Transcripts For CSPAN3 Politics Public Policy Today 20141020

Our campaign 2014 coverage continues with a week full of debates. On cspan tonight at 8 00 eastern, the georgia governors debate between governor nathan deal and democrat jason carter. And at 8 00, live on cspan2, the montana u. S. Senate debate with u. S. Representative republican steve daines and democrat amanda curtis. Tuesday night at 9 00 on cspan, the South Carolina governors debate between five candidates, nikki haley, vincent shaheen, tom ervin, steve french, and morgan bruce reeves. And thursday night, live at 8 00 eastern, the iowa Fourth District debate between u. S. Representative steven king and democrat jim mowrer. Cspan campaign 2014, more than 100 debates for the control of congress. Here are a few of the comments we recently received from our viewers. Ive been battling my local Cable Provider here, cable vision in new jersey, for over 18 months now to start offering cspan in high definition. I have never done anything like this before, but i thoroughly enjoyed this program. I never i like the History Channel where i live in naples, florida, and i thought this was absolutely really magnificent. I just sat glued to my chair for the whole hour. And i will continue to turn back to this program again. I just want to start off by allowing cspan to know that i do not watch any other channel on my cable selection besides this. And cspan 1, 2 and 3, so i really want to show my appreciation for this, for your services there and your ability to really keep it mixed up and really lively. And continue to let us know what you think about the programs youre watching. Call us at 2026263400. Email us at comments cspan. Org or send us a tweet. Join the cspan conversation, like us on facebook, follow us on twitter. Live now to the Brookings Institute for a discussion about Health Care Policy and the accountability care organizations. Were getting an introduction now by mcmcclellan, the director of the Health Care Innovation and value initiative. Physicians and other Health Care Providers that are increasingly involved in patient care. Clinicians get more flexibility in care, but they also have more accountability for demonstrating that theyre Getting Better results and avoiding unnecessary costs. The physicians and other Health Care Providers who take on accountability for the Overall Results and costs of a population of patients are called an Accountable Care organization or aco. And as well discuss, acos have been growing in medicare, private Health Insurance plans and state and Medicaid Programs across the country. Now, while this all might sound good in principle, there are some concerns. On the one hand, Accountable Care has been criticized as requiring too much change without Strong Enough support for it. Health care providers have to make Real Investments of time, effort and money to change the way that they deliver care. With bigger changes requiring bigger investments, and the savings from better results to pay for this dont come until later if at all. In this view, the idea of shared savings is not enough of a change away from fee for Service Payment to be able to support innovative payment models. Instead, a bigger shift away from fee for service towards more capitated payments, more are fully person level payments, as and as in the Medicare Advantage program for private Health Insurance plans might be needed in this view. On the other hand, others are concerned that movement away from fee for Service Payments and acos to make them would make them look too much like a replay of the managed care plans of the 1990s that were viewed by the public as skimping on care. In any event, there is a wide range of acos in existence today in a wide range of early experience and growing evidence behind the programs. Finally, many hospital based organizations have been viewed as part of a trend toward consolidation in health care which many see as leading to higher prices. What were going to do today is look at some of the latest evidence on Accountable Care, discuss strategies to overcome the unique challenges that acos face in succeeding in their mission of Better Health and lower costs, and also to provide an overview of the ongoing Accountable Care reforms across the country. Here at the Engelberg Center for Health Care Reform we have been working on issues related to acos and other forms of Accountable Care for quite a while, through our aco learning network and initiatives on value and innovation and health care. Were very pleased to bring together a wide range of experience and expertise from the public and private sectors to address these issues. The issues are very timely. Initial results of early aco experiences are starting to emerge, and while better data are needed, it is time to start looking closely at what the data show and what it means for next steps for Accountable Care were also approaching the next major phase in the medicare aco program, with the net version of aco regulations expected soon and probably including some significant revisions. And both private insurers and states are taking the Accountable Care concept in new directions. All of this should be informed by the discussions were having today. Id like to just mention a few brief housekeeping items as i noted at the beginning, this event is broadcast on cspan and via webcast as well as being video recorded. A full recording will be available on our event page at Brookings Health in the coming days. Were also expecting to have some time for questions in each of our sessions and well be using microphones in the audience for that. I encourage all of you in the room and those joining us by broadcast to follow us further on twitter using the hash tag acofuture. Please also follow the Engelberg Center twitter account and aco learning network. Im going to start with a brief overview of some of the current aco trends. This is an outline for the day, ill start with a brief overview of the current aco trends and results to date. Then were going to have opening remarks from Sean Cavanaugh, deputy administrator and director of the center for medicare at cms. Hell describe some of the latest aco results in medicare and some of the issues that cms is considering in term of the future of the aco programs there. Next a Panel Discussion on what we know about the evidence on acos so far. Well have a short break with refreshments out in the hallway. After the break, well reconvene here in this room for a panel on some of the big issues for acos going forward. And in that well focus on issues like engagement of beneficiaries. Immediately after well have a final session on aco policy issues and solutions on the horiz horizon. So just to begin with a little bit of an overview of where we are with acos in the united states, over the past few years the number of organizations forming acos has grown rapidly. Our own internal tracking shows over 640s a acos in every regiof the country working with health plans, the Medicare Program and state Medicaid Programs. Medicare acos continue to outnumber private sector acos but private plan acos have been growing steadily as well and are part of almost every major Health Insurance program, Health Insurance plan in the country. In addition, 19 states are now in the process of implementing medicaid acos. This slide summarizes some of the current takeup and results of acos. There is quite a bit of variation in beneficiary enrollment around the country and public and private sector. But it is becoming a significant part of both public and private insurance programs. Medicare acos serve over 5. 5 million patients and commercial acos are providing care to 10 million to 15 million beneficiaries for around 280 plans. In the results from these programs that we have seen to date, medicare has released some results over the past months, i think youll be hearing more about that from sean. These results generally show better Quality Performance levels on those Performance Measures that are key part of aco reimbursement. And in the medicare shared Savings Program, the largest aco program in medicare, which represents the step towards paying in part based on beating a cost benchmark while improving quality, doesnt take away the fee for Service Payments that aco providers receive as well, but it does set up a second track of payment. In that medicare shared Savings Program, overall savings were around 1 or so in the first year, with the significant improvements in quality. Thats on top of the slow rate of growth that medicare is experiencing in recent years. And a subset of these acos, about a quarter have achieved significant savings, large enough savings, large enough reductions off of expected trend to get some of those funds back. The shared savings fund back. Ill talk more about medicare pioneer acos in a minute. I did want to spend a moment on private plan experiences so far. As youll hear from our panel, these results are a little bit harder to compile, comprehensively, different plans report on their results in different ways, and perhaps not as comprehensively as we would like either. But if there is a basic finding that is worth noting, i think it is that many of these private plan acos do more than just provide shared savings up front. They provide more investment support through maybe capitated, partially capitated payments to primary care providers as in a medical home, they provide infrastructure support, data, care managers. But in conjunction with that, they also expect more in terms of impact on Financial Performance. That means more risk sharing. So instead of just shared savings, two sided risk, with the providers being accountable in part for Holding Trends close to overall growth in the economy, or achieving larger savings. And facing some Downside Risk if they dont. Many of these plans have shown some more significant impacts on savings as well as in the medicare case some significant improvements in quality with reported savings on the order of 2 to 12 in many of these major private plan implementation efforts. In medicaid, the programs are at early stages, but some promising results there as well. Many of the medicaid plans are also going beyond shared savings and in Traditional Health care to integrate other types of activities such as coordination with social services or behavioral support in other Community Based programs that may have a bigger impact for some vulnerable individuals than just the medical interventions alone. This is a slide that highlights some of the early medicare aco performance. It shows the distribution of medicare plans in terms of Quality Performance compared to the overall medicare Provider Community. Most of the acos perform at or above the 70th percentile, a shift on the slide to the right, towards a higher level of performance, on the quality measures that were established by medicare for this program, particularly good performance in areas of Patient Experience and coordination of care as you might expect. It is also important to note that there are a lot of different kinds of acos out there, some that are led by academic medical centers, some by qualified health plans, some led by hospitals or integrated Delivery Systems. And a growing number that are led by physician groups, often primary care physician groups that are willing to take on overall accountability but with a much smaller number of providers directly involved. And were starting to see some differences in performance, both across and within these categories of acos. The next slide highlights for the Pioneer Program. This is, as youll hear more about from sean, a program for a smaller number of Accountable Care organizations that have been willing to commit to medicare to move further beyond shared savings and to some more significant financial reforms and accountability for both cost and quality. The acos that are continuing in the program are showing some further improvements in the second year relative to the first year. Again, this is percentile of performance. You can see the shift to the right on the slide, thats higher levels of measured performance. This is a chart for the Pioneer Program that shows for their first two years results on both quality versus savings. As you can see here, something well discuss as well, many of the pioneer acos, just like many of the acos overall are doing quite well on the Performance Measures, so theyre over to the right side of this chart, but not some have not done as well in terms of achieving savings. And some of the pioneer acos have dropped out of the program, as you can see from this chart, those are the ones that are the red dots, all of those are ones that did not do well against the Financial Performance benchmarks that were set up by the program. And one of the things that well discuss today is what why is that, what is going on with the benchmarks and is this really row fle reflecting the aco performance accuracy or are there ways to learn from the early experience to try to encourage better performance and lower costs at the same time . So thats a little bit of an overview. I would highlight that a good bit of this evidence came from our work with a range of Health Care Providers, payers, associates, experts, and others through our aco learning network, to compile some of this evidence