Robert Provenzano, MD, Vice President, Medical Affairs, DaVita
In this short video, Dr. Provenzano discusses the ACO ruling and what it means for the Renal Community.
Robert Provenzano, MD
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Share on FacebookBeing a physician in an ever-changing healthcare world
Carole King put it so well: “Will you still love me tomorrow?” After three days of Supreme Court hearings on the constitutionality of the Patient Protection and Affordable Care Act of 2010, aka “ObamaCare,” it would be easy for physicians to be drawn into the political fray—angry, heated and accusatory. I must admit, after 23 years of practice I am sadly mystified at the partisanship and venom that proponents and opponents express related to this law. Surely the Supreme Court will judge the constitutionality of the law and decide whether or not it can be fully implemented or, as our system of government allows, it needs to be readdressed by our lawmakers.
So, will you still love me tomorrow? Or, to put it another way, will we (physicians) be relevant in the healthcare discussion? It seems to me that when we wake up we’re still physicians, responsible for providing care, in an environment where our professionalism dictates we not fall into partisanship. We will be expected to deliver care under a new value proposition. Frightening? It shouldn’t be; every generation of physicians has faced challenges, and changes in techniques, medical breakthroughs, new science and evolving expectations all changed the value proposition of their time. Surely the value proposition today should be looked at no differently that at any time in the past. John H. Cochrane weighed in, in his Wall Street Journal opinion: “What to do on the day after ObamaCare?” He rightfully points out that there is plenty of blame to go around, from “inefficient markets for health care” to “regulations that keep competition at bay” to restrictions on the number of new doctors thanks to congress and the AMA or anticompetitive “certificates of need.” He concludes that a deregulated health-care and health-insurance market can work.
So, will you still love me tomorrow? We should be continuing to deliver high-quality care in an integrated fashion, with the expectations by payers, by physician societies, and most importantly by the patients that we will continue to improve outcomes.
Not fair, you say? Maybe yes, maybe no, but one thing’s for sure: tomorrow patients will still turn to us whether or not “ObamaCare” is found constitutional. Of primary importance is our professionalism; our contract with society to provide care and our commitment to lead. No one disputes that all should have access to high-quality care or that we should focus on preventative as well as end-of-life-focused care. And just because you can do something doesn’t mean you should do something. Maybe this is a State issue; maybe not. Maybe each of us needs to take more responsibility for ourselves. Maybe…maybe…maybe.
So I’ll say it again; will you still love me tomorrow? Our relationship with our patients should not be contaminated by the political zeal of the moment. I am convinced that integrated care is here to stay, whether the individual mandate is found to be constitutional or not. Tearing down the artificial barriers between Medicare Part A and Part B is long overdue. Let us focus our resources, focus our skills, and focus our influence to see to it that tomorrow our patients can still depend on us—love us.
Robert Provenzano, MD
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Share on FacebookEvolving Relationships and Continual Leadership
I recently attended the annual Renal Physicians Association meeting in Washington, DC. As many of you know, the RPA has led by representing the needs of practicing nephrologists to regulators and payers to see that we are appropriately reimbursed for high-quality services. In this they have excelled! Indeed, I have had the honor of serving as a Board of Directors member and president. The board has managed to maintain a healthy mix of practicing nephrologists, academics and business-savvy practitioners and has evolved to meet the changing environment in which we practice. The RPA has balanced patient service with quality oversight, promoted a safety focus before it was fashionable (thank you, Alan Kliger) and developed a robust public-policy arm. In my opinion they have served us very well, working quietly behind the scenes, lobbying, educating and advocating.
But I couldn’t help feeling at this year’s meeting that they/we may be inadequately prepared for the challenges ahead; namely, those of integrated care. On a positive note, the RPA has partnered with Fresenius and DaVita in discussions with the Center for Medicare and Medicaid Innovation (CMMI) and it does seem that there has been some headway made, but when the rubber meets the road will they remain the quintessential leaders we need?
