LeadingAge Magazine · July/August 2014 • Volume 04 • Number 04

Coordinated Care, Technology and Long-Term Care Providers: a Conversation With Dr. Mark McClellan

June 30, 2014 | by Gene Mitchell

Coordinated Care, Technology and Long-Term Care Providers: a Conversation With Dr. Mark McClellan

As the structure of American health care evolves toward more coordinated and—we hope—less expensive care, providers of long-term services and supports are positioned to play an important part in improving quality, holding down costs and boosting the quality of life of seniors. Tasked with caring for populations with chronic conditions that contribute significantly to the high costs of health care, long-term care providers are trying to find ways to integrate with accountable care organizations (ACOs) and to leverage technology to help make better-coordinated, lower-cost care a reality.

For a look at where such coordinated care stands, where LeadingAge members can best direct their efforts toward integration, and how technology can be leveraged to help do so, we interviewed Mark McClellan, M.D., Ph.D., the international chair for LeadingAge’s Center for Aging Services Technologies (CAST). McClellan is a senior fellow and director of the Health Care Innovation and Value Initiative at the Brookings Institution, a former administrator of the Centers for Medicare & Medicaid Services and a former commissioner of the U.S. Food and Drug Administration. At Brookings, McClellan’s work focuses on promoting quality and value in patient-centered health care.

LeadingAge: During the CAST Commission meeting in March, you stated that long-term and post-acute care providers may not be on the radar screens of accountable care organizations (ACOs) at present, but that our members must find ways to get the attention of ACOs and to make a case for why they can play an important part in cost savings. If you were running a LeadingAge-member organization what would be your main talking points in reaching out to an ACO?

Mark McClellan: First, I think the attention ACOs are paying to post-acute and long-term care providers is increasing, so this is all the more reason for having a good plan for interacting with them.

The kind of information that is probably most relevant may vary by ACO. For many health care organizations, including hospitals and hospital-based ACOs, there is a lot of interest already in reducing readmissions, so any evidence that a post-acute or long-term care provider can give on how they will help keep readmissions down after a hospitalization will be useful from that standpoint.

In addition, many hospitals are also now participating in the Medicare bundled payment initiative and for those hospitals there is an added reason to try to keep readmissions down. Looking for hospital partners that are part of an ACO or part of a bundled payment initiative–and a number of health systems do both–means added interest in reducing readmissions.

Finally, for the physician-led ACOs, and ACOs moving beyond … just taking initial steps toward care coordination and who are doing the next round of efforts to manage population health, any information that a long-term and post-acute care provider can give on how they can help keep hospitalization rates themselves down is also helpful–not just readmissions–but steps they can take to prevent admissions in the first place. That’s probably the single biggest predictor of costs for our complex patients, whether they are admitted in the emergency department or the hospital. That’s both an important indicator of quality care and preventing health problems, and a great way to engage about cost reduction with an ACO.

LeadingAge: Also at the March CAST Commission meeting, you discussed CMS quality measures for ACOs, and you advocated “meaningful measures of patient experience, functional status and quality of life.” How far are we from reaching the point where such measures are in place?

Mark McClellan: I don’t think we’re that far; there are limited versions of those measures in widespread use now, and much better measures being used in places around the country. First, the Medicare ACO program already includes quality measures related to readmissions and preventable admissions, and those are very important things to focus on for a lot of reasons. They are good, readily available indicators of potential coordination of care problems and also good predictors of cost reductions.

Also, the ACO program includes general measures of patient experience with care, and they can be used for caregivers as well: These are the so-called CAHPS [Consumer Assessment of Healthcare Providers and Systems] measures.

Where I think we’re falling short is [in] measures related to what really matters to many patients with multiple chronic conditions and frailty and possibly dementia, and [those are] measures related to their quality of life. The measures included in most ACO programs today include things like hemoglobin A1c levels, blood pressure controls and cholesterol levels, and while those are not unimportant, they are probably not foremost in terms of care planning and what really matters to many of the patients in long-term services and support programs. So measures of patient functional status, like those included in many patient assessments, and the CARE [Continuity Assessment Record and Evaluation] tool that continues to be developed, measures of whether or not a patient is in pain and general measures related to quality of life in use in many pilot forms around the country should be a top priority for long-term services and supports providers to engage on, in really helping the whole ACO and payment reform movement to focus on what’s most important to seriously chronically ill individuals.

