ONC Turns 20!

Tomorrow marks the 20th birthday of the Office of the National Coordinator of Health Information Technology.

A few thoughts … 

a) ONC’s work is uniquely bipartisan.  There is little disagreement that information technology – well applied – can (will / must) improve the health of the people of the United States.  While different administrations have managed ONC’s work differently – the common theme remains an optimism about the role of information technology in improving population health, and the need for federal oversight of the tools with which this is done.  The impact of the work of ONC therefore can’t be overstated, despite the single thread with which ONC is sometimes conflated: the 1st five years of HITECH and the meaningful use incentive programs.  While these programs (yes – plural) catapulted ONC into the hearts and minds of most hospitals and clinicians, there was much work done before (and after) the flurry of activity that was HITECH.  Indeed, since ONC has been entrusted to coordinate federal technology work across federal agencies – quite a bit of what ONC has done isn’t visible to the naked eye.

b) I can’t describe ONC’s impact without expressing my gratitude to the team at ONC – past, present and future.  The impact that my 3 years there has had on my life has been extraordinary – and it truly changed the way that I view and understand the work of government.  For those who have not served in this way – I implore you to consider government service of some kind.  The alignment of a dedicated group of people to a shared goal (better health for millions of people) is powerful and exhilarating.  I had the honor of leading ONC for a time between Farzad and Karen, serving as Chief Medical Officer under Farzad – and serving as Deputy National Coordinator under Karen.  These were – in many ways – the best three years of my professional life.  I had planned to stay for “a year or two” – given that my home and my family were in Albany, New York and I was commuting to DC every week – so while the travel was not sustainable – the work was energizing and the team was fantastic – as it remains today.

c) And what’s next for ONC?  While I have some concerns about a few of the regulatory actions over the last few years (Don Rucker’s declaration of success – pulling back on some of the EHR certification requirements was – IMHO – premature) – the future of ONC remains bright – and as generative AI becomes part of day-in-the-life of most clinicians, ONC is well positioned to partner with others (CMS and FDA in particular) to guide the industry toward careful innovations that advance health equity.  It’s an incredibly exciting time – and while we thought (10 years ago) that three stages of “meaningful use” would get us from adoption to interoperability to improved health of populations – we are chipping away at all three.  Three stages?  Five years?  No.  We were too-optimistic.  But change moves at the speed of trust – and through that trust that ONC has now earned – (more) change is coming – for the better.

 

 

NYHER RFA – Addendum #3

Another update was posted today.

a) Here is the direct link to the updated RFA (warning – PDF) ..

b) Here are the addenda (#1,2,3) – just 4 pages – so you don’t have to download the whole RFA again.

Now let’s parse the recent changes:

Section II

The Applicant must be a 501(c)(3) or 501(c)(4) non-profit organization. The type of
501(c)(3) or 501(c)(4) non-profit must be one of the following entity types: Community-
Based organizations (CBO), Independent Practice Associations (IPAs), Health Homes,
Behavioral Health Collaboratives, Federally Qualified Health Centers (FQHCs), or
former/current Delivery System Reform Incentive Payment (DSRIP) Performing
Provider Systems.

Section III

Ensure that the SCN follows the requirements for the governing bodies of 501(c)(3) or
501(c)(4) organizations (as appropriate or analogous);
Making it clear that both kinds of nonprofits can participate.  What’s the difference, you ask?  Here you go:

  • 501(c)(3) organizations are charitable, religious, educational, scientific, or literary entities. Donations to these organizations are tax-deductible for the donor. They cannot engage in political campaigns and can only do a limited amount of lobbying.

  • 501(c)(4) organizations are social welfare groups that can engage in more political activity and lobbying than 501(c)(3) entities. Donations to 501(c)(4) organizations are not tax-deductible for the donor.

  

Social Care Networks – NY

The initial RFA for New York was posted weeks ago and got rather thorough coverage so I didn’t need to discuss it here – though (predictably) I have many thoughts on the matter.

Hot off the press today is an addendum. It’s a pdf but I’ve chopped it off so the link over there 👈 is just the 1st two pages of the addended document – all of which is here ICYMI.  I’ll review the addendum (changes in red) below with some commentary:

AddendumMy Comments

Note that this constrains the participants. Removing “including” means that others need not apply – clearly this precludes hospitals, health plans, or BHCCs from applying unless they were PPSs before.

I think this one just fixes a typo / forgotten word.

I’ll take this opportunity to get on my soap box to reiterate the reality that this requirement is a big deal, and a very good policy decision that DOH made in the crafting of this RFA.

More than 1/2 of the governance needs to be from CBOs. 

This would disqualify the vast majority of the DSRIP PPSs from the previous waiver, unless they play some sort of jujitsu by creating new daughter entities in (very) short order and have those entities do the application.  The policy goal here is clear: take the control away from the incumbent (medical) enterprises that still generate the majority of their revenue from fee-for-service care and therefore have conflict of interest with the policy goals of the program – which is to invest upstream – thereby reducing the quantity of fee-for-service care – especially acute care.  We saw (and felt) this all-too-often in DSRIP.  It’s great to see that DOH is taking this seriously.

DOH will be on the lookout for the jujitsu governance shenanigans and will disqualify applications that lack transparency of true CBO controlled governance.

Relaxing this requirement a bit – which I agree is appropriate.  Federal EINs are easy to come by – and this adds agility to the SCN.  Agility is necessary.  SCNs will need to be able to add and delete entities quickly so they can respond to the dynamic needs of their communities, and to hold their collaborating entities accountable.  Without this agility, SCNs will fail to accomplish their objectives (as did many PPS).
a) Removing 3 meals a day without constraints.  This may have been seen as a loophole too-big-to-retain, and may not have sufficient evidence to support trie ROI for the program with reduction in total cost of care.

b) Specifying that MTM is expected and that there needs to be a clinical justification for such comprehensive food assistance.

c) $1M as an upper threshold for CBOs would eliminate several of the effective CBOs such as Jewish Board in NYC and Catholic Charities upstate.  

 

Health > Care, Border Runs

November will mark the beginning of the 24th year of this blog.  

While my posts are far from frequent, I hope that each one is helping others in some way. 

That’s always been my goal.  Along these lines, I’ll offer the answer to a question I was asked by a start-up health IT company yesterday, and will also outline the process for the Costa Rica ==> Nicaragua ==> Costa Rica border run, which is both necessary and relatively easy.  

Health > Care

“Dr. Reider – why are you interested / willing to help our little company?”

Some context – and then my response. 

(After – “hey – don’t call me that.  Dr. Reider was my dad!”)

I have worked @ the intersection of health and technology for nearly three decades.  I am now realizing that despite my nearly adolescent playful demeanor, this makes me an old-timer.  I have participated in nearly every kind of endeavor in the industry:  I’ve worked for investors, served on boards, started companies, killed companies, worked for government, worked for large publicly traded companies, health systems, and have served as an advisor to companies of all shapes and sizes.  In June of 2023, my wife and I moved to Costa Rica – taking advantage of the sabbatical she had earned in her role(s) at an academic institution for the previous decade and a half.   I have expressed rather publicly that “work is overrated” and started only doing things I enjoy 100%.  No collaboration with people who are hard to be with, no working for a paycheck just to do something.   Avoiding “work” is not the same as being idle.  We’re both very active and even though we’re not technically working – we are both doing things – some of which generate revenue.  But we’re picky about what we do.  We need to be doing things that are perfect fits for our values, for our strengths, and for our own well-being. 

It’s an incredibly privileged place to be. 

I get that.

And I am grateful that we’ve been able excel professionally in a manner that enables us to do this. 

We can be picky.

So what are the criteria?

