Southeast Texas Medical Associates, LLP James L. Holly, M.D. Southeast Texas Medical Associates, LLP

Transforming Your Practice - CMS Quality 12.2015 TCPI
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SETMA’s Description of the TCPI Program

    The Transforming Clinical Practice Initiative is designed to help clinicians achieve large-scale health transformation. The initiative is designed to support more than 140,000 clinician practices over the next four years in sharing, adapting and further developing their comprehensive quality improvement strategies. The initiative is one part of a strategy advanced by the Affordable Care Act to strengthen the quality of patient care and spend health care dollars more wisely. It aligns with the criteria for innovative models set forth in the Affordable Care Act:

    • Promoting broad payment and practice reform in primary care and specialty care,
    • Promoting care coordination between providers of services and suppliers,
    • Establishing community-based health teams to support chronic care management, and
    • Promoting improved quality and reduced cost by developing a collaborative of institutions that support practice transformation.

    December 3, 2015 Your Life Your Health Examiner Column -- The initiative is designed to support clinician practices over the next four years in sharing, adapting and further developing their comprehensive quality improvement strategies. The initiative is one part of a strategy advanced by the Affordable Care Act to strengthen the quality of patient care and spend health care dollars more wisely. It aligns with the criteria for innovative models set forth in the Affordable Care Act:

Prepared prior to the 2015 CMS Quality Conference and the TCPI Meetings

    October 1, 2015 - Summary of Preparation for First Telephone Conversation with Christy Guillory, M.S., J.D., Senior Consultant for The Lewin Group concerning the TCPI Program - the content was a follow-up to the discussion in our telephone conversation.

    November 13, 2015 - Acceptance of Invitation to attend the TCPI Meeting December 1-3, 2015

December 1-3, 2015 TCPI and CMS Quality Meeting

    After the first meeting of the TCPI Potential Faculty, December 1, 2015, this note was sent.  It includes ideas about “story books,” an example of clinical practice transformation, the end of the beginning (four seminal events), and others.

    Contributing to the library which will be necessary for the success of TCPI - Automated Team, SETMA’s Model of Care, Summary of April, 2015 CMS/ONC meeting, Analytics, Process Analysis, Transforming Teamwork.

    Care Coordination, From Quantity to Quality, Activating and Engaging Patients through Trust and Hope, The power of Story Telling

    Response to a brief conversation about resolving disparities of care through the process of developing hope.

    SETMA’s “Offer” to CMS for the TCPI Program - SETMA’s website

    Note to the TCPI, Director, Center for Clinical Standards and Quality, CMS, about SETMA

SETMA’s Prior Contacts with CMS

    April 23, 2015 -- Team dynamic and Being a Learning Organization; Solid Philosophical Foundation, knowing both what we are doing and why we are doing it; Communication and integration of the healthcare team through the power of IT -- “Most of us at one time or another have been part of a great ‘team,’ a group of people who functioned together in an extraordinary way - who trusted one another, who complemented each other others’ strengths and compensated for each others’ limitations, who had common goals that were larger than individual goals, and who produced extraordinary results.  I have met many people who have experienced this sort of profound teamwork - in sports, or in the performing arts or in business.  Many say that they have spent much of their life looking for that experience again.  What they experienced was a learning organization.  The team that became great didn’t start off great - it learned how to produce extraordinary results.”

    SETMA’s Notebook Prepared for: CMS and ONC Co-hosting a Meeting on “Health IT to Support ACO and Group Reporting” -- A Note Book which was prepared for the April 23rd CMS/ONC meeting about ACO’s and Analytics

    October, 2015 Letter seeking direction to CMS’s Definition of team members working in hospitals; what RNs can and cannot do.

    Description of a Healthcare Team and the value of the members of the team -- The following is your charge to Dr. Anwar and to me.  You stated that, ““I feel it is imperative for SETMA to give specific examples of how the RN taking call is able increase efficiency but yet remain compliant with the rules in the Nurse Practice Act.”  This is my response.  In the midst of a months-long effort on the part of the Medical Executive Committees (MEC) of two Southeast Texas hospitals to limit the activities of registered nurses (RN), this is Dr. Townsend’s question to SETMA; I shall attempt to answer it.  The foundation of my answer began with SETMA’s beginning and a significant aspect of the MECs’ actions can be found in the history of physicians responses to nurses.

    Letter to Ms. Linda M. Magno, Medicare Demonstrations Program Group, Centers for Medicare and Medicaid Services, Office of Research, Development and Information, for clarification of her comment in a March 3, 2010 as to CMS’s definition of “Medical Home Services.”