In an integrated model of care, nephrologists’ partnership with their dialysis organizations will be essential. This certainly does not mean we will, or should, lose our independence or focus as patient advocates, but it does suggest that the current model of our relationship with dialysis providers will—or, more appropriately, must—evolve.
Nephrologists are essential in this model of care; indeed, it is what we have always advocated for and its time has arrived! But I was left with questions: Will the RPA continue to lead? How do they plan on shepherding nephrologists in this new world? How should we engage dialysis partners? Our hospitals? Our referring physicians? What is the value proposition? These questions are begging for answers or at least attention. Should the RPA be engaging in a more sustentative manner with dialysis providers representing the needs of their membership? I say yes, and the sooner the better.
All trade organizations must evolve or become irrelevant. Evolution can be painful, politically risky and open to harsh criticism by membership. It takes vision, leadership and . . . how can I put this . . . intestinal fortitude to accomplish.
I believe the time is now for the RPA to redefine who they are and why they are. I believe they are up to this challenge, as they have always been up to others. Importantly, we must support them in their efforts.
Always look forward, gaining strength from your past.
Robert Provenzano, MD
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Technology and social media necessitate new ways of communicating
Certainly those of you in the “midcycle” of your professional careers can easily remember when, as interns, you tried to reach an attending physician only to find he/she was “out for the evening, but a message would be left.” That was before pagers and cell phones and computers and the Internet.
Fast-forward to the 21st century; our practices have evolved in the past 20-plus years. No more can a subspecialist serve only one hospital and maintain a robust practice. Our patients have become mobile and decentralized; they will not come to the “big hospital” in town, but rather they will go to the satellite clinics in the suburbs or to the local hospital. All this necessitates a redesign of our practices to follow our patients. The same thing has happened with regard to how we engage our communities and advertise the services we offer. Gone are the days when a cadre of referring physicians knew who you were, knew what you stood for and knew of your quality of care. Competition to provide services has become intense; patients use the Internet to research who you are before they even schedule an appointment in your office. Patient peer-to-peer referrals have become the norm.
Currently over 50 percent of the world’s population is under 30 years old, Google® and Facebook® have become accepted norms in communication. Indeed, one in five couples now meet online. Our children are learning their lessons on iPads, not blackboards. LinkedIn® signs up a new member every minute. If Facebook® were a country its members would make it the third largest country in the world. As Erik Quailman, bestselling author of Socialnomics, put it, “We don’t have a choice on whether we do social media, the question is how well we do it.” Generations Y and Z consider email passé. Lady Gaga, Justin Bieber and Britney Spears have more Twitter followers than the countries of Sweden, Israel, Greece, Chile, North Korea and Australia. How’s that for reaching out?
Sales of ereaders have surpassed traditional book sales. Universities are no longer even assigning email accounts. If Wikipedia were made into a book it would be 2.25 million pages long and would take 123 years to read. Ninety percent of consumers trust peer-to-peer recommendations—think Yelp® and Angie’s List.® Only 14 percent trust advertisements. Welcome to the social-media revolution!
Facebook,® Google,® LinkedIn,® You Tube,® Yelp,® Bing®: that’s the world our patients live in. Fast and furious, it impacts all of us. Our ability to control our message—who we are or, more importantly, how we are perceived in the social media—is critical to our business success. It’s already happening. Many of your colleagues are experimenting with Facebook® pages and Twitter® accounts, reaching out to their customers, their patients. Just when I was getting used to our webpage, it’s passé! I may be old-fashioned, but I certainly am excited about getting involved in the new media. As we said in the ‘60s, “Be there or be square.”
I look forward to your comments,
Robert Provenzano, MD
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Share on FacebookHow Nephrologists Can Help Shape the Future of Healthcare
I am scheduled to give a business presentation next week at DaVita’s Physician Leadership Meeting in Las Vegas and have been asked to speak on “Growing Your Practice in Today’s Environment.”
This is not new territory for me. Over the years, I have worked with many nephrology practices. I have helped them focus on running their businesses in an efficient, accountable way, putting the patients front and center while understanding myriad government rules, regulations and coding.