  1. Health > Care.  This is my shorthand for how a company prioritizes its work.  Are we trying to maximize revenue?  Or are we trying to maximize the health of the people we serve – and (no margin no mission) earning money as a product of better health?   In this era of value-based payment, one would think that it’s easy to find companies with a PRIMARY focus on health (and therefore less of a focus on maximizing care / service / encounters, etc.) but this is actually quite rare.  Even companies that purport to participate on VBP programs – when one peels back the covers – can have transaction models that rely on selling more of something.  More things sold (encounters, DME, band-aids, etc.) means more sick people or more needs == more revenue.  This may be pragmatic and I respect the needs to do this – but it’s not where I want to spend my time.  So I say “no” to anything that violates my “Health > Care” criterion.
  2. Good people.  I don’t just mean kind people or nice people.  I also mean: people who are easy and fun to work with.  If we are not having fun – no-go.  I only collaborate with fun people.  And – yes – of course – no ass holes.  
  3. Learning.  I’ve been at this nearly 3 decades, but I have a ton more to learn.  So if there isn’t an opportunity for me to do something novel – learn a new culture or a new skill – then it’s probably better for me to say “no thank you.”  And so I do that too.  

 

That’s really it.  Three criteria that I apply to every opportunity.  If all three are 👍 – then we are ✅ and I’ll do a consulting/advising thing with the company.  Right now, I am doing this with ~ a handful of companies, and I don’t even think of it as work.  It’s all fun.  I need no more.  It’s perfect.


Border Runs

This section is written for a different audience, but (I hope) is equally useful.  US Citizens who live in Costa Rica have a few options for how to manage things.  Technically, until we are residents, we are tourists.  Tourists are allowed to own cars and homes and businesses.  It takes time (and quite a bit of paperwork) to become a resident – so while that process is ongoing – one remains a tourist.  Tourists are allowed to be in the country for 180 days. (This recently was changed from 90 days.)   If you overstay your visa, there is a hefty fine and the next time you try to re-enter the country, you might be denied.  So what does one do?  The border run.  I did that yesterday with two more experienced friends.  Here’s what to do.

a) Drive to the border.  For us, this was driving the ~ 2.5 hours from our little town of Brasilito to Peñas Blancas, the border town on Route 1 – the Pan-American Highway, a road that starts in Prudhoe Bay, Alaska, USA, and ends in Ushuaia, Argentina. While it’s incomplete in the Darién Gap between Panama and Colombia, it is roughly 19,000 miles long.  We were on it for about 100 kilometers.  The last 8 kilometers there were tractor-trailer trucks backed up on the side of the two-lane highway – making it into a one-lane highway in many places, despite bidirectional (two lane) traffic.  The trucks are all waiting in line to pass through the border on their way North.  The delay is not hours but days that these truck drivers wait in line to pass.  Step #1 is therefore to carefully drive past the trucks while not ending up in a ditch.  

b) Navigate the Costa Rica side of the administrative process. 

Follow along on the map:

1) Begin by parking your car.  Yesterday, we parked under a tree at the red circle.  There were some guys there hanging out doing who-knows-what.  A tradition in Costa Rica is that a local with often volunteer to watch your car for a fee.  You generally pay the fee afterward when you know your car has been safely guarded.  1000-2000 colones is fair in 2023.  I can remember when 500 colones ($1) was common but it’s more now.  We parked and a guy motioned to me that he would watch the car for me and I nodded and told him I’d pay him when we return. 

2) Walk South (back into Costa Rica) about 30 yards to a little green building.  This is where you pay your exit tax – which is $8 – payable in either US dollars or colones.  Get the receipt (the guy there put it in my passport) and now proceed to immigration.

3) That’s the green circle above.  It’s a white building with BCR (Banco de Costa Rica) signs.  There’s a BCR ATM there – maybe that’s why there are signs.  Inside – proceed to the desk, present your passport with the exit tax receipt and Chunk Chunk – get it stamped and you have now legally departed Costa Rica.  No questions here.  Super easy.


4) Walk North along the road.  Dodge cars and trucks if necessary.  Now you are leaving Costa Rica!

The green circle is here for reference – that’s where we left the Costa Rica Immigration office.
Walk North along the road and at one point (orange circle) there will be a person or two waiting for you.  Hand them your passport.  They will look at the photo and at you and hand it back to you.  Keep Walking.

5) Nicaragua immigration.  The white building (light blue circle) is your next destination.  About 200 meters past the technical border – where you showed your passport. At the door, there is a person collecting the tax for Cardenas Rivas, the local municipality. This tax is $1 US.  You should have ones with you.  They can give you change if you have a five but it’s best to have some ones handy. You’ll need another later.  They will give you a receipt but nobody will ask to see it.  Wait for a minute in line (my wait was a minute but it can take an hour as well – so YMMV). Answer the usual immigration questions (What is your profession? Where are you staying, etc.) I told the guy I was walking back to Costa Rica in 5 minutes and he nodded.  Chunk Chunk.  Stamps on the passport and pay a $3 US fee.  Get receipt.

6) Nicaragua departure.  After immigration, walk through to the other side of the building and back in the (other) front door and pay the municipality tax again for $1.  Get receipt again. Now back to an immigration officer at the window.  Fewer questions this time.  More Chunk Chunk.  $3 fee.  Another receipt.  Done.  

7) Walk back to Costa Rica.  At the physical border, you may (or may not) have to show your passport to a Costa Rica immigration officer.  We did but my travel partners said that’s unusual here.   Now back to the other side of the Costa Rica immigration building for re-entry.  No fee here.  Show the passport and show (on your phone if necessary) proof of a ticket that you have purchased (bus or plane) to depart Costa Rica at some point.  You can buy a refundable plane ticket and cancel it tomorrow.  Seems odd that they do this since they know you may just cancel whatever ticket you have and stay 179 days and come back here to the border but they want to see it.  I showed by receipt for a flight two months in the future on my cell phone.  The officer looked at it and Chunk Chunk – stamped my passport and wrote in 180 days and I was done.

Now walk back to the car.  Pay the guy whatever you like (2000 colones made him very happy) and brace for the scary 1st 8 kilometers home.

On our way South, we stopped at the beautiful Mirador de La Cruz for a quick drink and then a perfect lunch at teeny tiny Soda Sazon Cruceño.  Both highly recommended and only moments off Ruta 1.

ChatGPT Builds a Scan Server

Printers share attributes with fiberglass boats in that they do last a long time – especially if well cared for. 

We’ve had an HP Laserjet 1320 in the house for decades and it’s been quite reliable.  Our challenge is that it’s a USB (or parallel port) printer and we’ve struggled with the network contraptions I’ve built to connect it to our home network – so when I found a printer that uses the same toner cartridges, low page count, embedded scanner and networking capability on eBay – I jumped and spent $80 to upgrade us to another (very) old printer.

So long as the hardware works – we’re good – right? 

No.  What I learned from this little escapade is that unlike the Day Sailer – printers can be made obsolete by the companies that built them by making the software incompatible with the legacy hardware.   

(You may wonder why I chose this path.  The short version is that toner is expensive and we have plenty of it, I don’t like inkjet, we only rarely print things but when we do, it needs to just work, and I like the thought of a low-stress MFP that can scan and (gosh) even fax or copy.)

Things started well:  the printer has an RJ-45 jack and I plugged it into the network, it got an IP address and the computers in the house were able to find it and print quite easily using native drivers.

Scanning was another matter – hence this post.

a) The device is an HP M2727nf MFP
b) HP has software for scanning that runs on Macs and PCs.  It looks like it’s going to work (it “sees” the device) but it does not work – and HP’s site confirms that this printer isn’t supported by HP Smart – the software that seems to be replacing all previous products.  
c) Neither Mac OS nor Windows 11 will let me install older versions of HP scanning software

So … what to do to scan?

The sort version:

a) Find Raspberry pi in basement
b) Reinstall the OS
c) Install SANE (Scanner Access Now Easy) 
d) Install Dropbox (so I can get the scanned files from anywhere – even when not @ home)
e) Make a script that scans:

#!/bin/bash
DATE=$(date +"%Y%m%d_%H%M")
scanimage --format=pdf > ~/Dropbox/Scans/$DATE.pdf

e) Automate the script with a cron job
f) Fix, enhance.

