ACHE 2017 Congress on Healthcare Leadership Live Blog

Health care management is changing dramatically. The landscape has shifted in countless ways, requiring health care leaders to engage with different perspectives, insights and knowledge. ACHE's 2017 Congress on Healthcare Leadership offers endless possibilities and unlimited opportunities to collaborate and "think outside of the box" and to help leaders understand and prepare for the myriad challenges awaiting them inside a transformative health care environment.

Follow this live blog for updates, key takeaways, and photos from the conference. 

Thursday, March 30

American Hospital Association – Federal Legislative and Policy Update

By: Vivian Leopold, FACHE, Regional Manager for Mayo Medical Laboratories

Richard Pollack, President and CEO of the American Hospital Association, (left) and Thomas Nickels, EVP, Government Relations & Public Policy with the American Hospital Association (right)

Thanks to interactive video conferencing technology, Richard Pollack, President and CEO of the American Hospital Association and Thomas Nickels, EVP, Government Relations & Public Policy with the American Hospital Association, beamed in from Washington D.C. to the large crowd. After last week’s pulling of the Republican health care bill before the House could vote, here’s what they had to share.

What is agreed upon? What are the bipartisan issues within health care reform?  It’s been delivery system reform, payment reform, transparency, and IT.  Everyone agrees with movement away from fee-for-service to integration, value vs. volume and quality vs. quantity. 

So what’s been partisan?  Coverage and how to pay for it, use of taxes and income redistribution, creating another new entitlement.

Even on its best day, the Affordable Care Act (ACA) was not universal coverage. President Donald Trump had had enough of negotiations. He pushed for take it or leave it but it became obvious late last week that the House Republicans couldn’t muster enough votes to pass the American Health Care Act (AHCA) to send to the Senate. Where do we go from here? At this point, there are mixed signals.

What are the options?

  • Let Obamacare collapse
  • Fix it
  • Make it more Republican–work with the Freedom Caucus & Tuesday Group
  • Straight repeal
  • Bipartisan deal

There had to be some sort of replacement; you couldn’t leave everyone high and dry, but some Republican members of Congress were alienated. The AHCA bill is off the table now, at least for the time being due to the impending budget that has to be done, the upcoming debt ceiling, the vote on Supreme Court nominee Neil Gorsuch, a 2-week recess, and Trump’s next focus – tax reform.

Thomas Nickels, EVP Government Relations and Public Policy

In the 1200+ page ACA still in place, there are more than 2500 examples that say “the Secretary of HHS shall….” When it passed in 2010, that gave then Secretary Kathleen Sebelius the power to make changes. That now falls to HHS Secretary Tom Price who could shift his focus to more reforms within the existing ACA.

AHA shared examples of potential actions:

  • Create additional exemptions to employer mandate
  • Avoid IRS enforcement of individual penalties
  • Fail to enforce employer mandate
  • Revise medical loss ratio
  • Extend availability of non-compliant ACA plans
  • Stop Justice Department suits defending ACA
  • Failure to pursue premium stabilization actions
  • Increase barriers to enrolling in marketplace plans
  • Disable or defund the CMS Center for Consumer Information and Insurance Oversight
  • CMMI constraints
Richard Pollack, President and CEO of the American Hospital Association

Nickels provided a historic look at how past presidents were able to cross the aisle to get legislation passed. In 1986, President Ronald Reagan had the tax reform act. This was 1 ½ to 2 years in the making, but Reagan reached out to Democrats leaving some Republicans behind. In 1997 for the balanced budget act, President Bill Clinton left some liberals behind to strike a deal.  With the Bush tax cuts, it worked basically the same way in reverse. But just how far can one go reaching across the aisle? Well, we have House Speaker Paul Ryan now rather than John Boehner who lost his job working with the Democrats. And, don’t forget about mid-terms elections in 2018.

Is the ACA in a death spiral? The Congressional Budget Office (CBO) thinks that this year, 2017, will be the rockiest, with stabilization of the market coming in 2018. After all, the exchange market is relatively small, about 4.2%, compared to 49% with employer coverage. Seventy percent of the exchange markets do though, have only 1 or 2 options. On one hand, if there are continued premium increases, the exchanges could collapse. On the other hand, it is a limited segment of the market. 

How do you provide stability in the market? This is a flashpoint. If you want the market to function, you have to have subsidies go directly to insurers. If not, they will leave the market.

What is the American Hospital Association focused on? AHA’s Advocacy Agenda includes these Tier I issues likely to come up:

  • Offsets - regular menu, site neutral
  • Tax reform
  • Physician-owned hospitals (HHS Secretary Price seems to favor these)
  • 340B
  • Appropriations: health and education programs
  • Pricing transparency
  • ACA coverage provisions

For Tier II advocacy items, AHA will provide leadership moving forward.