I don’t think anyone would argue that running a business is our strong suit, but run them we must. I think we have all learned and done a better job. We have become much more efficient, patient care has improved, and outcomes are the best they have ever been! Yet despite these facts, we have been told we can do better and are now faced with a sea change in healthcare payment and process. We must now find a way to fit into an integrated healthcare world.
As I sit here and stare at my presentation, I’m not sure what to say. Do more with less? Reevaluate your business plan? Reevaluate your business structure and how it relates to the hospital? All of the above? One thing’s for sure — we need to understand today’s environment clearly and not underestimate what it means to us. We need to focus on how our practices fit in. We need to understand better the need to reevaluate our working relationships with our dialysis organizations. Most important, we have to lead. Part of that leadership is to acknowledge when we get things wrong. Over the years — and one can argue the reasons why — physicians, physician organizations and even physician leadership have not focused on the harsh realities of disparity of care throughout the country, wide variation in outcomes and inefficient practice styles.
That’s not to say that the hospitals are without blame. In a “volume-based world,” proper alignment can get lost. But that’s in the past, and we need to focus on the future. We will need to partner with hospitals. We will need to partner with our dialysis organizations, and we will need to lead. As you know, the Affordable Care Act (ACA) did establish the Accountable Care Organization (ACO) initiative. As a part of the Medicare Shared Savings Program (MSSP), this ties provider reimbursement to a quality matrix with the goal of increasing quality of patient care while reducing cost. In the first round, ACOs focused on primary care; all subspecialties were excluded. Recently, however, the Center for Medicare and Medicaid Innovation has indicated that it is likely to move forward with a demonstration program for specialty ACOs for chronic kidney disease (CKD) and end stage renal disease (ESRD). This could be good news, but there is a lot that needs to be learned yet.
Certainly, even the largest practices are ill prepared to tie the three big pieces of our care paradigm — CKD care, ESRD care and hospital care — together unilaterally. We need to be prepared to come to the table and act as the leaders who arrange the relationship between our practices, potential other practices within our region, our hospitals and our dialysis providers. That leadership requires a winning formula that takes into account the strengths and weaknesses of each of the parties; no one gets to “win” at the expense of another. Instead, honestly assessing what each party brings to the table is critical, as is the relative risk each party can or should be expected to accept.
I recently read the autobiography of Steve Jobs. Here is a man who saw the way things were and then took the path that others said couldn’t be done. That is what I am asking you to do: Take that path. No one better understands the needs, nuances, and realities of caring for our patients as we do. No one understands better, the working relationships between physicians, dialysis organizations and hospitals than we do. We have the opportunity to set the stage for the future of medicine and the future of nephrology care, which indeed is a rare opportunity. Things will change fast. It will be painful. It will be risky. It will not be easy in any sense of the word. Keep an open mind. Keep yourself informed. Be a participant! Maintain your passion for what you do — the world will be watching.
I look forward to your comments
Robert Provenzano, MD
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Share on FacebookBob,
I attended your lecture in Las Vegas and read the post above and I was intrigued and interested in your comments regarding ACO’s and applaud your efforts to keep us in the Nephrology community up to date on this important area. We have been innovative in my group and have led in many areas in our community regarding kidney care in the past, but thus far I haven’t heard any specifics about how or when even we take the lead or how to do so when it comes to kidney care ACO’s. As you said, they will be doing demonstration projects in subspecialty areas for ACO’s but when and where is that to occur? Do we wait until we are approached by hospital systems and then come to Davita so that we have something at the bargaing table? I guess what I and many of my colleagues wonder is, where do we go from here? We want to be on the cutting edge of this but how do we do this?
Thanks again to you and Davita for helping to support us now and in the future in this ever-changing landscape. I look forward to your comments.
