My Kind Of Town…

Bill Myers

Bill Myers

Bill Myers

Chicago—Hello, ProviderNation. Few things congeal the tissues more quickly than the phrase “panel discussion.” (Your Humble Correspondent will pay any price, bear any burden to avoid even staff meetings and has the performance evaluations to prove it.) But Wednesday’s inaugural edition of Provider’s IGNITE was one helluva toboggan ride.

Sponsored by the fine folks at PharMerica, IGNITE brought together naviHealth’s Chief Clinical Officer Dr. Clayton Ackerly, Signature HealthCARE CEO Joe Steier, Good Samaritan’s Divine Sharon St. Mary, and AHCA/NCAL’s own James Michel, who—despite having one of the most thankless jobs in Washington (running interference between members and regulators on payment reform? Have a chat with your guidance counselor, son…)—is perpetually so well dressed and coiffed some might wonder if he spends his spare time starching and ironing himself.

The topic was payment reform and, while I don’t want to spoil the ending, it was awesome. Your Humble Correspondent live-tweeted the red hot, provider-on-provider action, and if you missed it, go to the box, you know, two minutes by yourself, and you feel shame. A few notes, though:

  • PharMerica CEO Greg Weishar kicks things off. Standing (literally) in the shadow of the John Hancock building at the Ritz Carlton, Weishar tells the crowd that he and his team picked Chicago for its symposium “because Chicago is cool.”
  • Cheering is heard from the press box.
  • Weishar takes the crowd through his own history: He started out in long term and post-acute care pharmacy, “hit a roadblock,” and left. Eight years ago, he came back, thinking, “The industry is ripe for change.”
  • Weishar and the fine folks at PharMerica have spent a lot of time (and money) on their own communications systems, and now they want to help providers to come along, too.
  • “We’re trying to do our part to move the industry into modern telecommunications,” Weishar says. The focus isn’t just internal, but on that glory of glories—“interoperability.” Partners (such as a certain pharmaceutical company) are critical in the new era of managed care/bundled payments, Weishar says.
  • Next up is our very own Greg Crist, whose handkerchiefs cost more than the GDP of several developing countries.
  • He wears his AHCA/NCAL hat first, telling the audience about how to manage public affairs in Washington (like “hunting a bear with a switch,” he says).
  • In the two decades that Crist has been in Washington, D.C., the place has changed in three significant ways, he says:
  • It’s become “hyperpartisan,” traditional media has had, um, problems, and a “sophisticated policy apparatus” has arisen.
  • Lobbyist-Americans are always whining about “partisanship,” Crist acknowledges, but consider: In 2002, 103 of 435 House races were close (i.e., the margin of victory was 5 percent or less). By 2016, there were only 29 close races.
  • This means that the “middle has dropped out” of the People’s House, Crist says.
  • The decline of traditional media means that “the rules of engagement” have changed.
  • The Interwebs and blogosphere reward “gotcha,” and a public official’s career can unravel faster than you can say, “Delete that Tweet,” Crist says.
  • As an example of the new rules, Crist shows that terrific video of former US. Rep. Michael Grimm threatening to throw a reporter off a balcony.
  • I’m sure Crist makes some very salient points after this, but I can’t hear him: It would take a heart of stone not to burst out laughing.
  • As to The Sophisticated Policy Apparatus (which shall evermore be part of Your Humble Correspondent’s lexicon), Congress and regulatory agencies are simply stuffed with PhDs, Masters’ degrees, and other forms of genii, Crist says.
  • All of the foregoing makes it hard out here for a flak, Crist says.
  • At long last, the panel is seated. All agree that fee-for-service is the T. Rex watching that pretty light ball coming at him.
  • Ackerly says it best: “We’re moving into a new world, but we don’t know what it’s going to look like.”
  • CMS’ rulemaking notice on bundled payments for joint replacements, AHCA/NCAL’s Michel says, is the canary in the coal mine.
  • “It’s important because it sets a precedent by moving from a voluntary, demonstration-style of alternative payments to a mandatory alternative payment,” he says.
  • The government isn’t just experimenting with alternative payment models anymore: “They’re the new normal.”
  • St. Mary is on the panel because she has dispatches from the front lines: Minnesota has been in managed care for decades, and Good Samaritan has been aggressive about experimenting with different payment models.
  • For her, data are key. All quality efforts will require careful definitions and tracking and analyzing of data, she says.
  • Signature’s Steier is doing his best Eeyore impression today. The alterative payments, especially managed care, “are just killing us,” he says. “They’re creating instability, driving us crazy.”
  • He’s not sure that many providers will be able survive the days to come. “We think a lot of guys will just have to shut down.”
  • Steier talks very fast. Imagine everyone at a crawfish boil spontaneously bursting into flames, and you get the idea.
  • Ackerly, ever the doctor, wants to give it to you straight. He agrees that the joint rulemaking notice means bundled payments are inevitable, and maybe not all that palatable, “but we have no choice.”
