Quality Improvement Interview: Kaiser Permanente of the Mid-Atlantic States

Kaiser Permanente of the Mid-Atlantic States has been demonstrating high performance on NCQA’s annual health plan rankings for several years; due to a combination of quality improvements and high patient satisfaction ratings, the plan rose a total of 18 ranking places from 2011 to 2012. This year’s increase – up to number 15 in the commercial rankings and number 12 for the Medicare rankings – was a continuation of the plan’s high performance for the past three to four years.

We spoke with Bernadette Loftus, M.D., the Permanente Medical Group associate executive director for the Mid-Atlantic States, about what the plan has been doing recently to drive improvement. Dr. Loftus cites two key aspects as responsible for their exemplary performance: access and communication.

She emphasizes that the importance of access for patients, whether to primary, specialty or ancillary diagnostic care cannot be overstated. Due to a relentless diligence to improving access times and stringent requirements that patients must see their own physicians whenever possible, the plan maintains excellent access for patients so physicians spend more time listening to and engaging with the patient, not on extraneous issues.

According to Dr. Loftus, this simple focus has greatly impacted the way the plan interacts with patients: When patients see a doctor that they know, there is an instantaneous jump in patient satisfaction ratings.

Effective communication is the second key aspect to Kaiser Permanente – Mid-Atlantic’s steady improvement on the rankings. This refers to communication among physicians, the health plan and patients. In terms of the former, physician and staff buy-in is key, says Dr. Loftus.

The health plan has provided a comprehensive electronic medical record to the physicians, and supports staff and providers in its utilization. The plan’s leadership, along with Dr. Loftus, also maintains focused communication with all practices. She points out that evidence confirms that effective communication between physicians and a focus on patient access improves health outcomes and patient experience.

To facilitate communication with patients, the plan has implemented what Dr. Loftus calls “obsessive” outreach – continual prompting comprising “back sweeps” and “forward sweeps.” The “back sweep” report requires that all patients get scheduled for their needs (such as screenings, check-ups or physicals) during each visit. The “forward sweep” requires staff to look to future patient visits, and schedule any additional upcoming appointments for which patients are due on that same day, so the patient makes only one office visit.

These protocols have elicited particularly positive feedback from patients, some of whom credit the outreach with saving their lives, due to early diagnoses and treatment.

Kaiser Permanente – Mid-Atlantic now tops the rankings for three measures: Breast Cancer Screening, Acute Bronchitis Treatment in Adults and Diabetic Nephropathy Medical Attention. Dr. Loftus is also particularly proud of the plan’s hypertension control rate, which stands at number six in the nation – a remarkable achievement given that the demography of the Mid-Atlantic states shows the patient population to be vulnerable to hypertension.

The plan’s performance on this measure is an instance of both effective communication and greater patient access, as well as a rapid performance improvement cycle. The methods of effectively treating hypertension are well known: They call for a layering approach, tinkering with dosages and medications to find what works best. However, the plan realized that decision points needed to be more frequent, requiring blood pressure to be checked every few weeks. They quickly modified follow-up measures, and aided by aggressive outreach, the plan now boasts a control rate of over 80 percent. Dr. Loftus says that a widely accepted recognition of common standards regarding these measures enabled a quick and straightforward transition. The “HEDIS measures are based on evidence. No one argues that it is not the right thing to do,” she points out.

It is clear that quality improvement is not a unilateral effort, nor is it a goal that requires complex strategies and arcane technology. On the contrary, the process is fairly simple: By making it easy to do the right thing, says Loftus, these priorities and practices will naturally spread, and garner staff buy-in. Achieving quality performance demands relentless dedication on the part of the entire plan, as Kaiser Permanente – Mid-Atlantic has demonstrated.

“Quality is everyone’s job,” Dr. Loftus concludes.

Photograph courtesy of The Permanente Medical Group.


CareOregon’s Releasing Time to Care

October 1 was a big date for health care reform: At the start of this month, several provisions of the health care law took effect, including two Medicare programs that are designed to improve the quality of medical care by leveraging the federal program’s financial resources – quality-adjusted hospital reimbursements and the hospital readmissions reduction program.  October 1 was also the target date for submitting a list of essential health benefits for the upcoming state insurance exchanges to the federal government.