and share experiences. More to say about that a little bit later. What i would like to do right now is introduce Sean Cavanaugh, the deputy administrator and director of the center for medicare at cms. There sean is responsible for overseeing the regulation and payment of medicares Traditional Program providers, the privately administered Medicare Health plans, and the Medicare Prescription Drug benefit program. Medicare collectively provided Health Insurance coverage for 50 million elderly and disabled americans with a budget of over 550 billion. So sean definitely has his hands full in his day job. Prior to assuming his current role, sean was Deputy Director of programs and policy in the centers for medicare and medicaid innovation, so he came to the oversight of the overall cms Medicare Programs from some experience with the pilot programs like the pioneer aco initiative that i just described, and he there oversaw the development, testing of a range of new payment and Service Delivery models as well. Previously sean was the director of Health Care Finance at the United Hospital fund in new york city. Hes also served in senior positions at Lutheran Health care in brk lynn and new york city mayors of insurance access and Maryland Health services commission. He started on capitol hill on the ways and means health subcommittee. Sean, were very glad to have you here with us today. Please come on up. Thank you, good morning. Im going to speak for about 15 minutes and then leave about half the time for questions and answers partly because thats what mark asked me to do, but partly in recognition, i looked at the other panelists and the people here in the audience and i think very distinguished group and groups like this people like me from the government should do less speaking and some more listening. So my remarks, quickly i want to give you some big very big picture context of how we think of the shared Savings Program. So starting at 40,000 feet and then coming down fairly quickly to the ground level and talking as mark indicated about we are in development of proposed rule for the future, the next generation of the shared Savings Program. Lets talk to you a little bit about where that might be headed. So first, were about four years out from the Affordable Care act and probably more importantly we are one year out from the 50th anniversary of the medicare statute passed in congress, 50 years ago. So where are we . Most important measures, which are controlling costs, and improving the quality of care that our beneficiaries receive. On controlling costs, the news is historically good. We are in the middle, about a fouryear period where the cost per capita of providing care to a beneficiary is essentially going to be flat for four years. Some of that is data that is already in. Some of that is the actuary forecast for next year. Unprecedented performance on reducing the growth and cost per care. That bodes well for the program in many ways, one, the trust fund, the life of the Hospital Insurance trust fund. If you go back to 2009, the forecast was that it was eight years from being exhausted, that it would be exhausted in 2017. This year the trustees are saying were 16 years from being exhausted, that the life has been extended to 2030. Thats good news. Also i think when you control health care costs, it allows not just relief for the federal deficit, but also allows for better Health Care Policy. Probably the best example is serious discussions now about getting rid of the sustained growth rate provision in the medicare statute which many feel has outlived its usefulness, but that the discussion to get rid of it is only made possible by the low cost in medicare spending. So thats the cost side. On the Quality Improvement side, again, historically good news. Hospital acquired conditions, many forms of hospital acquired conditions, are dropping. Ventilators associated pneumonia, early elective deliveries, i could go on and on. Lots and lots of signs of improvement and care in our beneficiaries are receiving. Hospital readmissions dropping. One in five Medicare Beneficiaries, about 19. 5 , readmitted to the hospital within 30 days of being admitted. That is now in a precipitous decline now, about 17. 5 . So what is causing all this good news . There is a lost factors. Some is Public Policy, predating the aca and out of the Affordable Care act. Some has nothing to do with Public Policy, changes in professions and hospitals and Delivery System have made on their own, because i think what you see is the beginning of a genuine Quality Improvement Performance Revolution in health care, which we had in other industries, but sort of late coming to health care. We see actions by other payers, commercial payers, state, Medicaid Programs that are incentivizing changes. So were in very good position, we got challenges ahead, how do we continue this level of performance and improvement . Well, first of all, the challenges ahead are significant. One, the actuaries, though predicting that costs will continue to be flat next year, you look further out to the future of predicting a return of inflation of about 5 price growth every year, which is a challenge for us, but more of a challenge is the baby boomers in the next 20 years. We have 50 million give or take Medicare Beneficiaries today. And in the next 20 years well add another 30 million. So 60 growth in the next 20 years. Very substantial challenge. Even if we continue to control growth per capita. So thats sort of the landscape that we view the program in. Were in a great position with controlling costs. We have made some significant strides in improving quality. But we face very, very significant challenges. So i think the way we look at the landscape is we need to continue to support Delivery System reform and how do we do that . The secretary birdwell, within her first 100 days articulated a vision, providing information to providers so they know how to improve and where they need to improve. Improving the incentives, so making sure all of our payments and support improvement. And building capacity within the Delivery System for improvement. And i think the aca initiated a lot of that work. If you see on the quality side, on information, were providing quality measurement in almost every one of our Provider Groups in medicare, providing transparency with publishing these on our websites, whether nursing home compare, hospital compare, and more importantly, and this is where i wanted to get to, is were injecting the notion of value of paying for quality and efficiency into all of our Payment Systems. And what are those Payment Systems . Very briefly we have the Medicare Advantage program, we have the fee for Service Program, and we have got new models of care that mark referenced. In the Medicare Advantage program, a lot of progress, the Affordable Care act set us on a course to pay more reasonably, getting significant savings there, at the same time, were getting Higher Quality care and Medicare Advantage, 60 of Medicare Advantage beneficiaries next year will be in four and five star plans. Premiums have been essentially flat since the passage of the Affordable Care act. Good news there. In fee for service, hospital value based purchasing, physician value modifier, even in dialysis payments were building in the concept of paying for quality, paying for efficiency into all these fee for service models. But as mark said, for are many providers, they believe to truly achieve change and fundamentally change the way they deliver care, they need to move out of fee for service and move into a different model. And thats where acos and other models come in. Im not going to go into depth unless we get questions, but the Innovation Centers testing any number of models around acos, primary care medical homes, lots of variations. Ill focus on acos, but as i say, it is an important part of our strategy on new payment models. So where do we stand on the aco program . Early results and i would use very similar slides to what mark did, the early results are very promising. Particularly on the quality side. On the quality side it is pretty clear that most of the acos have figured out how to improve care beyond what is provided in the fee for service system. And we see that in beneficiaries. One measure we do is Patient Satisfaction. Patients in acos tend to be almost across the board more satisfied with their care than patients who are not in acos in the fee for Service Program. There is more quantifiable measures. The pioneers from one year to the next improved collectively on almost all objective measures of quality. I think 28 out of 33 measures they improved on. In the shared Savings Program, the shared savings acos outperformed fee for service in 17 out of the 22 measures, where Large Group Practices had reported quality measures. So on the quality story, very good, promising results. On the cost side, a little less more of a mixed result so far, but i would caution it is very early in the program, you recall if you went back to january 2012, there essentially was no such thing as an aco. And now we have as mark said i usually use the number 360 in the Medicare Program, but many more in the private sector as well. With 5. 6 million beneficiaries participating in them. Several pioneers have clearly figured out how to generate cost savings and do that consistently from year to year. A number of shared savings acos as well. But the story is still mixed and the question isnt can the leading edge figure out how to generate cost savings, but can we get the vast majority of the acos in the long run generating cost savings to go along with the Quality Improvement. So if the situation is promising, but needs to do better, how do we move forward . Again, i go back to the secretarys vision, we need to improve the incentives that the acos receive, improve the information and help build the capacity of the acos. Since as i mentioned were developing a new regulation for the aco program, i cant tell you specifically, but ill talk about now briefly are some of the areas where the private sector, the acos have come to us, including through the brookings learning network, and have told us areas where they think we can improve. They map perfectly to the incentives, capacity building. On capacity building, we have heard, you know, a lot of small practices that want to get into acos or in acos need help in understanding how to transform themselves. We heard this outside the aco community. How do we help small practices in clinical transformation . And thats something the federal government is talking a lot about. We even have spoken publicly about and solicited ideas, how could the federal Government Support small practices in transforming better . But specifically in the aco context, one of the things we heard is, well, since this is fee for service medicine, when we assign a beneficiary to an aco in one year, many of them are not assigned in the second year. And some have referred to that as the churn of beneficiaries. So it is harder for the aco to focus their interventions and resource investments on beneficiary if theyre not certain that theyre going to have that beneficiary in the long run. I think mark made reference to some of the Savings Opportunities are in the long run. So we have been talking to the private to many of the acos and thinking long and hard how to you get a more stable population for the acos. The challenge is this is fee for service medicare, meaning the ben fishe beneficiary is not locked into a network. And then broadly, i think, how do you get a nonchurning is part of a broader category of how do you get more beneficiary engagement. This is true not just in the aco context, but any context where providers are trying to provide care better and in a different way. How do you get the beneficiary engaged in the care so that theyre doing selfcare, following medication adherence, those sorts of things. On information, we heard consistently that acos need better and more timely information from the Medicare Program. We have been working hard to do that. We have a ways to go. I would say, though, for the in cmss behalf, two years ago we essentially were sharing claims data with nobody. Now were sending monthly claims fees to over 300 acos every month on behalf of with data of over 5 million beneficiaries. This has been an enormous change for how cms saw its role, but i think it has been a successful one, but it has a ways to go. I think working together we can figure out better ways to share information. And then most importantly we heard kuwait a bquite a bit of changing the payment rules for the acos. One of the things we do is we dont pay on the first dollar of shared savings because there say lot of variation year to year in medicare spending, so we create minimum saving ratios, first couple of sperpercentages. Many acos balked at that, feeling like they did generate change it wasnt a statistical anomaly and would like to be paid for that. One of the things that is implicit in all the numbers mark shared on who generated cost savings is what is the formula for what is a cost savings. The shared Savings Program followed the statute in the Affordable Care act of using a National Benchmark, meaning you start with the costs of your own beneficiaries historically, but