It’s not a beer

When we announced a few weeks ago that our IPA had executed our first contract, I found myself explaining what an IPA is and what it does.  An IPA is a business entity that assists multiple independent organizations to contract with managed care organizations (health plans).  But it’s uncommon (unheard of?) for an IPA to work with organizations that are not physicians.  We even had to update the Wikipedia entry on IPA to clarify that physicians aren’t the only ones who can create or join an IPA.

Where we are now

We have over thirty organizations participating in the IPA.
We have two executed agreements with health plans, and expect this to grow.
We have a technology platform that connects our community.

Where we are going (and why)

I re-read the 1990’s coffee-table Book “who moved my cheese?” recently, and am now reminded of the simple (yet complicated) lessons therein. The book provides a framework for how we respond to change. A key message is that change will always happen.  If we resist it, we will become angry, fearful and confused.  If we embrace it, we’ll find new opportunities and flourish.  Our IPA is focused on helping organizations embrace (rather than fear) the change that is happening.  These changes will, we hope, help us improve the health of hundreds of thousands of people in New York and beyond.  Our plan is to continue to build relationships on both sides of this work: growing the breadth and scope of the organizations who join the IPA, and growing the number of health plans with whom we partner.

While the metaphor of a well-oiled machine is overused, I reflect that the mechanics of Alliance are running well – primarily because we have learned to anticipate and embrace change.  Indeed, our comfort with change has become our secret sauce.  The challenges of early days of start-up disorganization and growth are well behind us, and while we’ll never be perfect, and the start-up of an IPA is non-trivial, our team is working together to do our best to serve our community.  I am honored and privileged to work with such a dedicated and talented group of people.

Conferences / Unconferences

Our (amazing) team at Alliance for Better Health is planning an event in June.  The purpose is to bring together people in our community who are using the Healthy Together platform, celebrate the community’s accomplishments, and strengthen the connections so that we can find greater success in the future.

I offered a thought this morning that perhaps this isn’t a conference, but an unconference.  I wikipedia-ed (it’s a verb, yes?) the term, hyperlinked it in my email and (after sending) went back to read the wikipedia entry.  It’s accurate and (I now know) expresses a long history of unconferences.  What surprised me is that one of the first unconferences in “modern” times was in 2003 and .. I was there!  Despite a dead website, I was able to find someone’s notes on my session @ bloggercon.  It’s funny how the world is a circle.

To me, the core of an unconference is not unlike the core of a nontraditional post-secondary education, and the core of a person-centered approach to health:  the goals are defined by the people who participate rather than by the people “in charge.”

  • Students at Hampshire College define their educational goals.  Faculty, staff, technical and physical resources are all there to support (and – yes – guide) students on their path.
  • Attendees at an unconference listen, learn, and direct the course of a community of co-participants.  Organizers are there to support (and-yes-guide) but the goals of the unconference are expressed by the participants, not dictated by the organizers.
  • People served by medical care providers, behavioral health providers, and social care providers are the ones who define their own goals.  Words like “noncompliant” or even “non-adherent” become laughably out of place once we understand who is really in charge.  We physicians are (I suspect) the worst violators of this imbalance of power, as we’ve been educated to “write orders” and “define treatment plans.”  Only recently have we discovered shared decision-making.  If “primum non nocere” is really our oath, perhaps we should converge it with “non satis scire” and offer some humility: audire ad primum non nocere, quod non satis sit scire.  (“Listen to do no harm, it is not enough to know.”)


A few days ago, I wrote about the convergence that seemed to be happening at Hampshire College.

Yesterday, the President and another Board member resigned.  There was cheering and excitement at Hampshire, facebook, and Slack.

Why was there cheering?  Because the President charted a course for Hampshire that many in the community felt was (so far) an unnecessary last resort.  Is it possible that Hampshire would some day need to partner with another institution?  Yes.  It’s possible – after other options are deemed infeasible.  The problem here is that the community doesn’t understand how/that Miriam Nelson sufficiently researched all other options, and how she deemed them infeasible so early in her tenure @ Hampshire.

She believed that what she was doing was good for Hampshire. Some members of our community were angry at her, and I understand that anger, but I never felt it myself.  In the same way, I don’t feel happy that she decided to step down.  This has been terribly difficult for her, I’m sure.

But this is bigger than her, or any one person (or even any group of people).  Now is the time to pull together, and her departure gives us that opportunity.  The convergence I described on Wednesday continues.  On campus, several members of the Alumni Advisory Group (AAG) joined the re-envisioning Hampshire Coalition meeting. It was eye-opening for me.  These folks are serious, dedicated, and working hard to make sure that all voices are heard.  That’s super important.

And now the really hard work is ahead of us.  Here’s a rough map of all of the groups that will need to converge on what the future Hampshire College looks like, how we fund it, and how we get there from here.  IMG_3761

The AAG met all day @ Hampshire yesterday, and we’ll do so most of today as well.  We’re a diverse team – with members from each of Hampshire’s decades, expertise in many domains, and (most important) diverse perspectives on how to interpret what’s going on at Hampshire and how to respond.  We are a microcosm of the Hampshire alumni community, and what’s fantastic is that we trust each other.  Since change moves at the speed of trust, this has enabled us to move swiftly toward consensus on many issues, and enables us to bridge connections between others through the growth of such a trust network.  Much more to do, and we wouldn’t be able to accomplish any of this without our canine member @Griffin.


Hampshire College: Convergence?

Yahoo! It’s Spring!

Wow.  It’s been too long since I’ve posted here.  I’ve been busy with my day job .. and writing elsewhere (some recent stuff referenced here)

Now .. the topic of today:

Hampshire College. It’s not in a good spot.  Lots of history here .. and here .. and here.  Yesterday’s Boston Globe article is a short summary of the most recent events.

