component, every single one of them regardless of how they're paying and ideally create incentives for greater efficiency and more careful use of appreciation resources that will devote increasingly to health care.

>> the error of human report that came out in 1999, shocking americans that 50 to 100,000 americans are dying in hospitals due to preventable medical mistakes. we know that there's very uneven quality. we also know that there could be much greater efficiency. when i think back to the question of the prior speaker about why is it that commercial payers end up making up the difference for hospitals. it's in part because they haven't had the need to be more efficient and cut out their

costs. they can meet whatever short falls they perceive from public payers charging more to commercial payers. there's the cost element that could be worked on further. if we create greater incentives for more efficiency we might get somewhere. the passage of the affordable care act spur payment reform because it set a blue print and path forward for medicine' care and the rest of the healthcare industry looked and said we better get on board. if we don't, we'll be the recipients of policy. it may not make sense for working-age people. there's a lot of interest in new delivery models. delivering healthcare that can happen if they have new payment models to support them. if you want physicians to make sure that patient care is coordinated. there isn't anything on the schedule to pays for care coordination or answering questions by e-mail or after

hours or making sure there are alternatives ways for patients to get primary care at night and on the weekends. if we want to see a more holistic patient center approached to healthcare we have to think about the individual fees that we pay but even maybe moving towards something more like we have in california more commonly than other places. where a holistic approach to payment is taken so all these elements of care can be taken into consideration. how much payment reform is there? c.p.r. gut started in the summer of 2010. at that time, i reached out to three big national payers, just out of curiosity, and said out of every dollar you are paying, what preportion is died to quality. at the time, it was between one and three cents on every dollar that had some kind of quality incentive tied to it. there was a tiny portion. in the years that c.p.r. has measured this and we get data

from health plans across the country and this is looking at the commercial market right now, we're at 50%. so about 50 cents on every dollar that is going to a doctor or hospital across the country in the commercial market is coming with some kind of incentive to improve the quality of care. one of the things that we're learning as we start looking at the evidence and i'll share more evidence with you, is the most common reforms happening to create those incentives are upside. they're saying to the healthcare provider, we'll pay you more or you will be able to earn an increase if you meet certain quality goals. there has been very little, what we call shared risk or payment meth odds or increase in payment methods that ask a provider to eat any costs where they've over spent on a budget that was agreed to or spent more than some might think is necessary for carrying for a certain population of patients. so for the most part, we're

seeing, again, upside only methods of payment reform built on top of a fee for service chassis. so on a daily basis, we're still paying fee-for-service and we're trying to correct them a little bit by adding some positive incentives for meeting quality goals. employers and purchases for the most part, who are of a se savvn these matters and engage, want to see increasing amounts of risk taken by providers. not to the point they can't handle or a point that would put them out of business, they want to see some shared risk so that it's not only those who are footing the bill who are taking the risk of the health of their population but it's the provider. increasingly we expect to see shared savings agreements where providers can share any savings that they produce. convert to shared savings plus shared risk where if they over spend on an agreed-to budget,

they will have to absorb those costs and have a stronger incentive not to over spend. and in between, there's bundled payments. this idea that not for everything a patient needs but for a type of care or procedure or episode of care, there could be a budget agreed to and quality met tick metrics. that has been talked about more than any other. there have been more conferences and we're still at fewer than 2% of payments in this country being made through bundled payments. that approach has a lot of promise but it hasn't taken off yet. so one of the questions i was asked to address is california any different from what we're seeing nationally? we have not had the chance to measure what is happening in california since 2013. these are dated points. the major difference in california versus the nation is

a lot more use of captation. we don't know really how other approaches to payment have evolved because we haven't had the chance to measure it. we're hopeful we have the chance in the next year to update our california score card on payment reform so you have information on that. as of now, i don't have more details on that. so, the other thing i was going to say is that the ability to reform payments requires willing parties on all sides. so, just because a purchaser or payer wants to change payment from fee for service to bundled payment, doesn't mean they'll be able t th to. the provider has to agree. it's difficult in markets where there's consolidation and market power and they're happy with the status quo and don't want to take on further risk. some providers think they can take on risk because they can

