Propelling Primary Care Towards Value-Based Care: Adam Boehler, Director of the Center for Medicare and Medicaid Innovation at HHS on Their Bold Agenda
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[Music]
Female: Welcome to C onversations and Health Care with Mark Masselli and
Margaret Flinter , a show where we speak to the top thought leaders
in health policy , health innovation, and the great minds who are
shaping the health care of the future. This week, Mar k and Margaret
speak with Adam Boehler, Senior Advisor to HHS Secretary Alex Azar ,
Deputy Administrator and D irector of the Center for Medicare and
Medicaid Innovation at the Centers for Medicare and Medicaid
S ervices. Director Boehler discusses t he ir new initiative to transform
primary care in this country, creating incentives that will pay clinicians
for value and outcomes not volume of services delivered.
L or i Robertson also checks in Managing Editor of FactCheck.org, looks
at misstatements spok en about health policy in the public domain ,
separating the fake from the facts. We end with a bright idea that’s
improving health and wellbeing in everyday lives. If you have
comments, please email us at CHCradio@CH C1.com or find us on
Facebook, Twitter, iTunes or wherever you listen to podcast. Y ou can
hear us by asking Alexa to play the program C onversations on H ealth
C are. Now stay tuned for our interview with Adam Boehler , Director
of the Center for Medicare and Medicaid Innovation on C onversations
on Health Care .
Mark Masselli: We're speaking today with Adam Boehler, S enior A dvisor to Health
and Human Services Secretary Alex Azar and also Deputy
Administrator and D irector of the Center for Medicare and Medicaid
Innovation, also known as CMS Innovation Center. Prior to joining the
federal government, Mr. Boehler was F ounder and CEO of Landmark
Health , a company that provides at home health care for chronically ill
and vulnerable populations. He also held several e xecutive level
positions at other health industry entities. He graduated from
Wharton School at the University of Pennsylvania. Adam, welcome to
C onversations on Health Care .
Adam Boehler: I'm happy to be here.
Mark Masselli: You know, we read in Forbes M a gazine that you ’re being described --
HHS is running the most important agency that very few people have
ever heard of , we heard of it, the C enter for Medicare and Medicaid
Innovation . It was created to test new ways to both improve quality
and drive down cost at the country's major health insurance
programs. When you add up all of the people who are in Medicare,
Medicaid a n d the CHIP P rogram, the Children's Health Insurance Plan ,
it's roughly around 120 million Americans. T here's been significant
accelerat ion of new rules at HHS and CMS to advance those larger
goals, getting better quality care and reducing cost. What's driving
this acceleration activity ?
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Adam Boehler: I think we're at a crossroads in health care costs, the Medicare
trustees report amount o f money for Medicare , looks like it'll run out
by 2026. W e're now at a point where roughly one in every $5 spent is
related to health care. It’s funny I was looking at spend in different
areas in government over the decades, and health care is one of the
o nly spend s that continually increases as a percentage, it's cut out
from 10% to 20% over the last several decades. I think we need to
accelerate our efforts to think about how we do things differently.
The goal of CM M I is to change payment to lower cost an d improve
quality for patients . T he most difficult things about our health care
system today is that we pay for volume. W hen you pay for volume of
services, our system called fee for service, then you get volume of
services. A lot of what we're thinking ab out is how do you shift from a
system that pays for volume to one that pays for outcomes .
Margaret Flinter: Well, Adam, let's zero in on the most recent initiative that was
released aimed at transforming primary care . T he Department of
Health and Human Ser vices has announced an ambitious strategy to
shift primary care away from the historic fee for service payments to a
system that pays for outcomes. You have long been a proponent of
blowing up the fee for service system a nd the person who's really
guided t he development of this new CMS Primary Care Initiative. How
does it work? W hat do you see the role of federally qualified health
centers, community health centers in this innovation as well?
Adam Boehler: Sure, I have been quoted as saying blowing up fee f or s ervice , a nd it's
an easy and kind of fun thing to say .
Margaret Flinter: Right, hard to do.