Independent of these deadlines, ACHP member plans have been assiduously contributing to the nationwide effort to improve the quality of care, safety and efficiency. We recently spoke with CareOregon about their innovative nursing and hospital support program, which underwent significant expansion in September.

The Releasing Time to Care (RT2C) methodology was developed by the United Kingdom’s National Health Service in 2007. Designed by nurses to help hospital nursing staff increase the time available for direct patient care, RT2C applies Lean methodology to the particular needs of nurses and hospital staff.

At the core of RT2C are three foundational modules – Knowing How We’re Doing, the Well-Organized Ward and Patient Status at a Glance – which lay a framework to help nurses collaborate, conduct ward assessments based on quality metrics, keep organized and track patient status. An additional eight process modules focus on core ward processes; they include, among other things, admission, observation, shift handoffs and medication administration.

Seeing an opportunity to catalyze hospital transformation in Oregon, in July 2010, CareOregon funded the first year of training in this methodology for four hospitals; last month, RT2C was expanded to an additional 13 hospitals, speaking to the program’s efficacy. RT2C is implemented unit by unit in a hospital by the frontline staff, engaging and empowering nurses to lead the way to change.

Amidst this wave of program expansion, the health plan continues to stress collaboration and networking among the participating hospitals. Dave Ford, president and CEO of CareOregon, remarks that the health plan plays a valuable role in building relationships with many entities, allowing cooperation in facing shared issues of financial strain.

“The learning that is being shared among the hospitals is really incredible,” states CareOregon Governance and Business Development Manager Barbara Kohnen. “This shared learning will help all the hospitals in the state become better in every way—including having a happier and more empowered staff.” Indeed, nurses have responded well to the program, which allows them to spend more time with patients and improve the quality of their care.

RT2C has “helped us refocus on why we come to work every day,” affirms St. Charles Health System Chief Nursing Executive and Vice President for Quality Pam Steinke (St. Charles Health System is a participating hospital). “My personal belief is that if I can help make my organization the best place to be a nurse, it will also be the best place of all to be a patient.”

For more information on numerous other case studies featuring the work of our member plans, please check out our website. A full-length case study on CareOregon’s experience with RT2C will be coming soon.

Photo courtesy of Getty Images.

Community-Based Health Plans Lead National Rankings

The National Committee for Quality Assurance released the 2012-2013 health plan rankings yesterday and ACHP members were once again at the top of the list. NCQA, which publishes its Health Insurance Plan Rankings annually, bases the rankings on their NCQA Accreditation standards, which are some of the most rigorous in the industry. These standards are developed collaboratively, with the help of health plans, providers, purchasers, unions, regulatory agencies and consumer groups.

For 2012-2013, seven of the nation’s top ten commercial plans, all of the top ten Medicare plans in the nation and six of the top ten plans in the Medicaid rankings are offered by ACHP members. While ACHP is excited to announce these outstanding results, such performance is not surprising: Our member plans have established a precedent of continually topping the rankings. Last year, 12 of the nation’s top 20 private plans were ACHP members. This performance has echoed throughout the past years as top plans demonstrate superlative quality outcomes.

In the next few weeks, we will be posting a series of blog posts that will provide more robust analyses on the rankings and quality performances of plans. Additionally, look forward to some posts offering insight on the value of these quality rankings, which serve as critical tools for consumers in assessing health plans. In the meantime, take a look at what Peggy O’Kane, president of NCQA, wrote in The Atlantic  earlier this summer about engaging consumers in learning more about the health care system.

Below is a table summarizing ACHP member plans’ rankings.