One more point: What’s also not captured well in terms of care coordination—and it’s a very important aspect of quality—is whether or not a patient has an overall care plan in place and whether or not that patient’s preferences are being followed. There are measures of patient engagement with care, and caregiver engagement with a care plan that could be used more widely and would be great indicators of quality, and probably would also hold costs down and would also help direct more support to the long-term and post-acute care providers that are really doing what patients want.

LeadingAge: Do you have an opinion on the quality of the measures you’re seeing now?

Mark McClellan: They’re getting better. The focus on readmissions is a step in the right direction. A next step that is very feasible is preventable admissions, avoiding the hospitalization in the first place. Measures of patient experience are starting to be used and it’s a very high priority for CMS and for stakeholder groups like the National Quality Forum. It will happen over the next few years but the question is just how fast, and the faster it happens the more support there is going to be for high-quality long-term services and supports programs.

LeadingAge: Will the CARE tool [the Continuity Assessment Record and Evaluation (CARE) Item Set] be the uniform assessment tool used across care settings for measuring functional abilities and quality of life?

Mark McClellan: The CARE tool is one of the leading efforts in that regard; it has probably had the most national testing and is a big part of CMS evaluations and I think it started back when I was administrator. It was a high priority to get better measures of functional status and a better basis of payment for long-term and acute services. There are a number of other tools out there that are used by state Medicaid programs that reflect their own needs and experiences. There was a good report released by the Long-Term Quality Alliance on the need for alignment in assessment tools and steps to get there, and I’d really recommend that for anyone who is interested in this issue.

LeadingAge: Despite their differences from the older HMO model, ACOs are widely seen as just another version of managed care, and managed care, rightly or wrongly, has a poor reputation with a lot of the public. Yet you have stated that ACOs take us “from a provider-driven system to a person-driven system,” which sounds very appealing and certainly flies in the face of popular negative images of managed care. Can you explain how the model makes that possible?

Mark McClellan: Managed care in the 1990s was primarily about managing costs, and it was a set of efforts led primarily by insurers. There was a movement toward capitation and getting costs down, and to a considerable extent, the health providers, physicians, hospitals and others were just not on board. The steps being taken involved blunt instruments … like squeezing down prices, and blunt efforts to restrict access in ways that health care providers [were] not on board with, that were not long-term solutions, and they led to a backlash.

What’s different this time around is that the leadership is coming increasingly from health care providers working with patients themselves. These are efforts where, in an ACO, the accountability is really on the physicians, the hospitals, and the long-term services and supports providers to identify the things they see in their practice every day that could be done differently to get better results for patients at a lower cost. Often under the traditional payment systems they just don’t get resources for that, they don’t get resources for using health IT effectively, or for coordinating care with acute care providers, and it’s those steps that payment reform supports. They provide more flexibility to get patients what they need, and that’s a very different approach from the managing-costs approach of the 1990s.

It starts with health care providers working with their patients to find ways to get better quality care … and that’s what leads to lower costs. I think this is a shift away from payment silos that often don’t reflect the best treatment at the lowest cost for a particular patient, that don’t support things like telemedicine, health IT and other steps like that. It’s a step away from traditional payment systems and toward more of a focus on the whole patient, the whole person, and that’s what I mean by person-centered care. These changes are being driven by leadership from health care providers themselves and not being imposed by managed care plans from outside.

LeadingAge: In all of these discussions we talk about providers, payers and regulators, and very little about consumers. What can consumers, if organized, do to push these systems in the direction of better care for less money? If you were addressing consumers what advice would you give them for impacting the system?

