Primary Care Doctors are Becoming Community Leaders

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Tapping Medicaid funds to tackle SDH

 

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SOMOS INNOVATION—the post-DSRIP future

As our city, our state, our nation and our world are struggling with the coronavirus pandemic, I first of all want to express my gratitude and admiration for your work on the frontlines of caring for coronavirus victims and protecting New Yorkers across the board. May you and your staff stay safe—and know you have the support of the entire SOMOS organization.

As you know, the DSRIP program formally concluded on March 31, 2020. It is a great disappointment that federal and state authorities opted not to renew the program’s mandate despite DSRIP’s many achievements. However, SOMOS will continue it groundbreaking work on behalf of the city’s poorest patients through SOMOS INNOVATE. It’s with an eye on that new chapter that I have drafted these notes.

The following draws on the recommendations and observations found in a report produced by the Helgerson Solutions Group (HSG), which earlier this year completed a strategic audit of SOMOS, precisely to map out its post-DSRIP future. HSG’s founder and principal is Jason Helgerson, the former New York State Department of Health Medicaid director and visionary behind DSRIP. He and this team know the health-care landscape intimately. It is a landscape being radically transformed by the Value-Based Payment (VBP) model and SOMOS INNOVATE will be our doctors’ guide and advocate.

As such, the HSG report proclaims that SOMOS INNOVATE is “about more than just being a VBP innovator. … SOMOS has the potential to revolutionize health and social care … and being a light in the wilderness for physicians and physician groups around the country.” As pioneered by DSRIP, the VBP model, a move away from the traditional Medicaid  fee-for-service payment formula, allows networks of independent physicians to bypass hospital systems and “contract directly with insurers (or the government) and take control of the total health care dollar and the flexibility those payment models offer to revolutionize care.”  With SOMOS INNOVATE at their side, our doctors can continue “to rise up and take control of their own destiny.”

SOMOS INNOVATE will continue the transformation of health care for New York City’s most vulnerable patients by continuing to “institutionalize cultural competence, empower patients and address the true root causes of bad health and social outcomes.” The fact that so many of our doctors share the same cultural background as the people they serve makes for “an exceptional closeness to their patient base, something that is very hard to achieve and harder to replicate by other organizations.”

To strengthen its clout and grow our network of providers, SOMOS INNOVATE will aim to engage other IPAs. It will also put a premium on partnerships with Community-Based Organizations to address Social Determinants of Health, a critical component in providing patients with comprehensive, wholistic care. Such care has the power to improve “community happiness” by “fully embrac[ing] the health, social and economic needs of the community.” It’s a model of care that revolves around the neighborhood-based primary care physician as trusted community leader.

To stave off competition, SOMOS INNOVATE will consider establishing “creative partnerships” with hospitals which might otherwise make access to specialty care more difficult. It will also pursue VBP contracts with Managed Care Organizations that would welcome SOMOS INNOVATION as a hospital competitor.

SOMOS INNOVATION has been operational for some time and continues to implement a rapid development strategy. The SOMOS Board of Directors appointed 20-year health-care industry veteran Dan McCarthy as CEO of SOMOS INNOVATION. An expert in value-based care, Dan has spent the bulk of the past year building up the organization and putting in place his management team.

The time is now, says the HSG report: “SOMOS is on the right side of health-care history. After years of delay, the health-care world is finally starting up really embrace value. New York State and Medicare are continuing their push to get virtually all providers into the VBP arrangement.” The goal is to position SOMOS INNOVATION on the forefront of publicly funded health-care innovation, state-wide and even nationally.

Achieving that objective will be critical if SOMOS INNOVATION is to succeed in enabling its doctors to remain competitive in a time of rapid change and in the face of the potential challenge of the Big Four—Apple, Google, Amazon and Microsoft—entering the arena of “technological innovation that will revolutionize the provision of many health-care services over the next decade,” stresses HSG.

In the form of robotics and Artificial Intelligence, “technology may replace as much as 80 percent of what doctors currently do and SOMOS will need to stay ahead of that curve on their physicians’ behalf.” A premium must be put on building “productive partnerships between doctors and machines.” Increasingly sophisticated technology will free up doctors from “routine tasks so that they can re-focus their time and attention to supporting their patients psychologically and helping them understand—as well as act upon—their medical condition.” Surely, this increasingly intimate attention paid to patients will be essential for delivering optimal value-based care.

Among the technological tools of the future will be smartphone apps that allow for 24/7 monitoring of patients. There will be sharp growth in the kinds of “wearable technology, biometric sensors as well as apps,” all working in sync to create an “Internet of the body.” “Doctors in the future will prescribe apps” allowing for patients’ self-diagnosis. Overall, technology will drive a “long-term shift from managing sickness to preventing it.”

The report says that in future, doctors may well be “dispensing their advice through chatbots, instant messaging and video calls instead of sitting in an office with a line of patients to see them.” Noting that SOMOS doctors “already excel at some of the inter-relational aspects of the job by virtue of being in, and of, the community in which they serve,” they will need training in acquiring a “new basket of skills” “to make the pivot to a more interpretative and context-providing role on its own.”