Chris
Leading by Example: DaVita’s Integrated Model Leads to Accountability of Care
Allen Nissenson, David Van Wyck, Kent Thiry, Dennis Kogod: the best overall clinical outcomes and vascular access care, lowest mortality, industry leading adequacy of dialysis, record-level metabolic bone disease management. What’s the relationship of these people to the outcomes that follow? They are leaders and lead DaVita teammates to excel. Drinking the Kool-Aid, you think? I don’t think so. If you look carefully, the leadership and the teammates within DaVita have quietly developed an integrated model of care as it pertains to ESRD patients.
A focus on patients, innovation, honesty, integrity, transparency, selflessness, going where others won’t, and never saying never: All of this is necessary to lead our industry, and lead we have.
What does all of this have to do with ACOs, you ask? Simple, accountable care organizations mandate the integration of various aspects of a fragmented healthcare system; DaVita has been there, done that. For years, Thiry, Kogod, Nissenson, and Van Wyck knew that dialysis was fragmented; we all knew it. Rather than settling for “business as usual,” they did something about it — they developed an accountable care system, or rather a system of accountability to care, within DaVita. The results speak for themselves! DaVita leads while others struggle to keep up.
Want more? Industry leading influenza vaccination rates, highest AV fistula rates, one of the most desirable places to work in the healthcare industry! Being willing to do things that others say aren’t possible, that’s what is necessary for the success of ACOs. If it’s possible with ESRD care, it’s possible in the healthcare system at large. Sure, there may be more moving parts in healthcare when compared to the dialysis industry, but that’s not the point; it’s about leadership.
Why am I being so self-serving? I guess if I were running for president, I would say, “It’s the process, stupid.” The process, of course, is pushed by example and by leadership and is followed by teammates who see the end results: improved patient care. DaVita processes, whether you call it drinking the Kool-Aid or not, work. Our accountability to each other and to our patients works. Outcomes follow accountability, not the other way around. The healthcare system would be well served by stepping back, understanding what DaVita has accomplished and how it can apply that its industry need — and then, lead!
Sadly, I rarely see healthcare leaders “leading by example.” Unless they’re willing to do that, no one will follow. It doesn’t matter how wonderful the processes are; when leadership doesn’t lead by example, nobody follows, and nobody wins.
We all have leaders, and leaders we all are.
As Babe Ruth once said, “Never let the fear of striking out get in your way.”
I look forward to your comments,
Robert Provenzano, MD
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A Critical Look at Healthcare and Payment Affordable Care Act
As I write my final blog of 2011 on healthcare payment, a friend commented that I shouldn’t be so cynical. Therefore I have decided that my 2012 New Year’s resolution will be to be less cynical!
That said, I remain concerned about where healthcare payment seems to be heading. My concern revolves around the government taking a more dominate position in overall healthcare reimbursement. Most don’t realize that when you tally all government health programs, Medicare, Medicaid, veterans’ affairs, State Children’s Health Insurance Programs (SCHIP), and Indian affairs, 46% of healthcare in the United States currently is taxpayer funded! The operative question is: What do all these programs have in common? They are all financially insolvent, bloated with layer upon layer of bureaucracy and inefficiency.
A recent editorial in the Wall Street Journal (December 28, 2011) examines the government’s role in the Affordable Care Act (ACA). They quote the work done by Christopher Conover and Jerry Ellig of the Mercatus Center at George Mason University; this center examines all government rules costing more than $100 million and assigns a composite score. Conover and Ellig found that “the federal government used a fast-track process of regulatory analysis that failed to comply with its own standards, and produced poorly substantiated claims about the ACA’s benefits and costs.” They scored the rules at the highest 25 out of 60, at the lowest 13! They opine: “These are not merely bad grades. They are relative F’s on the regulatory curve — about 35 to 40% lower than averages for the other rules.” The article comments: “Little wonder for a law that contains the phrase ‘the Secretary shall’ 1,563 times.”
So where does all this leave us? As a healthcare provider, I applaud and agree with a focus on measurable quality outcomes and patient-centered care. As a reasonable taxpayer, I wonder if our government can accomplish this goal in a cost-effective manner. After all, isn’t that what they are asking (telling) us to do? Do more with less? Added patient value? Hmm, I wonder if they can hold themselves to the same standard. Unfortunately, based on their historical track record, I fear I already know the answer.