Commercial Plans – Top 50

Rank     Plan

2          Tufts Associated Health Maintenance Organization
3          Capital Health Plan
4          Tufts Benefit Administrators (PPO)
6          Kaiser Foundation Health Plan of Colorado
8          Kaiser Foundation Health Plan of Northern California
9          Group Health Cooperative of South Central Wisconsin
10        Kaiser Foundation Health Plan of Southern California
12        Geisinger Health Plan (HMO/POS)
13        Kaiser Foundation Health Plan of the Northwest
15        Kaiser Foundation Health Plan of the Mid-Atlantic States
16        UPMC Benefit Management Services
16        UPMC Health Plan
19        Kaiser Foundation Health Plan – Hawaii
20        Capital District Physicians’ Healthcare Network (Self-Funded, PPO)
20        CDPHP Universal Benefits (PPO)
24        Capital District Physicians’ Healthcare Network
25        Capital District Physicians’ Health Plan
28        HealthPartners
33        Fallon Community Health Plan
36        Kaiser Foundation Health Plan of Georgia
38        Kaiser Foundation Health Plan of Ohio
42        Security Health Plan of Wisconsin
43        Priority Health
48        Independent Health Association

Medicare Plans – Top 25 

Rank     Plan

1          Kaiser Foundation Health Plan of Southern California
2          Kaiser Foundation Health Plan of Colorado
3          Kaiser Foundation Health Plan of Northern California
4          Capital Health Plan
5          Kaiser Foundation Health Plan of the Northwest
6          Geisinger Health Plan
7          Kaiser Foundation Health Plan – Hawaii
8          Fallon Community Health Plan
9          Group Health Cooperative
10        Group Health Plan (HealthPartners)
12        Kaiser Foundation Health Plan of the Mid-Atlantic States
14        Priority Health
15        Capital District Physicians’ Health Plan
16        Kaiser Foundation Health Plan of Ohio
18        Security Health Plan of Wisconsin
23        Independent Health Association

Medicaid Plans – Top 25

Rank     Plan

1          Fallon Community Health Plan
2          Kaiser Foundation Health Plan – Hawaii
3          Network Health (Tufts)
7          Priority Health
8          UPMC for You
10        Security Health Plan of Wisconsin
13        Capital District Physicians’ Health Plan
21        Independent Health Association

Effecting Change – From the Local Level to the National Scene

By John Bennett, M.D.

Health care is a hot topic these days. With the Supreme Court ruling on the Affordable Care Act and the presidential election in full swing, it is at the forefront of the news.

The polling group Gallup says health care and its associated issues – quality, access and cost – are a “latent concern” for Americans – essentially something that is always on the minds of the people. When specifically asked about the topic, Americans rank health care high among their concerns.

A Gallup report on June 29 (a day after the health care ruling), showed that in a recent poll, Americans put the cost of health care at the top of their list of economic issues. In addition, the “availability and affordability of health care” ranked as high as federal spending and the budget deficit.

With these statistics in mind, it is not hard to see the need for change. So the timing of the federal government’s nationwide Comprehensive Primary Care (CPC) initiative couldn’t be better. The program is the Centers for Medicare & Medicaid Services’ (CMS) plan to “deliver higher quality, better coordinated and more patient-centered care.”

The goal of the CPC is to test payment models to improve the quality and efficiency of health care. It invites payers to invest in primary care doctors who are committed to care coordination. Primary care practices that are selected by the government will be given financial incentives and other resources to better coordinate primary care for their Medicare patients.

CMS recently selected New York’s Capital District-Hudson Valley region as one of seven markets in the nation to participate in the CPC initiative.

While Capital District Physician’s Health Plan (CDPHP) is part of this federal initiative, the strategies that we will implement as part of the CPC initiative are not new for the company. In fact, CDPHP launched its own Enhanced Primary Care (EPC) program in 2008 that has helped transform the way physician practices in one region care for their patients.

The EPC program has gained national attention after demonstrating that patients get higher-quality, more cost-effective health care when primary care doctors are paid in a manner that supports spending more time with the sicker patients and organizing their office workflows to enhance access for the patient and coordinate their care.

On July 18, CDPHP’s Senior Vice President and Chief Medical Officer Bruce Nash, M.D. testified at a congressional subcommittee hearing on Medicare payment reform in Washington, D.C.

Since its inception, CDPHP’s innovative program has steadily grown. EPC now includes 75 local physician practices, encompassing nearly 100,000 CDPHP members and 384 network physicians. A new phase of the EPC program kicks off in August. The expansion will double the number of participating practices and cover an additional 70,000 members.

