efficiently.
That vision would be more than enough to justify an investment in the Kyruus products, but that was just the beginning. We live in a time of rapid change. One of the most effective presentations, “How to Drive Transformation in Healthcare Delivery” was given by Dr. Edmondo Robinson, the Chief Transformation Officer of Christiana Care Health System of Wilmington, Delaware. Dr. Robinson’s major responsibility is to drive Christiana Care’s transformation in a way that will enable the advancement of population health initiatives that move Christiana from volume based revenue to value based care with a special focus on consumerism strategies.
That challenge is fortunately occurring at a time when big data analysis with artificial intelligence tools is a rapidly developing source of managerial insight. AI is also as a path for the automation of much of the paperwork of healthcare. Dr. Robinson dramatically reminded us of the changes that are occurring at a rapid pace in our times. He presented a slide that showed two pictures labeled 2005 and 2013. The pictures were almost identical in terms of event, crowd and location. The 2005 picture showed the presentation of Pope Benedict shortly after his election. The almost identical picture was of the presentation of newly elected Pope Francis in 2013. The only difference in the two pictures taken eight years apart was that in the 2013 picture everyone in the “audience” was taking a picture of the new Pope with a smartphone. His point was that there are tools that have developed so rapidly that most of us are not taking advantage of the new options to improve care that are now available.
At conferences in the past I have enjoyed the commentary on the state of healthcare as interpreted by Dr. Bob Kocher a partner at Venrock, a venture capital firm that funds many start up businesses in healthcare. Dr. Kocher’s bio is impressive. He worked in the Obama administration:
Prior to Venrock, Bob served in the Obama Administration as Special Assistant to the President for Healthcare and Economic Policy on the National Economic Council. In the Obama Administration, Bob was one of the shapers of the Affordable Care Act focusing on cost, quality, and delivery system reform and health IT policy.
Dr. Kocher’s subject was “2018 Trends Shaping Health Systems Strategies.” It was a perfect fit with the overall theme of “systemness.” He began with a review of the impact of MACRA. You might remember that it passed in 2015 with huge bipartisan support. It has taken many physicians a little while to catch on to the reality that it is a forceful economic “nudge” to favor the shift from volume based payment to value based income. Kocher described the “goal” of MACRA as 50% of seniors on a Medicare Advantage program and 50% of physicians in an ACO by 2020.
The implications of these moves would be “less hospitals, less specialists, less expensive meds, and less SNF care.” Kocher notes that more will be spent on primary care and behavioral health. This sounds like radical change and some of the issues will be settled politically around whether or not healthcare access is ultimately managed at the national or state level. I would remind you that the Republican efforts to “repeal and replace” the ACA called for the granting of fixed sums of money to states. Those grants would have effectively transferred the responsibility for future advancements of economic support to the states. One can easily imagine that there would be substantial differences in the programs that some states would favor and that the move would effectively reduce access to care for many people who have benefited by the ACA’s expansion of Medicaid.
Dr. Kocher emphasized that whether care is ultimately managed at the state level, the national level, or privately, the core concern is, and will continue to be, affordability. I would add that the concerns about cost have been, and will remain, the greatest barrier to universal care. The argument that progressives like myself have made is that the costs of not providing universal care of high quality for all will ultimately be a greater cost and is not equitable or consistent with our stated values. The argument is similar to the idea that not limiting our greed and use of carbon based energy, and not addressing the issues of climate change now, dooms us to enormous expenses, disastrous damage to the planet, and a much more difficult, if not impossible job, in the future.
Dr. Kocher transitioned his talk on the point that human capital was the largest part of healthcare expense. That might be a point that some would argue. Defective management, unsafe systems, a lack of critical thinking, all generate huge costs. Poor quality care and sloppy management is always expensive, although usually accepted like the wasted thermodynamic energy of an internal combustion gasoline engine, and usually ignored as an opportunity for improvement.
Dr. Kocher brought data to his point by showing that the ratio of administrative healthcare employees to clinicians is increasing. That change is a function of the increasing complexity of our finance methods and the necessity to document work and comply with the requirements to bill third party payers. His point is that many of these jobs are vulnerable to automation, and that investors recognize the opportunity to fund the developers of systems that will increase administrative efficiency.
Kocher listed several things that could reduce the cost of care:
- Funding cost sharing rebates and risk adjustment
- Funding reinsurance and/or high risk pools
- Increase marketing to expand expand the risk pool (like “Covered California”)
- Enacting mandates at the state level (as was true after 2006 in Massachusetts)
- Mitigating hospital market power
Your reaction to that list of possible solutions is probably,”Yeah, just after pigs fly.” Improbable implementation because of the current political impasse over the future of healthcare did not limit Dr. Kocher’s enthusiasm for showing us the options. Following his list of things that could reduce the cost of care, he presented a list of actions that may lower premiums.
- Adopting non fee for service payment models ( If indexed to CPI + 0.5% and widely adopted)
- Tackling drug costs
- Improving end of life care
- Preventative care
- Medical malpractice reform
Those bullets seems more like a prayer list for the moment or a review of the ideas of the HMO era of the seventies than the core of a strategic plan for a future after pigs fly.
It seemed to me that Dr. Kocher’s analysis suggested that the interests of investors will drive much of the future of healthcare in this era of political confusion. As hospitals, especially those associated with academic medical centers, become too expensive to use for the management of problems arising from ambulatory sensitive diagnoses, and more and more surgical procedures in relatively healthy people are done in the ambulatory environment, investors see the advantage of purchasing primary care physician groups. There is now data to show that physician led ACOs with effective primary care do better than ACOs controlled by hospitals and specialists. Specialty income goes down in effectively managed ACOs.
