Alternative Payment Models and Value-Based Care: There’s a Framework for That

 In Analytics & Data Management, Healthcare Transformation

Aparna Higgins’ career has been focused on value-based payment. More than ten years ago, while she was at Booz-Allen, she co-led the design of the Medicare Hospital Value-Based Purchasing report to Congress. It was one of the first programs recommended to the CMS that defined how hospitals could be assessed and rewarded for care quality. The report’s recommendations were implemented when the CMS was authorized under the Affordable Care Act to implement the program.

More recently, as an executive at AHIP (America’s Health Insurance Plans), Aparna led organizational efforts on payment and delivery system reform, included examining and identifying industry-wide best practices in the design and implementation of Alternative Payment Models (APMs), and the core quality measures collaborative. She’s spent most of her career thinking about incentives, incentive design, and how to assess and reward performance.

These days Aparna is the founder and CEO of Ananya Health Innovations. She’s also a guiding committee member of the Health Care Payment Learning & Action Network, also known as “the LAN,” which was established to accelerate the healthcare system’s transition to alternative payment models. The LAN’s major contribution to the industry is the APM Framework, which provides healthcare stakeholders with a roadmap to understand, design, and assess the adoption of alternative payment models.

We asked Aparna to join us on the podcast to talk about how the APM Framework can help payers and providers achieve their value-based payment goals. On today’s show, we’ll take you through:

  • The LAN’s mission and how it created APMs (02:16)
  • The roadmap, benchmark, and other tools the LAN created to help payers achieve their VBC goals (06:06)
  • A dive into the APM roadmap’s three pillars: APM design, payer/provider collaboration, and patient-centered care (10:20)
  • Why having access to better data is better for providers (15:51)
  • How payers can support providers, especially smaller providers, in analyzing data and identifying areas to focus on (19:12)
  • How payers and providers are changing patient engagement in the real world (21:29)
  • Evolving an APM from retrospective to prospective (28:19)
  • The importance of outcome-focused measurements (33:09)
  • Key tips for payers on advancing their APM programs (35:15)
  • What providers need to be successful in APM models (37:00)
  • How leadership and organizational culture for both payers and providers is key to success (39:00)
  • Aparna’s closing thoughts (40:54)

Episode Resources

  1. Contact Patrick McGuigan
  2. Aparna Higgins bio
  3. The Healthcare Payment Learning & Action Network
  4. The HCP-LAN APM framework
  5. Research: Value-Based Care State-by-State
  6. Seminar: How Anthem is Scaling Value-Based Payment
  7. Value-Based Payment Resource Hub

Show Resources

ROB CAPPABIANCO: Welcome back everybody. I’m joined today by Aparna Higgins, the Founder and CEO of Ananya Health Innovations. Aparna, could we start out with you telling us a little bit about your background, specifically as it relates to your work in alternative payment models?

APARNA HIGGINS: Sure. So, first of all, I’m glad to be here and to be on this podcast with you Rob. So my career essentially has been focused on value-based payment. And it really has been a major focus throughout my career. I think back to over a decade ago when I was at Booz Allen and I co-led the design of the Medicare Hospital Value-Based Purchasing report to Congress. So this was really one of the first programs that we recommended to CMS in terms of how should hospitals be assessed, rewarded, for the quality of care that they were delivering. And that report to Congress actually got implemented when CMS got the authority under the ACA to implement the program. So it was very satisfying for me. More recently, as an executive at America’s Health Insurance Plans or AHIP, I led organizational efforts on payment and delivery system reform. And that included examining and identifying industry-wide best practices in the design and implementation of APM’s, some of which has led to published work in Health Affairs. I also led the Core Quality Measures Collaborative. And the reason I bring that up is because the focus of that work was really on how do you choose and align measures in these new APM contracts. So my career focus has been on thinking and doing work around APM’s and value-based payment, but not just the incentive piece but the other components as well. So I’ve spent the majority of my career thinking about incentives, incentive design, and how you assess and reward performance.

(02:16)

ROB: Thank you for joining us. Love to have you on the program. There’s another organization that you have been part of as well. Can you tell us a little bit more about the Healthcare Payment Learning & Action Network? What is its mission and the goal of what they call HCP LAN? Who’s involved in that network? And what’s your relationship with that organization?