Why do I care?  Because – well – Hampshire is an amazing place, doing amazing things, and the world needs it to be there forever.  I spent three years there as a student, and one year there (a few years later) teaching and working in the admissions office. I did well there, and that empowered me to do well in medical school, residency, as a faculty member and Associate Dean at Albany Medical College, etc.  What I mean when I say “did well” isn’t that I got good grades, because (for those of you who don’t know) .. Hampshire has no grades.  “Doing well”  in this context means (I think) that we move forward, have positive impact on the world, find happiness and share that positive  impact with others as widely as possible.  Hampshire discovered and fostered the “growth mindset” and reinforced it long before Carol Dweck started talking / writing about it. 

This is a blog. It’s not a facebook post, slack channel or shared strategic plan. It’s a set of observations that I’m choosing to share with you. I’m just one person. F83, P10 (That’s Hampshire-Speak for:  “I entered Hampshire in the Fall of 1983 and I’m the parent of a former Hampshire student who entered in 2010.”  I give money to Hampshire. I’m ready to give more. Some of my guiding principles for this post, and how I’ve tried to approach the current challenge:

  1. Be generous and assume best intentions. Decisions have been made. We don’t really know all of what went into the decisions. We may learn more. We may ultimately disagree with these decisions. But I refuse to judge anyone as evil, malignant, incompetent, etc. These words just don’t help. I’m going to assume that everyone here has the best interest of Hampshire in mind.
  2. Engage with shared success as the primary goal. It’s not important to be right. It’s important to listen, learn, seek understanding, and find the right path forward together.
  3. The Hampshire College that has been is not the Hampshire College that will be. Product-market fit has not been achieved in recent years. Many people will be unhappy with the changes that will need to happen.  These changes include:
    1. Administration / administrative overhead will need to change – ideally get (much) leaner.
    2. Hampshire’s educational offering(s) will need to better align with the wants/needs of incoming students. Yes. This means that some faculty won’t stay. We may love them as humans, but if they teach stuff that not enough students want to learn – isn’t it our responsibility to invest in different mentors? This concept may threaten long standing principles of academia.  So be it.  This is Hampshire.  We should do the right thing, not necessarily the traditional thing.
  4. There are some elephants (frogs?) in the room. Resolving them is going to need to be part of any cogent solution.
    1. The discount rate has been going up (and up). Translated: students who can pay full tuition are a small minority of incoming classes. The College therefore operates at a loss.  While many colleges operate this way, Hampshire’s investments (endowment) doesn’t generate sufficient revenue to cover this gap.  The endowment itself is restricted.  It can’t be used to cover operating expense. Hampshire needs to attract more students so that it can be more selective, and (at the same time) bring in more students who can pay full tuition.  
    2. Some students have not done well at Hampshire. Ideally, Hampshire is the right place for students who will excel in an educational environment that offers more freedom in exchange for more responsibility. Accepting students who can’t manage this responsibility puts everyone in a tough spot: students struggle, retention is reduced, cost is increased (see above – as discount rate goes up), and demands on faculty are enhanced (causing the College to hire support staff – and pressure to reduce faculty: student ratio). The Hampshire of the future will need to attract the students who will excel at Hampshire. Hampshire needs to be the positive choice for those who will flourish, rather than the negative choice for those who don’t fit in elsewhere.  It’s always been hard for Hampshire to find these students, but I believe that this is the only way for Hampshire to be sustainable long-term:  get more selective.  Focus on excellent applicants, not just unique ones.

What’s next?

I feel convergence in the air. There is growing consensus that an independent option may very well be viable. I see three key vectors – the latter two of which are converging:

  1. Strategic partner. I’m assuming that this is the University of Massachusetts. Sure – other options are being considered, but UMass makes more sense than any other institution. Much to work out here, and there is huge risk that the true identity/purpose of Hampshire is lost in a merger (acquisition) with (by) UMass.  
  2. The Re-envisioning project. Watch this as a good overview. It’s good. Lots of thinking and selfless collaboration went into this initiative.
  3. Hampshire2020. This project is smaller and quieter. Here’s their v1 deck. I hear there’s a V2 deck but I’ve not (yet) seen it. 

You’ll notice that the re-envisioning project and Hampshire2020 are similar. They’re both great starts, but both of them rely on huge fundraising efforts to save the day right now.  (See for links to fundraising activities, and also support Davis Bates as he takes a 17 mile fundraising walk this week).  Without a massive influx of $$, Hampshire can’t stay open in a form that will be attractive to the two populations most important to its future:

  1. Donors. Humans, alumni (also humans!), foundations, and corporations. People give money for many reasons – but “save this dying ___” is rarely a compelling message. Rather – “make an investment in this ___ so that the world will be a better place” is generally much more successful.  A healthy Hampshire College is indeed something that many could / would support.  We need a clear, believable plan.  My former boss (yes – that’s another story) Vinod Khosla offers what I think is the best overview of how to pitch an investor.  We need to pitch investors with a strong story about how we’re going to make the world better with a new Hampshire College. 

  2. Students. Hundreds of thousands of these people select higher education options every year.  Yes, there are fewer of them now, but there are still plenty of them, and plenty who would love Hampshire.  Simply put, they are the customer.  They make these choices based on a set of factors that are important to them, just like the customer at a restaurant, car dealership or online bookstore. I would argue that we need a core set of product management principles to be applied here.  I’ve seen very little of this in the re-envisioning project – and only tips of this iceberg in Hampshire2020’s proposal.  What are the market requirements? What resources do we have available to meet these requirements? How is our product differentiated?  I’m concerned that we’re a bit too focused on the asset we have (the current faculty, curriculum, structure) and not the one we need.  There’s compelling evidence (enrollment is the key metric, of course) that our current product isn’t well aligned with the market.