If you have an interest in specialty care you may want a more detailed outlook for specialists. Dr. Kocher has projections entitled “What happens to specialty income?”
- Total RVUs will decline:
Fewer referrals
Lower diagnostic intensity
Fewer Procedures
- Price per RVU will not grow to offset lower volume because the rate of physician payment increase is specified by law in MACRA
- Specialist supply will not decrease because specialist training slots are Medicare-funded, provide low-cost labor, support the teaching mission, and enhance brand prestige.
That is not a pretty outlook for specialists. Since both specialists and hospitals have clouds on their futures, what are their strategic options? Will they play offense or defense? A defense might be to continue to follow the “FFS playbook,” show clinical excellence, and continue to consolidate for leverage with payers. As I look across the systems that I know, I can easily see systems that are doing these things since it is the “playbook” that has worked well for them so far. The alternative “offense,” consistent with what I have advocated for years, is to differentiate on value, become partners in an ACO, and negotiate bundled payments/shared savings. Dr. Kocher summed it up this way: The choice is to try to become a super team, think Golden State, or follow the “Moneyball” search for value, think the Oakland A’s.
Having laid out the current situation and the future possibilities, Dr. Kocher advanced his predictions. To follow these predictions you need familiarity with MACRA and its payment options: MIPs and APMs. If you need a refresher on MACRA, click on the link.
- APMs and Medicare Advantage will become the biggest source of profits for PCPs
- PCPs will flee hospitals to start their own groups to retain shared savings
- Specialists and hospitals will choose MIPs and fight with PCPs over money
- Medicare advantage will grow substantially fueling more capitated PCPs and specialty groups.
He had very focused predictions for hospitals:
- Customer acquisition costs, long term value, and “churn” are the crucial metrics
- It is critical to choose, and be right, about being value oriented versus RVU oriented
- Figuring out how you will share “shared savings” will lead to extreme angst
- Becoming essential (to someone: patients, PCPs, or payers) will be essential
He finished looking even further forward. One must remember that he is a venture capitalist making high stakes bets on what will be profitable to build or buy based on an analysis of the future. I live in a different world, but I do not disagree with his analysis. I believe that Dr. Kocher is interested in building a future that is consistent with the aims of Crossing the Quality Chasm and the noble objectives of the Triple Aim. Here is his offering:
- Technology and information will strip out economic costs
- PCPs will grow in power
- Rationalizing hospital fixed costs will be slow and incredibly painful
- Care will get better and more enjoyable faster
After all the talk about the looming conflict between PCPs and their specialty colleagues, and the very problematic dilemmas and challenges that face even the best hospital systems, that last bullet, “Care will get better and more enjoyable faster,” may seem counterintuitive for you. You must remember ATLAS is a conference composed of people coming from systems that believe in innovation, embrace transformation, trust technology, and are committed to the vision of better care for everyone, or why would they bother to come to a meeting like ATLAS?
The conference was about exchanging ideas, stories of success, and stories of ideas that seemed to have promise but were hard to implement. The conversation was all about strategies, strategies to use technology to stay closer to patients while enabling self care, strategies to engage more physicians in the effort to implement technologies that support better contact with patients, and a host of other patient centered, quality improving, and cost reducing technologies that gave real credence to the idea behind the conference title, “SYSTEMNESS. IGNITED.” It occurred to me as the conference ended and as my wife and I drove back to New Hampshire that the message of the conference was identical to the core message of Crossing the Quality Chasm: Better, safer care is a product of good systems. What we could see as a possible solution in 2001 is a slowly emerging reality in 2018. The future of healthcare was always going to be a conflict between the status quo with its established interests and innovation and transformation in support of the best interests of our patients, our families, our communities, and the better future for everyone that is consistent with the voices of our current “better angels” and the previous work done by those who have struggled through the years to bring us closer to our ideals.
A Season of Transition
Summer’s pleasures last for thirteen or fourteen weeks. Winter is a long distance runner. We had our first snowfall and sub freezing temperatures this week and it is just as likely that sometime in April or early May, six months from now, we may have a night that is just as cold and has even more snow than the dusting this week. Fall is an electric and ephemeral experience. It’s an exercise in “catch it if you can.”
As I noted in the post earlier this week, an “Interested Reader” came by last weekend as part of a “see the foliage” weekend. The colorful foliage was there, but much of it was seen through rain or under very overcast skies. The best colors depend on a complex formula of perfect temps and light. Some years the stars don’t align and things go from green to very muted colors that quickly fade to brown. I have seen spring limited to a few scattered weekends, but you can always count on “mud season.” This year fall has been beautiful, even if cold, somewhat wet, and interrupted by some snow. It is new England.
My neighbor, who is becoming an accomplished drone photographer, continues to post fantastic studies of the beauty of the area. Today’s header is a screenshot that I took from one of those videos. It is “Autumn 2018 Chapter 2 ~ Along NH’s Route 10.” The link will carry you to that short video and to three others. If you watched them all it would be a less than fifteen minute investment that won’t substitute for a fall walk in nature, but will tide you over until you can avail yourself of some fall foliage. If you live in South Florida or some other place where summer never seems to end, it may be your best chance to see what you give up when you opt for a never ending summer.
I am hoping that you get your own walk in the woods this weekend. If you can’t find someone to go with you, do it anyway and try to “be in the moment.”
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