feel confident and they believe they're running an integrated system and so we can't generalize. payment reform is only possible when all the parties involved agree to work on it and i think there's a reason why we've seen the initial raise focus on upside only opportunities for providers rather than those that ask providers to take on financial risk. i was asked to address whether or not there's variation across commercial payers in their implementation of payer reform. there is. only around the fringes. for the most part, what i've shared that we're seeing nationally is what we're seeing among the health plans that we've examined. what i would say is that again, fee for service is alive and well. there's five or fewer percent of payments that don't have fee for service involved. for the most part, fee for

service is underlying everything. at first we saw pay for performance really grow and now we have shared savings take over. i think the difference is that we see across health plans are that some have moved more likely to ask providers to take on risk, especially in the context of accountable care arrangements. we have seen some health plans make almost no progress on bundled payment and others who are at least this year saying they're really going to start getting that it. there arget into it. >> i'm not sure if this is the right spot to make a comment. as a physician, it's an excellent presentation. speaking again from the provider standpoint, you can understand the complexity of this in terms of the measures of quality. measures of accountability. the concerns about adverse selection. as an infectious disease

provider, in the h.i.v. epidemic there were concerns that certain health plans were attempting to address the adverse selection by making it very unattractive to people who might be at risk for h.i.v., just as we've seen in mental health services. make themselves unattractive and the montra that needs to go on and the accountability when diagnosis are made that in fact services are delivered. from my recent experience at this meeting, the explosion of organizations that make claims in all these areas around quality and cost effectiveness, many do internal audits but there needs to be a whole industry of auditors who are independent who can step in and use criteria and i would hope you would address that briefly if you are planning on it. this does open up a potential

pandora's box and a lot of anxiety. >> there's got to be a middle ground somewhere in the burden this places on providers and how much it takes we from patient care. with the need to measure quality and know where one stands and where one needs to improve and to me people make choices and know how much to pay. and i think what happens is we focused on measures that were particularly easy to collect and that showed very little differration among providers because it was politically safe to ask providers to start reporting on things where they all look about the same. what employers and purchasers and consumers want to know is where the big difference is. especially in areas that matter to that particular individual. what their clinical condition might be or what care they need. at c.p.r. i've been asked by employers many times, what quality measures matter. how do i know what to focus on?

how do i know when my health reports to us how they're doing that they're telling me the things i should care about. we did some work to hone in on a set of 30 measures that we thought were those that mattered most because they were in areas where there was a greatest variation in performance. some of the highest spending and some of the biggest price variation as well. these were areas where we knew they were not getting a high-value product. and so, we were very pleased with ourselves that we came up with a list of only 30. since we have for the a.c.o. context have come up with a list of 10 we want to focus on. depending on who you ask, providers might want a different set for quality improvement purposeses. x-rays might want to look at something else. it is a very big challenge to really hone in on a corset that pleases everybody. but i think overtime, we should

focus in the areas where there's the greatest need for improvement and where there's a great potential, cost savings by improving quality. i don't know if that gives you a satisfactory answer but that's the way i think about it. >> it does attempt at the issue. i mean if one just takes a measure of blood pressure, the electronic medical record should be a boone to assessing qualities. health problems that say they do well in their pool of en rollies and sample 1,000 or five and don't sample the whole cross section, everyone that every visit, one should question the value of that. any look -- there was a recently a legislative attempt for a single payer system in california which specifically

allowed providers not to use an electronic medical record. i had concerns about any payment reform which allowed providers not to have something where one could begin to assess quality for every person they saw. >> all these points are really related to how well payment reform works. one of the ways you assess that to see if quality has improved. if there are challenges of measuring quality or we do have the right measures, we're limited in our ability to determine if payment reform is working well. i want to make the point we can evaluate payment reform is two levels. one is a macro level. if we look across the u.s. health-care system or just in san francisco, as a result of payment reform are people healthier? is the quality of care better and is care more affordable? those are the questions we want to scot a macro level. at a micro level, the specific program. the accountable care arrangements the city and county

