Hartford Business Journal

16 Hartford Business Journal • February 27, 2017 www.HartfordBusiness.com Doctors push value-based contracts, education By Matt Pilon mpilon@HartfordBusiness.com H ospitals and insurers face plenty of uncertainty as they try to discern how President Donald Trump's promised repeal of Obamacare and other potential health policy changes will impact them. Depending on how things play out, feder- ally encouraged (and even mandated) experi- ments with alternative-payment models like accountable-care organizations and bun- dling could be scuttled. That's created much anxiety in the health- care industry, particularly among doctors who insist that such "value-based" models — not all of which are yet proven to save money or improve health outcomes — are the right approach to steer the healthcare industry away from a long dominant fee-for-service model, which tempts medical providers to order unneeded tests and services. "Value-based health care will go forward in some way, shape or form, and the reason is that it makes a lot of sense," Dr. Richard Iorio, a New York University orthopedic surgeon, said recently in a Hartford stopver. "There are better outcomes for patients and it saves money in general." Iorio was recently speaking at St. Fran- cis Hospital and Medical Center as part of a day-long seminar that was essentially a crash course on healthcare payment models. The audience included approximately 20 physician- residents from St. Francis and UConn and sev- eral Quinnipiac University medical students. Other physician-residents watched doctor presentations via video feed from a medical school in Texas and an orthopedic institute in California. Iorio came at the behest of Dr. Steven Schutzer, an orthopedic surgeon and direc- tor of St. Francis' Connecticut Joint Replace- ment Institute. Schutzer said he agrees that value-based models are here to stay, regardless of politics. "I really don't think we're going to turn around and embrace fee-for-service as a dom- inant payment methodology," said Schutzer, adding that alternative-payment structures can only truly succeed if more doctors become experts in how they work. "At the end of the day, it's not that compli- cated conceptually," he said. "Operationally, it's incredibly complicated." Schutzer would know. In 2012, he spear- headed St. Francis' first foray into a bundled- payment contract, under which ConnectiCare pays a set price for a set of services related to hip and knee replacement surgeries. The con- tract has since evolved to include post-acute services and a "warranty" for the three months after a surgery patient leaves the hospital. Bundled arrangements remain a small piece of St. Francis' overall revenue, and are still uncommon at most Connecticut hospitals. One challenge, Schutzer said, is that newly minted doctors often don't know enough about value-based models, which can vary. Schutzer said the topic should be a larger part of the curriculum in residency programs and even medical schools. But it's not an easy sell. Schutzer said he invited residents from Massachusetts, Rhode Island and New York to the Hartford event, which took place in December, but was told they were too busy or unable to attend. The 20 residents that did show up were hard won. "I thought we would get 400 residents," Schutzer said. "We really had to beat the bushes to get them here." For the organizer of an event dedicated to exploring the measurement and application of healthcare value, Schutzer couldn't help but wonder if the many hours he and his colleagues spent organizing it were worth the effort. Like most things, it depends on how you measure it, he concluded. "I guess at the highest level we want to inspire a new generation of leaders that can change the mindset of others," he said. "If we have 20 kids here and maybe 50 online, and if half a dozen step up to become leaders, we've accomplished our goal." Though an eight hour deep dive into value- based contracting may not be enough to turn residents into healthcare-business experts, it at least gets them thinking about it, he said. That knowledge can also be useful to resi- dents in deciding where to work when they enter into practice, and it may yield more valuable offers from prospective employers, said Dr. Cynthia "Daisy" Smith, vice president of clinical programs for the American College of Physicians. "They need to understand the environ- ment in which they'll be practicing," Smith said. "High-value care is a team sport and participating in these alternative-payment models is a team sport." Curriculum review New financial models may provide the best realistic shot at stemming rising health- care costs, but Schutzer and his fellow alter- native-payment proselytizers contend it will only happen if doctors increase their collec- tive knowledge about how they work. They argue that such education should begin as early as medical school, though there is debate about that. From pre-med through residency, it takes more than a decade to train a new doctor. Given that time span, and the fact that pay- ment models evolve over time, educators grapple with placing more focus on payment models, given their core mission to teach the knowledge and skills needed to provide medical care. "That's an issue that every medical school wrestles with on a regular basis because every- thing is changing," said Dr. Bruce Koeppen, dean of Quinnipiac University's medical school. Koeppen recalled what one of his own teachers told him in medical school in the 1970s: "There's good and bad news. Half of what you will learn in medical school won't be correct in 10 years. The bad news is I can't tell you which half." Payment models aren't part of Quinnipi- ac's current curriculum, but it's possible they will be following an ongoing review, he said. At UConn Health, there isn't an official curriculum component for residents involv- ing payment models, though faculty has more recently begun to include it among the topics discussed during weekly academic sessions, according to Dr. Vincent Williams, who spoke at Schutzer's seminar. "We're starting to introduce that more and more," Williams said, adding that he agrees young doctors with that knowledge could be more attractive to physician groups. Several years ago, concerned about rising healthcare costs, the American College of Phy- sicians developed a curriculum for residency programs that includes alternative models, which has been updated several times since. Smith, who worked on the project, said hospitals are free to use some or all of the framework, which has been downloaded more than 45,000 times. "I think the impetus was we felt we really needed to do something," Smith said. "This is clearly an identified gap and I do agree the sooner you close it, the better." n Dr. Steven Schutzer (above) of St. Francis Hospital thinks alternative-payment models are the future of health care. Schutzer invited Dr. Anthony DiGoia (below), to speak to medical residents at a seminar on value-based payments. H B J P H O T O | M A T T P I L O N Insurance coverage mandates would face more analysis under Malloy proposal By Arielle Levin Becker CT Mirror A s they do most years, Connecticut legislators are considering a host of proposals that would expand what health insurance plans must cover. This year's proposed coverage mandates include inpatient substance abuse treat- ment, breast pumps, insulin jet injectors for people with diabetes, and fertility pres- ervation for people with cancer. Patients who testify in support of proposed benefit mandates often share stories about struggles they faced getting needed care or medications. And critics warn legislators that adding mandates increases the cost of insurance premiums. In some cases, they also take issue with the merits of the particular service being considered for mandatory coverage. But Gov. Dannel P. Malloy is seeking to change how coverage mandates are han- dled. Under a bill the Democratic governor proposed, the General Assembly, starting next year, would be prohibited from creat- ing any health benefit mandates unless they have first gone through a review focused on, among other things, the cost, effective- ness, safety, current availability, and impact on healthcare costs and insurance premi- ums of the particular treatment or service. The idea is to give legislators the infor- mation to determine if the proposed benefit change would "come at a cost to consumers or provide savings," said Chris McClure, a spokesman for Malloy's budget office. The concept drew praise from the top Republican on the legislature's Insurance and Real Estate Committee. But Senate President Pro Tem Martin M. Looney, (D-New Haven), who frequently proposes and testifies in support of insurance bills, described the measure as unnecessary and an inappropriate extension of execu- tive branch power into legislative matters, and said the timing is problematic. "We may need a lot of additional flex- ibility in terms of mandates and other things if the Affordable Care Act is repealed," Looney said. Malloy's proposal would limit how many potential benefit mandates could go through the review process each year, allowing the Insurance and Real Estate Committee to select up to five. The insur- ance commissioner would contract with the UConn Center for Public Health and Health Policy or an actuarial firm to con- duct the reviews. State law already allows for a health ben- efit review program for existing or proposed mandated health benefits, but the reviews are not required before a potential mandate becomes law, and are only conducted at the request of the insurance committee. McClure said the process is "seldom used," because it doesn't match the tim- ing or needs of the legislature. n

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