  • Private market stabilization -  cost sharing subsidies, risk adjustment, reinsurance, and risk corridors
  • Extensions (rural)
  • Medicaid DSH relief
  • Regulatory relief

There is an opportunity for bipartisan legislation, but the focus must be on improving care, not provider cuts, cuts, cuts.

Pollack closed the session with these words, “The health care field in undergoing a revolution. Not just because of the Affordable Care Act repeal and replace that didn’t happen, but due to rapid change in technology, advancements and how the continuum of care is managed. We are redefining the blue “H” to define the demands of the moment. The “H” has always been a beacon to anyone  who needs help. We are continuing to move to where a hospital is as much associated with health as it is sickness.” 


Thursday, March 30

David Shulkin, Secretary of Veterans Affairs

By: Vivian Leopold, FACHE, Regional Manager for Mayo Medical Laboratories

David Shulkin, the new Secretary of Veterans Affairs, (facing camera) attended the ACHE Congress reception last night, complete with Secret Service detail. Secretary Shulkin was approved unanimously for his Cabinet position on February 13, 2017. Here, he is conversing with Charles Stokes, FACHE, Executive Vice President and COO from Memorial Hermann Health System in Houston, TX (left) current Chairman of ACHE.  

Tuesday, March 28

Merit-Based Incentive Payment System Mastery: Strategic Deployment of the Medicare Access and CHIP Reauthorization Act in Your Organization

By: Vivian Leopold, FACHE, Regional Manager for Mayo Medical Laboratories

My head is still spinning from this hour-and-a-half session. A lot of regulatory information and details were presented on MIPS and MACRA and calculations. Here are some of the highlights:

  • The intention was to advance Medicare to value-based reimbursement.
  • By December 31, 2018, CMS' goal is to have 90% of Medicare fee-for-service payments tied to scores on quality and efficiency measures and 50% of traditional Medicare payments through APMs (alternative payment models).
  • MACRA has bi-partisan support and passage and replaces the doctor fix, which had just extended the physician reimbursement/fee problem.
  • The transition period is through December 31, 2018. Due to potential penalties, physicians could take up to a 9% hit if they do nothing.
  • MIPS final score components include quality, improvement activities, and advancing care information (old "meaningful use") for 2017 performance year, and adding cost performance in 2018 and going forward. (Percentages of each do change.)

 The objective is to have a single score from 1 to 100 that will be publicly reported–Physician Compare

  • MIPS payment adjustments will include a half -billion dollar pool for exceptional performance, not greater than 100% of billed Medicare charges.
  • MIPS participation election–individual (NPI) or group (TIN): final score assigned to each NPI/TIN; group reporting must include ALL NPIs who reassign to TIN, cannot pick and choose.

A question from the audience was, “Are all physicians grouped together or by specialty?” It is at the TIN level, so it all depends on how the TIN is set up. Think about the impact a poor-performing physician could have on the group score, or how this might impact what physicians your organization recruits based on their scoring. 

Please consult your CMS and regulatory experts in your organization.

Tuesday, March 28

Women in Leadership: Creating an Inclusive Culture

By: Vivian Leopold, FACHE, Regional Manager for Mayo Medical Laboratories

This panel discussion attracted a couple of men in the vastly female audience. Panelists were Michelle Stohlmeyer Russell, Senior Partner & Managing Director at Boston Consulting Group; Julie Creamer, SVP of Northwestern Memorial HealthCare system and President at Northwestern Memorial Hospital; and Laura Forese, EVP and COO of New York-Presbyterian. 

It was an interesting exchange between Creamer and Forese who came up the ranks through a female-dominated career path (nursing for Creamer) and male-dominated one (orthopedic surgery for Forese). Having female mentors can be very helpful—women tend to be strong in collaboration, teamwork, and empathy, although Forese shared that she never had a female boss or mentor. Men are inclined to take pieces of different role models to emulate, while women look for someone just like them. It’s important to break that mold as you may never come across that person.

In the workforce, there exists a hidden or unconscious bias. The higher up the ranks, women are not as well-represented. Men get promoted based on future potential while women tend to be chosen for promotion based on past performance. Referencing a study from Facebook COO Sheryl Sandberg’s book Lean In, when looking at a job-posting opportunity, women think they need to meet virtually ALL the job requirements or they don’t apply for the position. Men on the other hand, might meet 2 or 3 of the job requirements, and they go for it. Women are limiting their potential opportunities at the very beginning of the job search process.

In the health care arena, an inclusive culture also includes the composition of the board of directors. Forese said that if there is one woman on the board, she’s usually ignored; if two, the other members get them mixed up; so three or more are needed. In Fortune 500 companies, the tipping point seems to be one-third women on the board, and these companies are more successful. Companies perform better with more diverse composition. This should be kept in mind for committee composition/makeup also. Keep in mind what it is you are trying to achieve. Try to include someone knowledgeable but not necessarily about the particular project. This person can provide a fresh perspective. 