Bottom line: this works. Plop paper in the feeder, wait 59 seconds or less (the cron job runs every minute – checking to see if there is paper) and it scans, uploads to dropbox, deletes the local file. It works remarkably well. I even made a little web page to manage the settings. Here’s the code on Github. The API doesn’t work yet … but it will soon – then Alexa integration (its already connected to a cloudflare tunnel.)

Oh – and – yeh – ChatGPT wrote 95% of the code for this and helped me debug it. I couldn’t have done this without this assistance.


Pulling The Rope

Dan used to say to me that we needed to motivate our teams to pull the rope.  

At first – I wasn’t sure what he was talking about.  

Why would they pull?

What rope?

But then ..

What’s the opposite of pulling a rope? 

Pushing it. 

Think about how successful you will be when you do that.  Yeh – pile of rope on the floor.

 

When / how / if people pull the rope is a product of two things:

a) Their motivation

b) Our inspiration

It’s impossible to inspire people who have no interest.  It’s also impossible to inspire people without a compelling mission / story / reason.

If we have both – amazing things can happen.  

And they will!

 

Welcome Back Kotter: New York’s next 1115 Waiver

 

Months after the concept paper was published, I’ve finally edited my initial response in anticipation of a revised proposal and public comment period that will soon occur. I’ll likely author formal comments and will submit them to NY and/or CMS. I expect that my comments will mirror those below – at least in structure.

Perhaps others will find this framework helpful in the development of their own comments – hence my posting of them today.

New York’s DSRIP program succeeded in many ways and failed in many ways.  I experienced both of these, as the CEO of one of the 25 Performing Provider Systems (PPS) in the state.  This essay is my personal view – and while I do still have an advisory relationship with Alliance for Better Health and Healthy Alliance IPA – I am no longer the CEO of either entity.  These comments are therefore explicitly mine – and don’t necessarily represent the organization.

Let’s start with some context.  What did DSRIP 1.0 get right?

The program’s goal was to improve the health of New York Medicaid Members.  As a consequence – “preventable utilization” of medical services and therefore cost would be reduced. With this goal in mind, organizations statewide were formed with benevolence, collaboration, and engagement as guiding principles.  This is good. I am certain that the lives of many people were improved and even saved by the efforts facilitated by DSRIP.

Yet we also missed many opportunities to do better.  The causes of our missed opportunities were many – but I’ll outline a few as this will help guide our reading of the framework proposed for the next iteration – the Kotter Edition – named after the 70’s era TV show.

What was wrong with DSRIP?  Too many and too few.  That’s all.

  1. Too many.  
    1. Too many organizations.  Managing 25 PPS – many of which overlapped each other in geography – was an administrative challenge both for DOH and our communities.  It made DSRIP look and feel like a competition where PPS overlapped, and diminished the opportunities for whole communities to come together and solve fundamental challenges in how the needs of Medicaid members and the uninsured could be met.
    2. Too many targets.  The objectives of DSRIP 1.0 – a laundry list of HEDIS measures – made the program difficult to manage “on the ground” and too tightly tied to medical measures of success.
    3. Too many choices.  PPS were given choices about which projects they would work on – and by extension – which projects would be funded and measured. The projects were tactically expressed – and therefore too prescriptive – not just defining goals to be achieved – but presuming that DOH knew how goals would best be achieved.  In many cases – this mismatch between what to do and how it would be done was the cause of great frustration.  While DOH and CMS looked for accountability, they actually handcuffed the program by instantiating accountability as prescriptive demands that simply didn’t fit the reality on the streets.  Any innovator knows that learning and agility are imperative guiding principles.  This was largely absent from the program –  it was waterfall from the start.
    4. Too many dollars (going to the wrong places).  This is likely the paragraph that will get me in the most trouble. Here goes:  the front-loading of the DSRIP program caused dollars to go to PPS sponsors for setting up the program and for checking boxes (literally – “we had a meeting with so-and-so”) to satisfy reporting requirements and subsequent payments. These dollars were permitted to flow to sponsoring organizations (most of them medical care systems) in advance of any true performance expectations.  Indeed – the first ½ of DSRIP funding (so – billions of dollars) flowed to medical care systems in advance of any expectation of improved health or reduced preventable spending. The justification for this was often that there were anticipated losses of fee-for-service revenue – and that the medical providers needed to be made whole in advance of these anticipated losses.  As any economist will tell you – payment in advance of something to be done is not an incentive to cause that thing to be done.  It’s a handout.  Indeed – a disincentive!  By half-time of DSRIP – performance started to be the objective – and PPS had to choose whether to be effective or not.  In several cases (yes – I have personal knowledge of these) PPS leaders who wanted to do very well on performance (therefore undermining the fee-for-service revenue of their parent organizations) were let go.  Yes. This happened. (No – not to me!) The medical systems didn’t really want to change.  They fired PPS leaders who did – as a product of rather simple economic decisions.  Performance would net them $x from DSRIP, but maintained and maximized fee-for-service revenue would net them $x+$y.  Done.  Did this happen everywhere?  No. This was a minority of PPS. But it happened.
  1. Too few.
    1. Too few outcome objectives. By focusing on medical definitions of success (generally expressed as HEDIS measures), the program medicalized social problems and failed to explicitly recognize the significant role that social determinants play in the health of our communities.
    2. Too few governing organizations.  By permitting (encouraging?) the majority of PPS to be governed by medical care providers, the foxes were guarding the chicken coops.  Our organization was an outlier – in that the governing organizations permitted us – in conflict with their own interests – to act in a manner that aligned best with the health of the people we served.  This speaks to the integrity of our Board – maintaining their fiduciary duty to do what was best for the organization (and by extension the whole community) rather than (or – ok – in addition to) their own institutions. This was the case in a small minority of PPS – and even in ours – the tension was always there. As our Board will recall – we even bought hats at one point – to explicitly remind them to “wear their PPS hat” when making governance decisions.  It wasn’t easy.  Had PPS been required to have broader governance – including community-based organizations, health plans, faith-based organizations, Health Information Exchanges, and other nonprofits, we would have had more balanced governance decision-making that would have supported the policy goals of the program more consistently statewide.
    3. Too few dollars (going to the right places).  A core tenet of the program was that no more than 5% of the money could go to so-called non-safety-net providers.  The definition of safety-net providers explicitly excluded the true safety-net: most of the community-based organizations.  This structural flaw caused a cascade of funding challenges that (to this day) plague PPS successor organizations who do their best to get the dollars upstream – so they can prevent downstream cost and suffering.  

So with this too many/too few framework – let’s parse the Kotter Edition and see how we are doing.  I’ve cut/pasted selected sentences from the DOH document to make it easy to follow here – but (of course) the full document has more detail/explanation.  DOH prose has a blue background so you know what’s theirs and what’s my commentary.  Since you have already read the concept paper, (warning: pdf) feel free to scroll through the blue sections.

$17 billion over five (5) years to fund a new 1115 Waiver Demonstration that addresses the inextricably linked health disparities and systemic health care delivery issues that have been both highlighted and intensified by the COVID-19 pandemic.

Not a bad start.  They even separate “health” and “care” – (as they should)  👍

 Indeed, to address the full breadth of factors contributing to health disparities, NYS will not only pursue reforms and investment in the health care delivery system, but also in training, housing, job creation, and many other areas

Again – so far, so good.  The target includes upstream work. SDOH.  Cool.  Devil in the details .. How will this work?

Goal #1: Building a more resilient, flexible and integrated delivery system that reduces racial disparities, promotes health equity, and supports the delivery of social care.

1.1 Investments in Regional Planning through HEROs

HEROs, which will be mission-based organizations that build a coalition of MCOs, hospitals and health systems, community- based providers (including primary care providers), population health vehicles such as accountable care organizations (ACOs) and independent provider associations (IPAs), behavioral health networks, providers of long-term services and supports (LTSS) including those who serve individuals with I/DD, community-based organizations (CBOs) organized through social determinants of health networks (SDHNs, as described below), Qualified Entities (QEs) (which in New York are Health Information Exchanges (HIEs) and Regional Health Information Organizations (RHIOs)), consumer representatives, and other stakeholders.