trend that forward based on what happened nationally in the medicare fee for Service Program. Couple of things to observe about that. One is it is an interesting time to start the aco program because the fee for Service Program is essentially been not growing at all. So thats a very difficult benchmark to meet regardless. Two, a number of acos have said im in a community where costs are growing much faster than the national average. It is not fair to only give me a benchmark that grows by the national average. The only thing i would say is we have been listening very closely to these, but this was the point of contention in the drafting of the Affordable Care act and it is very delicate regional balances that come out in those discussions. But we are hearing quite a bit about whether the benchmarking methodology is the one we should stay with. We are proposing that acos that generate savings over a number of years and continue in the program that we would do something call rebasing, which is were using historical based period, we roll that base period forward. Some acos feel like if we keep rebasing them over time, their opportunities to generate savings will be diminished. Were hearing a lot of acos asking us to not rebase or to approach it differently. Mark made reference to a lot of acos want to provide care differently in ways that arent paid for by the medicare fee for Service Program. And they can do that, but theyre not paid on a fee for Service Basis when they do that. Essentially theyre investing their own funds. So we have asked we have been asked by the aco community for a number of waivers meaning they dont want to have to follow the threeday prior hospitalization rule in medicare, they want more generous access to the home health benefit, and then finally and probably most conceptually tricky as mark said, many of them want to not be paid during the year on a fee for Service Basis, but would prefer to be paid on a capitated basis. That would free up the dollars for them to do a lot of innovative things. As i said, it raises some conceptual challenges which is would the acos then be like an ma plan making payments to other providers, imemploy that thewou is a network. These are all ideas were taking seriously and considering as we propose a new rule. We hope the new rule will be out shortly so the public can comment on it. We will go through the normal Public Comment period, which is this would be a proposed rule, we would solicit comment and adjust the rule as appropriate to Public Comment and hopefully have a final rule early next year. But, again, this is in conclusion this is a major part of our strategy to continue the improvement on controlling costs in medicare and improving quality. It is part of an array of strategies that range from Medicare Advantage all the way to our fee for Service Payment systems. But it is one of the keystones and one we are looking forward to working on with all of you. So with that, i will pause and take any questions. And im almost right on time. So while sean is getting situated, there is a microphone you can clip right on there, ill just start with the first were framing the first question. A very broad overview fitting the aco program into a wide range of payment reforms taking place in the Medicare Program generally and in cmi in particular. One of the things that you highlighted was basically that how important it is to think of acos as not just about a payment model, that there are other changes that are needed too. You talked about a lot of the regulations in medicares Payment Systems on things like no requiring a threeday stay at a hospital before going to home health or post acute care facility. Uses of home health services, typically limited because of the restriction, because of the fee for service nature of medicare payment. And you also talked about the need for further steps, for smaller Accountable Care organizations or smaller Provider Groups to be able to get off the ground in these kinds of big payment reforms. And i know that more of this is going to come up in that regulation, which is coming out soon. Soon. Great. But you have made some other announcements recently from cms, the administration has, that pick up on some of these other issues, for example, just recently advanced Payment Program for rural acos. I wonder if you could talk more about that, maybe about recent announcement from the office of the Inspector General, i believe, about extending program to give acos and some other providers that are participating these new kind of payment arrangements, a bit of a pass from some of the restrictions on money across providers and the like, sharing resources across providers that, again, are intended to block some challenges in fee for service that may be less of an issue in the coordinated care approaches. Maybe you could talk a little bit about how you see acos in the context of some of the other policy changes and where those might be headed as well. Sure. And thanks for that question. And, again, just part of what i was trying to say in my remarks is acos are important and big and growing part of the program, but theyre part of a broader strategy to improve care and reduce costs. On the specific topics you raised, we had as some of you might know created a at the start of the shared Savings Program something called the advanced payment mod toll recognize there are a lot of providers that say, i get it, i think thats the right direction for us to go in, we can do well by our patients, we can improve the quality of their care, but we see it require an up front investment, but were just a group of small physicians or rural hospitals, we dont have the capital to do that initial investment. And so for want of that initial investment we wont be generating savings for years to come, and improve quality. So to help some providers get over that hump, we provided what is called advanced payment, which was the the name was chosen carefully. What it meant was this is an advance on future shared savings that youre going to generate. We gave it to 40 some acos and said here some money to help you through the beginning to hire nurses, beef up your i. T. System so you can improve care, but when you generate shared savings youll pay the money back to the federal government. It has been very popular. Some of them did very well in the early rounds of the shared Savings Program but we also heard that we we left some groups on the outside when we designed the original one. We also heard that some shared savings acos were able to get into the program, but werent sure they could remain in the program without some help. So we tried to design the new round of advanced payment to capture some who were in who wanted to stay in but needed some help and also rural hospitals, i think we really didnt define it right to get rural hospitals, particular areally critical access hospitals. On the waivers you were referring to, when we created the program initially, i mean, if you can think about the shared Savings Program, these are often not already integrated Health Systems coming together these are independent practices and fqhcs coming together for a common purpose, but oftentimes when they do that, they run up against fraud and abuse laws about how much theyre allowed to cooperate. The original program included some waivers from fraud and abuse laws, those waivers were due to expire this year. And the office of the Inspector General has extended them for a year. I think i think once we come out with the new rule and show where the program might be headed, i imagine everybody will go back to the drawing board and decide do these existing waivers still fit the new program. It does sound look a longer term commitment to making sure the fraud and abuse protections are appropriate for the Payment Systems being used. Yes. I think youll see continually as the program evolves, continued reevaluation of have we tailored them correctly to the way the program is operating and to what providers need and what the government is comfortable. In the same spirit of reinforcement of the basic ideas in an Accountable Care payment arrangement, were seeing in private sector are a lot of insurers putting in a number of different reforms at the same time, so not just acos with shared savings or two sided risk, but also medical home payments, bundled payments for special services and more advanced care, a number of payment reforms that all can be reinforcing. It will be challenging when medicare is trying out some of the new payment models and trying to figure out what the effect of each one is. I think what many of the private payers are finding they get more mileage by putting them all in together. Is that something that you all struggle with in terms of we do. But as you know, the Innovation Center is testing many different models, we have tried to allow participants to participate in multiple models. There is one statutory prohibition, which is provider cannot participate in more than one model that involves shared savings, we try to be cognizant and enforce that. But other models we think could be complementary. It does pose a challenge as you say for the proper evaluation of if you see a positive result, disentangling what contributed to that result. The one promising thing there is with the creation of the Innovation Center, we have much more robust evaluation of budgets than we have ever had in the past. So well do better, it will still be very much a challenge though to disentangle those effects. Well open this up to comments to those of you in the room. We have microphones. If you put your hand up and wait for a microphone, ill try to get to as many people as possible. And over here, someone had their hand up first. Ill wait just a second. Thank you. Jerry anderson, Johns Hopkins university. Sean, you mentioned the evaluation budget. You have a whole series of evaluations ongoing at cmmi. Some programs are working. Some are them are not. What are the commonalities of the programs that are actually saving money . First i would say i think im being rewired. I think it is too early to say. I apologize, but, you know, Innovation Centers first models went up january 1st, 2012. So, you know, to see measurable results, best Case Scenario would have been like this time last year. Thats if they had immediate substantial impact and even then it would be limited to the pioneer acos and the partnership for patients which is a big Quality Improvement. But the bundled payment for care anywhere ti initiative is getting off the ground now. Some models we have early results. Speaking quality tatively from what ive seen and not applying the level of rigor you tried to teach me at Johns Hopkins, i think what you see is it is providers who are in this mode long before the Affordable Care act passed, meaning providers who saw the problems with fee for service medicine, but were pursuing the right form of care, communicating well with other providers, staying close to their beneficiaries, focusing particularly on the high risk beneficiaries, long before all of our Payment Systems might have caught up to that seemed to be the ones who got going right out of the gate and did well. Those of whom are responding to the new incentives i do think there is a learning curve. I think thats why when we talk about the shared savings acos, i think you have a mix of those. You have some that are coming in saying, this is great, this is what i always wanted to do and some saying this is great, this is what ive always been doing and now ill get rewarded for it. So i think early on youre going to see that diffusion of performance, but the hope and expectation is that the big middle will catch up. For those early those early organizations that were committed early to this kind of approach to care, it is still important, though, to be able to have a Sustainable Business model to do that. And do you think the shared Savings Program is enough to get there, is your sense from many of those that they like to do more in the way of payment reform . Again, i think there is a huge diversity out there. There is certainly a leading edge of acos that want to move as fast as possible to more financial risk, meaning almost capitation. Though they tend to want to get away from shared savings, meaning they want to budget a perspective budget, they want capitated payments based on that budget, and they want to, you know, let the government take a couple of percent off the top as a discount and then on their way. I would say thats a small minority, but very large, sophisticated organizations. I think there is a larger group that are still feeling out what is the Business Model and what do they need exactly. But many of them clearly want better upside potential with less downside. Time for another question up here on this side. Thank you. My name is lee young. When we are talking about the budget or whether there is care, i have a very strong concern about it based on my research about hospital utilization and based on personal observation. I just wonder if you can address issues about accountability and the record and real patient care. In writing the response is totally absurd. And then you have abuse and unnecessary or even mental care. They have a private patient right rights advertising they will pay by the