In the book The Hidden Bias, it’s OK to have bias, but it must be recognized.

Diversity means that the people are there at the dance, while inclusion means they are actually dancing.

How can we achieve this diversity and inclusion in our organizations? Think much earlier in the career pipeline—don’t recruit from the same schools you always have, or try “interning” high school-aged kids to learn about health care opportunities long before the hiring process. Northwestern Memorial has such a program in conjunction with Westinghouse.

A question from the audience was, “Do you hire based on diversity over qualifications?”

The role should be hired based on skills, experience, performance, then on diversity.

Tuesday, March 28

What Health Care Leaders Can Do to Make Patients Safer

By: Vivian Leopold, FACHE, Regional Manager for Mayo Medical Laboratories

Progressing through a career as a physician, astronaut, and chief patient safety officer for Veterans Affairs, speaker James Bagian, M.D., P.E., now serves as Director, Center of Health Care Engineering and Patient Safety at the University of Michigan. With such a diverse background, Dr. Bagian witnessed how things were so different in health care vs. aviation. “It’s one thing to have a game plan, but you need tools and tactics to get down to action.” He posed the question, “If we had to do it all over again, would we have done things differently?” It’s critical to get away from blame, to build defense in depth. 

As an example, before bar-coded medication was implemented, the error rate for medication errors was 1 in 6. With bar-coded medication, it’s now tenths of a percent. 

Needless variation is a loser’s battle.

It’s important to speak up if things don’t look right. Why don’t people report? In a cultural survey conducted, 49% of people said they would be “ashamed” if anyone knew they had made a mistake. From your staff standpoint, blame-free infers unconditionally. This led to what later became “just culture” where the reporting person could only be identified if: 1) it was a criminal act, 2) the person acted under the influence of alcohol or drugs, or 3) the person did something intentionally/deliberately unsafe.

An interesting study between pilots and internists asked, “If your supervisor tells you to do something unsafe, would you say something?” 97% of pilots said yes, but only 54% of internists replied yes. The answer should be 100% in both cases. Why is there a reluctance to question the order? This points out leadership’s role to encourage staff to speak up without fear of retribution, and as a result, the patients receive what’s best.

Follow-up, or lack thereof, is another reason that staff may be hesitant to report safety issues. A survey indicated that one-third of problems brought up by staff were never fixed. And oftentimes, in cases of problems that were actually fixed, there was NO reporting of the fix.

Reporting serves two purposes: for learning and accountability.

Dr. Bagian told the crowd that a 1974 TWA flight crash in Washington, D.C., changed the face of aviation. Until then, a pilot’s license was suspended until any investigation was complete. So many pilots did not report near misses, even not of their own doing. That all changed. 

How leadership prioritizes reports is important, which should be transparent and risk-based. "Root cause analysis (RCA)" is a terrible term because it’s usually not just ONE reason, and it’s not just an analysis but ACTION required. RCA2 (squared) is more appropriate. Dr. Bagian encouraged health care leaders to lead by example. Fault is an "F word" in medicine. Instead ask: What happened? Why? What can we do to prevent this in the future?

Tuesday, March 28

Day 1 Recap

By: Andy Cousin

Last night, I finished my sessions with one of my perennial favorite duo of presenters; each year they provide an update and lessons learned, good an bad, on their value-based journey. Stephanie McCutheon, FACHE and Gayle Capozzalo, FACHE (and recent Gold Medal Award recipient), presented "Value-Based Care for Population Health: Sharing, Scaling, and Replicating to Accelerate Results." Stephanie, who is one of the sharpest and most honest speakers you'll ever meet, laid out the unsustainable health care spend trend—a well-known target of mine to those who read my blog. She also walked through the charge of the Health Employer Exchange (HEE) and the model that has driven their success in building successful value-based programs with large medical providers based on a four-step program:

  • Establish culture of health
  • Implement a population health management system
  • Restructure the delivery system and measurements
  • Replicate and scale successes in pilots

The program, rolled out at five systems and counting, come with some impressive stats:

  • 15% reduction in health plan costs in a three-year span where a 10% increase was forecast.
  • 20% reduction in ED visits with an estimated $2.4M in savings.
  • 34% reduction in PMPM costs in 770 participants with a 99% satisfaction rate.

Give their latest white paper a read, "Academic Health Centers and the Evolution of the Health Care System," to see the details of the program. 

Ms. Capozzalo then walked through specific experiences with Yale New Haven with an overview of their benefits design program, programmatic interventions, member engagement, and provider engagement programs. She noted a new focus on pharmacy and the desire to lower PMPM costs. It's exciting for us in the diagnostics space to see this kind of thinking given the proven linkage between diligent use of personalized genomics and the more effective management of pharmaceutical therapies. 