HEROS may be led by a variety of existing and new corporate entities (e.g., LLC, not- for-profit) including but not limited to local departments of health or social services, behavioral health IPAs and other structures formed by regional participants. HEROs would assume a necessary regional planning focus in order to create collaborations, draw insights from different data sources and needs, and develop a range of VBP models or other targeted interventions suitable for the populations and needs of each region.

  1. Planning Responsibilities

The primary deliverable for HEROs is a Regional Plan:

  • Uniform Social Care Assessment.
  • Measure Selection and Development.
  • Targeted VBP Interventions.
  1. HEROs Governance

In each region, the NYS Department of Health (DOH) will contract with a HERO entity, which may be an existing entity or a new corporate entity formed by regional participants, including MCOs, primary care and other clinical and community-based providers, QEs, SDHNs and others. The HERO entity must establish a governing body representative of each constituent group and with balanced stakeholder decision-making authority, along with appropriate sub-committees composed of participants, to collaborate on developing and coordinating the HERO’s planning activities. With limited modifications to governance structure, some existing PPSs would be ideally situated to function as the HERO entity in a region. Moreover, local health departments could in some instances be well-equipped to serve as the regional HERO, as they already have some of the necessary data infrastructure in place, as well as relationships with other government entities participating in regional planning efforts around SDH needs, such as housing authorities.

  1. Sustainability

NYS anticipates HEROs would extend beyond the period of the waiver and become self-sustaining entities that continue to act as coordinating bodies, engaging in stakeholder convening activities and research and data analytics on regional health equity issues.

Feedback: As I’ll express below – I don’t think the HERO layer in the program is necessary at all – and its description includes a repeat of some DSRIP 1.0 aspirations of true community collaboration that are unfortunately impossible in these days of narrow clinical networks and cut-throat competition in the medical domain among both health systems and health insurance providers.  

We need a more pragmatic approach – and that means we scale back the dream that competing organizations will collaborate toward improved population health.  Without explicit programs that require value-based purchasing, it simply won’t happen.

Planning.  A seed fund for planning simply replicates much of what the PHIP was supposed to do – but never really did – largely because it was under-funded and had insufficient leverage.  

HERO, therefore, opens the door to the same challenges we had with DSRIP.  Since the release of the draft document – we’re already witnessing health systems and former PPS across the state – begin to quietly jockey for position here – even organizations that explicitly walked away from the DSRIP program when the well ran dry.  These should be obvious disqualifiers for any HERO hopefuls – or organizations that seek to participate meaningfully in the waiver. Did the PPS or its parent(s) flush the money to itself and shut things down? If so – noooo. You don’t get to play this time around.  You’ve explicitly demonstrated that you care more about institutional success than regional population health.  Actions speak louder than … well … anything.  

What I like about the idea behind the HERO is that there is one regional entity that’s accountable for population health.  Who is best suited for this?  To me – it’s obvious: government.  Indeed – the government is the only organization explicitly committed to serving in the public’s best interest.  The challenge here is that the state government doesn’t have the staffing, infrastructure, or bandwidth to engage regionally – nor should they.  Yet regional governments – county departments of health for example – lack the funding, staffing, and experience managing matters that the HERO is imagined to curate.  They’d need to staff up – and (alas) they are also subject to the regional political influence that the health systems have, and the proclivities of county executives. I’d not be confident that the counties could manage this seamlessly. New York City is an entirely different game – and I expect that the NYC Department of Health could manage such responsibilities – but there’s only one of these in the state.  Perhaps – under NYC DOH’s strong supervision (a majority of Board votes?) – HERO could work in New York City.  Elsewhere?  No.  It’s too much (governance diversity) and too much (fiscal responsibility) to be managed apolitically.  Those with political power will retain it, and true public health decisions will be elusive.  

More on what I think will work North of Yonkers after we consider the SDHN…

Investments in Social Determinant of Health Networks (SDHNs) Development and Performance

I’m tickled that DOH recognized Alliance:

Examples of these developing SDHNs include the Healthy Alliance Independent Practice Association (IPA), which described itself as “the first IPA in the nation entirely devoted to addressing social determinants of health;”15 the EngageWell IPA, which “was created by New York City not-for-profit organizations working together to offer coordinated, integrated treatment options that include addressing social determinants of health—housing, nutrition, economic security;”16 and SOMOS Innovation “a full implementation of the holistic care model” and “the next step on the path to culturally competent Value-Based [H]ealthcare.”

So what is it?

Each SDHN would consist of a network of CBOs within each region of the State (which should overlap with the regions and sub-regions that align with HERO development) to provide evidence-based interventions that address a range of SDH. The State would designate regions and select a lead applicant within each region, which may be a CBO itself or a network entity (e.g., an IPA) composed of CBOs. As mentioned above, a SDHN could also be a PPS (or a component of a PPS) that seeks to convert, or have already begun to transition, into a network entity focused on SDH.

The SDHN in each region would be responsible for: 1) formally organizing CBOs to perform SDH interventions; 2) coordinating a regional referral network with multiple CBOs, health systems and other health care providers; 3) creating a single point of contracting for SDH arrangements; and 4) screening Medicaid enrollees for the key SDH social care issues and make appropriate referrals based on need. The SDHNs can also provide support to CBOs around adopting and utilizing technology, service delivery integration, creating and adapting workflows, and other business practices, including billing and payment. These SDHNs will coordinate and work with providers in MCO networks to more holistically serve Medicaid patients, particularly those from marginalized communities, effectively wrapping a social services provider network with existing MCO clinical provider networks.

Exhibit 2: SDHN Structural and Funding Diagram

        Social Care Data Interoperability Exchange

The New York eHealth Collaborative (NYeC) and 2-1-1 New York have received funding from the HHS Administration for Community Living to establish a trust framework and statewide governance structure to support collaboration and exchange of community information across existing networks and users. NYS envisions that this platform would serve as the basis for the social care data exchange that regionally-based SDHNs will use across the state, and would be aligned with national standards as they develop.

Well – this is valid but omits some important components of this initiative.  As one who has worked very closely with ACL, ONC, and CMS, (and I chair the HIMSS SDOH Committee, where National work is being done to converge SDOH infrastructure) – I’ll remind /inform readers that ACL didn’t just award funding to NYeC for this.  They converged three applications into one – and the NYeC / 2-1-1 project is just part of a unified project for New York that also includes Northwell/NowPow and Alliance/ Unite Us.  I’m a bit confused by the (intentional?) exclusion of the other two equal partners in this project.  It’s a good project, but I’m feeling a bit Rodney Dangerfield here, and – for the record – this project wasn’t selected as a Phase 2 winner.

Shared Learning and Sustainability

The State will leverage the learnings from the SDHNs in order to support the integration of high-value services into managed care contracts and VBP arrangements on an ongoing basis that extend beyond the life of the waiver. While there is ample evidence around the potential for SDH inventions to improve health, advance health equity and better manage health care costs, the research around the effectiveness of scaling the interventions to a regional and statewide basis has not been measured.

NYS anticipates that the demonstration evaluation would examine this question, in order to leverage findings for long term policy changes in NYS, as well as other states.