Doing – not just talking.

I’m ready to dig in. I’m ready to join the coalition of great people working toward an independent Hampshire. I’m ready to invest my time and my money in this initiative.   What do I mean by “this initiative?”  I mean the coalescence of re-envisioning Hampshire and Hampshire2020.  I’m ready to bring what I’ve learned in ~ 30 years of work in health, health care, information technology, investing and government to help us converge.  Because we must.


Why we’re launching a Consumer Directed Exchange (CDEx) project

If your first question is “what’s Consumer Directed Exchange?” please feel free to google it and come back.

Last week, Alliance for Better Health launched the first regional effort in the United States toward facilitating CDEx for Medicaid Members.

Here’s my short (?) version of what/why/how

We consumers (people?) are becoming increasingly aware of the information that others have acquired about us. We implicitly trust Facebook, Google, Apple, etc. to keep our information safe, and share it with others only when we choose. As health care has evolved from paper, there is now an extraordinary quantity of our health information that is stored digitally in hospitals, medical offices, and (yes – see above) Apple, Google, etc. When a provider of health care services needs your health information so that they can better serve you (or serve you at all), they can sometimes access this information through traditional means of health information exchange. There are several ways to do this, and I won’t cover them today. A short overview is here. Note that there is a difference between the activity of health information exchange (the verb) and an HIE (Health Information Exchange – the noun).

We usually give permission for care providers to exchange our information. The Health Insurance Portability and Accountability Act (HIPAA) and the important but often overlooked HITECH Modifications to HIPAA provide the framework for how, when and why our information is shared. A key feature of the regulations is that they apply to HIPAA Covered Entities (CEs) and Business Associates (BAs). The HITECH mods made big changes to the definition of a BA, and in so doing, made it very important for a BA to have robust security & privacy technical and process infrastructure. By making these changes, HHS shifted the responsibility for a BA’s behavior from the CE to the BA, so long as a business associates agreement (BAA) is in place. Before the mods, a CE needed to be certain that the BA had the right infrastructure in place, so they developed big spreadsheets with workbooks that every vendor would need to complete in order to document how mature they were. With the modifications, this shouldn’t be necessary, as the BA is now legally liable for any breach, rather than the CE, so the BA just needs to attest to the CE that they do have such infrastructure. Alas, old habits die hard, and most CEs (unfortunately) still make their vendors do the security workbook, or complete Hitrust certification as evidence of appropriate infrastructure. This isn’t wrong, but it’s also not necessary, and it creates thousands of hours of unnecessary work on both sides, as vendors need to complete security workbooks and then the security workbooks need to be reviewed, approved, or rejected/revised, etc.

But what if the food pantry, homeless shelter, city mission, or community health worker needs this information in order to help you? Traditionally, these folks are not CEs – nor are they BAs (they don’t have the security infrastructure or policies in place in order to satisfy the requirements of a BAA) and therefore the CEs and BAs (and their lawyers) don’t feel comfortable sharing health information with them. With good reason, as they lack the infrastructure required to keep information safe. These entities are therefore called Non-covered entities (NCEs).

In addition to the NCEs, information sharing between CEs and between BAs is sometimes less fluid than we would like. Have you ever arrived at a care provider’s office and found that the information that was supposed to be shared with them by another provider wasn’t there? Labs, imaging reports, a consultation report, a discharge summary .. all of these are often simply unavailable despite our expectation that they would/should/could be. We all have anecdotes – so I’ll share one: in 2015, my dad was having a procedure in San Francisco (at the “Best Hospital in the world,” and his physician in Boston (at the “Other Best Hospital In the World”) was to send dad’s records over. Both hospitals have electronic health records. Both hospitals had dad’s written permission to communicate with each other. When dad arrived .. guess what? No records. The SF hospital demanded that we hand them paper. Citing HIPAA, they refused to accept electronic transfer.  No, I’m not making this up. The solution? From my home in New York, I logged in to the patient portal for the Boston hospital (with dad’s username/password) downloaded them to my computer, “printed” them to a pdf file, logged in to my Doximity account, and faxed them to the San Francisco hospital. They accepted a fax.  This is consumer directed exchange. Albeit a perverse version of it.

When traditional methods fail, we use consumer directed exchange. Would most people have been able to do what I did? Probably not. Certainly not Medicaid members – who have neither the technical tools nor the e-fax capability of Doximity.

How can we make this all easier for everyone?

If knowledge is power – how do we make sure that the information upon which knowledge will grow – is available and portable? If I want my health information to be shared with ____, how can I make that happen quickly and easily?

This is the core problem we’re working to solve: we plan to make it easy for anyone to share their health information with whomever they please. Here’s how:

  1. Verify that you are who you say you are.
  2. Give you access to as much of your health information as we can access on your behalf. For our initial launch, this will be whatever is in our regional Health Information Exchange, Hixny. But we’re building this solution so that it can access other data sources too, and we hope that the tool we build will be used by others – both nationally and internationally – as our code will be shared under an open source license, and can be used freely by other organizations. This will not be a proprietary solution.
  3. Help you share the information. It’s yours. Once you control it, you can do anything you like with it. You can print it, share it with the person sitting next to you, even tweet it (but we don’t recommend twitter as a transfer mechanism, btw). We’ll help you choose the best method. The key is that you are doing the sharing. There is no “consent” or “authorization” or anything else that is part of this exchange, because no CE or BA is doing the information exchange. The consumer is directing the exchange. As they should.