An independent analysis of the CDPHP’s Enhanced Primary Care initiative has shown a 15 percent reduction in inpatient admissions, a 9 percent reduction in emergency room visits, and $8 per member, per month savings.

CDPHP now has the chance to prove that this model can work more broadly – in other communities across the country. The spotlight is shining on this relatively small geographic area. The best health care ideas for our country often are rooted deeply in our communities. What CDPHP is doing locally can change health care for millions of people.

With an eye toward the future, CDPHP, like many other health plans that are part of the Alliance of Community Health Plans, is doing its part to keep up with the rapidly changing health care landscape. The big question is how will other communities – patients and their families, physicians and hospitals, health plans and employers – approach the challenges that lie ahead?


Dr. Bennett is president and CEO of Capital District Physicians’ Health Plan in Albany, New York. To learn more about CDPHP, visit www.cdphp.com.

Oregon Takes a Leading Role in Health Care Reform

By Dave Ford

Hillel the Elder once asked, “If not now, when?”

As the national debate over the future of health care continues unabated, Oregon has answered with a resounding “Now!”

When a bipartisan majority of the Oregon Legislature and Governor John Kitzhaber agreed that now is the right time to go beyond the vision of the federal Affordable Care Act, they launched a period of health care transformation that is simultaneously heady and hectic.

Heady because the effort brings tremendous opportunities for improving the quality of health care services, the health of our citizens and the affordability of the system. Hectic because so much is to be accomplished so quickly.

As the largest provider of managed care services to members of the Oregon Health Plan, Oregon’s Medicaid program, CareOregon is partnering closely with members, providers, social and community agencies, legislators and other health plans in the transformational effort. Key to the state’s transformation of Medicaid is the creation of Coordinated Care Organizations (CCOs). CareOregon will set up or participate in five CCOs covering 11 counties.

As envisioned in Oregon, a CCO is an umbrella under which a community network of health care providers—including physical, mental and eventually oral health—will work together for Oregon Health Plan members. Each CCO will be a jointly and locally governed entity that contracts with the state, receiving payment not for individual services, but for whole-person care that improves care coordination, care quality and health status for the Medicaid population. We are viewing them as “Community Health Democracies.”

The objective is to develop a local “Health Commons” that mediates the limited resources available with the requirements for services by the community — citizens, providers — itself. Hopefully that will “drive Triple Aim” and improve whole community well-being.

As an example of what we’re doing and what we expect to accomplish, the Tri-County Medicaid Collaborative has provisional certification by the state as a CCO in the greater Portland area—Clackamas, Multnomah and Washington counties. CareOregon is a partner in this collaborative with Adventist Health, Central City Concern, Kaiser Permanente, Legacy Health, Oregon Health & Science University, Providence Health & Services and Tuality Healthcare, as well as the three counties.

Recently the Collaborative received a $17.3 million Health Care Innovation Awards grant from the Centers for Medicare & Medicaid Services. This grant will help expand five initiatives to help address the needs of high-cost, high-acuity adult patients.