Mark McClellan: One of my earliest experiences in government, just a few weeks after I started at the White House in 2001, was meeting with a group of protesters with an organization called ADAPT that had set up in the middle of 17th Street right outside the White House protesting the fact they didn’t have control over how long-term services and supports funding was spent on their behalf. Listening to them, they were pointing out that the traditional Medicaid entitlement was an entitlement for services in a nursing home, and while that was appropriate for some people, what they really wanted was an entitlement to appropriate long-term services and supports wherever they thought they could get it best. They said, “Look, give us more control over how we use our LTSS resources and not only will we be happier and able to participate more in the community and have fuller lives, you’ll save money at the same time.”

It turned out they were right. We looked into the data and that was a big reason for my support and our engagement in programs like Money Follows the Person.

While life is not always so simple, I think the general principle that giving consumers, individuals with disabilities, people who need long-term services and supports and their caregivers more control over how those resources are used is likely to lead to better outcomes, especially when they get good support in determining what services are available and more flexibility in getting those services.

It’s part of this shift that goes along with accountable care: away from paying for specific services that are on some kind of fee schedule and instead paying for the results that people want and giving them an opportunity to save money and get better care at the same time.

LeadingAge: What are your thoughts about the movement in many states to Medicaid managed care programs? Can any major conclusions be drawn or is it too early in most cases?

Mark McClellan: It bears watching very closely. There are a wide range of Medicaid managed care programs out there now in use for not just low-income individuals but for dual-eligibles and people with disabilities. Some of those programs seem to be doing some really promising work along the lines of we’ve been talking about today—breaking down silos of care and providing new support for better coordinated care, often much more in the community. Some of these managed care plans like Evercare have been at this for a while, and others are just getting going. This is all the more reason it’s really important to start tracking those kinds of performance measures we talked about earlier. The performance measures that really matter for this population are not things like whether their diabetes is under control so much as it’s things like quality of life, functional status and prevention of complications. There are some good opportunities out there in Medicaid managed care and it definitely bears watching closely and would benefit from a lot more support for the kind of performance measures we’ve described.

LeadingAge: In those states that have adopted managed long-term services and supports (MLTSS) programs, there is a lot of variation in the types of enrollments and in the MLTSS-specific quality measures used. Do you see this variation as an opportunity to test different models against each other, or do you see it as a problem?

Mark McClellan: I think it’s some of both. The variation in programs is actually a good thing in many respects, the way that services are provided, and the circumstances in different communities in terms of how hospitals and skilled nursing facilities and home health providers and others relate to each other vary a lot around the country. People are starting from different places and that’s a good reason for some flexibility and variation in how the MLTSS programs are being set up.

That said, it is very important to have meaningful quality measures in conjunction with these programs, and the more comparable the measures, the better. I appreciate the fact that many states have started in different places and have invested a lot in some cases in somewhat different infrastructures in measuring quality, measuring the things they think are important. But the more we can get to the standard use of some core meaningful quality measures, the easier it’ll be to really learn if these programs are doing the best job for particular kinds of patients.

LeadingAge: To wrap up, are there any additional points you would like to make to our members that we have not discussed here?

Mark McClellan: The thing I want to emphasize is that we’re right in the midst of some upheaval and transition in many aspects of the way health care is provided. A lot of the attention to those changes has happened on the acute care side with the formation of ACOs, and a lot of care moving out of the hospitals and some other innovative arrangements, but I think the bigger potential for both care transformation and quality improvement and cost savings really is on the post-acute and long-term services and supports side. That’s where most of the patients who account for most of the cost in our health care system spend most of their time and that’s where there have to be the best opportunities for care coordination and helping people with better and healthier lives.

LeadingAge: To achieve those goals, how important is the role of technology as an enabler, including interoperable electronic health records, the capabilities of analytics and clinical support and health information exchange capabilities?

Mark McClellan: I mentioned the importance of health IT … and obviously that’s got to be interoperable for it to be used effectively for care coordination. There’s no way to get these kind of improved measures of quality of care without not only being more reliant on electronic health systems but also reliant on things like simpler ways to monitor patients, wireless technology, and telemedicine, and those are also very important ways of communicating with patients and supporting them in these settings of care. So technology is critical in all of this and the payment reforms we talked about today can enable a business case for supporting those technologies in a way that fee-for-service payments simply can’t.