hospital, but they are really if you dont address this couple issues, the whole thing is meaningless. So could you i think youre making what is a point that i should have said at the beginning, which is our focus on Cost Containment needs to be matched by our focus on Quality Improvement. I think we have tried to do that, but youre right, anytime you create a new payment every Payment System has incentives. Whether it is positive or negative, whether they move you in the right direction. But when you create payment incentives to increase efficiency, you need to have some confidence that your quality measures are making sure that efficiency doesnt come at the expense of the patient. With that i would say, you know, the results at least so far in a shared Savings Program are very promising. Patients are happen yes, seem to be Getting Better care. Whether it is the shared Savings Program or elsewhere, i think our measures of quality have a long way to go. And i think they have come a long way, but i think there is a long way to go to make sure were measuring things we care about and capturing the other tension i would say is there is attention in the shared Savings Program between those two would want to measure everything, meaning we dont want any possibility of something adverse is happening to this patient, versus the acos saying dont drown us in reporting and measurement, allow us to focus on things that are really mattering, that are a handful of really salient measures. And i think that tension hasnt been fully resolved. Right. One that is part of the reason why youre doing so much work to try to expand out the scope of measurement while still reducing the burden on providers. Point out there are a lot of aspects of Patient Safety where it is very much aligned with the reforms and Accountable Care. So preventing rehospitalizations, avoiding costly medical errors that lead to complications, all those are steps that i think Accountable Care organizations, like the hospitals that you mentioned, now that the payments for admissions are being reduced, those organizations have stronger incentives to address. Are there any particular areas where youre worried about the other direction, that the Higher Quality care may actually be more expensive, maybe for some special some special conditions where there are expensive treatments needed, any particular areas stand out there . I know youre generally trying to Pay Attention to these issues. Yeah. What i would say about that is we have had some technology firms, some medical device firms come and say, you know, this new payment is wonderful, but youre going to squelch innovation. And what we have said is, you now, we dont want to squelch innovation. There is a type of innovation as you said that reduces costs. Even the ones that may increase costs but that are life saving or life enhancing, so were trying to find ways to measure that. We have been working closely with those industries to try to see if our Payment System should adapt and allow they asked for a pass through meaning. We come up with something new, dont include it in the reconciliation whatsoever. Were not willing to do that. But were continuing to focus on that to make sure as you said were not that particular type of innovation isnt being i would like you all to join me in thanking Sean Cavanaugh for joining us here this morning. Sean, thank you very much. All right and while i would like next to go straight into our next panel, and ask our panelists to come on up to the stage. Were going to talk now about the in terms of the state of Accountable Care, what we know about acos so far. This panel is going to explore in a lot more depth the kind of evidence that you heard about briefly in my introduction and in some of seans comments, the evidence on aco implementation, practice, and results. While our panelists are getting seated, ill introduce them. They include michael randall, the Vice President of Clinical Innovation for advocate Physician Partners in chicago. Randall previously served as manager of Business Advisory services in hospital operations for the camden group, Consulting Group that provides support on strategic and business planning, Financial Adviser and compliance and hospital and physician services. Next i would like to introduce Marcus Zachary, senior medical director for quality and population at brown and cohen medical group in california. Hes primarily responsible for the strategic and operational oversight of medical Services Related to the ambulatory care network at brown and toeland and the aco portfolio which includes their medicare Pioneer Program. With brown and toland, dr. Zachary helps design and drive initiatives linking quality, utilization and Information Technology in pursuit of the triple aim goals of improving quality outcomes, and reducing cost. Before being at brown and toland dr. Zachary was lead physician working on implementing electronic records for dignity hospital in san francisco. Next, j. Michael mcwilliams. Glad you could join us today, too, down from boston. Associate professor of Health Care Policy and a practicing general internist at brigham and womens hospital. His research, hes an m. D. And ph. D. Focuses on health care spending, quality access, and disparities in aging populations with chronic conditions. The overarching goal of michaels work is to inform the development of health care markets, Delivery Systems, Insurance Coverage and regulatory and payment policies that support value in equity in health care, particularly in medicare. Much of his work relates to evaluating Accountable Care programs, including the massachusetts blue cross quality contract. And finally, David Muhlestein is the director of research at leavitt partners, a Health Care Intelligence business where he oversees the firms quantitative and qualitative evaluation of the changing health care landscape. He studied the growth of Accountable Care organizations extensively with the center for Accountable Care intelligence at leavitt. And he leads the firms study of geographic variation in health care markets. His Research Interests focus on applying legal and legislative framework to evaluate the evidence of Health Policies for the benefit of government, and private policymakers. Now, ive asked each of our panelists to start out with some opening comments for this session on how they see the evidence on acos emerging. Any particular challenging areas, notable findings, what theyd like to see happen next. Comments along those lines. And were going to have some discussion across the group, and then with all of you here today. So, if i could start with michael randall, please go ahead. So, first to start, advocates, were excited to be here to share our journey with you. I lead many aspects of advocate strategy and operations, in total we serve about 600,000 lives in our aco. This includes commercial, medicare, and medicaid lives. In terms of how do we make the model more sustainable, i think youve heard some things that medicare is looking at. Commercial payers are also looking at. How do we design a model for shared savings that is able to support provider organizations to have Funds Available to invest in Information Technology and care model design. Before i get into those aspects in particular, i just wanted to share some of our results both in the area of quality, and also cost savings. So first in terms of quality, medicare shared savings side, we had our estimated total quality score, we saw that increase in 2012 from 79 to 86 in 2013. Of the scored measures, 21 of the 27 improved during this period of time. On the commercial side, also seeing improvements in quality. We track eight key indicators for our hmo population. Six of those eight improved in 2012. Were still finalizing results for 2013 but overall a net positive improvement. 2013 was a baseline steady for our ppo population. On the cost side, our results mirror that of the National Experience for the commercial plans, both hmo and ppo. Were seeing a year over year improvement of about 1 to 3 . For medicare shared savings, a little bit less. But our first performance year was a 0. 2 improvement ahead of the National Bench mark. All of which came in the last six months. That equates to about a 0. 6 improvements. Or about 3 million in net savings to Medicare Trust fund. To make the model more sustainable we believe that there are two areas of focus. One is Information Technology. And the second is care model design. So in terms of Information Technology, its very helpful to have a claims information, it gives us a glimpse into the total care that patients are receiving, but its not enough. And so, for us, were focused on marrying up the clinical and claims information. One example of that has been our partnership or collaboration, rather, with sernor where we developed a new hospital readmission risk tool that has a predicted value, thats 20 better than anything else on the market today. A second example of how were trying to merge clinical information claims data is our support of the development of a Regional Health information exchange. Advocate supported this through leadership, as well as investments of funds, and in the model design of the regional information exchange. Anticipating about 50 of their hospitals will be participating in this by the end of the year. Starting first in the exchange of admission, discharge and transfer data with clinical information to flow about the middle of next year. The second area to address is care model design. Like other organizations, we started by focusing first on our high risk population. We designed an Outpatient Care Management Program today that employs over 100 care managers, working in the field with our physicians to coordinate care for these patients. A second key program was investments in post acute care services. Development of a pan sniff network. Advocate only owns one Skilled Nursing facility yet we refer business to over 100 independent Skilled Nursing facilities throughout chicago. And so for us to be successful, we had to identify those organizations that shared a common vision to prove quality and lead to greater efficiency. Looking forward, we recognize that we need to go deeper into the Population Health triangle to engage not only the high risk, but the moderate risk patients, as well. Weve done some of this through our Patient Center home implementation. We are implemented this past year three new pilot programs. One of which is a Community Health work care program and as we look at 2015 we will be making additional investments in pilot programs. I think for you in the audience that has the ability to influence Public Policy or commercial development efforts, supporting the efforts to promote interofferability of data, and the exchange of data, as well as research to understand what truly is having an impact, and whats working, would be there as a focus. Thank you so much for your time. Great. Thank you very much, michael. And id like to turn next to dr. Zachary. Thanks for having me. Im Marcus Zachary from brown and toland. Im having a disconcerting moment that im the grayhaired guy up here on this panel. I guess ive reached that age. So for those of you who dont know, because theres not a lot of folks in california here, brown and toland is a fully physician owned and operated independent physician association, the largest in northern california, over 1700 docs. So we are truly hospital agnostic. We have no private equity partners. We have no hospital financial partners. We have a long history of managing mostly professional risk, and a cap dated environment. We, like sean was saying, are interested in taking more risk, and so with payment reform that was happening with the aca we jumped right in. We have shifted about 100,000 lives over the last three years into some form of risk sharing program. And that runs the gamut of alphabet soup, we have hmo, aco, ppo, aco, weve got a limited scheme for taking first dollar on Medicare Advantage patients, and then of course were pioneer for participants and happy to say we were one of your red dots up there where weve achieved significant savings, actually, in the first two years of payout with good quality outcomes. And were very proud of that. I think on a high level what wed like to see, you know, i think one of the things is, that i worried about from the beginning, is that if the payers attitude is, what have you done for me lately, i think were going to be in trouble. Were coming from double digit inflation in the Health Care Space and now were talking about actual savings. And there are a lot of inefficiencies, and there is a lot 6 of opportunity to raise the sea level but at some point, its only going to go up so much. And we will have to i think, accept the fact that there will be some growth for inflation. Also taking into account, again sean was actually quoting the exact figures. We know the baby boomers are really going to put a stress on the Health Care System financially, and resourcewise. So i think there has to be some dose of realism that the remarkable performance that weve seen early on at some point thats going to regress to the mean. To some extent. That doesnt mean we have to go back to double digit inflation. But, something realistic. And then, i think the other thing, and