APARNA: Sure. I’m happy to do that. So, the Healthcare Payment Learning & Action Network, or as some of us affectionately call it, or as many of us I should say, affectionately call it, the LAN, is really established to help accelerate the healthcare system’s transition to alternative payment models. And it was unique in that respect because it was really trying to harness the power of multi-stakeholder partnership and multi-stakeholder collaboration. So the LAN has a variety of different stakeholders at the table—payers, providers, obviously when I say payers, that includes CMS, consumer groups, and employers, and so forth. And I was formerly a member of the guiding committee. The LAN had a variety of committee structures, but the guiding committee essentially was providing strategic direction and was this multi-stakeholder partnership that was helping drive the work of the LAN. And I was formerly part of that guiding committee. In terms of how the LAN has gone about achieving its goals and missions, I would say through a variety of ways. One, as you and others are probably are aware, the LAN developed and released the alternative payment model or APM framework, and has been measuring adoption of APMs for the past at least three years, if my memory serves me correctly. And it has also released a series of white papers and recommendations around model design, both around both population-based models like ACOs, but also for clinical episode models, recommendations on how to think about measurement and how to think about financial benchmarking. I would say most recently, initiated its capstone project, it’s since been completed obviously, called the APM roadmap, that was focused on identifying and sharing promising or best practices for successfully implementing APMs. So that was a lot but if I were in a nutshell trying to describe the LAN mission and the LAN work, that probably is a good and fair characterization of it.

(05:12)

ROB: You’re certainly drawn over your career here to propelling the APM market. Did you see this as a capstone for yourself too? Just a place where you could deposit years of learning from Booz and AHIP and a number of your previous initiatives? Was this part of the calling for you to come to the organization or at least help guide it?

APARNA: I would say yes. I think my role on the guiding committee was certainly to help bring my experience and my industry experience. At AHIP, I spent a lot of time working with our members and understanding payment reform and design implementation challenges and so forth. And so was excited to bring that experience and expertise and perspective to the guiding committee, and also specifically to this particular roadmap effort serving as a strategic advisor.

(06:06)

ROB: Can you share some of the ways that the LAN helps payers achieve their VBP goals?

APARNA: Sure. So I think I would say that they help plan to achieve VBP goals in a few different ways. First I think it’s just for the plans who are participating to have a seat at the table and be able to interact and hear other perspectives from the other stakeholder groups that are at the table, be it the providers or the employers or the consumers. Usually those sessions are rich dialogue, but it’s also an opportunity for them to learn from each other. Some of the what I would call foundational tools that the LAN developed which I’ve talked about, the framework, how to think about performance measurement, benchmarking, certainly the roadmap, I think are all extremely useful tools for payers to employ in their own efforts to transition to APM. And I think there were also some other very specific collaboratives that were established that brought payers together to implement population-based payment models like CPC Plus, which was a multi-payer model. And then the measurement efforts certainly from the plans’ or the payers’ standpoint help provide a benchmark. So most plans are really committed to this journey around value-based payment and are trying to move the ball forward, but it’s also helpful for them to see where they are relative to everybody else across the nation. So I would say the variety of ways in which the LAN supports and helps advance plan initiatives around value-based payments.

(08:01)

ROB: One of the aspects that you spoke about was the ability to bring the constituents to the table. And I think that that’s a valuable concept I just want to dive into. Certainly, from my own experience, this is not a one-way directed initiative. You need to be able to pull in the employers, your providers, because it’s actually a behavioral change we’re going for in terms of how you form relationships. Can you speak to how the earlier meetings probably went? As you started to go, was there any reluctance there on behalf of the health plan or any of the constituents to get together? How does that help the market propel in these APMs?

APARNA: So I can’t speak to the early meetings because I wasn’t on the guiding committee the entire time from the time it was established. So I came into it in the middle of it. So there was a certain cadence to the meetings by the time I got there. So I will say though, having been part of the guiding committee, you had a group of very committed folks who really believed in the importance of value and figuring out a way to get to value through changing payment reform. So I think they all shared the common goal. Also a willingness to learn and understand the challenges the other stakeholders were perhaps, and then trying to think collectively about what can we do to move things forward? So in terms of how the early meetings went, I wasn’t involved so it’s not something that I can really comment on.