Well – yes and this is the core responsibility of the SDHN: to invest where investment is appropriate and not invest where it’s not.  Since I’m occasionally accused of being anti-academic, I’ll give my detractors more fodder:  I don’t think research is appropriate or necessary.  This can be done faster with rapid feedback loops of interventions and measurements.  Maybe this is just semantics – but the term “research” invokes years of study and papers written in academic journals.  We need front-line, agile program definition, rapid-cycle outcome analysis and the ability to change course when the evidence directs us.  My sense from the narrative is that DOH imagines that this work will be easier and harder:  easier to define initial projects – and harder to know if they work.  I disagree with both.  SDHNs will make mistakes; they’ll make investments in programs that result in few positive outcomes, and they’ll invest in programs that result in fantastic outcomes.  The program therefore needs to allow for (expect) such mistakes as positive steps toward long-term success.  Indeed – one measure of early success could be that there were failures!  Too few, and we know that SDHNs haven’t taken enough risks.  Too many – and – well we need to learn more/faster.  Healthy Alliance IPA has been doing precisely this work for five years.  Perfect?  No way.  Getting closer?  Yep.  Learning every day.  But there’s a big missing part.  Read on.

Investments in Advanced VBP Models that Fund the Coordination and Delivery of Social Care via an Equitable, Integrated Health and Social Care Delivery System

With the HERO and SDHN infrastructure established, advanced VBP arrangements will support the mid-to long-term transformation and integration of the entire NYS health care and social care delivery system by funding the services needed to address SDH at scale.

Incentive awards would be made available to MCOs (that have participated meaningfully in HEROs) providers and organizations in qualifying VBP contracts approved by DOH. MCOs would be required to engage in VBP contracts with an appropriately constructed network of providers for the population-specific VBP arrangement.

The VBP funds through this waiver proposal would encourage the evolution of the MCO- network entity agreements into more sophisticated VBP contracting arrangements that incorporate health equity design, fund the integration with social care, adjust risk to reflect both the health care and social care needs of their members, reward providers’ improvements in traditional health outcome measures as well as advanced or stratified health equity measures informed by the HERO, and/or use fully prepaid payment models that fortify against fluctuations in utilization based on pandemics. In particular, using socially risk adjusted payment—whether through accurate use of z-codes or the data collected from the uniform social care assessment tool described above—can incentivize and appropriately reward plans and providers for caring more holistically for these vulnerable populations.  Prepayment approaches would also be available to providers who are not the lead VBP contractor but are providing care to the lead contractor’s attributed members through a downstream targeted or bundled arrangement.

Additionally, this component of the waiver would seek specific authorities for NYS to utilize global prepayment payment models in selected regions where these arrangements logically apply; that is, where there is a lead or dominant health system or financially integrated provider-based organizations with demonstrated ability to manage the care of targeted populations in that region. In a global model, the lead health system VBP entity—whether part of an integrated delivery system or clinically and financially integrated IPA or ACO—would extend successes and performance across payor types, including Medicaid fee-for-service (FFS), Medicaid managed care, Medicare FFS, Medicare Advantage, and/or commercial plans.

Well .. there’s quite a bit to this part, which is the problem.  The foundation here is the SDHN and the HERO, and now – as with DSRIP 1 – DOH wants to bolt on the health plans (rather than incorporating them meaningfully in the foundation) – requiring them to craft VBP arrangements that may be tied to the HERO and/or the SDHN.

Confused? Yeh – me too.  It’s a bowl of policy spaghetti – and the drum solo at the end is regional global prepayment – a thinly veiled effort to re-boot the NCIP – which failed to get community support (or CMS support) and died.

Let’s simplify.  We have to start at the beginning.

  1. Regional Governance  
    1. In very dense areas, with highly capable local government – HERO may fit.  This is the case in NYC and perhaps a few counties just beyond NYC.  Make the government (which is explicitly accountable to the taxpayer) the majority governance authority – and allow that entity to rapidly define health needs and regional priorities.  Minimal (if any) planning dollars should be allocated.  Get to work.  Pay for outcomes, not planning, convening, gathering, establishing or any other gerund.  
    2. In “rest of state” (as those of us beyond NYC are sometimes referred to) – there is no need for the HERO – as we’ll see below.  County governments – the primary organizations responsible for public health – should receive funding to enhance their human and technical resources – connecting them tightly to the SDHNs and HIEs in their regions – adding epidemiologists, informaticists, and program managers who can help connect regional policies to SDHNs, health systems, health plans, and CBOs. What do we call this?  The GRHEO (pronounced “GREE-OH”) – the Government Regional Health Equity Organization. GRHEOs will require (much) less funding than the HERO defines – and will have less responsibility – focusing only on need definition and coordination of county health and prevention services with SDHN and HIE/QE activities.  There should be no funding for planning – nor an attempt to govern regional VBP or SDHN activities.  These activities can/must be self-governing or they will be neither sustainable nor agile.
  1. SDHNs
    1. The SDHNs should receive zero funding directly from DOH.  Yes.  Zero.  Rather, the SDHNs should receive 2.5% of premium dollars for each attributed member from all MCOs that serve the SDHN’s region – and each of these dollars should be matched by the waiver for the initial three years of the waiver (flowing through the MCO) – falling to 1% for year 3 and 0.5% for year 4 so that by year 5, the programs will have demonstrated clear return-on-investment to the MCOs and they will be expected to maintain 2.5% PMPY contribution to the SDHN ad infinitum, so long as the SDHN performs well. This puts the MCOs right in the mix – where they should be. They are the benefactors of improved health, and the (secondary) victims of persistent fee-for-service.  By passing SDHN dollars through the MCOs, DOH aligns their goals with the goals of the SDHN and leverages the SDHN as a trusted broker rather than the passive recipient of funding from the state.  The SDHN will have the autonomy – in collaboration with regional government leaders – to select initiatives for investment, primarily by collaborating with CBOs to provide essential services that address SDOH.
    2. It’s essential to understand that SDHNs – by aggregating health plan SDOH investments regionally – will eliminate many of the inefficiencies that exist today, primarily caused by well-intentioned siloed efforts wherein health plans make SDOH investments that are disconnected from each other – and only apply to their own members.  For example, one MCO might invest in food, and another in housing.  Now – depending on the color of an individual’s insurance card, they can get either food or housing but not both.  Yes – I’m over-simplifying, but these problems – expressed well  here – can only be truly solved by a convergence of fiscal resources so that they can be rationally apportioned for all. 

Redesign the VBP Roadmap to Address Health Equity and Regional SDH NeedsNYS will develop a comprehensive range of VBP arrangements for the HEROs, SDHNs, and MCOs to consider adopting based on the specific populations and needs within each region.

OK .. details matter.  We’ll see how this flows.

Advanced VBP Contract Requirements and Funds Flow

The provider agreement entered into by the MCO and VBP network entity would need to implement or build on HERO programs with a specific emphasis on prepaid or global payment models, and address local needs based on priorities identified by the HERO. NYS envisions that not every VBP arrangement will utilize SDHNs as the vehicle for CBO contracting, especially in areas where there is a strong cohort of existing CBOs or IPAs that are already successfully managing the needs of specific populations. However, under the waiver, NYS would give funding preference to arrangements that utilize SDHNs.

Well, this seems awfully complicated.  Again – without the HERO, and with direct $$ from MCO to the SDHN (and of course by extension the CBOs) incentives should align perfectly – eliminating the need to prefer organizations that use the SDHN.  Medical providers would be  crazy not to participate with SDHNs – and health plans can further motivate them.  We don’t need DOH or HEROs trying to pick and choose.  VBP will happen if (and only if) DOH (and by extension CMS) makes fee-for-service hurt enough.  As Adam Boehler said a few years ago when he was Director of CMMI:  “I’ve never seen ‘no downside’ work.”  Let’s heed Adam’s advice.  A pinch of downside risk and this whole thing falls into place.  Keep tiptoeing around?  We’ll get the same “we’re trying, it’s so hard” excuses.

        Leverage Ongoing Primary Care Investments

While moving to health equity-focused and advanced VBP contracts, these models will continue to recognize the important role primary care plays in care management and service coordination. The role of primary care is evidenced by the significant investments that have been and are continuing to be made through the New York State Patient-Centered Medical Home (PCMH) program.