this is just from brown and tolands perspective, because we have been managing risk and our docs are used to it, we definitely would like to see the continued evolution for the opportunity to take on more risk and to get at that first dollar which i think sean was sort of alluding to. Its not going to be for everybody and i would caution anybody thinking about it to really understand your organization and your ability to handle that risk because its not easy. When we get into questions id be happy to talk about tactics and strategies that were using sort of more into the weeds that seem to have been important to our success. But i think ill leave it there for now. Great. Thanks very much, marcus. Weve heard about results to date from the standpoint of a couple of the major organizations that are participating in aco efforts in both public and private sectors. And now were going to hear from a couple of the experts on looking at the Bigger Picture across all of the aco experience in the u. S. So far. Next up for that id like to turn to michael mcwilliams. Michael . So ill speak more from a research and policy perspective as mark said. And ill comment on three things. Two challenges, and one as far as results go. And i think one of the key challenges ahead from a policy perspective is getting the benchmarking methodology right, the spending targets for acos. Under the current model, the incentives for acos to generate savings are quite weak. Particularly because of the rebasing thats implied by the current rules. So if an aco achieves spending on one Contract Period, carrying the current rules forward that would mean that their spending target or benchmark for the following Contract Period would be lower by that amount. So to give you a sense of why that really diminishes the incentives, if you think about an aco increasing spending during a Contract Period, medicare shared Savings Program, aco for example that isnt facing any Downside Risk, they are penalized for doing that. And it increases their benchmark for the following Contract Period and then they can receive a shared savings bonus for doing nothing. Under the Pioneer Program, they are penalized for doing more, but again theres that offsetting effect by the benchmark going up and the subsequent Contract Period, so for pioneer acos the incentives are more akin to fee for service with a lag. Then, thinking about the fixed costs of investing in systems to actually control spending, the rebasing is that much more of a problem because it may be hard for acos to recoup their investments of investing in the right systems. So that is one challenge. And i know sean and his team is working hard on a revamped proposed rule for the shared Savings Program. Another challenge thats related is unless acos have more control over where patients get care in the aco programs that diminishes the incentives further. To give you a sense of that we analyze Outpatient Care patterns at baseline among acos and found, for example, that only 80 of patients that were assigned to one aco in one year were assigned to the same aco in the next. Thats just over a twoyear period. Among the highcost patients that number was even lower, about 75 . So that instability, that churn in the assigned population, suggests diminished returns on investing, in specific patients. A lot of Specialty Care leakage, so even among the most specialty oriented acos we found that over half the Specialty Office visits were occurring outside of the acos. And then something we termed contract penetration, the proportion of Outpatient Care revenue thats devoted to the patients under the risk contract, that was only 40 in our study. So that suggests very weak incentives to roll out or implement changes that might spill over onto other medicare patients. And we think that those spillovers are probably likely, for example we found spillovers in massachusetts from the alternative quality contract which is a commercial aco contract sponsored by Blue Cross Blue Shield onto the medicare population. Then lastly so those are two challenges that require some rule changes if not some developments in the market, like medigap select plans oriented around acos to help sharpen the incentives. And then thirdly, despite those weak insent sieves in the constraints that acos face the results have been quite positive. I think there have been some fairly convincing reports of early savings. We have some results coming out soon, demonstrating a positive impact of the medicare aco programs on Patient Experiences, including improved or more timely access to care, better overall care ratings among the complex patients that are more likely to be targeted by the Care Management programs. As well as patients perceiving their care to be more better coordinated. So from my perspective i think overall it seems like a good start. But the need for some changes, new developments, to make the program a true winwin both for medicare providers, as well as patients. Just one before going on to david, just one quick followup, is that stated as a resource hypothesis i think youre basically saying that if the financial the new financial incentives created by an aco program are pretty weak because of things like turn or shared savings, and no Downside Risk and the potential for losing out on that contract. And the subsequent year, youre not going to see very big effects. You have done some work, as you mentioned with the aqc, the blue cross alternative quality contract, which is, i would think, bigger, in terms of those kinds of financial incentive measures, there have been bigger effects there, are you willing to say anything about whether doing more in terms of these kinds of strengths of incentives will lead to bigger effects, is there evidence for that . So the aqc doesnt have that rebasing involved. So if an aco is looking over a longer time horizon the incentives are certainly stronger. I think thats true among most of the commercial aco contracting. So theres a negotiated budget, and it will stay there, or theres at least no rule saying it will get ratcheted down every time savings are achieved. The aqc is rather interesting in that it was implemented in a country broad hmo network. So there are no restrictions, or financial incentives for patients in the aqc to go to the participating aqc Provider Groups. There are, however, mechanisms, because it is an hmo plan for providers to deny care outside, because they do need they need to have primary care doctors, and the pcps can approve or deny referrals. Anecdotally it sounds like the aqc groups, the Provider Groups have successfully without those financial incentives been able to corral care in and contain it within their Provider Groups. Man of those groups are quite large. And more effect on savings as well as quality . Right. And so the other from the aqc is real savings effects and real improvements in quality. So whether thats related to the stronger incentives or not i think just remains to be seen. Its massachusetts. So, thats also a potential difference. Still need more research. And i know david youve been doing a lot of work around the country on this. Really appreciate your perspectives on what the research has shown to date. So im going to focus on three different areas. The first is the variability among acos. So when we talk about Accountable Care its often referred as somewhat of a Homogenous Group of providers, but, in fact theres a lot of variability among them. There are acos that have 30 physicians and there are acos that have 30 hospitals. As you can imagine they have very different needs, concerns and approaches to managing a population. And so what were starting to see is that when you talk about Accountable Care it needs to be subdivided into the different aspects of the providers that are participating. And the reason for that is because they really have a different glide path. They have a different opportunity to progress toward achieving the same common objective. So if we want to provide better care, we want better Patient Satisfaction, and lower costs, it can be achieved, but with different provider types theyre going to focus on Different Things. And they really should prioritize Different Things from day one. So thats one of the challenges, is that many of the acos are focusing on topic a, when really given their individual structure they should be focusing on topic b. The second area talks with the real challenge of becoming an aco and managing populations. There are two kind of core broad groups of acos. Some of those have been in effect acos for a long time. Theyve been managing populations, they have relatively integrated services. They have somewhat developed h. I. T. , and then there are those organizations that have been strictly fee for Service Shops in the past and theyre trying to make that transition. What we found is that its a long and hard transition to become a population focused Provider Group. So its not something that we expect organizations to make that transition over the course of the first year. Its not even something thats necessarily going to happen within three years. Its going to be an ongoing challenge. Some of the big challenges that they mention are obviously the h. I. T. , what they should invest in, and when. But probably the biggest challenge is just giving the provider buyin. So you can imagine if you have a group of physicians that have been working on a fee for Service Basis for the past 20 years and you say now we need to focus on a population, getting them to change their practice patterns, getting them to work more as a team, getting them simply to change the referral practices, is a challenge and it takes a lot of time and effort. And so while wed like to see results in the first year and have a good indication of whether acos are going to work or not, one year really isnt enough time before trying to evaluate the organizations that are trying to make that transition. The third thing to talk about is the strengths of the different types of Accountable Care programs. So medicare, medicaid, and the commercial. Medicare what i really view as an enabling program. It has a relatively low threshold so providers are able to go in and start to focus on Population Health in the shortterm. Also, if you only have if theres no Downside Risk, theres not a huge financial barrier or disincentive to enroll. And so while there are startup costs, its really a way to enable a lot of providers to start to bear risk and experiment with this. On the commercial side, we think of this as a program that allows Additional Resources to the acos. A lot of the large commercial payers out there have a series of different contracts that they work with providers on. So initially theyre not in a full risk bearing contract. Theyre not a fullblown aco. But theyll do pay for performance bonuses but its a stepwise progression. Where over a period of years they help train the providers in the skill set necessary to manage a population. And so its really a longerterm track as opposed to just jumping in and being an aco right away. On the medicaid side, this is really where i see theres a lot of opportunity for states to push the Accountable Care movement. And the reason for that is that they have a disproportionate ability to force providers into bearing risk. And so where weve seen these states that have a strong focus on Accountable Care, were seeing a lot of activity both within the medicaid space, and also outside of the medicaid space. As providers are being forced to consider becoming an aco for the Medicaid Program, theyll want to look for other opportunities to experiment, and so those where theyre afraid that the Medicaid Program will move that way, the providers, for example, are more willing to just enter into the Medicare Program. The last thing that i would make is that aco growth within a market has not happened by itself. Theres very much a lot of strong Market Dynamics at play. And you dont see an isolated aco. When theres one aco all of the competitors in the market either form an aco right away, or create an aco plan over the next few years. And so, within individual markets, theres a lot of overlap in terms of the different providers that are participating, and it really is happening at a market level. Not just at the organizational level. David, thanks for summarizing a lot of evidence and experience quickly. You know, i just follow up on the point about states and Medicaid Program. You mentioned a lot of activity, including some fairly significant reforms, away from fee for Service Payment. Anything you can say about actual results from some of those programs so far . They are pretty early. Sure. The one good example is oregon. Theyve, what we would consider to be most aggressive tactic in moving their entire medicaid population to ccos, or care coordination organizations. And they have seen generally positive results. They are mixed. But they are somewhat positive. There are a number of other states that are just starting this year to move their population or next year even or the next few years, and so it really preliminary results even earlier than the shared Savings Program. Id like to thank both of you for those Research Presentations and maybe go back to marcus, and our other michael, to get a followup sense from you about