Our hypothesis is that with better access to information, better decisions can be made – avoiding unnecessary or harmful interventions. We’re excited to launch this initiative regionally, and hope to see it spread across the nation.

Apple, Cerner, Microsoft, and Salesforce

… all rumored to be in the mix to acquire athenahealth.


Why not?

a) Apple doesn’t do “verticals.” It’s that easy. Apple sells products that anyone could buy. A teacher, a doctor, my mom. Sure – they have sold high-end workstations that video editors can use, but so could a hobbyist filmmaker. Likelihood of Apple buying athenahealth ~ .01%

b) Cerner Nah. While (yes) they have an aging client-server ambulatory EHR that needs to be replaced by a multi-tenant SaaS product (like the one athenahealth has built), they have too much on their plate right now with DoD and VA and the (incomplete) integration of Siemens customers. Likelihood of Cerner buying athenahealth ~ 1%

c) Microsoft. Like Apple, it’s uncommon for MSFT to go “vertical.” They have tried it. (Who remembers the Health Solutions Group?) But the tension between a strong product-focused company that meets the needs of many market segments, and a company that deeply understands the business problems of health (and health care) is too great. The driving force of MSFT, like Apple, is to sell infrastructure to care delivery organizations. Owning a product that competes with their key channel partners would alienate the partners – driving them to AMZN, GOOG and APPL. Likelihood of Microsoft buying athenahealth ~ 2%

d) Salesforce. I’d love to see this. But it’s still unlikely. athenahealth has built a product, and they (now) have defined a path to pivot the product into a platform. This is the right thing to do. Salesforce “gets” platform better than everyone (aside from, perhaps, Amazon). But Salesforce has struggled with health care. They’ve declared n times in recent years that they are “in” to really disrupt health care, and with the evolution of Health Cloud, and their acquisition of MuleSoft, they have clearly made some investments here, but the EHR is not the “ERP of healthcare” as they think it is. (Salesforce’s success in other markets has been that they dovetail with – rather than replace – the ERP systems to create value and improve efficiencies.)) The way that Salesforce interacts with the market is unfamiliar (and uncomfortable) to most care delivery organizations. So if Salesforce “gets” platform, and athenahealth wants to be a platform when it matures, could these two combine It’s the most likely of the three, but I still see the cultures of the two companies (I know them both well) as very different, and not quite compatible.Likelihood of Salesforce buying athenahealth ~ 10%


a) Phillips. ?They have enough $$, are getting into population health, have IoT “last mile” business alignment, and understand the need to migrate from FFS to value on a global scale.

b) Roper / Strata. Yeh – you didn’t think of this one! Roper owns Strata Decision. Cost accounting fits well into the revenue cycle roots of athenahealth. Strata is getting deeper into the role that clinical activity (and deviations from best practice) plays in cost. Dan Michelson (Strata CEO) understands the EHR market incredibly well.

c) Amazon. Platform. ABC. 1492. I’ll say no more. If you don’t know what I’m talking about, LMGTFY.

d) Value Act.? Elliott’s not the only big player that may have interest in owning this real estate.

e) IBM. Yup. Could happen. They have made significant investments in health (and health care). Unlikely but possible.

I’m sure there are more. This will be interesting. athenahealth has a vibrant culture, fantastic people, a strong, devoted customer base, and an active developer community. Remember:? this is a revenue cycle company, not an EHR company. The EHR is a new game they’re playing. It’s an important one, but Todd and Jonathan got into this business with the goal of solving business problems for their customers. That vision remains. It turns out that a healthier population is (or should be) good for business, and an EHR is (for now) part of that picture. But as the needs of the market evolve, athenahealth will evolve. They’ve demonstrated this well, and this agility is what will cause them to be successful in the long-term.

Funding Disruptive Innovation

“Innovation” is a provocative word.

For some, it invokes an eye-roll of disdain: “why can’t we just get our work done?” They pexels-photo-1038914.jpegrhetorically ask. Sometimes, the way we are doing things is just fine. Why distract ourselves with new variants of people, processes, or products just for the sake of doing something new?

These folks have a point. Sometimes we just need to do what needs doing.

And sometimes the way we’ve been doing it (or even what we’ve been doing) isn’t optimal. “There must be a better way” says … someone.

That someone is the innovator. The eye-rolls The innovator is used to eye-rolls. And much worse. Indeed, the innovator has been maligned, undermined, threatened, disciplined, and even fired for thinking about the better way.

There’s a good reason for this. Most innovations fail.? When innovators dream of a better way, and therefore spend time thinking, working on projects that may or may not bear fruit, “wasting” valuable time and money so that they can .. what “Improve things!?”

Such is the healthy tension, especially in the industry known as “health care.” Lives are at stake, so we must innovate with extraordinary care, lest we harm people. There is good reason for this.

Or is there?

When I was in medical school, I was “spoken to” because I asked questions of a professor who was teaching us tradition that was (even at the time) not supported by science. Thirty years later, what he was teaching us is now well-known to be inappropriate. The path to better care (and more health) is asking whether there is a better way:? questioning the assumption that “we’ve got it right” and always challenging ourselves to look at things from another perspective.

As CEO of Alliance for Better Health, I serve with an amazing team of people who are helping our community change. We are a New York DSRIP Performing Provider System. New York’s DSRIP program is an experiment. The hypothesis is that we can reduce unnecessary spending on acute care if we focus instead on the health of our population. Healthy people don’t need to go to the hospital. I would argue that this needn’t be just a hypothesis, as the data is clear:? we can. The harder question is whether we will. I’m reminded (again) of the old joke that my dad (the psychiatrist) used to tell:? “how many psychiatrists does it take to change a light-bulb Only one, but it needs to want to change.