of san francisco has. is that working and successful? both of these are really important. we feel it's important to look at both because if you just look at the micro program by program we might be missing the bigger story where providers buckle down for a particular program and do well for that but do more poorly elsewhere. we think it's important to look at both. let me give a few examples of things that employers and other purchasers are trying and what we know about the results. there have been efforts to change the fee asked. we are living in a fee for service system what's can we do to change the relative amounts we pay for things to encourage better quality. one program locally, the pacific business group on health worked in southern california to create a blended payment amount to be labor and delivery services and by paying the same for caesarian delivery and vaginal birth, they

were able to reduce see syrian birtbirth by 20%. medicade stopped paying for early elected surgery and while they had sickness that area, when they stopped paying they found a drop in something like, now even in the country, we've seen a dramatic drop but in south carolina they've done better than anywhere else by stopping payment for them. bundled paper ha payment has coh healthcare providers. wal-mart, for spine relationship has a relationships with those they selected. two separate bundles, one for the evaluation of the patient will whether or not they're an appropriate candidate for spine surgery and the other for the surgery itself. that way the providers has a

lessened incentive because they're getting payment for evaluating the patient and turning that patient way. wal-mart has found that 50% of patients ended up being sent back home without the surgery because they didn't need it or weren't going to benefit from it. santa barbara is working with an independent vender to find health systems a little bit outside of santa barbara proper where there's a monopoly and it's very hard to get a good price. through bundled payment, they have saved $70 per participant in their health plan based on a limited number of joint replacements that they've conducted through the program so far. there's been a lot in the news about employers direct contracting with accountable care organizations. for the most part, unlike what we're seeing from commercial payers, all of these arrangements include a shared

risk payment arrangement. so they are putting the provider at some risk for quality performance as well as spending. intell was an early one that gotta announced and its connected care program they're saving about 17% for employees in the plans. boeing of course has been in the news for information. they have quality improvement and improved patient experience. the a.c.o. with two different providers has found so far a 1% savings. qualcomm corporation launched with scripps health in san diego and general motors is working with henry ford in a direct arrangement in detroit. whether there's results are not are putting a financial risk on the providers. those are little nuggets of ant.

method by method there are mixed results. the data are more available in the public sector because public purchasers tend to feel accountable to tax payers or its their responsible to share result zoos people can learn. we have much less. because they're based on fee for service many haven't been able to demonstrate much impact but maybe it's logical because the size of the positive incentives being create solider diminished by the perverse incentives that continue on. i'm not going into detail here

but this shale shares various finding at accountable from the connected care program by intell and also a colorado medicade program. we're seeing it approach to accountable care being experimented with all sectors. we're just not at a place where we can say that accountable care approaches are a slam dunk but people like to say if you have seen one a.c.o. you've seen one a.c.o. ex they're different it's hard to come up with a generalization yet. same for bundled payment although i think people of saying a lot of promising results here when it comes to quality improvement and because we want to learn more whether or not it can contribute more

greatly to quality improvement and to cost savings. at a macro level like i said we think it's important to measure the impact of payment reform as well. just over the last few months, we have two years of work funded by the johnson foundation and the laura and john arnold foundation released three new score cards on payment reform at the state level that were calling score card 2.0. we are continuing to measure how much payment reform there is and what type but we're also looking at a set of indicators that we think can let us know if writ large these sweeping changes to payment are panning out in members of quality and affordable. >> we've been working in colorado which will be released on the 13th. as well as new jersey and virginia which we released over the last couple of months, i'm sharing the info graphic from

the commercial score card that shows they're above the national average that are value orient inside someway. they have a significant amount of shared savings like in other places. there's some similarity and some differences across the throw states that we've looked at but if we go to the next slide you will see that spent time to help about a macro level and the changes to payment were working. we have a combination of measures that get at system transformation as well as outcomes. this is the first year we're doing these score cards. these are just point in time and bits of information but there are some areas where people are very concerned and so in terms of thinking ahead about a road

ma'am for payment reform the idea would be to see if the changes that are made going forward have any impact on these metrics as they're gathered year over year looking ahead. not to get into a keep discussion of how well payment is working in virginia but it's good to look at problematic level as well as the big picture whether or not to see whether or not it's working. what is next? there's alberta of activity happening there were payment reform and until we figure out a bay to pay providers that leads to a better combination of quality and affordability. if fee for service is underlying so many of the these approaches to payments, and we're paying