    During the CMMI Summit, Dr. Holly responded to some of the presentations.  In the introduction to the conference, reference was made to the participants.  Repeatedly, the names of companies who make products were mentioned.  Dr. Holly’s comment was: “....(he) discussed "companies," "companies," "companies!!!"  Companies WILL NOT, companies CANNOT, transform healthcare. Providers and Patients WILL make this transformation happen!!!  “Healthcare reform can be top down and with enough pressure and regulation, reform can bring temporary change, but sustainable, permanent, self-perpetuating change requires transformation. Transformation comes from internalized values and personal passion, which operates independent of reform and which will in fact find reform slow, ponderous and inadequate.  “Real change will require a dynamic partnership between government, private companies, academics and practicing healthcare providers. To imagine success while functionally ignoring the last group will result in either failure or at best partial success. “Top down will not work. Collaboration, dynamic partnership, between all four groups will get us where we want to be and it will keep us there.  The best which reform demands cannot match what transformation will produce.”

    With funding from the Centers for Medicare & Medicaid Services (CMS), RTI International, a nonprofit research organization, conducted a research study to analyze patterns of care, health outcomes, and costs of care for Medicare fee-for-service (FFS) beneficiaries receiving healthcare services from clinical practices that are National Committee for Quality Assurance (NCQA)-recognized medical homes. In particular, they were interested in determining if there are particular attributes of medical homes that are more favorably related to better outcomes of care. The information from these analyses will be used by CMS to help design Medicare and Medicaid medical home demonstrations.

    In January 2011, SETMA was  invited to participate the Medical Home Study conducted by RTI International (RTI) with funding from the Centers for Medicare and Medicaid Services (CMS). The study compared patterns of care between clinical practices that have received National Committee for Quality Assurance (NCQA) recognition as a medical home and clinical practices with similar characteristics that have not received NCQA medical home recognition. To thank SETMA for participating, RIT prepared the attached report summarizing information for SETMA’s three clinics (SETMA I - Calder; SETMA II - College; Mark A. Wilson Clinic - Dowlew; providing comparative information with two groups: a bench mark group of non-Medical Home practices and the NCQA recognized Medical Home group.

    RTI used Medicare fee-for-service (FFS) billing data as the information source. For practices with multiple practice sites, a report was produced for each practice site.

Payment Model Discussion with Texas Insurance Commissioner - November 1998

    November 1998 Testimony to the Texas Insurance Commissioner’s Public Hearing.  The unfolding of events in Austin at Public Hearing.  This link is to the testimony I delivered to the Texas Department of Insurance Commissioner, 17 years ago.  I am personally amazed at how this is as valid today as it was 17 years ago.  There are a few factual differences but essentially SETMA has fulfilled the promise which this presentation made to the Commissioner. 

    2015 responses to 1998 testimony - “Larry,  you really are a prophet. Your observations in 1998 are spot on. You could update your 1998 remarks with a couple of value-based catch phrases, and it would be as good a description of cost-effective care as I have heard since joining Health Leaders last year.  Always a pleasure hearing from you, Chris.” - “Dear Larry,  I am so pleased to be included in this circulation. Your paper was inspired then and is inspirational today. Especially for Australians grappling with a similar system to the one you worked in 17 years or so ago. It isn't surprising that robust principals survive the decades.  My regards, Michael.” - “Impressive---good medicine has not changed much---good ethics have become more inconsistent with the secular logic that is being applied--- good people practicing quality care remain the same.” - “What a powerful message! Those very issues are about to become far more significant than many providers are prepared for.” - “Larry. We had a cascade of meetings in the past 2 weeks and your name and thoughts were mentioned and highly praised from us all here.”  -- “Truly prescient!! Congratulations! Ken.”

    Text of 1998 testimony to Texas Insurance Commissioner’s Public Hearing.  Mr. Commissioner, every physician who makes his or her services available to the public takes risk that no one will respond.  And, society, whether as an agency of the government or as an agency of a private business, assumes the risk of paying for healthcare services for a defined population.  The only way to eliminate risk - and indeed the only way to significantly reduce risk - is with a concomitant reduction in freedom.  As physicians who have embraced the managed-care model of healthcare, we want to be able to accept risk.  And, we would ask you and your Department not to limit our ability to choose to take that risk.  In the old healthcare system, where physicians were rewarded on the basis of how many units of work they produced, rather than how much health they created, and in a system where others had the responsibility for paying for that care, there were no checks or balances on utilization.  In the old system...