(09:45)

ROB: What about in your own experience?

APARNA: I think that during the time I was on the guiding committee and attending the meetings and so forth, I found it to be a very collaborative forum. And kudos to the two co-chairs, Mark McCall and Mark Smith. Their leadership obviously was very instrumental in establishing the collaborative nature of the forum as well. But I think everybody shared a common goal and there was a lot of good work that has come out of that collaboration.

(10:20)

ROB: Can you give the listeners an overview here? It’s a very nicely structured roadmap in several different pieces. I like the notion of this promising practices. Can you just describe it to the listeners so they can visualize it in their mind and maybe even encapsulate what are some of the modules or steps of the roadmap?

APARNA: Sure I can. So I just want to clarify a couple of things. So I think some of the comments or remarks I made were more broadly focused on the guiding committee because that’s how I understood your question and what I’m going to talk about. So I want to do a little bit of level setting with respect to the roadmap itself first before I talk about promising practices if that’s okay.

ROB: Absolutely.

APARNA: Okay. So I wanted to give a little bit more background as to why the LAN guiding committee thought it was important to take on this capstone project. The LAN had been measuring progress towards APM adoption and the guiding committee felt that it was important to shift from tracking adoption of APMs and not thinking about, well, let’s implement APMs for its own sake, but really ensuring that successful models were being adopted. And understanding as you said, the best practices associated with success. And then in keeping with its tradition of making available useful tools to the field, the guiding committee felt that it was important to share these best practices more broadly with the field to really help accelerate the adoption of successful APMs. Again, I think that ties back to the mission of the LAN. The roadmap itself, just before I talk about promising practices, to give the audience a bit of understanding about the scope of who we talked to and what kinds of models were included in the roadmap, there was a very structured process and methodology that was followed to come up with the promising practices. I’m not going to talk about that. People who are interested can go to the website to learn more about it. But suffice to say that what’s reflected in the roadmap is based on a literature review as well as data gathered from about nine national and regional payers and also 13 provider organizations. Now even though there are only nine payers, they accounted for about 135 million covered lives. So in terms of scope, it’s pretty broad. It was also pretty broad in terms of focusing on what we call in the LAN category three and four models, which include shared savings, shared risk, global budgets, and then both episode models, as well as population-based payment models. So that’s just a little bit of tactic setting, so as they talk about promising practices the audience has a sense for that. So in terms of the practices themselves, I think given the rich nature of the discussions that we had with these nine payers and provider organizations, there were a number of practices that emerge. But I would say, and we characterized it in this way, into three broad themes or domains. One is around APM design. The other was around payer/provider collaboration, which I’m sure is not surprising to you. And the third leg of this stool or the third domain, I would say, is around person-centered care. And the roadmap has lots more specifics and detail around each of these three main domains. And individuals who are interested can do a deep dive into each of these domains. But it might be helpful for me to highlight some examples that I think would be of interest to the audience. So as you and I’m sure many in the audience know, collaboration between provider and payer is key both in the design phase, but also in the implementation phase. I think what we’ve heard from the providers is that they want to have more input into the APM design phase. And while this is not always easy to accomplish, I think there are approaches that are being used that could work. So for example, some payers were identifying small cohorts of providers who were more advanced, designing and testing it out with them before they rolled it out more broadly. Others were using approaches like establishing joint operating committees where there was ongoing dialogue and communication and collaboration around APM design. So that’s one example where there are some challenges as you try to get these kinds of collaborations going. But they’re also some tested approaches in the field to help that happen.

(15:51)

ROB: I have found that’s a continuous evolving practice that you have. You don’t have it as you would in the whole old fee-for-service world, you meet three years, you put your dukes up and you kind of fight about 2 to 3% increase. I’ve seen at least in our own practices here that if you’re meeting with those providers quarterly that are involved in your evolving efforts of APM, depending on what kind of model you’re using, that it is a practice that you continue. It’s not something you start and finish with. It’s something that goes along with the operations of the program. Would you agree?