HSG notes that telemedicine, remote patient care, will have a $130B market share by 2025; and “the healthcare artificial intelligence market is projected to reach $19B by 2026.” All that innovation means that “the future of medicine will be more precise, personalized, participatory and preventive. These attributes align perfectly with SOMOS’ existing values.”

Indeed, helping and training our doctors “plan and prepare for the technological disrup4tions of the future” will be a hallmark of SOMOS INNOVATION. It is part and parcel of its overall commitment to empower our providers to offer the best possible care to New York City’s most vulnerable patients, and to bring about lasting reform of publicly funded health-care delivery.

How to fix Obamacare

HEALTHCARE advocates for the poor let out a collective sigh of relief when attempts to repeal the Affordable Care Act (ACA) went down in flames. But the story is far from told. Legislators on both sides of the aisle agree that Obamacare, as the ACA is better known, needs significant re-engineering to become economically sustainable.

Criticism, particularly on the part of conservative legislators, is focused on the cost of the plan’s expanded Medicaid provisions. The critics have a point. The established administration of Medicaid-funded healthcare is inefficient. By some estimates, waste and corruption cost U.S. taxpayers close to $140 billion a year, some 12 percent of the program’s total budget.

Lawmakers eager for a solution need look no further than a revolutionary Medicaid reform program in New York State, designed by state Medicaid Director Jason Helgerson and championed by Gov. Andrew Cuomo, who secured $7 billion for the five-year initiative. It’s called the Delivery System Reform Incentive Payment (DSRIP) program. 

This jargon-laden moniker obscures a highly innovate formula for healthcare reform. Gone is the traditional fee-for-service Medicaid model that compensates the health care provider for tests, office visits, and procedures. In sharp contrast, DSRIP shifts to a value-based payment (VBP) model in which the doctor or healthcare system is paid according to the long(er) term health outcome for individual patients.

It makes sense! Health care providers are rewarded for keeping patients healthy. This means the provider—in keeping with the medical calling, it should be added—invests time and energy in comprehensive, holistic, preventive care – ensuring patients follow medical directives, take their medicines, keep their appointments. Suddenly, the patient is at the center of the equation.

At the end of its five-year run, in 2020, DSRIP is on target to reduce unnecessary hospitalizations by 25 percent, which will represent a savings to New York State taxpayers of $12 billion. Reducing avoidable emergency room visits and hospital stays is precisely the fruit of comprehensive, holistic care. Today, it is all too common for Medicaid patients to fall through the cracks and wind up in the ER at great cost to the system not to mention the patient. Let us not forget that we are talking about real people, human beings whose illness and suffering carries its own, often-overlooked cost.

At this writing, the DSRIP program—after 30 months of laying the foundation of a complex infrastructure of clinical care models and performance measuring tools—has entered the second half of its five-year mandate. Since April 1, all 25 so-called Performing Provider Systems (PPSs) are being measured by the state according to performance targets and clinical outcomes. Encouragingly, in the first two years of the program, PPSs earned 95.78% ($2.53 billion of a possible $2.64 billion) of all funds.

It is important to note that NYS Medicaid Director Helgerson’s vision goes beyond the strictly medical and behavioral health factors that determine the well-being of a Medicaid recipient. His goal for healthcare transformation is to also address the social determinants of health. He asserts that successful, long-term reform of the Medicaid system means that, as he put it, the “healthcare sector must embrace a broader role in the communities in which we serve.” 

Research has amply shown that non-medical factors have a significant impact on a person’s health. For the bulk of vulnerable and poor Medicaid recipients living in urban settings, social or environmental conditions have a huge effect on physical and mental health: poor living conditions, pollution, crime, unemployment, lack of access to healthy foods. The list goes on.

The U.S. lags significantly on this front—even though it is very clear that neglecting social determinants of health is costing the country billions of dollars a year. In Helgerson’s vision, the primary care physician, the neighborhood doctor of old, is at the center of a coalition of service providers with expertise to address the gamut of a patient’s needs, medical and otherwise.

One notable stumbling block is the relative shortage of primary care physicians, particularly in lower-income areas. Across the board, less than 30 percent of U.S. physicians provide primary care, compared to well beyond or close to 50 percent in Canada, France, and Germany. Millions of Americans lack access to a primary care doctor, the very person who could play a central, comprehensive role in their health and well-being.

On this score, Advocate Community Providers (ACP) stands out as the only physician-led PPS in New York State. ACP’s vast network of 3,500 providers includes 1,400 Primary Care Physicians and 1,700 specialists who practice in the Bronx, Brooklyn, Manhattan, and Queens. What’s more, many live and work in the same neighborhoods as their patients—patients with whom, in many cases, they share the same ethnic background. Cultural competence is strongly emphasized by the DSRIP protocol and strongly embraced by ACP.