whether that overall summary of a National Experience with acos today fits with your own. You all are obviously not at that early basic stage of just starting to get provider buyin, and making some of the initial investments. You are both organizations that have been at this kind of approach to patient focused care for awhile. But youre different kinds of systems. Advocate has a hospital base involved. And marcus, you highlighted that brown and toland is a physician group. Any comments on what you heard . Or points that youd like to especially emphasize or clarify . Yeah. I think particularly that point about the fee for service transition, and it being a painful one, spending a lot of time in california, i think sometimes, you get a little bit isolated, were surrounded by groups that have been in capitation, managed care, heavily so for a long time. And then when i have the opportunity to come out of the state, and meet folks who really have a managed risk, and you really begin to get a sense for what that really means. You dont have any of the infrastructure that any Typical Organization Provider Group that i would encounter in california, in other states where theres just fee for service, or heavily fee for service, they never had to adapt. Theyve never had to develop these services. And so, beyond what happens at the provider mentality level, by the organization thats supporting them, theres a lot of work to be done, and that takes a lot of time, a lot of investment. But one point i do want to make, which i think is important, as a physician, one opportunity that i hope is not squandered in this, is that the fee for service churn is so disaligned for the patient, and the provider. And there really is an opportunity here where folks can get the right care with the right person at the right time. Physicians, if theyre willing to give up aly bit of their autonomy, and work in a teambased approach, will be able to spend more of their time working to the top of their license, and most importantly, spend a lot of time talking to the patients who really need them the most. I mean thats what really drives me. What really motivates me to see this work through. Unfortunately at that, weve got a great group of physicians in our Provider Group, and i think that, more than anything, has to do with our success. But thats what i really worked towards. Just like to delve on that. Davids comments on what does it take to change culture of an organization. So youve heard, you know, some examples shared in terms of physician culture. We, too, while weve had ten years of experience working with our physicians to improve quality to our clinical integration model, its been a shift for our organization to now take a perspective outside of the four walls of our hospital, and to do that we created what we call an advocate care index, Population Based measures that all of our Senior Executives down to the director level, as well as in the physician side, create alignment for the organization to move forwards improving overall quality and cost of care regardless of where that care is delivered. And the physician office, you know, the points about patients supporting staff to practice at the top of their license, a cultural shift for our organization, you know, has been actually physically placing care managers that we hire into independent physician offices. So thats a big shift in dynamics, in that office space environment. And back to michaels comments about the shift in your Financial Support to make those kinds of Business Models sustainable. I expect theres some challenges around especially being a hospitalbased system where a lot of the revenues have come from the kind of procedures that michael is highlighting, is maybe getting that revenue getting in the way of making some of these changes. How have you dealt with that . Yeah, so, its clearly the model needs to move towards take ing cost out of the system. I think that was the comments earlier about evidence based practice, reducing unnecessary use, so thats a component of it. Theres also a component of how do we achieve greater economies. And, you know, part of that scale in terms of an organization, but also looking at greater efficiencies in terms of systematic change, marketing services, human resources, those types of aspects, supply chain. So were on a threeyear journey to take out about 2 of operating costs each year to make sure that the model is sustainable. Id like to open this up to discussion from the audience, as well. Sort of a question in the back there. Well bring the microphone over. Josh sideman, from the advelair health. Dr. Mcwilliams it was really interesting the comments you were making about the beneficiaries experience of care. Im curious if you are actually also the providers from the groups, have any insight into whether some of the incentives in the sometimes critiqued cms approach to beneficiary attribution and assignment are having an impact on how youre engaging beneficiaries. So its hard to know from the empirical analyses, weve done whats specifically mediating the changes in Patient Experiences that we observed. As far as the mechanisms for Patient Engagement go, i doubt theyre playing a big role. My understanding is that most Medicare Beneficiaries are unaware that theyre even in an aco. They get this letter about data sharing that some are confused by, and some throw away, and some opt out of. But the Patient Experiences that are in the quality part of the aco contract are very much more along the lines of caps measures. Overall ratings of care, and physicians, and how access to care is. Whether physicians are interpersonally connecting with them. Whether their care is coordinated. Those are things that i think the acos are probably impacting more through the systems that theyre putting into place, whether its new scheduling referral, access systems, Care Management programs that are really focusing on the needs of the complex patients. Rather than anything going on between medicare and the patients. Now, this does beg the question now how will patients view the medicare aco programs . I think certainly one concern is that if patients do not like the brand of care that acos are providing, then that would not bode well for the programs because they are voluntary and that could lead to market share losses and maybe discourage groups from staying in the programs. Michael, marcus, how much do your patients know that theyre part of Accountable Care arrangements, or are they just experiencing care differently for other reasons . Yeah, i think it definitely varies, and theres truth in that there are beneficiaries who probably dont realize that theyre in the program. Patient engagement is definitely a key element that needs to be executed on to be successful. And we also participate in some other cmmi innovation projects like iocp. So ive had a lot of discussions with other Provider Groups, and its interesting. The medicare population is not one size fits all. That there is regionalism even down to the level of certain cities. So like for our group, reaching out, sort of cold call style to beneficiaries was not well received. Whereas in other communities, that was acceptable and they were able to get Patient Engagement. So we generally had to kind of circle back around to our providers and work through those offices to get to those patients, and i think to your comments, that as far as Patient Experience goes, i think that we have put a point of emphasis in the Provider Groups for Patient Satisfaction that get score cards every quarter. Its part of their bonus incentive program. So there has been some attention and some improvement there. But a large part is, as you were saying, youre creating a Large Organization behind the providers, and the Patient Experiences all of that. And that is generally good. So thats a good thing. Thats coming out. Even if its not directly soming from medicare, or directly coming from the providers office, per se, patient is still benefiting. And david, from your you highlighted the different types of acos and how that might mean different steps that they should take to achieve some of the goals. Presumably better Patient Experience is a key goal for all of them. Any comments about differences that youre seeing, and how theyre approaching the challenge of more effective patient Patient Engagement and experience . One observation is that i agree with michael that theres not really that focus on telling them that theyre part of an aco, but its really the benefit of the view by what are the providers serving. They say were going to provide additional care coordination. Were going to provide enhanced access with primary care. But its not saying you are part of an aco now. Thats not the marketing strategy. Across the groups it really does vary. And it also varies across organizations. Some really dont put the excuse me, the Patient Engagement as a high priority. Others are trying to build their entire strategy around that. So a lot of variability across organizations. Thanks. Next question, up here. And then in the back. Im dr. Carolyn coughlin a primary care physician and an attorney, and this is actually a followup question. Im perplexed by the fact that you, the acos, many of them are getting High Satisfaction ratings, and youre also having trouble with churn. That people are drifting outside the aco. And usually sick patients who are happy with their care, what theyre concerned about is being forced to change their provider, rather than they want to stick with providers who know them and that they know. So i would think that would reduce churn relative to a sort of a wideopen fee for service. And im curious about who is drifting away. And if you looked into why. I can address that. Okay. So, what youre talking about is the attribution methodology, and the joke i have is that attribution is the languagest fourletter word in health care right now. Its an evolution in terms of how much data is being used, and into the methodology, and the logic. And i think that fundamentally is the issue at hand. And so, what we experience at pioneer over the first two years is about a 30 turnover rate. Between people going out and people coming in. So, its and i get, doctor, the question that youre asking. And its just its not as simple as that and its not just about the relationship between the patient and the provider. It depends on, for instance, what doctors did you put into the attribution level. So for instance, we have 1700 physicians in our network. But only 300 of them are part of the pioneer aco. And that was a strategic tactical decision that we made. So thats one aspect of it. There were some rules in the beginning about visits, how frequently they were occurring, and if they werent occurring you would lose the attribution. So that plays a role, as well. So its and actually we found that for folks who arent technically attributed to us, theyre still going to see our physicians. Theyre still connected in our network, and thats not going to be true for, say, Orange County where theres tremendous amount of competition. More Provider Groups competing. The bay area, san francisco, is a little more concentrated. So theres a number of factors that go into it. And i wouldnt take what youre hearing as an indication of dissatisfaction from patients. Its more about the attribution methodology. Other comments on this . I know the attribution methodology and this issue of relationship to churn, and relationship with churn to beneficiary dissatisfaction is an important area. And all of you have thought about this. I might just add that if there is increased satisfaction, then it may very well decrease the churn. I dont think we know that. We dont have a good handle on that. But there may be a sizable effect from that. And the other i make one other point, which is that i think sometimes the kneejerk response is to fix the attribution methodology. But that probably wont accomplish a whole lot without addressing the fact that beneficiaries assigned to an aco have unrestricted choice of providers without any incentives to direct them back to the aco providers and we just know theres tremendous care dispersion among beneficiaries in part for that reason. And thats sort of what the acos are up against. Other comments on this . Okay, great. A question up here. In the front of the room. Hi, morey med eker from hackensack. I heard sean discuss very, very briefly information, and his comment was that monthly they were supplying claims data to the acos. But we all know that the claims data from krms can be up to 12 months delayed. So even if youre getting it monthly, you cant accurately predict whats happening with your population and make changes. Now, weve had some brief discussions about Health Information exchanges, and data sharing. But it seems clear to me that the successful organizations, be they acos or not, are able to share data, clinical data, and be able to make appropriate decisions based upon that information. But yet, the government, with all its regulations has absolutely no Regulatory Oversight over Electronic Medical records and transfer of information. And has sort of left that to the private sector. The question is, is there a mechanism that we can utilize to improve data sharing to be able to really change our