The gap between what we humans can do (what we are capable of) and what we do (what we choose to do) is wide. We can exercise more, but we do not. We can stop eating trans-fats or foods with nitrosamines (both of which are well established to enhance the likelihood of disease) but we do not. People addicted to chemicals (nicotine, opioids, alcohol) can stop, but they do not always do so. Why don’t humans do what is objectively better for us We seem to have a reason to preserve the status quo. Why Why do we reflexively resist the people (or ideas) that ask if there’s a better way?

“People change in many different ways and for a multitude of reasons. The psychology of change is a broad and fascinating subject in its own right. In one sense, in fact, psychology is the science of change.” ? – William Miller & Stephen Rollnick in Motivational Interviewing Preparing People to Change Addictive Behavior.

So if innovation is about change, we need to understand the barriers to change. Only when change is embraced will the benefits of innovation be perceived to outweigh the risks. Now let’s get back to DSRIP and innovation.

Last week, we announced our second innovation award program. Last year, we awarded over $5.5 million to members of our community.

The purpose of the program this year is to nurture a culture of innovation in our region, with an emphasis on disruptive innovation.


Why are we focused on disruptive innovations Take a look at the classic graphic that Clayton Christensen often uses to explain the theory. Sustaining innovations improve existing products and processes, and improve the performance of existing markets. Disruptive innovations create new markets. They meet the needs of those who are not well served by the existing infrastructure, often because providing services to these folks is perceived by incumbents as low-margin and therefore not profitable.

Before you continue, please read this. It’s important, and, yes, if you are applying for one of our innovation awards, there will be a test (your application) at the end of this. As Christensen and team express, Disruptive Innovation is often invoked, but not always understood:

In our experience, too many people who speak of ?disruption? have not read a serious book or article on the subject. Too frequently, they use the term loosely to invoke the concept of innovation in support of whatever it is they wish to do. Many researchers, writers, and consultants use ?disruptive innovation? to describe?any?situation in which an industry is shaken up and previously successful incumbents stumble. But that?s much too broad a usage.

The difference between sustaining innovation and disruptive innovation may seem arbitrary for us and our innovation award program, but I would argue that it is not. The funding for this program is a small portion of the > $30 million that we are distributing the the community to help care delivery organizations migrate away from fee-for-service business models. Most of this money is supporting improvements to current processes, workflow, and technology. These are therefore, by definition, sustaining innovations.

The $4 million is therefore set aside to explicitly support activities at the low end of the health / health care market. For example, social determinants of health are often addressed by community-based organizations. Literacy, health literacy, housing, transportation, violence prevention and behavioral health are all matters that have enormous impact on the health of a community and the primary care and acute care services that are used. But these issues are low-margin (or have no near-term revenue model at all) and are therefore ignored for the most part by care delivery organizations (the incumbents).

Our goal is to provoke investment of time, strategic thinking, human resource allocation, and (most important) interest in meeting the needs of this “low end of the market.” This is disruptive innovation.


Parsing Volume to Value, Proxy Measures, and the Streetlight Effect

Despite some concern that the migration from fee-for-service to value based payment (VBP) is being reversed, there remains strong momentum for VBP – both nationally – in the form of the bipartisan 21st Century Cures Act that was passed and signed into law last December, and many state and commercial initiatives, including the one I’m personally involved with, New York Delivery System Reform Incentive Payment Program (DSRIP). Defining value, of course, is not easy. I’ve often returned to Michael Porter’s short essay on this topic when I feel my definition meandering. Go read it now. Please.

Ok, you’re back? Cool. That was good, eh? I love the last paragraph:

The failure to prioritize value improvement in health care delivery and to measure value has slowed innovation, led to ill-advised cost containment, and encouraged micromanagement of physicians’ practices, which imposes substantial costs of its own. Measuring value will also permit reform of the reimbursement system so that it rewards value by providing bundled payments covering the full care cycle or, for chronic conditions, covering periods of a year or more. Aligning reimbursement with value in this way rewards providers for efficiency in achieving good outcomes while creating accountability for substandard care.

As CEO of Alliance for Better Health, I’ve been working with care delivery organizations in our community to navigate the path forward. They clearly have their feet in two canoes: the majority of their reimbursement continues to come from traditional sources with a traditional structure: more patients seen = more money. And then – from the edges, they have people like me telling them that the future is something different. It’s new, it’s going to pay them to do something that they would like to do – but they’re not quite sure how to do it, and, yes, some fear accountability.

