More than 200 people representing various healthcare constituencies and employers, including providers, payors, advocates, and purchasers, attended “Healthcare Convergence: A Collision Course,” a comprehensive symposium hosted by Gibbons P.C. and PwC at the Woodbridge Hilton in Iselin, NJ, on January 30, 2014. Leaders from a diverse range of healthcare and employer sectors led dynamic discussions on the requirements of the Affordable Care Act (ACA) and the industry’s shift from fee-for-service, which have positioned “value-based purchasing” as the new healthcare delivery model and encouraged increased collaboration among payors, providers, and purchasers – stakeholders who, historically, have had competing interests. This article summarizes the program’s presentations and conclusions.
Frank T. Cannone, Esq., Chair, Corporate Department, Gibbons P.C.
Simon J. Samaha, M.D., Principal, PwC
Hosts Frank Cannone of Gibbons and Simon Samaha M.D., of PwC, leading authorities on the implementation of value-oriented solutions for the healthcare industry, outlined the speakers and panels who would be examining the industry-wide effort to bend the healthcare cost curve while maintaining high quality standards. They introduced the concepts of “convergence” in the new healthcare delivery model, the increased collaboration among various healthcare constituencies – including hospitals and physicians, insurance companies and employers providing benefits, consumers, and government agencies – as well as value-based purchasing, the use of purchasing power to influence quality.
Dr. David Levy, M.D., Founder, Franklin Health; Former Leader, Global Healthcare Practice, PwC
Dr. Levy is a leading healthcare strategic thinker and successful entrepreneur. In his keynote address, Dr. Levy emphasized the critical gains in health, productivity, wealth, and longevity that he believes are likely to result from the healthcare industry’s realignment. He noted that science, demographics, and this country’s ongoing drive to innovate all support his conclusion, as does the success of similar laws and public/private healthcare partnerships in other parts of the world.
First, Dr. Levy discussed the new public/private sector dialog necessitated by the ACA and new models of care that become possible when healthcare delivery, financial processes, and customer service are aligned through partnership between the public and private sectors. He emphasized that the government is not purporting to be a healthcare innovator through the ACA, but rather is refocusing and strengthening its role with regard to quality oversight and access. Meanwhile, the private sector, which the law grants a more level playing field through increased competition, can exert itself around efficiency and innovation. Dr. Levy gave examples of flourishing public/private healthcare partnerships in other areas of the world, including Europe and Africa. For instance, in Spain, the government incentivizes the private sector to take responsibility for the entire range of healthcare services, from immunizations to outcomes.
Dr. Levy next discussed the industrialization of the healthcare sector, which in the U.S. has lagged behind the technological advances in other business sectors. As healthcare finally progresses in terms of industrialization, process improvements become more possible, which are the key to unparalleled efficiency and quality. Again, he presented examples from other countries that, despite being less developed in numerous ways, have invested in healthcare technology infrastructures to facilitate process perfection and specialization. By improving our understanding of logistics and supply chains, we can pay for outcomes; that is, we pay for services that create value. In the healthcare industry, problems migrate to solutions; Dr. Levy contended that, with increased industrialization, solutions will begin to migrate to problems, and precision-based care, as opposed to population-based care, will become the norm, with targeted, custom therapies and diagnostics increasing efficiency and innovation while decreasing costs.
Finally, Dr. Levy assured the audience that healthcare can, in fact, be a social right for consumers while remaining an economic driver for providers and payors. For every increment of cost in the new healthcare delivery model, a corresponding increment of human productivity and longevity should result from these innovations and fresh interventions.
Moderator: Brett Hickman, Partner, Healthcare Advisory, M&A and Strategy, PwC
Annette Catino, President and Chief Executive Officer, QualCare Alliance Networks, Inc.
Joseph Healy, Jr., Ph.D., Executive Vice President, Managed Care, CenterLight Health System
Jeffrey LeBenger, M.D., Board Chair and Chief Executive Officer, Summit Medical Group
Betsy Ryan, Esq., Chief Executive Officer, New Jersey Hospital Association
Susan Walsh, M.D., FACP, ACO Medical Director, Jersey City Medical Center
The symposium’s first panel, moderated by Brett Hickman of PwC, comprised healthcare innovators and discussed their organizations’ partnering arrangements with each other, their communities, government agencies, and other stakeholders to focus on, for example, preventive care, as well as health care delivery models across the range of a patient’s medical needs. They spoke of various barriers to integration, and the worry among providers that convergence might not be able to be simultaneously both profitable and effective, as well as among communities that do not want to lose access to their longstanding local hospitals and other institutions; the new integrated system, therefore, needs to align payment to incentivize all providers to coordinate care across the continuum. The panel also noted that providers as a whole were not trained to collaborate or integrate, so this is an entirely new model, and one that requires sophisticated communication and data sharing for which the industry does not yet have the infrastructure.