Ms. McCutcheon is on of the most quotable people I've ever had the pleasure of listening to and I'd be doing you all a disservice not to capture some of her best:

"[Healthcare and payment] is complicated. Get over it. If we don't fix this, someone far less competent will."

On those who dismiss the need for change as overblown:

"If you don't like change, how do you like irrelevance?"

It's funny because it's true. 

I would also like to thank the Mayo Clinic Care Network (MCCN) for its kindness in extending me an invite to the member reception. A number of us from Mayo Medical Laboratories joined MCCN at the Hilton Palmer House for a great reception with MCCN members from around the country, and we met some forward thinkers and all-around great people. Thanks to Lenae Barkley and Eric Crockett for their hospitality.

Monday, March 27

A Rapidly Adaptable Management System

By: Andy Cousin

This one sure hits home. What's the right way to lead, structure, and keep a team nimble in the maelstrom that is health care change?  Maryjeanne Schaffmeyer, our faculty for the session, and another face familiar to us at MML as she is the former chief operating officer for ThedaCare Hospitals, moderated a great interactive session.

Ms. Schaffmeyer shared some great ideas and described the need to determine a "true north" that sets a common purpose for the enterprise and aspirational objectives. With that, she talked of the need to limit strategic objectives to a critical few. She walked us through a series of case studies and left a great model to apply to our teams.

Monday, March 27

Payor Partner, Friend or Foe

By: Andy Cousin

If the quality of the first breakout session is a preview of the Congress as a whole, it's going to be a very thought-provoking week. The faculty, from ECG Management Consultants, shared trends they're seeing, examples of collaborative payor/provider models, a regional case study from Ohio, and the strategic implications of these partnerships on providers. There is a lot of content to capture, but here are some key takeaways:

  • The pace of collaborations is accelerating, and the academics seem to be latest to the game. They identified 55 regional alliances covering 75% of the geography of the U.S.
  • The role insurers and equity firms are taking in practice mergers and acquisitions is unprecedented and disruptive. Optum (UnitedHealth) has invested in 20,000 physician practices for imminent strategic purposes. The landscape is changing.
  • Two models with either payors and providers becoming one, and providers and payors working together.
    • Becoming one: CHI, UnitedHealth buying practices.
    • Working together: Anthem Blue Cross Vivity, Aetna and Inova, Philly eight-player collaboration, UHC telemedicine to reach 20 million.
  • Wear the payor hat: How can I compete differently than before?
  • Readiness survey with weighted scoring and national benchmarking to identify and actively manage value-based readiness and needs.
  • Too many providers are entering the value-based space by changing the way they agree to get paid. But, they're NOT changing the other operational and organizational infrastructure to enable it.

The role of good laboratory medicine, genetics, interpretation, and cooperation with practitioners is an unsung hero in this story, and it's high time we start singing.

I'm off to introduce myself to our speakers, grab a Diet Mountain Dew, and get ready for a lunch session on patient safety.

Monday, March 27

Opening Presentations

By: Andy Cousin

The ACHE Congress opens with the distinguished lecture and presentation of 2017 Gold Medal Awards. This year, the Gold Medal honorees are two names familiar to Mayo Medical Laboratories. Congratulations to Gayle Capozzalo, FACHE, Chief Strategy Officer at Yale New Haven, and Dr. Rulon Stacey, FACHE, Managing Director with Navigant Leadership Institute and adjunct faculty member at the University of Minnesota.

ACHE President Chuck Stokes, FACHE, Chief Operating Officer at Memorial Hermann, used his opening remarks to motivate the crowd about our responsibility to address the crisis of 250,000 to 400,000 deaths annually in the United States due to medical errors, citing it as the third leading cause of death in the U.S., or 747 crashing every few hours. He urged all to engage in conversations this week about quality, teamwork, and technology changes we can make to eliminate these errors and strive toward perfect practices. The buck stops with us.

It can't help but punctuate the importance of the research that Curtis Hanson, M.D., Chief Medical Officer at Mayo Medical Laboratories; Don Flott, Utilization and Integration Services Director at Mayo Medical Laboratories; and teams are doing in linking laboratory and pathology intervention to improved decision making, personalization of care, and better outcomes.

Ann Compton

Finally, this year's distinguished lecturer is former ABC News White House Correspondent Ann Compton. Ms. Compton spoke on her observations of the likely perspectives that the new administration will take on health care and the impact such legislation might have on providers, insurers, and, most importantly, the patients and families we serve. She compared and contrasted the presidencies that she's covered and urged the crowd to participate in the conversation of change. What a speaker!

Off to my first breakout session: Payor Partners, Friend or Foe.

Andy Cousin

Andrew Cousin, FACHE, is the Director of Product Management and Marketing for Mayo Medical Laboratories. He has worked for Mayo Clinic since 2006.