Adam Boehler: But a lot more difficult -- yeah. There’s really two very important
things. One is a very strong commitment to primary care, primary care
is 2 to 3% of Medicare spen t , but it's so much more important. T he
second thing is what does an outcomes or value based system really
look like? W hat was important to us, if you wanted to design an
outcome based system that works for every physician, not just larg e
groups, but down to the individual doctor , and so t here's really two
tracks to our primary cares initiative. The first is, for smaller physician
groups, the initiative is called primary care first, where instead of
paying a fee for every service, we're g oing to pay a simple payment,
half monthly, half simple visit . T hen physicians will have a downside
risk amount of about 10% and a symmetrically high upside amount of
50%.
I f you're a primary care physician today, and let's say you make
$150,000, you would have downside of $15,000 i f your patients went
to the hospital and didn't stay healthy . Y ou would have an upside of
50% , s o you would make significantly more from 150 to $225,000 i f
you are one of the leaders, and keeping your patients healthy, and at
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hom e . P hysicians didn't go to medical school to churn and burn
through patients every five minutes , t hey want to spend time with
their patients. Ou r goal has been, let's get time off of the computer
a nd let's simplify so that we can spend time with patients a nd those
patients that need it. The second track is called direct contracting,
that is very sophisticated physician groups are going to say , you know
what, if you have a whole bunch of patients and you would like , you
can take full cost of care accountabil ity for those patients.
I t's very hard for the central government to manage every aspect of
health care. If we can empower local physicians and local
communities , that's going to be much more effective , they know their
patients . T hat's not what our job is , o ur job is to empower and enable
them . To your third question around federally qualified health
centers, part of the things whether the y’re primary care physicians,
they can partner up to form direct contracting entities. I would
imagine given the role of F2HC the important role in serving
communities that they would certainly be a part of this.
Mark Masselli: Adam, I think it's axiomatic that the folks who lead HHS , CMS think
about data is a force multiplier , and o bviously, that data needs to be
good. But you're also thinking about data in another bold way , a nd
you've announced a plan to make electronic health data available to
all patients on their smart p hone at no cost. I can't say enough about
how exciting that is, at this year's health data Palooza [P H] you
recently addressed that gathering to talk about another program a nd
that's the AI data challenge. I'm wondering if you could talk about the
drive to move data more freely into patients hands, getting
developers to create a better artificial intellig ence to take on this new
challenge of moving from volume to value.
Adam Boehler: If I were to simplify our two jobs to lower cost and improve quality, I
come to two things, release the data and change the incentives. W e
sort of spoke earlier about the chan ge the incentive aspect and -- but
on the release of data, you'll see a lot of CMS ’ s interoperability efforts
are focused on that area. T his country spent billions and billions of
dollars on electronic medical records. R eally what we got are revenue
cycle systems that don't speak to each other. T he interoperability
initiative is saying, hey th is need to speak to each other , a nd we need
to be able to freely exchange data. W e need to empower patients and
their physicians, that's patients information, if they want it they
should be able to get their own data . W e don't want to hear stories of
I can't get my own data , that's yours , o r here's a CD - ROM with your
data. I'm not sure about you, but -- I mean, why do n't they give me an
eight track ---
Mark Masselli: M y old Mustang might have them but outside of that ---
Adam Boehler: Exactly. Y ou can go and listen to your patient ’s record maybe in your
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Mustang. T hen we just introduced an AI channel, the million dollar
challenge . W hat we're saying is, as we're releasing this data what can
we learn so that we can help physicians treat their patients and if
you're a primary care physician, you're going to have 2500 patients. I
want that one physician, Akron, Ohio, to have all the learnings of
every physician in the United S tates, so that when something presents
to him, that's unusual, somebody can update and say, hey look you
may want to look for this.
O ne of the concerns that comes up around AI is, oh does it
de humanize health care ? I would posit just the opposite . I f you h ave a
good technology that takes the technical time out, it actually
humanizes medicine because it's going to enable the physician to
spend more time with the patient , s o that's the goal, the challenge .
W e're really saying, hey how can we reinvent metrics now that people
are going to care about keeping people healthy at home, since we've
created those incentives?