  • Interdisciplinary Community Care Teams provide high intensity engagement, coaching, health literacy, and care coordination support to patients with high ED and hospital utilization, and who struggle with socio-behavioral challenges and co-existing medical conditions. The model enhances primary and specialty practice teams with a non-traditional outreach worker who provides support to these patients outside the walls of the health care setting, in the community or in patients’ homes. The help these enhanced teams provide may range from one-to-one collaboration with patients on improving self-care and following treatment plans to assistance with social skills and basic needs, such as housing. CareOregon will oversee this intervention based on its existing Community Care pilot program.
  • Care Transitions Innovation (C-Train) provides intensive nurse management and clinical pharmacist support for medical patients who are at high risk for readmission to the hospital. The intervention begins with risk assessment and individualized discharge planning while the patient is hospitalized and then proceeds with home visits and telephone calls immediately following discharge. A critical component of the intervention is facilitating a high quality, timely connection with primary care follow-up. This was piloted at Oregon Health & Science University, which will join with Legacy Health to oversee the expansion.
  • The Transitions Standardized Discharge Program aim is to create a standardized hospital discharge summary format to be used in all area hospitals for effective communication of critical admission history and discharge instructions to primary care providers. The anticipated outcomes are an improvement of the hospital transition process and a reduction in hospital readmissions. This informational technology intervention will rely on a new technology solution that will transfer the standardized discharge summary within 24 hours of discharge to each primary care system’s EMR. Legacy, Providence and OHSU are key partners in this effort.
  • The Intensive Intervention Team provides short-term intensive case management and mental health services to psychiatric inpatients and emergency room users discharging to the community. The goal is to assure the engagement of high-risk individuals into appropriate community-based services and supports in order to divert inpatient psychiatric admissions and prevent readmissions. This intervention is based on a model implemented in Washington County, where it reduced readmissions by 26 percent. Providence will subcontract with each county to administer this project.
  • ED Guides Program uses non-traditional workforce members to reduce the use of emergency department services for non-emergent issues. These guides will link patients to primary care homes and support services, including referral to the Community Care Team intervention and self-management resources. Providence has piloted ED Guides in several of their facilities and will oversee the expansion of the program to additional hospitals.

These programs are examples of the kind of collaborative innovation that partnerships in the CCOs can nurture. They can help focus resources on the 20 percent of members whose conditions are such that they require 80 percent of Medicaid costs.

We expect other benefits from the close collaboration as well, from quality improvement programs among hospital nurses, to expanding patient-centered, primary care medical homes, to cultural competence and health equity improvement.

CareOregon is also a partner in the Columbia Pacific CCO with Greater Oregon Better Health Initiative, to serve members in Northwest and coastal Oregon; PrimaryHealth of Josephine County, with Oregon Health Management Services, Grants Pass Clinic, Siskiyou Community Health Center, Three Rivers Community Hospital and Options of Southern Oregon; Jackson County CCO, in collaboration with La Clinica, Community Health Center, PrimeCare, Asante Rogue Valley Medical Center, Providence Medical Center and Medical Group, Addictions Recovery Center, OnTrack, Jackson County Health and Human Services,  and Jefferson Regional Health Alliance; and Yamhill County CCO in collaboration with independent and employed physicians, Providence Newberg Medical Center, Willamette Valley Medical Center, Virginia Garcia Memorial Health Clinic, Physicians Medical Center, Mid-Valley Behavioral Care Network and NW Senior and Disability Services.

The expression, “May you live in interesting times,” has been quoted as both a proverb and a curse. For those of us closely involved in Oregon’s health care transformation, we fully expect to look back on this “interesting time” as a blessing.


Dave Ford is president and CEO of CareOregon in Portland, Oregon. To learn more about CareOregon, visit www.careoregon.org.

After the Supreme Court Decision: Full Speed Ahead

A panoply of high-profile health policy leaders, running the gamut from constitutional experts to health plan executives, from academics to state Medicaid directors, gathered in Washington earlier this week for a conversation about the path ahead for health care reform. The event, “After the Supreme Court: Moving Ahead to Implement the Affordable Care Act, Improve Health and Health Care and Lower Costs” was organized by Health Affairs, the nationally-recognized health policy journal. While the speakers incorporated a range of perspectives on the intricacies of the law’s implementation, they also addressed broader concerns about health care delivery and impending changes in the health care marketplace. Several themes, including affordability, collaboration and accountability emerged as “must-do’s” for a changing health care system.

Remarkably, in this period of intensely partisan rhetoric, two former administrators of CMS, Dr. Mark McClellan and Dr. Don Berwick, the former a Republican, the latter a Democrat, served as the conference co-chairs. They framed the discussion around a few core issues: the imperative of lower costs and the need for payment reforms; shifts to systemic approaches in health care delivery that  center on what the patient needs; stronger collaboration between the federal government and states;  and the need to assure safety net coverage for those who can’t afford care.