Call me cynical! Just remember most New Year’s resolutions are broken by February; I’m a bit ahead of the curve!
Happy New Year’s to all!!
Robert Provenzano, MD
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“Badly Written Rules: New Studies Show the Quality of Federal Regulation Is Plummeting.” Editorial. Wall Street Journal 28 Dec. 2011: 9. Read full article…
Share on FacebookA wrap-up of Accountable Care Organizations discussion in 2011, and a peek into where it’s going in 2012
As 2011 winds to a close, I feel almost breathless looking back at all that has happened in healthcare payment reform! This is a good time to look back, reflect and strategize as we prepare for 2012.
This spring, preliminary regulations on Accountable Care Organizations were published and roundly criticized by healthcare providers as placing too much risk on providers, being onerous in IT requirements and downright backwards in patient assignment. These and other concerns were addressed, and the final regulations were published by fall. Importantly, patient assignment concerns were addressed as well as financial risk for physicians. But despite these changes much angst remains. Contacts are set to be offered in the spring and summer of 2012 and, to date, there has not been a flood of takers.
Patients seem to be almost ignored “passengers” in this process even though the program is “voluntary”….for now. As physicians, we are ethically bound to “do no harm,” our population of patients is at disproportional risk. Although acknowledged by CMS, and supported by data from the ESRD disease demonstration project, we had little success is convincing CMS to allow the ESRD population be considered a stand-alone ACO.
Enter 2012. The Center for Medicare and Medicaid Innovation (CMMI) has been in continual communication with the RPA, ASN and dialysis organizations (large and small), and is considering allowing a “renal integrated care program.” This program will allow nephrologists and dialysis providers to expand on the lessons learned in the ESRD demonstration project to a broader patient base, hopefully as the first step in allowing our population, with their unique needs, to stand-alone in a future payment model. The integrated care program would work with local hospital and healthcare systems placing nephrologists in clinical lead positions to render care being sensitive to the reality that “one size fits all” often doesn’t apply to medicine.
This is a great opportunity for all nephrologists to lead with what we have learned over the past 30 years from the ESRD program.
I suggest you stay involved or get involved! This is your future, your patients’ future and can still be shaped by you! Contact CMMI (innovate@cms.hhs.gov) – let your views be heard!
As always, let me know your thoughts!
Merry Christmas and Happy Hanukkah
Robert Provenzano, MD
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Share on FacebookMy thought about ACO’s and pay for performance: The best patients will be “Cherry Picked,” the older population and those severely ill will less likely be offered dialysis, and those of us who can, will stop practicing or adjust their practice so as to limit medicare or medicaid exposure. We looked into forming an ACO..but it is not for our group..I have stopped trying to even keep up with the changing ACO req.: We are simply growing our group as large as we can: hopefully we will be too big to fail..Just like the automotive industry..the banking industry etc…The more you can control a region, the better the politics treat you because I am sure some day we will be forced to sell out…My opinion isle are taking many steps in the wrong direction..There are many better means of reform than what are being offered..
Aligning Care for the Best Patient Outcomes
The ACO final regulations are in; let the fun begin!
Recently, a frustrated colleague complained to me about the schism in physician and hospital perceptions of problem solving. Part of his “day job” requires he attend his institution’s “Safety Huddle.” This meeting includes all patient stakeholders; nurses, security and section chiefs, who review real or perceived patient safety events for the previous 24 hours. The thought is that patterns will be indentified and processes can be adjusted to keep a focus on patient safety.
He shared a recent occurrence, which I fear, sadly, may not be atypical of other institutions. In an effort to aggressively address rising incidence of patient falls, floor nurses were informed that they would be “written up” if any of their patients fell. Needless to say they took the most conservative route and severally cut back on ambulating elderly patients. The net result – increased length of stay, increased PM & R consults and decreased patient and physician satisfaction. Sounds like a simple fix, right? Not really, we forgot to throw in the legal liability issues, greater harm (debilitation vs. fall) and on and on. Sound familiar yet?