Margaret Flinter: I want to go back for a moment to the initiative to transform primary
care . Y ou've talked about payment reform as one way to fac ilitate
transformation and allow physicians and nurse practitioners and the
P As in primary care to really focus on their patients and not on the
volume of visits. But another approach you've talked about is the idea
of collapsing the office visit. Certainl y , telemedicine and telehealth
have an important role to play here. But what other strategies a re you
recommending deploying in this pursuit of collapsing the office visit
that might spur this kind of transformation that you're seeking?
Adam Boehler: What we need to do on all these is h ow do you modernize definitions
of things? Does the hospital have to be in physical location, if it c an
provide the same services. 20 years ago, yes, because there is no
other alternative. Now, that may not be the case, there may be
hospital services that can provide it in a 24 /7 cents at home, as an
example at the very high queuing side. T hen as you go on the
tele medicine side, there may be plenty of opportunities for visits. I
think at the end of the day, our job is to defin e services but then
empower patient choice.
I f somebody would like visits over video, then I think as long as the
clinical value is there, our job is to kind of remove regulation and then
empower things like that . W e hear a lot from rural communities, and
what models are appropriate for them, because we need to consider
of those challenges as well. We're looking at ways and working with
rural communities that we can help transform, maybe from more of a
hospital based setting over time toward behavioral heal th more than
the ambulatory setting. I think the re in particular, we need to be
flexible on what will work for patients there.
Mark Masselli: We're speaking today with Adam Boehler, Deputy Administrator and
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D irector of the Center for Medicare and Medicaid Innovation. A dam I
was thinking about the number of folks that are heading towards
having full onset of diabetes . I think it's one third of all Americans by
2050 a nd not only sort of the personal impact, but the associated
health costs are just staggering. Y ou all have been thinking about
ways to start moving dialysis into the home, finding ways to prevent
end stage renal disease . T alk about the work you're doing to
dramatically increase home dialysis .
Adam Boehler: The current status quo cannot continue be tween the end stages of
chronic kidney disease and then renal failure . W e spend about as
much as we spend on drugs in the United States. I mean, you're
talking over $ 100 billion of spend a year. I think our system is set up
to wait till somebody has end st age renal disease and then treat them
in dialysis in a center. Not only does it cost a lot, but a patient that's in
a center and spending hours and hours on a daily basis really loses
their ability to live an independent life. Th e quality outcomes are not
great , a nd so we've been saying how do we re - envision this sector . It
hasn't been alone , I mean, we've been doing this with the dialysis
centers, and other physicians , primary care.
I n the United States today, about 11% of Medicare patients did
dialysis in the home . In Hong Kong that ’s 75%. Then when you get
dialysis at home, not only is it lower cost but you ’d have better quality
outcomes. We want to change the system to one that says okay, as
somebody is progressing, and they have chronic kidney disease a nd
they're going up the levels, there's five levels of chronic kidney
disease, let's slow that progression by focusing on different
preventative services so that people don't ever get from CK D 4 or 5
end stage renal disease. If they get the end stage renal disease, let's
get a transplant as soon as we can , l et's get them home for dialysis if
it's appropriate as a last resort . It’s kind of reversing in that direction.
Margaret Flinter: Yeah. For a moment, let's go way upstream. You really are proposing
some i deas that are gaining traction about using resources to pay for
the upstream issues that can impact health and prevent the onset of
disease. I don't think this is widely known that CMS has issued a rule
allowing the Medicare a dvantage dollars to be utilize d for such things
as fresh produce, or even carpet cleaning for people with lung
disease. We also saw that the i nnovation c enter announced updates
to the model of value based insurance design which offers Medicare
a dvantage plans flexibility to offer more tailored benefits that might
be completely non medical interventions, but yet have a chance to
make a big impact on overall health. This is a concept that's been
around for a long time, but still not monetized. Tell us more about
your vision for reducing m edical cost through interventions like these
upstream approaches .
