Tag Archives: Fred Goldstein

An Interview with Dr. David Shulkin and a Review of His Book

I recently had the good fortune to interview Dr. David Shulkin, the ninth Secretary of the Veterans Administration on PopHealth Week regarding his book “It Shouldn’t Be This Hard to Serve Your Country: Our Broken Government and the Plight of Veterans”. What a story! He goes through the unique interview/non interview he had with then President elect Trump, where he was not sure if he was interviewed, if he was offered a job or not and then to learn about his appointment via the the media.

One of the big surprises for me was learning that certain Veteran’s groups, in particular Concerned Veterans of America is really a Koch brothers funded organization which is pushing hard for the complete privatization of the VA. This group created trouble throughout his time as VA Secretary. The problem I have with complete privatization is that there are unique issues that Veterans face, that are much different than the general population, Medicare or Medicaid. Things such as traumatic brain injury, spinal cord injury, blind rehab, hearing issues, PTSD, prosthetics and orthotics, poly trauma and environmental hazards of war; for which there is little to no expertise to treat these in the private sector. These are areas in which the VA has developed expertise through years or research and experience. Dr. Shulkin clearly articulated that the VA serves a unique role, that the Veterans deserve top notch services, and that a hybrid public/private system is appropriate. But that you can’t just push Veterans into an unprepared or inappropriate private sector service.

He also proposed an interesting idea for changing the VA structure. His approach would make it unlike other departments by removing the political appointees and making the Secretary a four year appointment, in a model similar to the Federal Reserve.  This idea seems to make sense given the VA’s unique mission and what should be a Veteran centric versus political approach.  At the same time, Veterans need to have a voice and how one assures their voice is heard through the very political process in Congress is important.   I fear it might create pressure on Congress via heavy handed lobbying groups seeking to regulate the purse strings, although that goes on now.

During his tenure he worked on a number of important issues including wait times, the opioid crisis and Hepatitis C, among others. In each of these cases he had the VA put in a systematic and measurement based approach to improve these issues with an excellent example being Hepatitis C where they essentially worked to treat everyone, something we could learn from in the Private sector.

One thing that is I found bothersome was Dr. Shulkin’s belief that the President was unaware of what his political appointees were doing. I just kept thinking to myself “Why do you continue to separate in your mind the President and for example his Chief of Staff from the political appointees, using terms like “While largely unaware of the political appointees’ scheming…”. I cannot fathom that the President was truly unaware of what was going on, or that this was not all part of the plan. But Dr. Shulkin still believes that the President was unaware of these things. Now what that says, positive or negative about the President is clearly up for debate. But assuming as President Truman said “The Buck stops here”, as a former CEO, I fall on the side that, “being unaware” is a failing.

My recommendation to you, It Shouldn’t Be This Hard to Serve Your Country: Our Broken Government and the Plight of Veteran is a great read, both from a healthcare and political perspective. The unique insights it provides into the VA, their issues and President Trump and his administration are deep and important to understand. There’s much more that I did not cover in this post, including the major ethical issue Dr. Shulkin faced regarding his trip to Europe and the Wimbledon Tennis match, what it really was, and how it was used in the end to remove him. But you’ll have to read the book to get those.

After our interview, Dr. Shulkin said he’d be happy to come back on and discuss more about his experiences, thoughts, and the book. I hope to take him up on that offer.

Click below to listen to the show.

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ACOs and Value Based Care: The Best of Times Or The Worst of Times? It Depends!

By Fred Goldstein, MS and Gregg Masters, MPH

This past year has seen major changes to the Medicare Shared Savings Program (MSSP) that launched the huge growth in Accountable Care Organizations (ACOs) a principal workhorse in the transformational copy of the Affordable Care Act (ACA).  It seems that the Center for Medicare and Medicaid Services (CMS) and the industry had a difference of opinion as to how successful ACO’s were under the original model, and of course CMS won.

The argument had to do with just how well the ACOs involved in the Medicare Shared Savings Program Track one participants were doing.  For those new to this, the Track 1 model were the least risky model, with most ACOs choosing this upside risk or shared savings only track which had a term of six years before they had to begin taking on two sided risk.