Prepared in the Past Relevant to Practice Transformation

    An illustration of celebration of an accomplishment which promotes success in the future.  “The fourth seminal event was that we determined to adopt a celebratory attitude toward our progress in EMR.  In May, 1999, my cofounding partner was lamenting that we were not crawling yet with our use of the EMR.  I agreed and asked him, ‘When your son first turned over in bed, did you lament that he could not walk, or did you celebrate this first milestone of muscular coordination of turning over in bed?’  He smiled and I said, ‘We may not be crawling yet, but we have begun.  If in a year, we are doing only what we are currently doing, I will join your lamentation, but today I am celebrating that we have begun.’  SETMA’s celebratory spirit has allowed us to focus on the future through many lamentable circumstances and has allowed us to press forward through many disappointments.  Focusing on our successes kept us moving forward and the cumulative effect was always success.”

    SETMA and Care Coordination, Medical Home and Behavioral Health - The following statement which has no relevance for SETMA, ““Providers, in the old days, used to discharge people into the community and had no idea what happened in the form of follow-up. With managed care companies, physical health was the focus, but there was nothing regarding behavioral or mental health.”

Transformation Introductory Concepts

    Transformation of an Organization Requires Changes of and by Leadership --   The type of leadership needed from The Joint Commission and needed at the local organizational level is transformative because it is self-sustaining.  With a reform/pressure philosophy, SETMA will only pay attention to the standards of The Joint Commission after the 18-month widow of no surprise visits passes, at the end of which we’ll have to think about these things again, lest you “catch us” relaxing because the “pressure is off.”  Can you imagine the impact The Joint Commission could have if  rather than being an “overseer,” (as stated on your certificate), you embraced the organizations with which you work as the sustainers of “quality and safety” where both see each other as collaborators, colleagues and consultants rather than one as the sustainers of excellent (The Joint Commission) and the other (the practice, hospital or other organization) as the one who only pursued quality and safety as they were forced to by the oversight of The Joint Commission.

    Transformation Through the Power of Electronic Patient Management -- The foundation of modern healthcare began before the 19th Century, but patient medical records really began in the 1800s.  That history can be briefly summarized in three steps:  19th Century records, such as they were, were produced by pencil and paper.  20th Century records were produced at their best  by dictation and transcription.  With the advent of extensive technologically-based care and with expanded access to care, these methods became obsolete.  Even in the last quarter of the 20th Century, it became obvious that old methods of documenting, storing, sharing and using of healthcare information and of medical records were inadequate.  In the 21st Century, excellence in medical records was going to be electronic.

    Accreditation and Transformation - Sustainability -- The Question:  2. You note that "The provider must be an extension of the family. This is the ultimate genius behind the concept of Medical Home, and it cannot be achieved by regulations, restrictions and rules."  Are you implying by this statement that there is no role for "regs, rules, and restrictions", or simply that they are insufficient to sustain long-term change?

    The Answer:  No doubt, as our accreditation efforts suggest, we believe that there is a key place for standards and guidelines.  My point is directed at the government’s preoccupation with creating “change” with demands and dictates.  I have said to the ONC often, “if you demand that everyone must do the same thing, the same way, every time, you will eliminate creativity, generative thinking and transformation.  Tell us what you want done and let us demonstrate our unique way of doing it. Then evaluate it and find the ‘best practice or best solution’ and promote that.”

Value-Based Payment Model

    What are the key factors for physician practices to consider when weighing involvement in value-based payment models?

    1. Do they have the infrastructure to measure value?
    2. Have they begun a cultural change to focus on value measurement?
    3. Have they achieved or are they working toward achieving PC-MH recognition or accreditation and preferably are they committed to gaining both NCQA Tier III recognition and accreditation by one or more of the following:  AAAHC, URAC, The Joint Commission and/or Planetree.
    4. Do they recognize and accept the inevitability of value-based payment models as the future of healthcare.  At the TEPR Conference, May 11, 2000, in San Francisco, California, addressed the reality, responsibilities and rights of healthcare providers.   The following link is to the entire address:  Managed Care and Electronic Patient Records.

    Value-Based Payment Models, Questions for the Industry, Health Leader Media, Answers by James L. Holly, MD April 15, 2015.  SETMA believes that the key to the future of healthcare is an internalized ideal and a personal passion for excellence rather than reform which comes from external pressure.  Transformation is self-sustaining, generative and creative.  In this context, SETMA believes that efforts to transform healthcare may fail unless four strategies are employed, upon which SETMA depends in its transformative efforts:

    1. The methodology of healthcare must be electronic patient management.
    2. The content and standards of healthcare delivery must be evidenced-based medicine.
    3. The structure and organization of healthcare delivery must be patient-centered medical home.
    4. The payment methodology of healthcare delivery must be that of capitation with additional reimbursement for proved quality performance and cost savings.
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