Walk before we run, or jump right into the deep end? How do we traverse this gap between where we are and where we would like to be? One framework says that here is no traverse at all: we need to leapfrog to tomorrow and start from scratch. Iora Health is one such model. Care providers are focused on personalized, proactive care. The practice is led by health coaches, nurses, physicians, and administrators working together as teams to maximize health for the communities they serve. Reduced cost is a byproduct of great care, not a target itself. The office workflow is different from a traditional practice, the architecture is different, the hiring practices are different, the EHR is different. This model steps out of the old canoe and into the new one. For those with the guts, it’s a great model. For the rest, a slower path may work better. Of the slower paths, there are a handful of options, and many of them are complimentary rather than mutually exclusive. Accountable Care Organizations represent a compelling alternative to the Iora-style leapfrog. By offering a migration path – with increasing levels of shared risk, an ACO can coalesce a community of providers, collaborate with the federal government or commercial payers to standardize care for the better, and improve health outcomes. There are many models of ACOs, but I would argue that a common thread for the successful ones is that they have maintained laser focus on two guiding principles: a) success will attract the right partners; b) great primary care is the keystone of an ACO. Let’s parse this for a moment: why do I say that success will attract the right partners? There is a misconception that one should start with the creation of a large ACO. Growing the numbers of care delivery organizations will grow the number of “accountable lives” (people) and therefore, if one follows the “bigger is better” hypothesis, one can take advantage of the scale to reduce overall risk, and create a more powerful negotiating lever with the payers. While seductive, this hypothesis is flawed. A big network is hard to manage, and an ACO will be forever “herding cats” if they start too big. They won’t see shared savings, and they won’t be able to meaningfully accept risk, because they can’t be confident that they will perform well. An alternative model, and one that has been followed by all successful ACOs, (which, of course, includes my friends at Aledade) is to start small. For the first turn of the ACO wheel in a community, focus on a small group of providers who are “all-in.” They are fully engaged and dedicated to the success of the program. When successful, this attracts others – like moths to a light bulb – to the program. The ACO can then attract great partners (great primary care providers) rather than working hard to corral everyone and then re-educate them to the new ways. The difference, of course, is “pull” vs “push.” “Pull” usually works – and if it doesn’t, it wasn’t meant to. “Push” never does. We call this Motivational LeadershipTM (More on this in another blog post.)

DSRIP Performance. Many states have DSRIP programs, and it’s beyond the scope of my essay today to explain what DSRIP is, or what exactly New York’s variant represents. Today, our focus is on DSRIP Performance. Click on the image over there for a snapshot of what I mean. Each line is a measureAlliance Performance Measures and our performance against this measure will determine a payment from the New York Department of Health. The program (more than) pays for itself: with improved health of a population, unnecessary acute care services are prevented. Healthier people, better care experience, lower cost. In that order.  One challenge that we have is that the dependent variable here is our community’s performance, yet we won’t know what that is for 6-12 months .. which gets us to the heart of our story today: proxy measures and why we need them.

  1. Problem to solve: we want to pay our community for performance against DSRIP goals. Most of these goals of course are measures. We call them outcome measures but internally we know that most of them are process measures. That’s ok. It’s all a continuum. We’re not going to measure life expectancy (we don’t have 50 years)  so we?ll have to draw the line somewhere  and preventable ED visits? (and the 38 other measures you can see by clicking on that thumbnail above) may be just fine.
  2. Hurdle to leap: DSRIP funds have too long a payment lag. Telling a CBO or small practice or a hospital CFO that I’ll pay you Tuesday for a hamburger today (I’ll pay you in 2019 for preventing ED visits now) just won’t work.It’s too far. I can’t train my dog to sit by rewarding him in an hour. I need to tie the positive reinforcement to the act that I’m reinforcing.
  3. Opportunity: we?ve created an incentive program in which we have committed to distribute funds (which we have in the bank) in advance of performance. Up to 30% of the funds that could be earned this year will be distributed quarterly (up to 7.5% per quarter) for near-term performance.
  4. You are now asking the right (next) question:? How will you know what near term performance looks like? Aaahh .. yes! We will need to measure performance! In some cases (preventable ED visits) we will do our best to mirror DOH methods with the data that we have available from claims data, from clinical data feeds, and other sources that are available. Of course data we have available is a classic quality measurement challenge the so-called streetlight effect. We’ll avoid that as much as possible by using proxy measures.
  5. Proxy Measures are therefore a big topic of conversation in these parts. What’s a good one? What’s not? We want to let the community do some of this work as thinking about how to measure value is a great exercise for them as they transition to value based payment. We don?t need them to make these perfect!? That’s what I think is the elegance to this model. Worst case:? they make easy proxy measures that look like success, get 30% up front, miserably fail on the real? measures from DOH and we get $0 at the end. This is fine. We will have tried and they will have cheated? us for 30%. But we have the 30% this year to cover our experiment because of the evolution of New York DOH’s DSRIP program: this year, we still get some funding to support “pay for reporting.” Next year, we shift to nearly 100% “pay for performance” and $0 for “pay for reporting.” By allowing for this evolution, we encourage providers to experiment with proxy measures, allow them to be imperfect, all while pulling (not pushing!) forward into value based payment.  It’s unlikely that they’ll fail miserably and “cheat” us. Much more likely is that this enough to cause them to work really hard for true success. The 30% is then just a pre-payment  and they’ll get the 70% next year when it flows from DOH for our extraordinary performance.What’s an example of a proxy measure? Ideally, a proxy measure is a perfect reflection of the “real” measure we’re aiming to satisfy. So if we want to reduce preventable Emergency Department visits, and our performance measure will be “% annual reduction in preventable ED visits,” then a monthly (weekly? daily?) measure of this would be optimal. Indeed, if we had rapid insight, we could intervene. This where quality measurement, if performed real-time, actually becomes decision support. (This is a topic for another day …) So here’s an example of a less obvious but perfectly reasonable proxy measure: if we accept the hypothesis that preventable ED visits are a given percentage of all ED visits, and the hypothesis that ED visits resulting in hospital admissions are less likely to be preventable ED visits (they represent conditions that merit a hospital admission) then if the proportion of ED visits that result in hospital admissions grows, one might conclude that the number/proportion of preventable (unnecessary) visits fell.  Long-term, this would be a terrible performance measure, since it may cause the ED staff to feel pressure to admit more patients. But as a proxy for a reduced number of preventable ED visits, I think it does a nice job. Do you agree? Disagree?

You can play too, if you like. Here is an editable spreadsheet with all 39 of our measures. Add/edit columns with your ideas for proxies! You can also see much of the baseline data for the DSRIP performance measures (and others) by poking around here.