What’s my point? A hospital with all of its moving parts and operational responsibilities including legal exposure can often have a different alignment of priorities than its physicians. I am concerned that this alignment will not be miraculously resolved with the publishing of final ACO regulations. Indeed, I would argue that where there is a natural alignment between physicians’ needs, patient needs and hospital operational realities, there should be no problem; yet there continues to be.
Yes, I was concerned that there was no tort relief in the final regulations, which certainly could have made this transition period easier, but that is only one small aspect of a complex system.
I really can’t recall any government regulation that has accelerated a process that wouldn’t have happened on with own-with the parties involved resolving their own isses.
In this week’s issue of NEJM (N Eng J Med 365;22, pp2045-2048), Richard Bohmer, elegantly explores these differences in what he terms “The Four Habits of High-Value Health Care Organizations.”
He points out that “…experience suggest that not only do new delivery models…not necessarily live up to their promise, but they are surprisingly difficult to transfer, even when successful…”
Don’t misunderstand my pessimism; I do believe integrated care is the right thing to do. But we all have to do better! CMS has to do better! Physician leadership has to do better!
The recent “Super Committees” unsurprising decision to not permanently fix the sustainable growth rate (SGR) really shows how little CMS (and Congress?) values the promise they made to the elderly to provide healthcare and to healthcare reform as a whole. Part of that promise includes maintaining qualified physician participants. Let’s hope that this problem isn’t exacerbated by the rush to the latest answer to the “healthcare crisis”!
I look forward to your comments,
Robert Provenzano, MD
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Share on FacebookBob : before the party starts Nephrologists will need orientation of the leaders, medical organizations, etc how to protect our independence in our practices. Particularly when we don’t know with whom we will be working in the ACOs. Hospital integrated systems vs Dialysis Co integrated systemsvs PMC integrated systems?
Greetings
I read with interest an editorial by Kathleen Parker, writing for the Orlando Sentinel, which commented on Steve Jobs. Rather than focus on all of his successes, as many have done, she focused on his failures, concluding as many of us already know that “sometimes you have to fail to succeed.” Jobs himself recognized his failures in his now-famous 2005 commencement speech at Stanford University. Risk-taking is so ingrained in the psyche of Americans that it is viewed by many, myself included, as a major factor in differentiating us from other countries. In India, for example, risk-taking is frowned upon, which hampers small start-up companies from getting a foothold in a growing entrepreneurial environment.
So what does that have to do with accountable care organizations (ACOs)? In my many interactions with my colleagues, I often bring up a similar point as Parker about the fear of failure. Physicians are selected as success stories — the brightest person in grade school, high school, undergraduate and medical school. Failure was never an option. We didn’t get into medical school by collaborating with anybody. We got there by outperforming. My argument when discussing the business side of medicine is that if you have no failure, you’re not taking enough chances, and therefore someone who is willing to take those chances will succeed where you have not.
I think we all understand that risk-taking, rightfully, has no place in the clinical practice of medicine. Our conservatism serves us well in that arena. Outcome-driven data drive our practice of medicine. But as we embark in the reinvention of the relationship among care providers, healthcare payers and healthcare systems, I would urge caution. Failure in the ACO world is entirely possible. Physicians need to lead as the ultimate advocate for the patients who face the greatest risk from the failure of a system attempting to integrate historically distant parties.
I agree that failure is good. It often helps define who we are and leads to a better product or process; it has served the American business sector well. But we must maintain our diligence when it comes to applying this philosophy to the healthcare industry. Failure in that venue, particularly uncontrolled failure, would impact the outcomes of real people.
I look forward to your comments,
Robert Provenzano, MD
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Bob : I agree politics and the judiciary system should not dictate to Drs how to take care of our patients. We have to remind ourselves on and on again the reason for our existance is to give our best care to our patients.
Greetings