Well, if we’re being evidence-based, let’s carefully consider whether PCMH has really gotten us very far.  Most of the principles of PCMH are table-stakes in 2021.  It’s a program that’s been around over fifty years.  There’s nothing progressive about PCMH anymore – let’s not pretend there is.   Primary care – with downside risk, level 3 contracts, and high-bars for quality?  Yes! That’s progressive.  Plans and providers should receive compelling PMPM adjuncts for increasing levels of risk – making primary care providers engaged participants in understanding and reducing unnecessary acute care episodes, unnecessary medications, diagnostics, and therapeutics.  

        Capacity Building and Training to Achieve Health Equity Goals

Workforce and training are critical foundations to achieving the health equity goals under this proposal and to developing delivery systems of “well care” capable of serving the whole-person. To provide the SDH interventions through the SDHNs, NYS will need to expand the number of community health workers, care navigators and peer support workers, particularly drawing from low-income and underserved communities to ensure the workforce reflects the community they serve. Workforce training will also support regional collaboration under the HEROs, the SDHNs, and the move to advanced VBP models.

Yes – and all of this can be managed through the funds-flow model(s) I define above rather than through an intricate – over-designed (and likely too-prescriptive) model defined and enforced by DOH and or a HERO.  With the right incentive structure, the MCOs, the primary care providers, and the SDHNs can make the workforce investments.  If there are jobs, the training programs will occur, and with sufficient funding, the SDHNs can (as PPS did in the past) collaborate with community colleges to create training and/or certificate programs.  Why SDHNs and not MCOs or GRHEO?  Because the MCOs only rarely collaborate (so training would be siloed) and GRHEO would be too slow to respond to workforce needs.  It has to be the agile, committed SDHNs that would lead this work.  Input from others?  Yes.  

Ensuring Access for Criminal Justice-Involved Populations

Based on historical data in New York, approximately 83 percent of incarcerated individuals are in need of substance use disorder treatment upon release.  Meanwhile, the share of individuals in New York City’s jails who have mental illnesses has reached nearly 40 percent in recent years, even as the total number of incarcerated individuals has decreased.  Incarcerated individuals with serious health and behavioral conditions use costly Medicaid services, such as inpatient hospital stays, psychiatric admissions, and emergency department visits for drug overdoses at a high rate in the weeks and months immediately after release. This population can then be more effectively served as part of the health equity-informed VBP arrangements described above. With this purpose in mind, NYS seeks approval for the following eligibility changes:

Reinstate Medicaid Eligibility and Enroll Incarcerated Individuals 30 Days Prior to Release

Therapeutic Residential Treatment Pilot

While I agree – this section begins the “kitchen sink” part of the waiver draft.  Nothing is bad here – but I wonder if these could be folded into the above narrative to allow regions to address these issues with sufficient clarity and sensitivity to local needs.  

Goal #2: Developing Supportive Housing and Alternatives to Institutions for the Long-Term Care Population

Overall, the initiative has shown a reduction in the number of emergency department visits and inpatient hospital stays. On average, Medicaid claim costs declined by about $6,800 per person with high utilizers of the programs having an average savings of $45,600. Programs that transitioned individuals from nursing home settings saved an average of $67,255 the first year and $90,239 the second year in housing.

 

NYS seeks to extend this effort through additional supportive housing programming, which the State expects will be necessary to address downstream effects of the COVID-19 pandemic, such as additional instability in housing for many Medicaid-eligible individuals and families and an urgent need for supportive housing for people experiencing homelessness.

 

  1. Investing in Home and Community-Based Services as Alternatives to Institutional Settings

  1. Local & Statewide Planning & Coordination through HEROs

This coordinated approach to housing will utilize HEROs outlined in the earlier section, as we anticipate housing to be a universal need. HEROs would conduct an inventory of supportive housing programs in each region and identify the gaps that exist, mapping existing efforts and any gaps by area and vulnerable population.

  1. Statewide Housing and Home-Based Services Initiative

Through this waiver, the State will establish a Statewide Housing and Home-Based Services initiative to consolidate and expand its array of supportive housing and medical respite programs. This initiative will be coordinated across state agencies and result in the development of a comprehensive and unified supportive housing and respite services menu. The services provided could include, among others

  • Medical respite models of care for post-hospitalization discharges and transitional housing;
  • Case management and care coordination, including tenancy assistance, rental assistance, transitional support services, and referrals and linkages to care;
  • Behavioral health supports, including substance use disorder services;
  • Environmental supports and accessibility modifications;
  • Employment and vocational services; and
  • Additional SSI state supplemental funding for high needs populations.

NYS will also reach out to community partners to solicit additional and innovative ideas for new types of services that can be piloted and tested for their ability to enact long-term improvements.

Again – this is another example of DOH separating an initiative that should be converged.  Housing insecurity is a social determinant of health.  A simpler approach here is therefore warranted, leveraging the 2.5% PMPM payment from the MCO to the SDHN.  Regional needs assessment would be performed by the GRHEO and the SDHN, with investments made by the SDHN where indicated.  So – yes – we agree completely that DOH and other agencies should coordinate well here – but this shouldn’t be a separate narrative, funding stream, accountability cascade, or governance matter.  Keep it simple.  

Specific Supports for Individuals with Behavioral Health and Substance Use Disorder Needs

  • Enroll eligible individuals in Medicaid 30 days prior to discharge from a correctional facility
  • Authorize Medicaid reimbursement for Critical Time Interventions models to help people transition across levels of care
  • Expand available services to support reintegration into the community

Yes. This all makes sense – but (again) why create a new silo here?  Make reintegration an element of the SDHN’s commitment to DOH and the MCOs.  Done.  How this gets done will vary by region, because the challenges and available resources (or lack thereof) of reintegration vary by region.  

Goal #3: Redesign and Strengthen Health and Behavioral Health System Capabilities to Provide Optimal Response to Future Pandemics & Natural Disasters

Although this waiver demonstration’s primary focus is to address disparities in access to quality health care and social care and achieve an equitable pandemic recovery, the COVID-19 pandemic also revealed that NYS must have a ready-to-execute strategy to respond to a significant increase in demand for acute care services. This includes a greater volume of hospitalizations, higher intensity of care services, and the need to replace disrupted acute and chronic healthcare services that are attributable to a pandemic. Redesigning the healthcare delivery system to efficiently achieve better outcomes in underserved areas during non- emergency times must be done in a manner that also supports rapid mobilization of resources for pandemic response demands on hospital capacity, workforce, supplies and continuation of essential healthcare services and quality care during an ongoing crisis.

(Sigh – note that this section was clearly written by a different team – as they use “healthcare” rather than “health care.” As noted above, the latter is correct.

Pandemic Response Redesign

  1. Physical and IT Infrastructure Preparation and Planning

  2. Inventory Planning

  3. Training in Order to Respond to Needs and Minimize Disruption to Delivery of Needed Healthcare Services

Develop a Strong, Representative and Well-Trained Workforce

Even prior to the COVID-19 pandemic, areas of NYS were experiencing workforce shortages across the health care continuum. Building on the work from the prior waiver demonstration that ended in March 2020, proposes a substantial reinvestment in Workforce Investment Organizations (WIOs) to focus on the needs of their respective regions and coordinate with the other WIOs across NYS to facilitate a cohesive approach to workforce development and share best practices. Planning efforts will involve a variety of stakeholders, including government entities, labor organization, provider organizations (inclusive of former PPSs with proven workforce strategies), and CBOs. Importantly, this investment would both expand capacity through a well-trained and culturally informed workforce and recognize that training investments themselves function as an important SDH, related to job insecurity and unemployment. Funds would support initiatives targeted at addressing workforce needs and the specific projects outlined for this waiver demonstration, and would include:

  1. Recruitment and Retention Initiatives

  2. Develop and Strengthen Career Pathways

  3. Training Initiatives

  4. Expanding the Community Health Worker and Related Workforce

  5. Standardize Occupations and Job Training

The workforce components of the waiver draft all seem appropriate elements of the right strategy and yet – gosh – I can’t quite put my finger on it – how we get this all done may (or may not) be through the methods expressed in the draft.  For example – I’ve already mentioned above that Community Health Worker expansion may happen organically when(if) SDHN/MCO investment in this domain grows.  But we know well that one size doesn’t fit all, and it’s possible that Community Health Workers aren’t what a given market needs.  Market forces will be more sustainable – both for expansion and (if necessary) standardization.  Several communities attempted both (g) and (h) above through DSRIP, with suboptimal results.  This part of the waiver proposal should be re-expressed as a strategic goal – with SDHNs and MCOs collaborating with GHEROs to define roles and then hire the people – eliminating much of the up-front cost and delay of funded planning activities.  As I’ve said above – pay for outcomes and expect regional work to define and implement the right programs.  If the methods are defined in some office (or home office) of DOH staff, and negotiated with CMS staff, we’ll propagate waste and miss the opportunity for efficiency and truly effective programs.