These neighborhood doctors know their patients intimately and understand the social and environmental factors that impact the household. They are committed to the comprehensive well-being of their patients, their families, and the communities at large. This rehabilitation of the role of the family doctor is driven and encouraged by the Value-Based Payment model, as it promotes a holistic approach to healthcare reform.

Such could be the next chapter for America’s healthcare reform, with individual states or the federal government adopting a Value-Based Payment formula to improve the quality of Medicaid care, even as it reduces waste and fraud. Making the considerable investment in a nationwide DSRIP program has the potential of truly enormous savings down the road—savings that in turn could keep Obamacare premiums for non-Medicaid insureds in check. Such radical reform should be able to garner bipartisan support.

Finally, to dream even bigger, why couldn’t the for-profit insurance companies who are part of the Affordable Care Act work with their providers and also introduce—not to say enforce—a Pay-for-Performance formula? Monies spent in the best possible way and savings achieved will benefit all parties—patients, first and foremost, but also providers, insurance companies, and the government. For the business-minded party in charge of the Administration and Congress, truly smart reform of Obamacare at all levels should be a no-brainer.

Comprehensive, holistic care will keep Medicaid patients healthier

It is the story of summer 2017 and a nation’s differences are laid bare as Congress struggles to formulate an acceptable law to replace the Affordable Care Act. Are the proposed replacements “mean,” or do they not go far enough? How do leaders reconcile the practical drive to slash the nation’s public health care budget with the repugnant (and politically unattractive) prospect of leaving at least 22 million fewer Americans without health insurance coverage?

How do legislators come to terms with proposed Medicaid cuts that would jeopardize health care for more than 70 million people—among them children, the elderly, people with disabilities and pregnant women—by 2026?

There is no doubt that health care expenditures in the United States need to be curbed; compared with other industrialized nations, we spend the most per capita but deliver inferior care. Medicaid as we know it has been prone to waste and fraud. However, simply cutting the health care budget will only worsen the situation for those at the lower rungs of society. These are the men, women and children our government is dutybound to provide for, and to do it well.

True reform—a goal apparently lost in the partisan bickering—would be to get smarter about exactly how health care dollars are spent, so that costs can decrease even as the quality of care improves.

A revolutionary experiment underway in a handful of states is aiming to do just that. California, Kansas, Massachusetts, New Jersey, New York, Oregon and Texas have authorized versions of the Delivery System Reform Incentive Payment program. At its heart is the value-based payment formula, which stipulates that health care providers are compensated based on their patients’ longer-term health outcomes rather than the volume of services provided (that is, transactions such as office visits and tests).

The D.S.R.I.P. model—executed in New York State by 25 performing provider systems (also known as P.P.S.’s)—incentivizes health care providers to keep a close eye on their patients’ progress, monitor adherence to medical directives, assess mental health factors and empower patients to self-manage chronic conditions. The objective is to prevent 25 percent of unnecessary hospitalizations, which, at the end of the program’s five-year mandate, is projected to save New York taxpayers $12 billion.

Imagine such a strategy implemented in all 50 states; the Affordable Care Act’s drive to cut Medicaid spending could be achieved even as the quality of care improves. This is truly the best of both worlds, satisfying both patient advocates and budget hawks.

The visionary behind D.S.R.I.P. is Jason Helgerson, the Medicaid director of New York’s Department of Health, who passionately argues that we must take into account the social determinants of health as well as a patient’s medical condition. On this score, the United States lags behind other developed nations that recognize the significance of these factors in providing health care to the poorest citizens.

Social determinants include patients’ housing situations as well as their economic, employment and educational status. In many cases, they are also affected by the criminal justice system. These nonclinical issues directly impact physical as well as mental health, and they should be taken into consideration as part comprehensive health care designed to produce lasting results.

Case in point: A recent briefing for P.P.S.’s by the New York State Department of Health on housing issues reported that indigent households often choose to pay rent over buying food; this is a practical decision but one with serious health implications, particularly for young children. Rent and housing instability is shown to put mothers at a 200 percent higher risk of depression. There is also the impact of mold, lead paint and pest infestations. As a recent study by New York University’s Furman Center showed, an increase in “poverty concentration—the extent to which poor New Yorkers are living in neighborhoods with other poor New Yorkers” compounds the impact of a troubled housing situation as a social determinant of health.

In the vision of Helgerson—who likens the D.S.R.I.P. model to a start-up driven by venture capital—the neighborhood-based primary care physician becomes a true community leader who engages local leaders and activists in the areas of housing, employment and education to form community action teams. Their mandate is to make comprehensive resources—both medical and nonmedical—readily available to the poorest Medicaid patients in order to ensure their long-term flourishing.

Comprehensive, holistic care is the solution to keeping Medicaid patients healthier, taking control of chronic illnesses and avoiding expensive emergency room visits and hospitalizations. Such comprehensive care is commensurate with respect for the human dignity of each and every human being. Our nation’s political leaders should commission research into the social determinants of health and refocus their attention on health care reform that provides states with incentives to being truly smart and innovative in how public health care funding is spent. Billions of dollars can be saved while millions of lives are lastingly improved.