too much for some service that's happen too often, too little for other things or nothing for things that we know should be happening more we have to address those discrepancy and while there's a very lengthy process involved in the medicine' care physician fee schedule and commercial payers use that as their benchmark there will be exciting announcements from one or more payers where they're going to diverge from that fee schedule and makeshifts so they can hopefully produce a better mix of services for the patients that are responsible. the last thing i'll say is that the incentives we provide to providers, need to be considered in the context of the incentives that we give to consumers. if we're holding providers accountable for how well they do at screening their patients but patients have too much out of pocket costs for getting the

screenings or don't perceive they have the coverage or ability to pay for them, we're asking a provider to do something that's very difficult and we're also not necessarily getting the patient the care that they need. that is just an example. we've done a lot of thinking about for each approach to payment, what kind of benefit sign would best support it. i encourage considering the things together and as well as network design and. >> there's still a huge amount of confusion in providers. whether medicare pays for one history and physical at the beginning of medicare or an annual and how one codes that in this fee for service environment if it's annual. i mean, how do you not code other medical problems when the

health plan wants you to code the other medical programs to get higher reimbursement but the members get are entitled to certain benefits for health. for health screening. this is really more complex than sometimes it looks like on the face about how to negotiate all of that. i appreciate the attention to that. we have to be concerned about our paving the cost that patients or drugs they need. so that they don't have financial barriers to getting certain services. the emphasis is primarily on primary prevention. it's not really been commonly used for patients who are already have chronic conditions for whom it's important to visit a provider on a given schedule or get certain screenings or certain medicines so they're going to try to figure out how

to do that. i'll wrap-up by saying, it's hard as an employer, purchaser to figure out how to evaluate programs. we can make numbers say anything that we want them to say or other people can too. we have tried to you use the example of basing blood pressure control on five patients or something. what is an adequate sample size. do you need a comparison group that sort of thing. we also are creating frame works for valu evaluating payment pro. if you want to go on the next slide, we have also put out

template that they can use foray count able care organizations whether directly or through a commercial payer who holds the contract with those providers -- whether an a.c.o. is reporting well. we will continue to push for more payment reform, more experimentation and also evaluation so we can learn what is working and continue until we get it right. >> i have one question. this effort started, what, about a decade ago? >> almost. >> yeah. and in another life i was in another world and we met before. i was hoping that you had solved some of these issues. [laughter] over the past decade. we're coming to a point of nirvana. i understand that there was a real sort of conundrum of trying

to get focused about where you were really trying to target your efforts initially. and i'm somewhat encouraged now that you have gone past that. there seems to be a broader sentiment trying to say this is what we're about and these are the outcomes we're after and so fourth. i commend you for taking this past decade to plow through all of this stuff. thank you, again. >> thank you, very much for the report. is there any public comment here? >> good afternoon, everyone. my name is hugo aguilar. i am a pharmacy student at ucsf. this is a particularly interesting topic. >> could you step a little closer to the mic. pull it down towards you and you talk right into it.

>> this topic was very interesting because it kind of touches on the realm of work i will be engage in the near future. hearing about this study that is now 10 years in the making and i'm thinking about pharmacy and how pharmacy is growing as say practice and as a provision, and our involvement being more in the patient care setting as far as the expanded roles of pharmacies having clinics, right, one thing that i'm thinking about here is how can we improve that quality and that evaluation and those met ticks. recently there was a bill, a senate bill initiated by senator jeff stone, that touched upon i.c.d. codes, i.c.d.10 being included on prescriptions so that this facilitates processing of payment and authorization for treatments for patients. this all improves patient care.