APARNA: Yes. I would wholeheartedly agree with that. I think that is what we observed and that’s within this roadmap effort itself and that’s also based on my own experience outside of the roadmap. I think that’s very true. And the other area where I think collaboration really matters and an area that’s super important as you know is data and analytics. You hear a lot about the importance of data and analytics in these new models and certainly we found that to be the case in the roadmap as important for success. But it’s also true as you know that getting access to data and the ability to use these data varies a lot among providers. So there are ways in which providers are trying to overcome those challenges I think, in cases where you have smaller providers that may not have the infrastructure to or the capacity to ingest, let’s say, claims data directly from the plans. They tend to rely more on analytic reports like care gap reports and so forth that plans share with providers. Although some of the larger systems we spoke with had built integrated claims and clinical data repositories, and so having access to claims data they felt was really important. And that was one thing that they did bring up, providers did bring up as important in the context of taking on and managing downside risk. So having better data and better information was, they felt, was one of the important things for success.

(19:12)

ROB: I completely agree with you. You need to be ready, especially as the payer and you’re thinking about your rural areas and places like that to be ready with data and be ready to discuss it, get down into the details. But one provider explained to me their experience as we were developing out some of the analytical reviews, was getting into some of the early APMs was like getting into a cockpit of a plane with no instruments in front of them. Therein lies the reluctance to get on board. So there was this notion of information transparency, mainly around the idea that the relationship change happens and the payer becomes an opportunity provider to their doctor partners in that I want you to sign up with these programs, especially when you’re going to go into downside risk, which I think I want to come back to because it’s a pretty meaty topic. But you need to be able to show them how to win. It’s not that they don’t want to win. They would like to be more efficient. They got into health to perform and do good work and promote outcomes. So I think the role of the payer in the relationship becomes less of a financial transaction management entity to one that says, got a lot of data and it gets even better when I share it with you and we have a dialogue about what it actually means because coding behavior is not always exactly about the care that’s going on. Let’s have a dialogue about that. A foundation in analytics, a foundation in sharing is part of that relationship chain.

APARNA: Right. Right. And then I think the other piece of this is, I think it’s two aspects. One is flexibility, which I think the payers, at least on the plans’ side, they’re very sensitized to and really try to tailor because they can. It’s much easier for plans to tailor each contract to each provider and to their specific circumstance. And so if it’s a smaller practice, what we found through the roadmap, is that as you can imagine it’s harder for them to take on a lot of the functions whether it’s practice transformation or trying to make sense of the data and the reports that they’re getting on their own. And this is where I think the payers are stepping in and providing that support. And smaller providers can overcome some of the challenges by working with their payers to identify areas they could focus on. For example, for QI, how they can use care management and other infrastructure fees that the plans are providing them with, to change their workforce for example, if they had to hire a care coordinator. And also again, how to use data and reports to manage their population. And I think that flexibility in terms of structure, but also calibrating the level of support is something that we observed relative to the plan provider relationship, depending on whether the providers were smaller versus larger systems who certainly have a lot of infrastructure and more resources to take on transformation efforts.

(21:29)

ROB: Absolutely. And I think sometimes especially in the journey to APMs, that there’s a realization that whether you choose to move into pop health structure or bundled payment, P4P program, etc., there’s a lot of alternative things you can learn out of the analytic discipline, referral traffic and patterns, the care coordination patterns, what is broadly referred to as that providers medical network, their neighborhood of doctors that they rely upon in their care practices are regardless if you move them into a value-based payment or an alternative payment model, gives a tremendous insight into both the payer and provider and how care is actually taking place. So I’m glad you brought it up because there’s a lot of additional value just really understanding the transaction beyond the coding level really provides to you. One thing I really like about the model, love the fact that you have a specific domain around patient-centered care. I think a lot of efforts are around the transactions and training and learning to have a new relationship, outcome achievement. And I love the notion of benefit design. Because I want to be around when we move from project around APMs to products where you actually have and have gone to the last mile where you pull in the member benefit because again, you’re pulling the consumer into the design there. I really like the domain piece there that you didn’t lose sight of who I think is most important, it’s all of us. We’re at the center of all this stuff. So do you want to talk about that last domain there?

