Donald Crane is President and CEO of the California Association of Physician Groups (CAPG), the leading association representing physician organizations practicing coordinated care. Mr. Crane spoke with a member of the CAMH team on August 4th.
Crane: As a trade association, we committed to moving 90% of our members’ Medicare business into capitated arrangements by 2018. While many of our members are already committed to this model, others are adopting a variety of new approaches that involve taking risk, even in PPO and fee-for-service products. As an association, our favored model is capitation because it offers superior quality and a better patient experience. We want to move more members in that direction.
Crane: Our members have achieved higher levels of both efficiency and quality. On the efficiency side, if you compare Medicare Advantage (MA) practice in a given community to practice in Original Medicare, you see 35% lower hospital utilization along with lower admissions, lower length of stay, lower days per thousand, and generally much more efficient delivery. As for higher quality, the Integrated Healthcare Association just released a study comparing commercial HMO to PPO products. For five of the six quality measures examined, HMO products delivered by integrated groups were 11 to 46% more compliant with various quality guidelines than PPO products.
Crane: It starts with the conviction of our members that they, and we, can deliver better care in a capitated, clinically integrated system. This is in our DNA. We believe this is the way to deliver better care, without waste, and with higher quality. Also, we’re watching the market. MA penetrates 30% of the Medicare population now. It will be 50% in five years. The balance will be in a mix of ACOs, patientcentered medical homes, shared savings programs, bundled payment, global budgeting, etc. All of Medicare is moving into risk. I think we will easily get 90% of our members into capitated care in Medicare by 2018.
There is a push and pull at work here. The market is the push, with both Government and commercial payers moving in this direction. The pull is the stronger business case for delivering capitated care. We now have tools not previously available, such as data warehouses that enable data mining for a higher level of outreach into the community, for risk stratification, etc. All of these tools contribute to a better care delivery model in a capitated environment.
Crane: We do hear often about patients’ frustration in navigating the fee-for-service system. They are relieved and grateful to find better care coordination and more assistance in navigating the system when they move into a coordinated care product, like Medicare Advantage.
Crane: The nationwide move from volume to value is underway. Physician groups are moving into risk-based models. I think everyone needs to do it with some degree of urgency. If we move too slowly, an impatient policy world will take steps that could actually impede the progress. I urge everyone to get about this business and take a bit of a leap of faith. Waiting around another decade won’t help. This is a plea for responsibly rapid pacing.
On a personal note, I find it very gratifying being part of this massive movement to change the payment and care model for the good of all. It can bring a better, sounder economic footing for our country, and produce a healthier population at the same time.
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Emily DuHamel Brower, M.B.A., is senior vice president of clinical integration and physician services for Trinity Health. Emphasizing clinical integration and payment model transformation, Ms. Brower provides strategic direction related to the evolving accountable healthcare environment with strong results. Her team is currently accountable for $10.4B of medical expense for 1.6M lives in Medicare Accountable Care Organizations (ACOs), Medicare Advantage, and Medicaid and Commercial Alternative Payment Models.
Mr. James Sinkoff is the Deputy Executive Officer and Chief Financial Officer for Sun River Health (formerly known as Hudson River HealthCare), and the Chief Executive Officer of Solutions 4 Community Health (S4CH); an MSO serving FQHCs and private physician practices.
Victor is the Chief Medical Officer for TennCare, Tennessee’s Medicaid Agency. At TennCare, Victor leads the medical office to ensure quality and effective delivery of medical, pharmacy, and dental services to its members. He also leads TennCare’s opioid epidemic strategy, social determinants of health, and practice transformation initiatives across the agency. Prior to joining TennCare, Victor worked at Evolent Health supporting value-based population health care delivery. In 2013, Victor served as a White House Fellow to the Secretary of Health and Human Services. Victor completed his Internal Medicine Residency at Emory University still practices clinically as an internist in the Veteran’s Affairs Health System.
Dr. Brandon G. Wilson, DrPH, MHA (he, him, his) joined Community Catalyst as the Director of the Center for Consumer Engagement in Health Innovation, where he leads the Center in bringing the community’s experience to the forefront of health systems transformation and health reform efforts, in order to deliver better care, better value and better health for every community, particularly vulnerable and historically underserved populations. The Center works directly with community advocates around the country to increase the skills and power they have to establish an effective voice at all levels of the health care system. The Center collaborates with innovative health plans, hospitals and providers to incorporate communities and their lived experience into the design of systems of care. The Center also works with state and federal policymakers to spur change that makes the health system more responsive to communities. And it provides consulting services to health plans, provider groups and other health care organizations to help them create meaningful structures for engagement with their communities.
Tamara Ward is the SVP of Insurance Business Operations at Oscar Health, where she leads the National Network Contracting Strategy and Market Expansion & Readiness. Prior to Oscar she served as VP of Managed Care & Network Operations at TriHealth in Southwest Ohio. With over 15 years of progressive health care experience, she has been instrumental driving collaborative payer provider strategies, improving insurance operations, and building high value networks through her various roles with UHC and other large provider health systems. Her breadth and depth of experience and interest-based approach has allowed her to have success solving some of the most complex issues our industry faces today. Tam is passionate about driving change for marginalized communities, developing Oscar’s Culturally Competent Care Program- reducing healthcare disparities and improving access for the underserved population. Tamara holds a B.A. from the University of Cincinnati’s and M.B.A from Miami University.
Dr. Peter Walsh joined the Colorado Department of Health Care Policy and Financing as the Chief Medical Officer on December 1, 2020. Prior to joining HCPF, Dr. Walsh served as a Hospital Field Representative/Surveyor at the Joint Commission, headquartered in Oakbrook Terrace, Illinois.