The panel pointed out that, in a new delivery model that emphasizes coordinated care and prevention, payors should be part of a patient’s overall care team, along with physicians, nurses, aides, social workers, and the patient him- or herself. Health benefit plans and integrated provider networks can analyze data that those on the ground providing care cannot see; for example, determination of the best outcome for a patient can hinge on whether that patient has outside issues, such as illiteracy, behavioral health, family support, or a life transition, that prevent him or her from following a doctor’s orders.
The panel also examined real-life examples of organizations, projects, and programs that are adding value to patient populations and improving outcomes. Medicaid reform and expansion have been huge components of the ACA; the federal government sponsors a program, adaptable at the state level, called the Program of All-Inclusive Care for the Elderly (PACE), which provides comprehensive long-term services to Medicaid and Medicare enrollees. An interdisciplinary team of health professionals and other care providers offers coordinated care, which enables patients to receive care at home rather in a nursing home. PACE centers also provide opportunities for primary care visits, behavioral health check-ups, and even socializing. Panelists with PACE program experience reported that it is working exceptionally well in New Jersey and New York.
The panel noted that the Accountable Care Organization (ACO) model similarly includes various types of physicians, behavioral health specialists, skilled nursing, nurse practitioners, rehabilitation facilities, unified electronic records, and care management departments to treat patients. Even traditional hospitals are becoming more consumer-centric; panelist Susan Walsh, M.D., ACO Medical Director at Jersey City Medical Center, spoke of her organization’s “Wealth from Health” program, teaming an informed customer relations navigator with a patient’s care providers to deliver comprehensive service.
Finally, this panel focused on current trends in preventive care, and how organizations are partnering on the wellness side of the equation to use data to engage populations before diseases erupt. Here is where, according to the panel, community organizations can play crucial roles. Community wellness offshoots of hospitals offer education, often complimentary, in the areas of fitness, nutrition, and stress management. ACOs publish print materials, host lecture series, and maintain call centers, and they also partner with community groups such as YMCAs to provide substantive programming on preventive health topics. The panel also brought up private sector engagement, such as blood pressure screenings at local pharmacies, and an area supermarket chain employing registered dieticians to escort customers through its stores to help them shop nutritionally.
Moderator: Barry Liss, Esq., Director and Healthcare Team Leader, Corporate Department, Gibbons P.C.
Joseph DiBella, Managing Director and Executive Vice President, Conner Strong & Buckelew
Brian Doherty, Director of Human Resources, North Atlantic District, UPS
Anthony Melfi, Senior Vice President and Chief Financial Officer, Brother International Corporation
Frank Winter, Partnership Manager, Government Centers for Medicare & Medicaid Services (CMS)
The program’s second panel, moderated by Barry Liss of Gibbons, comprised healthcare purchasers, with representatives from the country’s largest purchaser – the federal government’s Centers for Medicare & Medicaid Services – as well as large private employers. Together, these constituencies represent 2/3 of all covered Americans.
Beginning with CMS’s perspective, Frank Winter discussed the effectiveness of initiatives to foster convergence and collaboration models, particularly in terms of bending the cost curve and maintaining and improving quality for Medicare and Medicaid patients. He mentioned that, for the first time, there is a real awareness that payment has to change the processes. CMS has identified some clear problems, such as infections in hospitals, readmissions, and poorly coordinated care for high-cost patients, and persuaded providers and insurers to hone in on those problems as well, targeting areas in the system that are driving costs, identifying challenges (e.g., electronic records, fraud and abuse), and learning how to optimally utilize technology. This has spurred energy and ideas around such successful models as the medical home and ACOs, which all require quality reporting to ensure that less expensive does not translate into less attentive or less effective.
Joseph DiBella, of Conner Strong Buckelew, explained the insurance broker’s role in the new system, which has shifted as healthcare delivery models become complex. Beyond helping employer clients select the best carriers at the best prices, the insurance broker now serves a broader, more complex advisor and navigator role, all while helping smaller employer clients contend with new laws and often higher costs. Meanwhile, the larger employers on the panel brought up new opportunities for cost savings and proactive care as key factors in attracting and retaining a motivated, high-performing workforce. Bringing the discussion back to the first panel’s topics, these employers talked about designing benefit plans that keep costs down while supporting healthcare collaboration, sophisticated data management, proactive wellness campaigns, including weight management and smoking cessation programs, and other targeted initiatives that government studies have shown to be effective.
Finally, the second panel maintained that efforts to increase transparency in cost and pricing are invaluable in achieving more effective value-based purchasing models and enhanced quality effectiveness.
David A. Filippelli, Esq., Chair, Government Affairs Department, Gibbons P.C.
Simon J. Samaha, M.D., Principal, PwC
Heather Howard, Director, State Health Reform Assistance Network, Princeton University (and former Commissioner, NJ Department of Health)
Ms. Howard, Mr. Filippelli, and Dr. Samaha focused on the government’s responsibility to citizens in terms of healthcare, and how the ACA is a first attempt to reconcile that responsibility with the economic concerns of providers, purchasers, and payors. In Ms. Howard’s estimation, the law is beginning to inspire more efficiency on the government end, more productive healthcare partnerships among all kinds of constituencies, more effective delivery models, and lively competition in the private sector.