Speaking as part of a panel on “The Urgency of Attacking Costs and Improving Care,” Dr. Michael Cropp, president and CEO of Independent Health in Buffalo, New York and vice-chair of ACHP’s Board of Directors, pointed to what he termed “individual agency” – the recognition that sweeping systemic problems can only be addressed if all stakeholders acknowledge their roles and responsibilities – as one of the most critical components to sustainable payment and delivery reform. This sentiment was repeated by several other panelists, including Helen Darling of the National Business Group on Health, who noted that cost shifting has become the status quo, and finding someone else to foot the bill frequently masquerades as “affordability.” Reforming our unsustainable and convoluted payment system, she stated, will require transparency, delivery reform and an eye to accountability.

Scott Armstrong, president and CEO of Group Health Cooperative and ACHP Board Chairman, underscored this theme, noting that payment policy is essential, but far from sufficient. Contrasting his roles as the leader of a community health plan and as a member of the Medicare Payment Advisory Commission (MedPAC), Armstrong pressed for greater alignment between payment policy and what happens on the ground, in communities, where care is delivered. There must be alignment among all sectors around a common goal: the improved health of the patient population. No single stakeholder has all of the answers. Amplifying this point, patient and family advocate Debra Ness, president of the National Partnership for Women and Families, observed that patients and their families are, after all, the ones for whom this system is designed. To improve the health of populations, she observed, patients and their families must be engaged as equal stakeholders along with providers, health plans, employers and governments.

Armstrong pointed to several fundamental elements that define a high functioning health care system: among them, systemic alignment around the common goals of better health, better health care, and lower cost; positioning primary care as the centerpiece of the system; using technology to support the easy transfer of information that will improve care and coordination; and designing health care coverage and delivery to incentivize patients and the system to do the right things at the right time.

Both Armstrong and Cropp emphasized that the path to a sustainable, quality health care system will be forged locally, and not inside the volatile, highly partisan world of Washington. What works in Seattle may not work in Poughkeepsie; building on key elements of the Triple Aim is the foundation of transformative design changes that are emerging in cities as different as Spokane, WA and Buffalo, NY. Finding common ground and points of collaboration is not simple, but it is possible in communities, even as it seems so elusive nationally.

Bill Kramer of the Pacific Business Group on Health urged accelerated implementation of what is already working in some areas to reduce costs and improve care, such as private-sector innovations and strategies. By building, strengthening and expanding on payment redesign and aligned incentives, so-called “fringe” methods will become the “new normal,” providing a foundation for market-based reform.

Dr. Cropp cited HEALTHeLINK, a health care “information highway” in Western New York that allows for the quick and reliable sharing of electronic health data among other unconnected medical professionals. Propelled by the “agency” of leaders who see themselves as accountable, HEALTHeLINK was developed as a community-owned asset that puts the patient at the center of design – protecting their privacy, but also assuring that information can travel across multiple providers and payers to support better care and streamlined coordination for patients and their families. Although providers and payers are often at odds, in Western New York they are partnering to achieve the shared goals of better patient health and more effective and efficient care.

The organizers of this forum are to be commended. Health Affairs provided an open arena, incorporating players from across the full spectrum of the health care marketplace and from divergent political perspectives into a dialogue intended to engage and educate. The uncertainty of what health care reform will look like going forward loomed over almost every discussion, whether or not it was directly addressed. Notably, the forum offered a chance to share experiences: what works, what doesn’t, what might. Most of those examples came from communities – communities where accountability and collaboration are the hammers and nails of systemic change. Disagreement remains on what health care reform should look like, but there was no quarrel on the need to improve health, improve care and lower cost.

-Patricia Smith
President and CEO, ACHP

A recording of the webinar is available at the Health Affairs website, located here.

Putting the Patient in the Center: Star Ratings Congress for Medicare Advantage Plans

As I like to say, Medicare Advantage (MA) is one of the best kept secrets in Washington.  When it comes to creating better health, providing better health care, and lowering costs, MA plans are on a path to creating value, and a model for the future of our health care system.

Let’s start with some basics.

Today, one in four people with Medicare are enrolled in a Medicare Advantage plan.  In fact, as of January of this year, 12.8 million beneficiaries were enrolled in an MA plan. The number of seniors enrolling in MA plans is rising at a rate of 5 to 10 percent a year.  And the number of plans participating in the program is also rising.