Parsing eCW’s $155M payment to the government

UPDATE: ?Here are the public records for the case. ?More details there about the original complaint. ?Excerpt:

@eClinicalWorks to pay $155M fine:

But what’s it mean?


The purpose of any certification program is to create a method for the purchasers of a product to have confidence that the product safely and reliably does what it is supposed to do. ?One example from USDA:

Turning Point for Meat Inspection In 1905, author Upton Sinclair published the novel titled The Jungle, taking aim at the poor working conditions in a Chicago meatpacking house. However, it was the filthy conditions, described in nauseating detail?and the threat they posed to meat consumers?that caused a public furor. Sinclair urged President Theodore Roosevelt to require federal inspectors in meat-packing houses.The Pure Food and Drug Act and the Federal Meat Inspection Act (FMIA) became law on the same day in 1906. The Pure Food and Drug Act prevented the manufacture, sale, or transportation of adulterated or misbranded foods, drugs, medicines, and liquors. The FMIA prohibited the sale of adulterated or misbranded meat and meat products for food, and ensured that meat and meat products were slaughtered and processed under sanitary conditions.

In this case, the government moved to protect the public because a subset of meat packers was putting profit above public health. ?After The Jungle was published. public outcry caused the government to step in and regulate the industry. ?Regulation is not, therefore, a four letter word. ?It’s there to protect us from evildoers.

Before Health IT Certification

You may not remember this, but I do. ?Before there was certification, Health IT development companies (some people call them “vendors”) created software and sold the software with claims of improved provider productivity, improved public health, and (yup) improved billing (among other impressive?capabilities). Sometimes these claims were completely valid. ?Sometimes they were not. ?In the case where the developers’ functional claims were not quite valid, buyers had little recourse. ?One might say “well, the markets will take care of that. ?Bad actors will lose sales.” ?But that’s not the case here for several reasons:

  1. The buyer may not be the one using the software. ?A hospital buys software for clinicians. ?Clinicians complain to hospital. ?Hospital may or may not be a strong advocate with developer.
  2. It’s very hard to migrate from one system to another. ?EHR purchase / deployment / optimization is a multi-year initiative. ?If you bought a lemon, you may try to make lemonade as the though of migrating to something else will give you R11.0.
  3. Shame. ?You don’t want your patients / competitors / peers to know that your EHR doesn’t work as expected. ?You made a mistake. ?Human nature is to hide our mistakes rather than treasure them as educational opportunities.

After Health IT Certification

The program isn’t perfect. ?I was on the developer side of this work from ~2006 – 2010 during the when CCHIT was the only certification path, and then for ONC’s first iteration of certification (2010 – 2011). ?Indeed, the imperfection of the program was a motivating factor for me to join the government in 2011. ?I wanted to help evolve the program toward perfection. ?Certification criteria needed to be less prescriptive (more flexible) but still provide sufficient guidance/ structure so that they could be reliably tested and replicated. ?This balance is hard to get right. ?Sometimes we got it wrong. ?Some have appropriately argued that there remains quite a bit of “check the box” busywork wherein health IT developers need to spend time building and configuring their software just to have it certified. ?”Trust us and don’t make us do this busywork” was the persistent message from the developer community. ?Recently, there have been renewed calls for scaling back the certification program and its many criteria, citing the maturation of the EHR incentive programs (meaningful use) and the fact that some of the certification criteria define capabilities that are not invoked by the incentive programs. ?The argument is that ONC has no place creating certification criteria for capabilities that aren’t part of “meaningful use.” ? I disagree. ?The ECW case is a great example of why I disagree.

About the eClinicalWorks settlement

What happened) You’ve read the press release from the Department of Justice by now. ?Excerpts (my emphasis added):

In its complaint-in-intervention, the government contends that ECW falsely obtained that certification for its EHR software when it concealed from its certifying entity that its software did not comply with the requirements for certification. For example, in order to pass certification testing without meeting the certification criteria for standardized drug codes, the company modified its software by ?hardcoding? only the drug codes required for testing. In other words, rather than programming the capability to retrieve any drug code from a complete database, ECW simply typed the 16 codes necessary for certification testing directly into its software. ECW?s software also did not accurately record user actions in an audit log, and in certain situations did not reliably record diagnostic imaging orders or perform drug interaction checks. In addition, ECW?s software failed to satisfy data portability requirements intended to permit healthcare providers to transfer patient data from ECW?s software to the software of other vendors. As a result of these and other deficiencies in its software, ECW caused the submission of false claims for federal incentive payments based on the use of ECW?s software.

As part of the settlement, ECW entered into a Corporate Integrity Agreement (CIA) with the HHS Office of Inspector General (HHS-OIG) covering the company?s EHR software. This innovative 5-year CIA requires, among other things, that ECW retain an Independent Software Quality Oversight Organization to assess ECW?s software quality control systems and provide written semi-annual reports to OIG and ECW documenting its reviews and recommendations. ECW must provide prompt notice to its customers of any safety related issues and maintain on its customer portal a comprehensive list of such issues and any steps users should take to mitigate potential patient safety risks. The CIA also requires ECW to allow customers to obtain updated versions of their software free of charge and to give customers the option to have ECW transfer their data to another EHR software provider without penalties or service charges. ECW must also retain an Independent Review Organization to review ECW?s arrangements with health care providers to ensure compliance with the Anti-Kickback Statute.