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Adam Boehler: S ecretar y Azar and I have fo ur focused areas for transformation of
health care. The first is patients as consumers, the second is providers
as accountable guides , t he third is paying for outcomes , a nd the
fourth is prevention of disease before it occurs . B etween Medicaid
and Medicare today, we spend about 1.3 trillion a year. T he only way
that we're going to significantly change that is by prevention and
preventing disease. I us ed to run a large physician group that took
care of patients in their homes . W e would have Medicaid patients
that would not have homes that would be homeless, that would go to
the hospital, significant amount of time in a given month, sometimes
honestly ju st because they were lonely . I'm very interested in how can
we invest to be proactive.
O ther programs, I think there has -- a food program called F armacy
with an F, where they're giving healthy food to a diabetic patients.
N ot only are the patients doing a lot better, they've saved a lot of
medical cost. I f I'm saying to a large physician g roup or provider, you
have accountability for your community, as long as they're doing it in
appropriate way, why wouldn't they be able to invest with certain
populations in these areas . T hey're going to have a better sense on
the ground at what's going to work , our approach is to say, hey, let
me create an accountable structure a nd let's empower local
communities and providers to offer services like this.
Mark Masselli: O ne of the cost of health care people don't often think about is the
cost of moving patients to where they can get care. We've been
focused in on one particular area which has been e - consults which I
know CMS has been supportive of. But sometimes you have t o move
the patients to where they can get care. Your department is exploring
really new initiative, emergency triage, treat and transport which will
incorporate multiple treatment options for EMT s in the field . U tilizing
these EMT s not just to transport to the hospital , talk to us about this
concept.
Adam Boehler: It was funny when I started at CM MI they said, h ey I'd like to hear
from the team. I say , what are your best ideas to lower cost and
improve quality? S omebody came up and said, w ell I've been talk ing
with the fire department in New York a nd when you call 911, he said I
don't know if you know this, but they're only paid if they take people
to the hospital , and t hat was surprising to me . I thought of the
incentives . O bviously, that creates kind of a poor incentive. W e met
with the chief medical officer there, he said 30 to 50% of the people
that we take to the hospital, we certainly don't need to . W e could
either treat them in place, or we could take them t o an alternative
destination, like an office location for physician or behavioral health
center. W e would just lose so much money if we did that , a nd that's
what patients want.
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W e want to kind of create a neutral incentive . Y ou're paid to do
what's right for the patient, and not open it up , s o they'r e paid for
treating place . Also , for alternative destination, they can listen to
what the patient and the situation demand and do what's right. M y
favorite thing about the initiative actually is he said, Adam if we’re
allowed to do this, we have a fixed am ount of ambulances. T he key if
somebody really calls 911, because they need it, they're having a
heart attack, they're having a stroke , response time, the most critical
for every minute of response time , our survival rate is so much better
if we get there quicker. W hat you're doing is you're focusing those
trips at the hospital where people need them a nd so our response
time is going to i mproved and we're going to save lives too. I th ink it
was really kind of a win all around.
Margaret Flinter: We've been s peaking today with Adam Boehler, D eputy A dministrator
and D irector of the Centers for Medicare and Medicaid Innovation at
the Centers for Medicare and Medicaid Services. You can learn more
about their work by going to innovation . CMS.gov or you can follow
A dam on twitter @ AdamCM Mi . Adam, we want thank you for your
creativity, your commitment to innovation, and for joining us on
C onversations on H ealth C are today.
Adam Boehler: Thank you, Margaret , t hanks Mark.
[Music]
Mark Masselli: At C onversations on H ealt h C are we want our audience to be truly in
the know when it comes to the facts about health care reform and
policy. Lori R obertson is an award - winning journalist and Managing
Editor of F act C heck .org a nonpartisan, nonprofit consumer advocate
for voters tha t aims to reduce the level of deception in US politics .
Lori what have you got for us this week ?
Lori Robertson: Senator Bernie Sanders introduced the latest version of Medicare for
th
all legislation on April 10 with 13 democratic co - sponsors, including
fo ur other presidential contenders . Senator s Kirsten Gillibrand,
Kamala Harris, Elizabeth Warren and Cory Booker , l et's take a look at
what Medicare for all would be. As the name indicates , Sanders ’s plan
would expand Medicare, which now covers primarily tho se age 65 and
older to everyone , creating a new universal single payer health care
system in the United States. The Veterans Health Administration and
Indian Health Service however would remain.