ability to quantify best practices and minimize wasteful spending. You think were going to come back to policies, new policies around Information Technology and data sharing later. I would like to ask both michael and marcus emphasize the importance of Information Technology in everything that theyre doing. But, what is the state of the Research Evidence on the extent to which better access to data, whether its through Health Information exchanges or other areas translates into better or greater success of the aco effort . Or is that just another area where the research is limited . Im asking david and michael to start. So, this is more observational data. The first is that, Information Technology is still very much a work in progress with most organizations. So, most of them have an emr that works. Theyre able to look at patient level data, being able to aggregate that to a population and track that over time is more challenges. Theres a lot of investment right now going into Predictive Analytics and Care Management platforms. But whether or not theyre choosing the right platform or doing it at the right time is still to be determined. So theres a lot of kind of push and pull among acos about how theyre going about this. One other observation about information exchanges is that the primary focus of the organizations is sharing information within the organization as opposed to sharing between organizations. The focus is trying to keep people in network and communicating between people that are quote unquote on the same team. And so the focus right now is how do you make sure that your outpatient is talking to your inpatient. Particularly when you might be on different emrs. We know of acos that have over 20 different emr platforms. Theyre just trying to integrate and speak amongst themselves, let alone trying to bring in all the other outside platforms. I would just add quickly its a Major Research challenge. And i think that the data that davids group, for example, is collecting will be a major contribution to allow really rigorous analysis on that. And michael and marcus, any final thoughts on working effectively with cms data . Yeah. Weve spent a lot of time working with their actuaries trying to sort of solve the black box. I think one last closing comment i would want to make is, valuebased purchasing is here. There was a lot of hand wringing back with the election in the Supreme Court case, but by that point, particularly with deals like what devita did, its very clear the marketplace has spoken. And folks that are the doing fee for service now have got to start changing their ways. Because this is coming. Its in medicare fee for service. Its in commercial now, and so it is imperative for their survival really that they start making the changes were talking about here today. Any other final thoughts on the panel . It is with this pastmoving area, and this fastmoving attention around value based payment it is a very challenging area for the research to keep up. And we very much appreciate the discussion that all of you had about the state of that research and its implications for further steps with acos. So id like to ask all of you to join me in thanking our panel for an excellent discussion. [ applause ] all right. We are now going to take a short break until about 10 45. Well reconvene with our next panel on big issues for acos going forward. As you can tell there are a number of them. Thank you. Well have more from this forum on Health Care Policy and Accountable Care organizations in about ten minutes. A short break here as you heard. Up next will be a panel on the future of Health Care Policy and acos. While we wait, a portion from this discussion from this mornings session. Good morning. Im going to questions and answers, partly because thats what mark asked me to do. Partly in recognition i looked at the other panelists and the people here in the audience, and i think very distinguished group, and in groups like this, people like me from the government should do less speaking and some more listening. So my remarks quickly i just wanted to give you some big, very big picture context of how we think of the shared Savings Program. So starting at 40,000 feet, and then coming down fairly quickly to ground level, and talking as mark indicated, about we are in development of a proposed rule for the future, the next generation of the shared Savings Program. So lets talk to you a little bit about where that might be headed. So first, were about four years out from the Affordable Care act and probably more importantly, we are one year out from the 50th anniversary of the medicare statute passing congress. 50 years ago. So where are we . The most important measures, which are controlling costs, and improving the quality of care that our beneficiaries receive, on controlling costs the news is historically good. We are in the middle of about a fouryear period where the cost per capita of providing care to a Medicare Beneficiary is essentially going to be flat for four years. Some of that is data that is already in. Some of it is the actuary forecast for next year. So unprecedented performance on reducing the growth and the cost per care. That bodes well for the program in many ways. One, the trust fund, the life of the Hospital Insurance trust fund. If you go back to 2009, the forecast was that it was eight years from being exhausted, that it would be exhausted in 2017. This year the trustees are saying were 16 years from being exhausted. That the life has been extended to 2030. So thats good news. Also, i think when you control health care costs, it allows not just relief for the fed cal deficit, but also allows for better Health Care Policy. Probably the best example is, serious discussions now about getting rid of the sustained growth rate provision in the medicare statute, which many feel has outlived its usefulness, but the discussion to get rid of it is only made possible by the lowcost medicare spending. So thats the cost side. On the Quality Improvement side, again, historically good news. Hospital acquired conditions, many forms of hospital acquired conditions are dropping. Ventilator associated pneumonias, early elective deliveries, i could go on and on. But lots and lots of signs of improvement in the care that our beneficiaries are receiving. Hospital readmissions dropping. So historically one in five Medicare Beneficiaries, about 19. 5 , readmitted to the hospital within 30 days of being admitted. Thats now in a precipitous decline now at about 17. 5 . So whats causing all this good news . Well, theres a lot of factors. Some of it is Public Policy both predating the aca but also things coming out of at fordable care act. Some of it has nothing to do with Public Policy, its changes that the professions and the hospitals and the Delivery System have made on their own because i think what you see is the beginning of a genuine Quality Improvement porpance improvement revolution in health care, which weve had in other industries, but sort of late coming to health care. We see actions by other payers, commercial payers, state Medicaid Programs that are incentivizing these changes. So were in very good position. Weve got challenges ahead. How do we continue this level of performance and improvement . Well, first of all, the challenges ahead are significant. One, the actuaries, although theyre predicting that medicare costs will continue to be flat next year, when they look further out into the future predicting return of inflation of about 5 of price growth every year. Which is a challenge for us. But more of a challenge is the baby boomers. In the next 20 years, we had 50 million give or take Medicare Beneficiaries today. In the next 20 years well add another 30 million. So, 60 growth in the next 20 years. Very substantial challenge. Even if we continue to control growth per capita. So thats sort of the landscape that we view the program in. Were in a great position in controlling cost. We have made some significant strides in improving quality. But we face very, very significant challenges. So i think the way we look at the landscape is we need to continue to support Delivery System reform. And how do we do that . Well the secretary burwell, within her first 100 days articulated a system of Delivery System reform which was providing information to providers. So that they know how to improve, and know where they need to improve. Improving the incentives, making sure all of our payment incentives support improvement. And building capacity within the Delivery System for improvement. And i think the aca has already initiated a lot of that work. If you see on the quality side on information, were providing quality measurement in almost every one of our Provider Groups that are in medicare. Were providing transparency with publishing these on our websites, whether its nursing home compare, hospital compare, and more importantly, this is where i wanted to get to, were injecting the notion of value with paying for quality, and efficiency, into all of our Payment Systems. And what are those Payment Systems . Very briefly we have the Medicare Advantage program. Weve got the fee for Service Program. And weve got new models of care that mark referenced. In the Medicare Advantage program, a lot of progress. The Affordable Care act i think set us on a course to pay more reasonably so were getting significant savings there. But at the same time, were getting high quality care in Medicare Advantage. 60 of Medicare Advantage beneficiaries next year will be in four and fivestar plans. Premiums have been essentially flat since the passage of the Affordable Care act. So good news there. And fee for service, hospital valuebased purchasing, physician value modifier, even in dialysis payments, were building in the concept of paying for quality, paying for efficiency, and to all these fee for service models. But as mark said, for many providers, faithfully to truly achieve change and fundamentally change the way they deliver care they need to move out of fee for service and move into a different model. And thats where acos and other models come in. Im not going to go into depth unless we get questions but the Innovation Center is testing any number of models around acos, primary care and medical homes, lots of variations. All focused on acos. But as i say its an important part of our strategy on new payment models. So where do we stand on the aco program . Early results, and i would use very similar slides to what mark did, the early results are very promising. Particularly on the quality side. On the quality side its pretty clear most of the acos have figured out how to provide care beyond whats provided in the fee for service system. We see that in beneficiaries. One of the measures we do is Patient Satisfaction. Patients in acos tend to be almost across the board more satisfied with their care. But theres more quantifiable measures. The pioneers from one year to the next improved collectively on almost all objective measures of the quality. I think 28 out of the 33 measures they improved on. In the shared Savings Program, the shared savings acos outperformed fee for service in 17 out of the 22 measures where Large Group Practices had reported quality measures. So on the quality story, very good promising results. On the cost side, a little less more of a mixed result so far. But i would caution that its very early in the program. You recall, if you went back to january 2012, there essentially was no such thing as an aco. And now we have, as mark said, i usually use the number 360 in the Medicare Program. But many more in the private sector, as well. With 5. 