  1. ECW faked their certification testing. ?The examples above are just examples. ?There are other instances wherein ECW faked the testing and convinced the testing body that the software could do something that it could not do.
  2. Since the software was not certified, any physician or hospital who received incentive money and attested to the use of certified software was in fact fraudulently attesting to the meaningful use of certified software.
  3. The Corporate Integrity Agreement (CIA) commits ECW to:
    1. Oversight from an independent third party
    2. Notify customers of any safety risks (there are many)
    3. Provide software updates for free
    4. Support migration to other EHRs for free

So what?

Reminder: ?The purpose of any certification program is to create a method for the purchasers of a product to confirm that the product safely and reliably does what it is supposed to do.

  • ECW is a big company, with ample resources. ?Their software is used by tens of thousands of clinicians every day. ?The lives of their patients (many of whom are Medicaid beneficiaries – as many federally qualified health centers use ECW) depend on the safety and reliability of this software.
  • ECW’s software doesn’t do what they claim. ?Now that the government has investigated, and is holding them accountable, the message is clear: ?the public’s interest is being protected.
  • ECW is not the only organization that cheated on certification. ?They may have been the biggest, boldest violator, but they were not the only one. ?Others have already started internal reviews of their own performance, and those who have not yet done so are very likely to do so tomorrow. ?This case is a wake-up call for the CEOs of all EHR development organizations to dig deep, and have honest direct conversations with the small teams that prepared the software for certification testing, and performed certification testing with the test labs. ?My advice to these CEOs: ?look these teams?in the eye and ask “is the software that was tested exactly the same as the software that is available to all of our customers?” ?In many cases, the answer is no. ?As Farzad tweeted today, a very common case is in the domain of interoperability: ?can the system exchange data as it was certified to do) All too often, the answer, when we speak with the EHR developers, is “yes, if you pay us $$$ to enable that capability for you.”

Today’s announcement is the culmination of several years of work – all focused on protecting the public and holding a company accountable. ? As I’ve asserted both privately and publicly, the regulatory infrastructure of EHR certification is important because sometimes there will be bad actors. ?While the “good actors” may be inconvenienced and annoyed by processes that seem unnecessary, for such important elements of our nation’s health infrastructure, we can’t have government abdicate this responsibility. ?With or without the incentives programs, or MIPS, or 21st Century Cures, there is a set of capabilities that these systems need to have, and for which they must be certified. ?The breadth of this set of requirements, and the depth of certification testing for any criterion are the needles that must be threaded. ?I’m confident that Don Rucker and the team at ONC can navigate the balance well.

National Coordinator 6.0: A Blueprint for Success


1.0 Brailer
2.0 Kolodner
3.0 Blumenthal
4.0 Mostashari
5.0 DeSalvo
5.1 Washington
5.2 White
6.0 Rucker

Now that it’s public, I’ll offer my thoughts on the next steps for Don and ONC. ?Don Rucker is a good pick for the nation, and will be a great National Coordinator. ?I’ve gone on record as saying that some others are not qualified, and as many of you know – I don’t mince words. ?Don is smart, focused, thoughtful, intentional, and will make good decisions for ONC and HHS. ?I have known Don for 20 years. ?He’s got a long track record of integrity, he’s a nice person, he deeply understands the challenges, limitations, and opportunities of Health IT. ?I have no doubt that he’ll do a good job. ?He’s got a lot on his plate.

Where should he focus?

  1. Stay the course with health IT certification. ?I disagree with the growing meme that ONC has broadened its certification scope too far. ?Certification has one purpose: ?to provide consumers with a way to be confident that the product they are purchasing will do what the seller says it does. ?Some people seem to have forgotten (or don’t know) that some of the companies that sell health IT solutions have claimed that the products do things they do not do. ?There needs to be a process by which these claims are tested, verified and, yes, certified. ?If this program is scaled back, health IT systems will be less safe, less interoperable, less usable, and less reliable. ?#KeepCertification.
  2. Keep the Enhanced Oversight Rule in place. ?My former colleagues (and Don’s former colleagues) in the vendor community will disagree, as do some of the house Republicans. ?As Don will learn first hand in his initial few weeks as NC, some of the companies that have been selling certified health IT products have been misbehaving. ?In some cases, products have been de-certified. ?In other cases, there have been investigations and resolution of problems without de-certification. ?ONC is protecting the public by doing what?Congress asked it to do initially. ?The certification program is more than testing of products in a petri dish, it’s about what happens with the products in the real world. ?Surveillance is therefore a necessary part of making sure that the products do what they were certified to do. ?#KeepOversight.
  3. Trim ONC. ?Under National Coordinators 1.0 and 2.0, the organization was small, and focused on two things: ?policy and standards/certification. ?With ARRA, the organization grew to support the REC program, the HIE program, the SHARP program, and many smaller grant/cooperative agreement programs. ?ONC staff grew fivefold, and with that growth came the distractions of the grant programs, the expense of salaries and physical space required to support such a large team. ARRA is over, and ONC now has responsibility for a small number of grants. ?ONC should retain its autonomy (it should not become a daughter of NIH or CMS) but should now retract back to the small organization it once was. ?Grants (with the people managing them) should migrate to AHRQ. ?The policy work of ONC should focus on interoperability (much of the work assigned to it by congress in the 21st Century Cures Act), certification, and the usability and safety of health IT. ?ONC’s standards work should focus on acceleration of standards for health IT systems, through very tight collaboration with HL7 (also required by 21st Century Cures). #TrimONC ?#FocusOnCertandStandards

That’s it. ?The three-legged stool of ONC’s future success. ?On a silver platter, for ya, Don! ?Have fun! ?The people at ONC are hard-working, dedicated public servants. ?They are excited to work with you.

BTW, thanks, Jon. ?You will forever be 5.2 to me. ?Great job.