and so i think it's interesting that the study presented here today didn't include pharmacy but maybe they wouldn't have known how pharmacy would be the big role it would have now in the future, post the board to take into consideration, looking into senate bill 1240 that would help as far as providing the data for future study and evaluations. that's all i have, thank you. >> thank you. >> thank you, very much for that comment. you know, again, coming back from this meeting in new orleans, one of the areas where there's been an explosion of industry is pharmacy benefit management programs. and it's quite curious to me. again, in some of these

workshops, some of the speakers argued against transparency. against transparency in the relationship of pharmacy benefit management programs and pharmaceutical manufacturers saying there's no proven effort that transparency would improve cost or quality. and so these -- there's a lot of concern over, again, independent ant verification of some of the claims of cost savings that each one of these programs and there are probably more than 30 different pharmacy benefit programs out there vying for contracting. i think your comment and these comments are really critical to understanding this sort of challenge that's we all face in every single area including pharmaceuticals. >> thank you. >> any other public comments? >> i direct something to the

director, is pbgh focused on any specific aspect of this beyond what is cited here in their more they're partners on the quality indicators and there are a number of initiatives that they have underway on various quality indicators and through our partnership with both organizations, there's some complimentary and intentional overlap of the work in order to kind of get us all aligned and working together. i find it most helpful. there's a number of score cards that c.p.r. has put out that pbgh has been a participant in. there's a strong compliment tree. >> it's time to take a break unless someone objects. >> not at all.

>> we will be on break for 10 minutes.

foray count able.

[ please stand by ] [ please stand by ] >> presentation by juan anderson

and dr. neil mills. >> good afternoon. juan anderson from aon. i'm going to tag team with dr. neil mills, who is right behind me. he will be coming up in a few minutes. he is one of our national medical directors and he has been engage with sfhfs. and he has been supporting clinical expertise as it relates to your programs. so what we're going to cover today is actually a broader category that we're calling a care coordination and health navigation of which a component is the care management more of the clinical side that dr. mills is going to talk through. so in terms of the agenda today, we wanted to frame this in terms of level setting on what it is that we're calling care coordination and health navigation and what it does, what we want it to accomplish.

this is annie involving are an e of the ways they want to define it is within your realm in terms of customizing what this experience means for your membership. we'll level set on what it is. the various comb upon ant cam pd walk through the next steps. as you ratified the strategic plan last month, i wanted to call out the care coordination hits on engage and support that is outlined on page 2. what i've turned is outlined the objectives and bolded the categories where we think that this care coordination health navigation will support of that objective. if we move on to page 3, we wanted to define what the purpose and desired outcome is for a health navigation. we want to be sure to set what

those out exam outcomes and pris are. as you heard earlier in the conversation a key components has to be quality and cost so we wanted to have expectations for navigation to drive those levers in terms of cost and quality. navigation is really addressing the fragmentation of what we see in the health delivery system so we want to make sure we create a member experience that is easy to navigate and support the healthcare for your members. we also want to make sure that in this care coordination health navigation, that we put it in the context of your broader health ecosystem so you've got lots of great programs not just the benefit design but your well-being program. how do we integrate and connect those service to your membership. and then we obviously need to set some priorities as it relates to the vendors. if we look on page 4, we believe

that there are desired outcomes and priorities in six basic pillars or honey combs that you see here. we think this is really to enhance your benefit strategy, optimize the use of your programs and resource and drive better outcomes for your membership, ultimately the organization at the end of the day. you heard suzanne talk about activating high value. we think some of these services will really help activate the use of high value programs. so one, again, the fragmentation, we want to make sure we're simplifying the experience for the member in accessing their benefits. we want to make sure that they're optimizing the programs and resources and to be able to actually track impact on program management with this service. we believe that a portion of the navigation is helping members

use quality service and so that is providing selection and network providers. we want to provide them to the better, higher quality, better outcome providers. at the same time, we want to make sure we enhance their health and reducing their health risk. and then a component care coordination is really around navigation around clinical care and care treatment decision. where we'll hit reducing the waste lever. page five gives you details in members of the capabilities that we may want to see in those honeycombs. so for example, with the member experience, we want to understand the depth and breath of the resources we're calling care coordination. do we mean it's engaging live

resources and digital cale capabilities. to personalize the interaction so that could be the member experience and that's also part of your strategic plan. we talked about program navigation. it's an opportunity to educate and problem resolve for the members. and it's to ensure there's integration between your programs, vendors and resources. if there's anything he is. on the provider selection we talked about guidance to best providers based on cost and call quality metrics and real time redirection of provider choices. within that framework we're also saying part of care navigation and health navigation is really the appointment support so helping a member find the right provider, set the appointments and help them get to their appointments on time. a big part of the care coordination that dr. mills

would talk about is the education decision guidance. the care navigation around care management, chronic condition management. page 6 is kind of putting in all of those different capabilities and services and how it would impact a member. you see the member at the interest, they may ask questions about my health plan. what does it cover. i need to find the right doctor. i want someone to make sense of these bills and forms i need to fill out. and i really need to understand my diagnosis and my treatment options. so the navigation support is either by live engagement or digital engagement. it can be combinations of both and we likely sew a combination of both depending on where you are in your healthcare spectrum and the needs that you have. and they are the resources that will direct you to the right place at the right time.