And here we are – finally – something in my wheelhouse.  For readers who haven’t tracked my career – I’ve worked in health IT for nearly 30 years – and (yes) I agree wholeheartedly that robust IT is an essential part of a healthy New York.  

Goal #4: Creating Statewide Digital Health and Telehealth Infrastructure

A silver lining of the COVID-19 pandemic has been the opportunity for—and accelerated realization of—widespread consumer and provider use of digital and telehealth care, including tools such as remote patient monitoring, innovative care management technologies, and predictive analytics. Consumers report high satisfaction with telehealth options, with prominent surveys showing satisfaction levels of 86-97%, often higher than for in-person visits. 

The State will therefore use waiver funding to create an Equitable Virtual Care Access Fund to assist such providers with these human capital investments, resources, and support.

Significant additional planning and investment is critical to create a robust infrastructure for telehealth, telephonic, virtual and digital healthcare. Through a statewide collaborative group, the State will identify local strategies/solutions for mutual assistance and to also inform statewide standardization of technical requirements, workflows, as well as training and technical assistance to further build the necessary infrastructure to meet the immediate and long-term needs.

The details expressed in this section outline the many advantages of telehealth, e-consults, etc.  The Equitable Virtual Care Access Fund would assist medical, behavioral health, and (presumably) other parts of the safety-net such as CBOs, to invest in the human and technical infrastructure so that telehealth becomes a “new normal.”  Yes. But once again, the DOH proposal involves quite a bit of planning and rather little trust in the entities that would (see above) have been empowered to address these issues and in fact have already done this.  We’ve seen this movie before: in 2009, the HITECH Act, part of the American Reinvestment and Recovery Act, funded incentive money for medical providers and hospitals to invest in information technology.  The program(s) – often described as the “Meaningful Use Incentive Programs” – or “MU,” provided incentive dollars for medical providers who made meaningful use of certified EHR technology.  The plan was that there would be three stages:  1) Adoption, 2) Connection (interoperability), and 3) Improvement. I was an HHS leader for three years during the heart of these programs, and therefore learned a great deal about how (and how not) to implement policies to accelerate adoption of new technology and new ways of providing health services.  Stage 1 worked incredibly well.  With the help of Regional Extension Centers (RECs) – thousands of practices selected, purchased, implemented, and optimized information technology.  The goals of the stage were clear and yet sufficiently flexible.  (Stages 2 and 3 were much more difficult for reasons we’ll not go into now.)

So if the goal is to provide support for service providers to implement and optimize telehealth – why not emulate what worked in the past?  Let’s sidestep the potholes on this road ahead, limit “planning” and statewide committees – and use a framework that will get us there without building from scratch and learning the lessons learned before:  simply create explicit, simple methods for organizations to apply for Equitable Virtual Care Access Fund assistance for:

  1. Selection and implementation of telehealth tools
  2. Service provider training and optimization
  3. Ongoing Software-as-a-service fees

During the pandemic, Healthy Alliance IPA supported many CBOs and behavioral health providers in the transition to telehealth by purchasing licenses to secure video conference services and donating laptops where necessary.  This isn’t difficult.  The tools (as any pandemic-era 6th grade student can confirm) are now commodities and after some early security hurdles – are secure, reliable, and ubiquitous. Let’s just do it.

I do see a bit of telehealth myopia here and wonder if there aren’t additional opportunities to assist CBOs and behavioral health providers in the procurement and implementation of functional health information technology. (These folks were left out of the federal incentive programs.)  Products offered to these organizations are often not aligned with the ONC Standards and Certification regulatory framework and therefore these organizations can’t participate with health information exchange (the verb, not the noun) as can medical providers and others who participated in “MU” back in the day.  Within the allocation to the SDHNs – these organizations could request funding for health information technology to support day-to-day operations, and such funding could be tied to implementation of only products that meet the ONC’s ISA. By invoking a federal standards framework, DOH sidesteps the work required to define and enforce criteria, and aligns New York with HHS priorities and objectives.  This is self-evident  (to me) yet absent from the draft proposal.

Summary

The 2021 1115 Waiver proposal from New York DOH describes an ambitious agenda that does improve on the DSRIP program that was implemented from 2015 – 2020.  How does it fare in the context of our “too many, too few” evaluation framework?  

Too many.  

    1. Too many organizations.  Too many targets.  
    2. ✅ If we can compress (or eliminate) the HERO – and have very few SDHNs – I think we can check the fist box easily. SDHNs need geographic scale to be effective.  Healthy Alliance IPA has been working – through partnerships – in three markets (Capital Region, Adirondacks, and Central New York) and this has worked quite well – making infrastructure investments more feasible and spread over a broader service area, while maintaining “local flavor” of CBO interactions and service optimization
    3. ✅ Again – devil in the details, but if SDHNs – in collaboration with MCOs – in a true “trusted broker” model – can define measures of success autonomously – this will work well.  The draft proposal does recognize the limitations of medical measures of success (HEDIS and others). 
  1. Too many choices.  
    1. ✅ By avoiding the mistakes of DSRIP – this program avoids the laundry list of tactical programs and would allow regional efforts to define and then focus on what’s important.
    2. 🟨 Too many dollars (going to the wrong places).  We’ll have to see.  The HERO model concerns me – and if left as-is, there is simply too much responsibility put in its hands – with high risk of misalignment with true public health priorities.  With modifications of the HERO model as I express above – and funds flow from DOH ⇒ MCO ⇒ SDHN, we solve this. ✅

Too few.

    1.  
  1.  
  1. Too few outcome objectives.
    1. 🟨 I don’t see any clear outcome objectives and this concerns me – as does the frequency with which “planning” is mentioned as a solution to our problems.  Some strategic planning is always necessary – but as a step 1 toward implementation.  The outcomes here that we seek are clear and achievable: All New Yorkers are healthy and happy.  How do we measure this?  We may be ignoring an easy method:  just ask.
    2. 🟨 Too few  governing organizations.  
      1. We’ll see what happens.  I’m optimistic that DOH understands what happened and won’t repeat it – but the structure of the HERO could very well replicate flaws of the previous iteration.  My GHERO idea – putting local government in control will be a big step in the direction of fixing this – though I do have a nagging concern that politics could still interfere. We have certainly seen this with Covid-19, where elected county leaders made decisions that were in conflict with public health objectives. We will therefore need a way to protect county public health leaders from political consequences – protecting them and making them accountable to DOH.
      2. Too few dollars (going to the right places).  
        ✅ “Safety Net” is mentioned several times, but it’s still not clear if this means what it meant for DSRIP.  If so, we have a problem.  If we can expand the definition – so we don’t have the 5% problem that we had before – we’re good here.  I’ll be optimistic.

So there we have it.   It’s a great effort and I suspect that the work is the product of quite a bit of political needle-threading for our colleagues @ DOH.  Hopefully, we can sand off the edges, collaborate well with CMS, and get this thing kicked off ASAP.  

Primary Health! Now from Circulo

BLUF – in October, Circulo acquired my little company, Huddle Health. We are now fully integrated into Circulo – and it’s time to describe the rationale for our convergence and some of what comes next.