CMS looked at the 2016 data and was seeing limited savings particularly with the overwhelming majority of participating ACOs enrolled in this track. In May of 2018 Seema Verma (CMS Administrator) hinted at a new approach pointing to a study by Avalere that ACOs not only did not save money, but they have increased federal spending by $384 million, versus a projected $1.7 billion in net savings from 2013 to 2016. Couple this concern with the ongoing debate on whether Medicare Advantage Plans (MAs) are still costing the Treasury (via over funding or “up-coding”) vs. advancing the needle on the Triple Aim (better experience of care, better outcomes at lower per capita costs).

Of course, the industry, led by the National Association of ACOs (NAACOs), were completely against this decision and stated that the ACOs had indeed saved money when they reviewed the 2017 results, which indeed showed net savings of $314 million dollars. NAACOS also stated that if these changes were made many ACOs would quit , pointing to a survey they had conducted showing that 71% of the ACOs in track 1 would quit if they had to take on 2 sided risk.

But by then it was too late and in last December CMS announced their new Pathways to Success models with the following by Seema Verma:

…the presence of an “upside-only” track may be encouraging consolidation in the marketplace, reducing competition and choice for Medicare FFS beneficiaries. While we understand that systems need time to adjust, Medicare cannot afford to continue with models that are not producing desired results.

The key changes were as follows:

  • Only 2 years before ACO must accept down-side risk
  • Beneficiaries notification of ACO participation at 1st primary care visit
  • Payment for tele-health services
  • Incorporates regional spending into ACO targets
  • Authorizes termination of ACOs with multiple years of poor financial performance
  • Could potentially save $2.2 billion in Medicare costs during the next 10 years

The new tracks and their “glide path” are as follows:

So what does this mean for ACOs?

What better place to figure this out than the Florida Association of ACOs annual meeting. Florida has been leading the way in ACO participation and performance and while this conference is in beautiful Orlando Florida in the fall, the attendees and speakers are national so one can get a full view of the impact and what’s working.

For an update on market conditions including an overview of the annual conference from FLAACOS CEO Nicole Bradberry, listen here.

Florida Association of ACOs

Attending the 2019 FLAACOs annual conference you’ll hear from Aneesh Chopra, President, Care Journey and former CTO of the United States opening the conference, followed by, you guessed it, a panel on MSSP ACO and Pathways to Success with Sheila Fusé, Vice President, Policy and Payment Models Navvis Healthcare, Kelly Conroy, Executive Director Holy Cross Physician Partners ACO, Travis Broome, Vice President for Policy and ACO Administration, Aledade a technology enable physician practice management company who recently reported some rather impressive results for 2018 from their network of clients ACOs.

The conference will then dig deeper exploring such topics as the new CMS primary care contracting models, Social Determinants of Health (SDoH), Direct employer contracting 2.0 and mental/behavioral health from a rather packed agenda.

So, join us November 7th – 8th in Orlando Florida to network and learn from those getting it done in the ACO world.

For registration details, click here.

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Interview on the “Unlocking Accountable Care” Podcast

I was recently  a guest on the Unlocking Accountable Care Podcast to discuss community efforts to improve health and H.R. 660 The Community Health Improvement and Leadership Development Act of 2019 – 2020.  You can listen to the podcast here.

Thanks to the folks at Day Health Strategies for providing me with this opportunity.

 

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The Population Health Colloquium: Social Determinants of Health, Precision Medicine and the Triple Aim

By Fred Goldstein, MS and Gregg Masters, MPH*

 

The field of population health continues to grow and create new areas of exploration and integration. Population health practitioners are called upon to play a central role as health systems, health plans or healthcare organizations work to implement their strategies designed to improve health care quality, access, outcomes and cost while weaning the US Healthcare system away from its fee-for-service reimbursement paradigm.

From the emerging recognition that Precision Medicine is not antithetical to population health, to the development of unique approaches to address the social determinants of health, it’s an exciting time.

This year’s agenda for the Population Health Colloquium reflects the dynamic nature of the field, featuring leading healthcare experts from academia, healthcare systems, health plans, data and analytics companies, population health companies, regulators, innovators and entrepreneurs. Continue reading

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An Interview with Kaveh Safavi at HIMSS

Every year at HIMSS, Gregg Masters and I get a chance to sit down with Kaveh Safavi, MD Senior Managing Director, Head of the Global Healthcare Practice at Accenture. It’s become one of the meetings we most look forward to.  This year Kaveh discussed Accenture’s recently released Digital Health Consumer Survey and he also discussed a little bit about his thoughts on AI that he shared in a recent piece in Forbes.

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