APARNA: Sure. So the roadmap actually in terms of trying to learn about person-centered care we talked about that with both payers and providers. And both the payers and providers are working to address the issue of patient engagement in a variety of ways. So from the payer standpoint they’re looking at a variety of approaches trying to promote shared decision making and ensure health literacy. They are working with their providers to establish care compacts with their patients, so this is not just having a treatment plan but also kind of thinking about what’s the role of the provider and what’s the role of the patient, whether it’s if you’re given a prescription it’s around medication adherence, for example. And I think one area where there’s still maybe some work to be done is payers engaging patients or consumers in the actual design of the model. And I think that’s something, forward looking, would be an area that would require some additional work. We also found that in doing this roadmap effort, or undertaking this roadmap effort, that there’s a lot of work payers are doing around trying to address health equity. We all hear a lot now about social determinants of health and they try to do that through using multidisciplinary teams and being able to identify community resources that patients can reach out to whether it’s food or transportation and so forth, and really trying to address those social determinants of health. And then through the incentive structure payments to providers trying to make sure that they’re indirectly supporting provider efforts in this area. Now from the provider standpoint, patient-centered care is kind of what they’re about. And it’s very hands-on. It’s very direct obviously because they’re involved in that direct relationship with the payment [patient]. And even the providers in these new models, some of the best practices that we heard is how they engage their patients through a variety of channels, using smartphone apps or portals. And then trying to get them engaged in their communities, whether it’s schools or foundations or local community centers, those sorts of things. We also heard, and this was interesting for me, providers are convening patient advisory committees to get patient input. And so in terms of their experience with the practice, but then also use those patient advisory committees as an opportunity to share or push information out relative to access to care after hours, things of that nature. And increasing access for patients is obviously a big focus for many of these practices. They also said that for some of the patients getting to the practice might be challenging which was where the transportation services comes into play. But trying to improve access in other ways. I was, after hours and trying to avoid unnecessary ED utilization, and potentially using telemedicine as a way to engage patients. So I would say there’s a lot going on in the area of patient engagement. I think with benefit design that was not a major focus of exploration for us with the roadmap. We did hear from the payers about benefit design and obviously validate benefit design is one of the ways that they’re approaching this and trying to incent patients and consumers and get them engaged in the care as well. I think there’s more work to be done there. There’s also the challenge of purchases wanted to give their employees choice. And so when you have benefit design, a particular way you’re trying to balance that with choice and open access and so forth. So there’s always that tension. And then I think the other area that’s starting to develop that we heard about in the roadmap is these products that are designed around ACOs. But I think there’s more room for future work in terms of understanding where the market is today and thinking about where it needs to go.

(28:19)

ROB: As you progress in your models, especially if you’re thinking about moving from retrospective to prospective, there’s certainly, if you think about how prospective is paid and you don’t think about how that affects the downstream payments, especially from a patient or a member or a beneficiary depending on the constituents you serve, is these products were built upon co-pays and out-of-pockets and certain percentages that the consumer is in charge of. And so when you make a financial arrangement especially in the prospective area and probably even greater when you’re involving risk that you haven’t necessarily fully automated it if you can’t really tie it back to, okay how did that affect the way that the patient or member, consumer was supposed to pay? Because you’ve changed a little bit of the financial underpinnings of the traditional product that was purchased. So as I’ve gotten mature in the area, and just started to think about some of the frontier problems or opportunities I guess I should say, is really starting to think about some of those future mechanics around the product design. Because without that, you’re not automating it to a place that I think you can scale. So when I saw benefit design in the piece, I’m like okay there’s some aggressive thinking. So I like that. Aparna, would you disagree with my categorization that those domain themes we broadly talked about are great for organizations just starting out, maybe looking for some pointers on how to additionally mature their program? But then you also have a path forward section that may give some evidence for those that have highly mature programs but are looking to evolve again. Would you say that’s correct? Incorrect? Did I miss something?