If you haven’t read my short essay on Primary Health, please go read that first.  We’ll wait.

Ok … back?  Great.  Now, let’s resume the story.  

Years ago, I was on the faculty at Albany Medical College. We had a course called Health, Care & Society wherein students were challenged to learn and think about ethical issues, health policy principles and engaged in conversations on the role of medical providers in our communities. It was a “soft” class that many students seemed to feel was peripheral to what they would do as physicians. They didn’t take the course as seriously as biochemistry, pharmacology, or anatomy.

And this is a symptom of our problem.

Physicians are taught medicine – not health.  This is why it’s called medical school and not health school.  Our training prepares us well to diagnose problems, respond to those in need, order testing and treatments, prescribe medications and other therapeutics.  Notice that much of what we are doing is reactive – focused on managing illness rather than optimizing health.

Over the last few decades, we’ve marketed medical services as the center of our communities’ health lives.  But medical services are not the center of any community – and with good reason.  As Clay Christensen expresses, our people, products, and processes weren’t designed to optimize health.  Rather – they were designed to optimize care (and the revenue that care creates). 

This is hard for many of us to really understand. “You mean my doctor wants me to be unhealthy?” Well – no – of course not. We hope. Some consider Fee-for-service to be evil. I won’t go that far. Let’s stick with “misaligned incentives.”

Why does this happen? More volume = more revenue. Incentives generally aren’t aligned.

But there is hope, Luke Sykwalker. As more medical service providers have migrated to value-based payment, interest in health (rather than just care) has grown.

This is good!  But it’s just one step on a long path.

Over a decade ago, Eric Dishman described the “shift left” as a way to “get more people on the end of the health continuum with lower levels of chronic disease, lower levels of functional impairment, lower costs of health care, and a higher quality of life.”

His focus was the self-evident migration away from the hospital and toward the home as a focal point for health, but allowing for other service locations and other kinds of services along the continuum. Rather than waiting for problems to worsen enough to merit a trip to the medical office or hospital, Eric argued that the shift left would also enable us to prevent problems – reducing both cost and suffering. 

And this is the shift we are ready to make.   As William Gibson offered, “The Future is here – it’s just not evenly distributed.” Let’s consider a few examples of the future:

  • Iora Health started 10 years ago and developed an extraordinary model of person-centered care.  Iora’s visionary leader, Rushika Fernandopulle, led the company through a series of saltatory phases of growth and discovery.
  • ChenMed was built on the foundation of a small practice in Miami and has grown to serve thousands of members in the southeast and mid-Atlantic markets.
  • Oak Street Health launched in Chicago and focused on value-based person-centered primary care for Medicare Members.
  • VillageMD empowers primary care practitioners to participate in value-based payment arrangements.
  • Aledade has built a broad network of independent and medium-sized primary care practices that share analytics infrastructure, processes, and other resources to optimize care experience, quality, and cost.

Each of these companies is taking a different approach, and while one might view them as competitors, we see them as co-travelers – bushwhacking through the forest of fee-for-service in search of a better model. 

Most medical providers haven’t let go of fee-for-service, in part because they don’t have the opportunity. These companies (and a handful of others) have forged a way to the future.  Yes – they compete a bit with each other, but as a group, they demonstrate to the majority of others a better way

Huddle Health was created to learn from our predecessors, question the healthcare industry’s assumptions (who/why/how problems are solved), and work hard to meet the needs of the people we serve.  Especially members of underserved communities – Medicaid Members and the uninsured. Learning from time that several of us spent at Alliance for Better Health – we knew that we need to focus on social determinants of health as a key element of our work – not just bolted-on as an adjunct or afterthought – but at the core of our work. What we had was a great team and a great model. There is a better way. 

Circulo was created to express two guiding principles:  first, information technology in general and automation, in particular, is an essential component of the future we seek to create. Things that weren’t possible in the days of paper are possible now. Yet, much of the technical infrastructure created has remained focused on maximizing efficiency and, therefore, the volume of care rather than optimizing health.  Therefore, we have demonstrated that technology and automation could change things, but so far, we’ve aimed them at the wrong targets. Second, the needs of Medicaid members and the uninsured have not been well addressed.  We can/must/will do better.  We need to reinvent Medicaid.  There is a better way.

See a theme? Me too.

Our shared sense of urgency, our impatience to make things better, and rejection of the status quo are the ties that bound Huddle Health to Circulo. 

We are now one team – committed to making the world a better place as Circulo Health

Stay tuned for the next post – how we will do this!

Organizational Optimization

 

Progress is impossible without change; and those who cannot change their minds cannot change anything.” ~George Bernard Shaw

I was asked by a member of my new team (more on that to follow) to share some resources that might be helpful as we migrate toward perfection.  Rather than plopping this into a Slack message – I’ll share here so he’s not the only one to benefit.  

Since humans are imperfect, any convergence of humans will also be imperfect – as will the products of our shared work.  Nonetheless – our goal will always be to make our work product(s) as close to perfect as possible.  

Step 1 – figure out where is the organization is now

This is a review of the people, products and processes in place.  Are teams in place?  are they well aligned?  Is there clarity of vision? 

For this step – we use the Strengthsfinder 2.0 – available here (digital – test only) or here (hardcover book – includes test).  It’s important to really understand what this does (and what it doesn’t do) – and how to use it well.  If you don’t have someone with experience guiding you through administration of this – please read this first.  

We use Strengthsfinder to identify team balance.  Hiring managers will often subconsciously hire others like themselves.  This is human nature and natural and unavoidable – without a tool like Strengthsfinder.  Consider the strength domains:

Likes attract likes.  So a strategic hiring manager will hire strategic thinkers, a “relationship building” leader will hire more relationship builders, etc. The key here isn’t that one strength is better than another.  Rather – great teams have balance.

Here’s a team I worked with a few years ago.  Each row is a person.  Can you guess what the CEO’s strength profile looked like?  Yup.  Relationship/Execution.  No Strategy.  Where did the org suffer?  Strategy.  They were DOING but there was no North Star. The teams were confused and challenged.

And then .. a year later – after some strategic hiring – still biased toward relationships but much more balanced:

Teams that have this balance will support each other well, build trust and develop interdependencies. as they traverse from competition to collaboration.  Strengthsfinder is therefore the foundation of organizational maturity.  What’s next?

Step 2 – chart a course to Stage 4 of the Tribal Leadership model

David Logan, John King and Halee Fisher-Wright published this book as a product of work to best understand how to differentiate high-performing companies from those who are more challenged.  Here’s the visual:

Ask someone how things are going – and you get the phrase quoted in each stage above. 

Very few orgs live at stage 1 (they’d just die) .. nor do many live at Stage 5. The vast majority of organizations live at Stage 3 – which is normal – but suboptimal. 

At Stage 3, we put energy into competing with each other internally – in order to find affirmation from superiors and/or stand above our peers. 

At Stage 4 – we put all of that energy into collaborating with our peers – maintaining internal drive (yeh – ok – another book) and achieve great things together.  Here’s the fun/fascinating part.  Many visionary leaders live at stage 5.  They don’t notice/understand that their teams live at stage 3.  But a rule of thumb is that communication across more than one level is impossible.  When a Stage 5 leader communicates their vision, their aspirations, their objectives, level 3 teams hear “compete with each other” and work hard for affirmation – so leaders need to learn to speak in language that their teams can hear.  If a team or team member is living at stage 2 (angry) – then we need to offer affirmation and encourage the egocentrism of stage 3!  This is counter-intuitive – given that stage 4/5 culture is our goal.  But nobody leapfrogs from 2 to 4 .. we need to maximize stage 3 to motivate the traverse to stage 4:

Step 3 – optimize, integrate, maintain focus. 
Are we finished yet?   Well – no.  But we’re started.  And that’s good.  Other stuff to weave in:

The secret of getting ahead is getting started. The secret of getting started is breaking your complex overwhelming tasks into small manageable tasks, and starting on the first one.” ~Mark Twain