Improving the quality of care and rewarding value in MA has long been a goal of Medicare policy experts.  And the drive toward these goals began nearly a decade ago when Congress began to consider policies to move MA – and the rest of the Medicare program — in this direction, including:

  • Under the Medicare Modernization Act of 2003, the Institute of Medicine (IOM) was directed to evaluate ways to improve quality and value. The IOM issued a 2006 report, “Rewarding Provider Performance: Aligning Incentives in Medicare,” that recommended Medicare begin to test pay for performance in the MA program.
  • Beginning in 2004, the Medicare Payment Advisory Commission (MedPAC) recommended that Congress establish a quality incentive payment policy for Medicare Advantage (MA) plans, reflecting its view that “one of Medicare’s most important goals is to ensure that beneficiaries have access to high quality health care.” With their history of measurement and accountability, private plans were a logical starting point for quality-based payments.
  • The Affordable Care Act (ACA) incorporated significant changes to the MA program, including a quality incentive program based on established quality metrics and a star ratings system, to start in 2012. At the same time, Congress established or extended quality reporting and payment requirements for hospitals, physicians, and other providers serving Medicare patients.

What we have seen is steady improvement on a wide range of quality measures year after year.  In a number of key clinical areas, Medicare Advantage plans perform at a higher level than their commercial counterparts.

I have the honor of working with a group of health plans that embraced the challenge Medicare laid out by providing high quality care to hundreds of thousands of seniors.  Some 98 percent of Medicare beneficiaries enrolled in an MA plan that received a 5-star quality rating from CMS (the highest possible rating) are in ACHP member plans.  In 2011, the National Committee for Quality Assurance (NCQA) ranked 17 ACHP Medicare plans among the top 25 in the country.

But instead of merely reiterating our successes, I’d like to share some of the things that we have learned over many years of pursuing higher quality care, even when the system didn’t provide any financial incentives.  Essentially, putting the patient at the center of care is critical; leadership and systems should be built around this central feature.

This commitment starts at the very top of an organization, meaning that CEOs and their leadership teams must send a clear message to staff, partners and communities that they hold themselves and their organizations accountable to better experiences of care for their patients.  Higher quality also requires systemic thinking, such as building new systems and processes that support safe, effective, patient-centered, timely, efficient and equitable care.  One aspect of this systemic thinking is building a close relationship between health plans and their provider partners – and once again, putting patients at the center.  A commitment to training and culture growth can pull an entire health care system toward a new organizational DNA – one that is all about better health, better health care and lower costs.

There has been some criticism recently about the ACA’s MA star ratings program, which links payment to quality and therefore creates incentives for the Medicare program to actually buy value.  I could offer a slew of statistics reaffirming the benefits of MA and paying for quality, but I think it would be more effective to share a story from one of our member plans, Priority Health in Grand Rapids, Michigan.

“Michael” is a member of Priority Health, and, like many Medicare beneficiaries, Michael suffers from multiple chronic conditions.  In fact, his health history includes diabetes, back pain, congestive heart failure, depression, and chronic obstructive pulmonary disease, among other conditions.

Before he joined an MA plan, Michael did not have a primary care physician, and was socially isolated and experiencing frequent hospitalizations. At the time, he was on a ventilator and his doctors were doubtful that he would recover.

Once he was enrolled in Priority Health’s MA plan, he chose a primary care physician, and a complex care management team worked to address barriers to Michael’s care.  They provided him with counseling on how to manage his chronic conditions. They taught him what he needed to know about his medications, and set up a home telemonitoring program.  As a result, Michael has avoided readmission for nearly ten months. He better understands how to manage his multiple conditions, and is enjoying a much better quality of life.  He even has a girlfriend now.

Health plans like Priority Health focus on quality outcomes, care coordination, and patient engagement. Instead of a long litany of uncoordinated services that run up a huge bill and deteriorate the patient’s quality of life, people like Michael – and there are millions of them in our country today – get the care they need, when they need it, from trained professionals who put the patient at the center of care.

-Patricia Smith
President and CEO, ACHP