  • An audience member raises questions about whether regulators are over-relying on the Five Star system to judge quality, and there are nods and (slight) murmurs of approval.
  • Michel says he’s already seeing low-rated centers fold up.
  • In principle, “maybe bad centers should go out of business,” but given the, um, funny math behind Five Star, Michel is worried that some “low rated” centers that actually offer brilliant care are going to shuttered unfairly, which in turn, might jeopardize care.
  • Someone in the audience suggests that Five Star could be tweaked if regulators added a risk adjustment measure.
  • Ackerly gives the notion a hearty thumbs up.
  • “Risk adjustment is crucial,” he says. He says he’s worried about the frail, or otherwise high-risk patients, who might well be ignored if some centers feel they have to “cherry pick” to keep their quality ratings up.
  • St. Mary says that one obstacle is that different caregivers use different languages for care. The data will have to be streamlined along the entire spectrum of care.
  • “How can we have a successful outcome if no one’s talking with each other?” she asks.
  • Medicalodges’ own Fred Benjamin (a man of unimpeachable character, taste, and judgment, as so many exiled Chicagoans are) joins the discussion from the crowd.
  • He says that, watching previous government experiments with alternative payments, many providers “seem to have come out of nowhere” to succeed.
  • There’s a corollary, though: “A lot of guys are going to be left behind,” he says.
  • Steier agrees vigorously, and says that he worries that the fetish for data will have an unintended consequence: If a care center’s numbers seem bad, it’ll scare off potential new buyers and investors, he says.
  • He also has his own ideas about how (and what) to measure. “I would love to see metrics driven by empathy, connection with staff… the whole human experience,” he says.
  • A woman in the audience asks the panel about managed care, and there are more than a few choruses of mutiny, mutiny, mutiny, grumble, grumble, grumble in the crowd.
  • “Killing us,” Steier says, “just brutal.”
  • St. Mary, though, suggests that providers should rethink their goals.
  • “Are we trying to get someone home so they can run a marathon,” she asks, “or are we trying to get her home without her needing any further services, or limited services? Don’t we want to get them home as soon as possible?”
  • All this means, though, is that providers can no longer wait until patients get to their centers to start their work, St. Mary says.
  • “You need to be a case manager way before they get to you,” she says.
  • Michel also is not sure that managed care is any better positioned in the new world, either.
  • He says that many managed care companies are worried that accountable care organizations, for instance, “will lock them out.”
  • For Michel, the uncertainty means there are plenty of “opportunities for innovation” in managed care.
  • The discussion shifts to whether it’s relationships with hospitals or the quality of the care that are key.
  • Ackerly says that this might be a false opposition: If providers are going to offer quality care, they’re going to have to be well ahead of their residents’ needs.
  • That means, almost by definition, that providers will have to make relationships with case managers and practice managers long before someone is scheduled for surgery.
  • And, while Ackerly agrees that interoperability is important, it’s “not going to fix the things we need to fix. It’s not the substitute for good care.”
  • For Ackerly, there’s “simple math” behind quality care.
  • Assess the needs of people in a community, assess the capacity of caregivers in a community, and line up people who need care with the care that they need.
  • “Just get it right,” he says.
  • Crist announces that “we’re moving to the lightning round.”
  • Your Humble Correspondent, who has been live-tweeting this event, contemplates seppuku.
  • “Health care reform is here to say,” St. Mary says. “We’ve got to get our heads out of the sand.”
  • For Steier, training is the essential thing.
  • “Leadership is the toughest issue,” he says, adding that it’s not enough merely to train up an administrator and hopes that it trickles down.
  • Ackerly comes back to the question of managing expectations—including your own expectations.
  • “I know it’s hard, but you really have to resist that urge to be all things to all people,” he says. “Figure out what you’re doing today that you won’t do tomorrow.”
  • For Michel, not only is health care reform here, but it looks like it’s just warming up.
  • It’s clear, he says, that the Obama administration wants to lock as many reforms as possible before he leaves, 16 months from now.
  • The good news is, “providers are really engaged in this” already, Michel says, pointing out that regulators were pleasantly surprised when so many providers volunteered for alternative payment demonstrations.
  • “You clearly have a voice,” he says. “Get your feet wet—engage.”
  • The discussion wraps.
  • It went more than four hours.
  • No one uttered the words “stakeholders,” “buy-in,” “pushback,” “circle back,” “close the loop,” “this space,” or any other of Washington’s charmless bureaucratese.
  • And there was much rejoicing.
  • Chicago is cool.
  • (And I have the expense report to prove it.)

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter (now!), @ProviderMyers.

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Filed under Long term care, Post-acute care

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