The new universal Medicare program would cover comprehensive
health services, including dental hearing and vision coverage, which
aren't included in Medicare benefits now . T here would be no copays ,
deductibles or premiums with the exception of prescription drug co -
pays capped at $200 per person a year indexed for in flation. The bill
calls for everyone to get a U niversal Medicare C ard fo u r years after
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enactment of the legislation. As for private insurance, it could still be
available but in a very limited role. It could only be sold to cover
additional benefits that t he new universal system didn't cover. There's
also the potential for direct pay private contracts between health care
providers and individuals f or services for which the provider will not
seek reimbursement from the government.
The Secretary of Health and Human Services would set a global
budget each year , set fee schedules for providers and negotiate drug
prices. As for what the plan would cost , there's no firm price tag. The
Urban Institute estimated in 2016 that a similar plan put forth by
Sanders would increase all national health spending by $6.6 trillion
over 10 years . I t would increase federal spending by 32 trillion over 10
years . Sanders has proposed various suggestions up for debate on
how the plan could be financed, including through payroll and income
taxes.
A house version of Medicare for All is co - sponsored by Representative
Tulsi Gabbard, Tim Ryan and Eric Swalwell who are also running for
president. Other congressional bills would make much less sweeping
changes. They call for a public option based on Medicare or Medicaid
in the Affordable Care Act exchanges and Medicare buy in programs
at age 50. T hat's my fact check for this week. I'm Lori Robertson
Managing Editor of FactCheck. org
Margaret Flinter: F act C heck.org is committed factual accurac y from the country's major
political players and is a project of the Annenberg Public Policy Center
at the University of Pennsylvania. If you have a fact that you'd like
checked, email us at C H Cradio.com w e'll have FactCheck.org’s Lori
Robertson check it o ut for you here on C onversations on H ealth C are.
[Music]
Margaret Flinter: Each week C onversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Baltimore ,
Maryland has one of the highest emergency medica l call volumes in
the country and it results in a significant number of patients being
taken to the ER for conditions that could have been treated outside of
the ER . The University of Maryland Medical Center and the Baltimore
City Fire Department teamed up in the hopes of reducing unnecessary
ambulance trips and hospitalizations. They created a new pilot
program which pairs doctors and nurses at the hospital level with
paramedics in the field, bringing medicine right into the patient's
homes .
Male: W e monit or the 911 system so that we c o - dispatch a paramedic and
either nurse practitioner or doctor to the scene of low acuity calls. Ask
the patient what they would like to be treated as s cene . We then
treat them at scene, discharged them with prescriptions as n eeded.
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T hen we follow up with them within 24 hours to make sure they got
what they need.
Margaret Flinter: Dr. David Marco zzi of the University of Maryland Medical Center says
that this mobile Integrated Health Care Community P aram edicine
Program has a two prong goal . O ne, reducing unnecessary trips to the
ER, two, to keep vulnerable patients being released from the hospital
healthier was paramedics doing frequent follow ups over a 30 day
period .
Dr. David Marcozzi: F or T HS or the Transitional Health Suppor t the 30 day follow up
program , o ur data demonstrates that the patients who are followed
in our program are admitted to the hospital significantly less and
utilize their primary care services significantly more . T hat translat e
into lower cost to the system , from a p hysician b illings construct , from
the hospital construct , from an ER construct .
Margaret Flinter: Dr. Marcozzi estimates that the two year pilot will save the University
of Maryland Medical Center at least $4 million and the fire
department expec ts to save just under 2 million. The Mobile
Integrated Health Care Community Pa ram edicine Program rethinking
how pa ra medicine is deployed in the field , reducing unnecessary
emergency room trips. Now that's a bright idea.
[Music]
Mark Masselli: You've been listening to C onversations on H ealth C are , I'm Mark
Masselli.
Margaret Flinter: And I'm Margaret Flinter.
Mark Masselli: Peace and health.
Female: C onversations on H ealth C are is recorded at W ESU at Wesleyan
University , streaming live at C H Cradio . com, iTun es or wherever you
listen to podcast. If you have comments, please email us at
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