APARNA: I would say mostly correct. I would clarify in a couple of ways. The domains I think and all of the sub-themes and the promising practices that are associated with all the sub-themes, to me they are useful to payers. But I think they’re also useful to providers irrespective of whether they are starting out or a new entrance to these kinds of models so that they can kind of learn from their peers and see how they figure out how they might succeed. But I also think it’s useful for organizations that are mature because it gives them a way to benchmark. So it says well, here, let’s take data and analytics. Let’s take a look at what the best practices are around that and then compare that to what they already have in place. I actually heard somebody recently—I was at a conference in San Diego, the APG conference and spoke on a session about the roadmap—and some folks came up and said afterwards that it was really helpful for them to benchmark and hear what I was saying because it helped them benchmark what they were doing. And it was kind of reassuring for them to say a lot of what we have in place is kind of where the field is or where the best practices are. So I would say in that sense, the roadmap is really kind of meant for both early entrance and maybe some people are newer to these models as well as more advanced organizations. The path forward section is really more about areas where we felt or the guiding committee and the LAN felt that further action would be needed to accelerate these options. You had some remarks in there about how important it was to think about benefit design and how you evolve benefit design. That’s certainly one area. I think the quality measurement piece is also something that where, based on this work, I would say an important area for further development shifting away from processed measures. A lot of the measures that were used in these models that we examined as part of the roadmap were mostly HEDIS-based measures. And then greater focus on measure alignment, which obviously is something that everybody recognizes is important. So I think those paths forward are really areas that are important and the roadmap has suggestions for taking immediate action in some of these areas because it’s important more generally for accelerating the adoption of successful APMs.

(33:09)

ROB: Any thoughts on beyond HEDIS? Where would you go with some outcome?

APARNA: Sure. And this is, I would say, this more represents my viewpoint. And I’ve written about this. I’m published in Health First blog, so it’s public. But I would say, and it draws upon some of the LAN’s earlier work too, is the outcome-focused measurement. So especially as we think about measuring for accountability, which is what these models are moving more towards, outcome-focused measurement, I think is an important part of that. I think and also measures that are longitudinal in a sense that you can identify and assess performance based on the entire care continuum over time as well as across settings. And in some extent, you want to be “site neutral” because you’re really trying to assess how well the patient did across the continuum. But I think certainly the emphasis [being] more on the outcome-focused measurement is where I think the field needs to go. But there’s a lot of work that needs to be done to help make that happen, especially if you want to move into an outcomes more broadly that involve use of multiple sources of data. Whether it’s claims-based, clinical outcomes using clinical data, and then of course patient-reported outcome measures.

(34:52)

ROB: Hopefully it’s not protected by a form-fill or subscription.

APARNA: No. It’s not. So the two recent blog posts that I have—one was with Mark McClellan and then the other one was with Dana Saffron—but both very much focused on this issue of outcomes, finding outcomes for focus measurement.

(35:15)

ROB: I like it. Pushing the envelope. That’s great. Based on your work on building out the roadmap, I’m sure you gained a lot of great insights that our listeners would like to understand. What advice would you give to payers looking to advance their APM programs?

APARNA: So I would say, highlight some of the, come back to some of the things we talked about. Obviously, provider readiness varies. So it’s really important to recognize that readiness, which I think many of the payers are already doing, but allowing for flexibility both in the structure of the payment and the contract but also the intensity of support as we talked about. Being able to calibrate that. I think looking ahead, the issue of benefit design is an important one to tackle in the context of provider payment reform and also figuring out how to engage patients in the design of the models. I think if one of the challenges that we heard in the roadmap from providers shouldn’t be surprising is around alignment. And alignment of quality measures, but also some of the other key elements of APMs. For example, if you think about episodes, ensuring that there are common definitions that are being used so that providers don’t have three or four different definitions for the same clinical episode. So those are all kinds of things that I think would help in terms of exfoliating APMs and certainly something that came out of the roadmap effort loud and clear, and ways to reduce that burden on the providers so they can really focus on transforming care delivery.

(37:00)

ROB: Excellent. Let’s flip hats and say same question, but to the provider population evaluating APM contracts.