and also connect you to all the resources that sfhss has which are outlined below. i'll stop there for a minute and see if there's any questions. or if this is resinating in terms of what it is? >> it's the ultimate intent here to help people know what they have in their benefits portfolio. how to access it more easily? be sure it's matched to maybe an initial diagnosis or if you are not quite sure what they have, they know where to go to get it. is that what trying to get here? >> also providing the clinical guidance and decision support, is this the right treatment for me? >> ok. >> the communication is going to be done how?

not by telephone? >> there are a variety of models out there. the models that we see both real people, talking to real people and having digital support as well from a technology perspective. >> i see the word concierge up here in the slide. >> you are reading ahead. >> am i ahead one point. >> i use air quotes there. >> well, anyway, i just point that out. a big comb phon component follon the ability of members to get second opinions within their health plan coverage, in my experience having been a provider in all of those health plans that they didn't really scratch the surface well enough. that the protocols that may be available to our speakers or to

you didn't reflect what the providers could do and have done and will continue to do and so members need to be i am paneled and they need to understand a little bit about how the providers can actually advocate for the members as well and that is a big component of this in addition to what we at hss can do. >> right. there are things that are embedded in the healthcare delivery system and how physicians talk to their employees and there's also kind of the member choice of getting that expert opinion or someone outside. i know neil can talk about that. so if we move on to page 6, this is annie involving landscape. we have vendors everyday that are coming into this space calling themselves health concierge and health navigation so it's across the board. what i'm trying to show on page 7, if you look at kind of the potential impact as the y axis

and the x axis is whether the scope of services are narrow and broad or broad and what the costs are associated with the various models that are out there in terms of health navigation and page 7 reflects what we're calling live so really picking up the phone and talking to a live person versus online. so if you look at the far left, you will see the category of point solution. right now hss obviously has an expert opinion and it's called a point solution where you are plugging it into your healthcare delivery system. the space and services are expanding as you move to the right and they're broadening in terms of the scope of services they provide as well as the fees associated with those services. if you move to the right of point solution, we're calling advocacy and some of the actual services are around education,

problem resolution, it's delivering to the individual to other resources within hss system and it is able to answer clinical questions. they're able to help you find the right doctor and explain the cost and quality and provide assistance and decisions support and really help with the care coordination and navigating the delivery system. if you move to the right of that, we're calling that health concierge where this model is where the concierge or the health navigation is the first point of contact versus going to the health plan. right now as a member if you are a kaiser or blue shield member you can call member services as your place to go to answer questions and you have hss customer service but if you want to get into the nitty gritty of the health plan you call the health plan directly.

this is replacing that call center with this concierges that will be the first point of contact. the goal of that is that you now have a member contact with the members and maybe they're calling for a benefit design and if you actually explore further, you are going to realize that this person has diabetes and maybe they're not clenching the resources that hss has related to diabetes and can direct that individual to the resources available. so that is the model of that first point of contact. they're going to take lead on the problem resolution and they're going to help integrate with your health system and other services that you provide. they're actively engage in how your accessing care and making sure that you are asking the right questions and you are getting the right clinical care. that's what we're calling health concierge. if you move to the right of that, where employers are thinking about and emerging and

approach and it's a care management as the first point of and the utilization care management and case management and they're doing that all in-house and really the health plan and after the services have been rendered. there's different challenges with the far right and this is just to show you broad scope of services and we think about hss and where you are today and where you want to go you want to move to the right and it could be in that space of advocacy and health and navigation concierge that we're calling there on page 7. >> maybe i'm just having a memory lapse, but what's.a