6 million beneficiaries participating in them. Several pioneers have clearly figured out how to generate cost savings and do that consistently from year to year. A number of shared savings acos, as well. But the story is still mixed. And the question isnt can the leading edge figure out how to generate cost savings. But can we get the vast majority of the acos in the long run generating cost savings to go along with the Quality Improvement. So, if the situation is promising but needs to do better, how do we move forward . Well, again, i go back to the secretarys vision, we need to improve the incentives that the acos receive, improve the information, and help build the capacity of the acos. Since, as i mentioned, were developing a new regulation for the aco program, i cant tell you specifically, what ill talk about now briefly are some of the areas where the private sector, the acos have come to us, including through the brook beings learning network, and have told us areas where they think we can improve. And they map perfectly to the incentives, the information, the capacity building. On capacity building, weve heard you know a lot of small practices that want to get in to acos, or in acos, need help in understanding how to transform themselves. And weve heard this outside the aco community. How do we help small practices in clinical transformation . Thats something the federal government is talking a lot about. We even have spoken publicly about and solicited ideas, how could the federal Government Support small practices in transforming better. But specifically in the aco context, one of the things weve heard is, well, since this is fee for service medicine, when we assign a beneficiary to an aco in one year, many of them are not assigned in the second year. And then what some have referred to that as the churn of beneficiaries. So its harder for the aco to focus their interventions, and resource investments on a beneficiary if theyre not certain that theyre going to have that beneficiary in the long run. And i think mark made reference to some of the savings state of Accountable Care weve had a chance to hear this morning already from Sean Cavanaugh and cms perspective on where Accountable Care is headed. And a panel of expert researchers on the evidence so far about Accountable Care. Were now moving in to our next panel which is more an ontheground look, an ontheground set of perspectives on big issues for acos going forward. We talk a lot about the national context. What we want to do now is turn to some of the major challenges on the ground for existing and new acos as they implement changes in practice, as they move forward on engaging, and activating patients, as they take steps towards the culture change around improving care, and focus on value as you heard in earlier remarks this morning. In those panels, there was a big emphasis on Patient Experience, and Patient Engagement. About some of the challenges to that based on both the way that americans have historically gotten their health care, and challenges related to the fee for Service Payment system. On the other hand, patients are have been a bit skeptical about being engaged in payment reforms that are in the name of improving quality. But too often end up seeming more focused on reducing costs through reducing access. So this is the set of issues around challenges for acos are definitely focused on some of the challenges around effectively working with patients in new ways. In these new kinds of care models. Just briefly, ive highlighted engaging beneficiaries as a key challenge facing Accountable Care today. Related to this are issues with payment formulas, paying based on quality and cost. Its different than paying based on volume and intensity. As you heard earlier, the methods revolving and may not be as aligned as well as they could be with some of the key goals of better care for patients at a lower cost. Weve talked about bearing financial risk on the one hand, the advantages of moving from shared savings to more of that first dollar ability to redirect resources to improve care and lower cost, but also some of the concerns about skimping our access to care that come along with those kinds of larger shifts. Managing startup costs has definitely been a key issue. You heard about some of the new steps under way to help address those challenges for organizations that especially are smaller and dont have a lot of resources inhouse. Better data and Performance Measures. Ways of combining Accountable Care reforms with other reinforcing payment reforms. Like medical home changes, and other kinds of valuebased payment reforms. And then finally, identifying best practices for clinical transformation. This is hard work as youve heard and the best step forward for a particular organization depends very much on its market circumstances, its own characteristics, and the best opportunities for improvements with their patient population. All of this makes being an aco a challenging task to undertake. And weve got a panel to discuss some of these key issues related to Accountable Care Organization Success going forward. This includes, ill introduce them now and were going to hear from them, jennifer sweeney, the Vice President at the National Partnership for women and family. Where she works with foundations, federal government leaders, Health Care Providers, communitybased organizations, consumers and others, to develop and implement strategies for improving the quality, safety, efficiency and patient and family centeredness of the Health Care System. Jennifer has extensive experience with multistake holder engagement in processes intended to achieve these goals and a deep knowledge of Delivery System models in Quality Improvement strategies aimed at more Patient Centered high Quality Health care. Next is kelly taylor, the clinical director of Quality Improvement for mercy clinics in des moines. She received her b. S. N. And m. S. N. From the university of iowa. Shes a nationally certified in Case Management with over 15 years of Case Management and disease management experience, and in des moines shes getting some firsthand experience with some of these challenges and opportunities around not only Case Management and disease management but engaging patients more effectively in their care. And finally, Morey Menacker the president and chief executive officer of hackensack alliance, Accountable Care organization. Moreys been a member of Forest Health Care Associates since its inception in 1997. And hes worked there on implementing a comprehensive, multidisciplinary approach to help patients become partners in their own care and wellness. And is very much engaged on the ground in trying to implement some of these aco reforms. Im going to start out as we did with our last panel asking our panelists to make some opening or framing comments, and then well have a back and forth discussion. Jennifer, like to start with you, please. Sure. Thanks for having me. I enjoyed this mornings presentations. So i work for the National Partnership for women and natio partnership for women and families. We are here in washington. We are a Consumer Organization. We have been around for more than 40 years working on Health Care Issues including system delivery reform. As a Consumer Organization we have historically been supportive of new delivery models that have the potential to lower costs, to improve outcomes and to improve Patient Experience. From the beginning we have looked at acos as a potential benefit to consumers and to patients. I think, though, like the Provider Community from the beginning we have also had concerns about acos. You touched on some of them in your remarks. I think the two biggest concerns is that this would devolve into just a Financial Mechanism instead of acos taking the opportunity to transform care. I think the second concern we have had is on the issue of Patient Engagement. Sometimes when people talk about Patient Engagement it sounds like what we are really looking for is patients to be better patients versus looking at an opportunity for Health Care Providers and aco leaders to really partner with patients at multiple levels. I will go into that in a minute. So as we look across i think todays landscape of acos, some of the other speakers talked about the variability, we it in terms of those two areas. We think some acos are looking at this as an opportunity to transform care clinically. Some are really looking at this at an opportunity to partner versus getting them to be better patients. My sense is that a lot of acos has sort of shelved those issues. I understand that to a degree. There are a lot of challenges in starting up a Business Modelism as i look forward into the future in my mind representing consumers and patients this model wont realize its potential without the focus on the clinical transformation and the Patient Engagement. I will just take another couple of minutes to look at the Patient Engagement piece. I think there are four levels that we see Patient Engagement. First is at the direct care level in things like shared decision making. Second is at the governance level. It is interesting to me when i talk about the acos about including beneficiaries on the acos is helping understand what patients need and want from an aco. I am seeing a lot of confusion and lack of interest which is concerning to me. The second piece is partnering with beneficiaries and patients at the design level. So we know some acos are doing a really good job of not just surveying patients about their experiences in the aco but then they are forming patient and Family Advisory counsels and working with those members to codesign care that meets their needs. And then the other level i would say is at the community level. I think in my experience acos and Health Care Providers in general dont partner with communitybased organizations like meals on wheels and the area agency on aging. Those are critical to doing transitions well. The other thing i want to speak to is the concept of whether or not patients will stay in an aco and how we help them understand that they are in an aco. What i am hearing recently is the concept of marketing to patients about an aco. I think we need to take a building awareness and education approach instead. This isnt a sales pitch. Patients dont need to be sold on aco if they are getting that patientcentered care that they need and want and if they are being partnered with at all four of those levels. I will stop there. Thanks very much, jennifer. Kelly . My name is kelly taylor. I am now the director of quality and Care Management for the mercy aco. Mercy clinics has traditionally for the last 12 years really worked on care transformation focused at the primary care level. In february of 2012 we became an aco and on 1 1 15 we will have over 1,800 providers. We have had rapid growth. That is one of the big challenges, i think, to really sustaining this. We have been successful as an aco, surprisingly so. I think one of the things the data puts you on is this roller coaster because in our interim report we did not share enough or save enough moneys for medicare. In our final we did by a lot. And so with that it kind of was the cumulation of a really good year for us both in the commercial setting, the governmental setting and then also with our own employers. We have a Big Initiative in working directly with employers going on as part of this work. I think part of the reason kind of taking off on your comments that this is here and this is here to stay, i think one of the reasons we were successful is we have kind of been saying that my leader who many of you probably know has said that for ten years we have been planning and working on this for ten years. I add to it that for those of you that are in 100 fee for Service World like we are in iowa you dont have to wait. You can do it now and you can make it work in a fee for Service World, as well. Ten years ago we did some fairly inexpensive things in terms of implementing disease registries which are a heck of a lot less expensive than emrs. You can get an immediate return on investment with them and we embedded Health Coaches in our primary care clinics. In a fee for Service World that more than paid for itself. I didnt have to have a health strategy. Once providers realized this was good care and they could be successful and pay for performance and they made a little money on that. Now the same group of wonderful nurses are leading us into the value world. So the same things that they have been doing all the time, working with patients, focusing on quality, working with them on the issues of medication adherence, of self management support, finding out from them whats important to them, what do they want out of their health care . And helping the rest of the care team then implement those importances and desires has really been i think what has made us successful and i think will take us a long way into the future, as well. Thanks, kelly. Thanks for inviting me today. A little bit of background. Ive been a practicing internist for about 30 years. And also am the director of Population Health for Hackensack University health network. In that role i initiated and was assisted by the hospital in developing our aco. We were in the first group in 2012 for the mssp program. We looked at it a little bit differently. Our philosophy was we were going to use this as a clinical laboratory. We were jumping into the value based reimbursement scheme. And so we decided to limit to primary care physicians, to mandate Patient Centered medical homes for all of our primary care offices that we bore the cost of all of the training for the Patient Centered medical homes. We mandated Electronic Medical records and we purchased a relatively strong Population Health Electronic Health system which emrs fed data into. This was all up front moneys that the hospital surprisingly enough was willing to invest in this organization. We started with a little over 12,000 mssp patients, with a little over 50 physicians and im happy to say we saved an excess of 10 million on those 12,000 patients. Now, i also agree that this model is not the model for everyone and that there are many mode out there. The end result is what counts. We all want to get to the same point. Clearly our paths will all be different. We chose some, what we consider to be innovative projects, demonstration projects which help fuel our success. Number one is we invested heavily into nurse navigateers. We embedded them in each of the practices. Therefore they were there to see the patients during their visits to develop a relationship with the patients that the physicians may not have had time to develop, to call the patients on a regular basis, especially the high risk patients and to intervene when necessary as the first line of defense when one of the patients wasnt sure which medication to take or should they go to the emergency room, et cetera, et cetera