APARNA: Sure. I would say readiness. I think and here readiness means something different. So it’s helping providers to think about what components do I need to have in place to be successful in these models? I think data infrastructure and learning how to use and apply the data to manage patients and really as part of care delivery transformation is key. Practice transformation, obviously, I think is difficult to be successful in these models without those efforts. That could include anything from hiring staff, which is care coordinators to figuring out how you work with hospitals, and there’s timely sharing of information, for example. And then how do you work with other specialists? So, for example, if you’re a primary care physician participating in these models, how do you think about your referral network? And then finally, also, I think fully being able to understand the terms of the contract and what this all means for them. The one area that I want to emphasize that I don’t think we touched upon it which came up as important both from the payer perspective as well as the providers perspective is leadership and cultural change. So that’s really big. From the payers’ standpoint, that’s not something that they directly control within a practice, but they obviously look for certain characteristics when they’re selecting practices to move into APMs and leadership and organizational culture is one of them. And they also work intent to engage closely with the clinical leaders within these provider organizations. But from the provider perspective, that’s really a big area that emerged from the roadmap as being critical for success. And the importance of having a clinical champion and being able to get all the clinicians within the organization to understand and embrace those goals, that they’re set at the organizational level. And this was something that I found interesting, I think there’s been a lot of discussion about how even though organizations are entering into contracts with payers that changes the way payment is being made, that within the organization, within the provider organization, most clinicians are still being paid on a fee-for-service basis. I think that’s generally what we all hear and think about. So within the roadmap, when we’re talking to these organizations, what we found is some of that is starting to change. And these organizations that participated in the roadmap, some of them are using both financial as well as non-financial incentives within the organizations to achieve their goals. So, for example, some of the provider organizations tied front-line clinician incentives to achieve quality performance, or tying it to shared savings. Other non-financial ways of motivating and rewarding clinicians like transparent reporting of performance. So I think we’re starting to see how incentives or payment structures that have been established at the organizational level are starting to cascade within the organization. And I think that’s an important learning that came out of the roadmap would be good for the field to be aware of. But also to really recognize the importance of leadership and culture change.

(40:54)

ROB: What I’m hearing is that we need some more time. Maybe we’ll have you come back and we’ll dive into some of the deeper issues because you have a very balanced perspective coming out from the deep background that you bring to the community. Final words of wisdom?

APARNA: Sure. Well I guess my final words of wisdom would be to say keep at it. I think we’ve been doing this, we’ve been embarked on this APM journey now for about a decade and experienced some success. Still have a long way to go. Obviously if you looked at the data, healthcare spend relative to GDP, and working towards that true transformation is critical. And I think we need more disruptive innovation. Maybe in the way that Netflix came and changed the way we consume content for example. So important to stay the course in terms of moving away from fee-for-service. Now having said that, it’s not easy. We’ve had this fee-for-service system, I don’t know if I even want to call it a system, for a long time, about 50 years. It’s not easy to shift a whole industry that’s been used to doing business one way into a completely different approach. I think we’ve made great strides, but I think it’s important to keep the momentum going. And I realize it’s not easy. And I thought, this is one of my favorite quotes actually from a former president who said, we choose to go to the moon and do these other things, and I’m paraphrasing here obviously, “… not because they’re easy, but because they’re hard.”

(42:36)

ROB: Absolutely. It’s a part of progress in the old adage of anything worth doing is going to take some time, take effort, but we are starting to make a change. I would also add on to that, it is changing. There is no stopping it. I believe yes, we’ve been doing it for ten years but if you’re not participating you’re putting yourself in the laggard’s position. Pick up what you can. Change is hard. There are partners out there that are valuable community members. For the listeners, if they wanted to learn more, Aparna, about the HCP LAN, or affectionately called the LAN’s work, or connect with you, how would they do that?

APARNA: Well if they want to learn more about the LAN, the best place to do that would be to visit the website. I would encourage everybody to visit the LAN website and specifically the roadmap website. It has a fantastic interactive roadmap tool. There’s a PDF version of the report for those who want to download it. But there’s also a much more interactive way of learning all of the promising practices, some of which I’ve touched upon in today’s discussion, as well as other LAN resources. I would say the LAN website is the best place to go for people who want to learn more about the LAN and take advantage of the roadmap and the resources available to help understand better the promising practices associated with design implementation of APMs.

ROB: Fantastic. And as I did, you can always find Aparna on LinkedIn. She’s out there.

APARNA: That is true.

ROB: Aparna, really appreciate your time. Enjoyed the conversation. I’m hoping we might be able to entice you to come back again to touch on some of those other areas.

APARNA: Sure. I’d be happy to come back and I really enjoyed the conversation as well. And thank you so much.

ROB: Thank you.

An estimated 798,000 clinicians will be MIPS eligible in the 2019 performance period.[1] CMS predicts 74% will earn an “exceptional performance” bonus for 2018 with a minimum distribution of 0.25%[2], while those choosing to not participate will be assigned...

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