81st Presidential Advisory Council on HIV/AIDS (PACHA) Full Council Meeting | June 5, 2024 | Part 5

welcome back uh as you may know Pac will issue a report to the Secretary of Health and Human Services that will describe our key findings from this public meeting on addressing the needs of patients with chronic complex chronic conditions or serious illness and populationbased total cost to care models we now have time for the committee to reflect on what we've learned in our sessions today we'll hear from more experts tomorrow but want to take a few minutes today to gather our thoughts before adjourning for the today committee me Members I'm going to ask you to find the potential topics for deliberation uh in your um folder it's tucked in the left left front pocket of your binder to indicate that you have a comment just flip your name tent over or raise your hand if you're on Zoom Lauren Josh and I'll ask who would like to start sure I'll start so you know I I think um it was a really good day of learning for me uh and really appreciated all the insights and expertise from our subject matter experts you know just a few kind of big picture takeaways for myself um it was gratifying to hear our experts confirm that um this is kind of the population to focus on in terms of cost savings um to Medicare not that that's what uh that's not that that's everything but that is a big focus of of Pac is um payment models that will improve quality or keep hold at the same while lowering costs um and so uh it was gratifying to to hear that um and kind of the secret ingredient I heard to uh these care models that have actually worked to save costs uh and improve quality at the same time is uh I think it was Dr um Dr Smith who said an activated primary care physician you know uh and Dr Wayne mentioned this idea of uh being available 247 uh having having an infrastructure in place where when a patient needs you uh you're there uh or a provider is there to take care of issues um and so that seems to be a common theme that I I heard uh throughout the day today and lastly um I really appreciated uh another theme which was um that we aren't measuring what matters for this population of patients um and that's because what we're measuring our patient diagnosis and basing payment off of those diagnoses but that's not adequate is what I heard uh from Dr Phillips uh and many others on on different panels throughout the day Jen I agree uh with all of Walter's comments uh and uh want to thank the PCD P pcdt team uh for really uh uh putting together a phenomenal uh day uh what I heard was that in terms of care delivery um one of our speakers said uh we know what to do this is an implementation issue which I thought was was interesting and what I heard from the delivery perspective uh the best practices for many of our speakers included uh being holistic and not disease focused uh developing effect Ive communication uh with patients and developing strong relationships that are culturally tailored uh we've talked about this in the past but we heard again today that close monitoring or high touch uh one uh speaker talked about uh a daily huddle uh to evaluate their patient panel uh and respond promptly to acute episodic care concerns is necessary we heard that the patient the family must participate in order to be successful and that by adding patients and caregivers to governance models uh was a best practice uh we also heard uh that uh primary management should be the strategy versus uh co-management and I was compelled by uh hearing that we need more care than Care Management which I think is really true we heard a number of speakers talk about that we also heard that making Equity an explicit goal is uh necessary uh and that we should be thinking about stratifying our programs and our data by patient characteristics versus uh uh disease or diagnostic only uh then what I heard with regards to Performance um of the system was that we again need to create compelling incentives for participation or to get action uh and structure incentives ensure uh Revenue flow we also heard that we need to create incentives to scale Beyond pilots and one of the suggestions was to ensure that uh there's a focus on aligning uh Medicare and Medicaid strategies together uh for those patient populations uh we also heard that uh we need to drive attribution to Primary Care and had lots of pie conversations um but what it made me think about was uh what about uh the appetizers and what about the entree um how are we Thinking Beyond uh just um Part B strategies and we also heard that there needs to be a prospective patient to Primary Care uh and to have real dollars available um to create those kinds of compelling uh incentives uh and then I heard three last things uh providing protection for downside risk while uh developing or implementing um a program or participation is necessary and I think that's we've heard those themes um over many of our our sess sessions uh and we also heard loud and clear for this specific patient population that incenting Partnerships with local and communitybased safety net programs uh is very important uh and and uh one of our last speakers used the word uh create knitting uh among those those programs and I I think that's really Germaine and then last we heard about being more efficient uh in eliminating friction one classic example uh was prior authorization uh but I also heard that eliminating the reporting of data that doesn't matter or doesn't impact outcomes should be a focus and there should be consideration for uh measures uh that may be uh of high value um from a risk adjustment perspective and we heard a couple of different speakers talk about Frailty in this patient population being an important uh metric uh to track not only from an outcomes perspective but also a consideration of risk adjustment great thank you Jen I think Lauren was up next I'll just add a couple layers to that because John you covered so many of the points that I was going to say too so um definitely really interesting themes around um deep drivers of cost of the population related to U Behavioral Health and also the impact of um health related social needs and poverty on on cost and and access the importance of developing um a reactive system so 247 access to help um with disease management symptom management but also the competency skill set and systems for anticipatory management of symptoms disease but also um proactively addressing social needs um in the population in the interdisciplinary teams thinking wisely about who's on that team um the concept of operating to top of license but also looking at um are we using the right efficiency with the number of people at the table and the roles and how they're organized um having a lane so Primary Care definitely is a center of this work but what if the reason for complexity and cost is that Primary Care is failing so what is the other Center of that care or how can that capacity be invested in intentionally as part of this and then um the importance of running risk stratification frequently as much as monthly so um we're really looking at real data about what is occurring for um clients and their families and then the importance of integration of data so Health Data utility and data interoperability to really have a holistic view we're really going to seriously address Health Equity and take into consideration health related social needs we need to have a holistic picture of what's happening with the clients and then one point we didn't get to go into to deeply but Caroline on her slides brought up the correlation was social connection measures and loneliness and I think I see that as a really emerging area in this population um that I see in practice and I'm hearing more about so I think that's also worth looking um more deeply into so really really rich day great job pcdc in planning this thank you Lauren I'm not sure if chinny or Lee was next but please being a gentleman thank you um excellent day I thought the pcdt did a phenomenal job bringing this group of people together so not to repeat too much of what's already been said um I'll go into larger themes the first thing that struck me was multiple speakers spoke almost about a personalization are we asking the right questions are the questions leading to functionality um how are we asking questions that came up multiple times and so I think it lends itself to really looking at our patient outcome measures our quality measures to saying what exactly are we asking and what does it lead to so that to me was a larger theme of of a personalization as to Patient outcomes the second thing that struck me as a larger theme was a patient connection and Trust multiple speakers spoke about um outside Care Management organizations that are outside the primary care not being effective virtual Care Management not being as effective vendor related you know I'm not sure I necessarily completely agree but I do think that the concept that the patient has to trust the care provider is fundamental in getting the patient to sort of quote unquote say yes to things and that came up multiple times so the concept of trust connection and saying yes other things that multiple people have said but caregivers um not just governance but actually attaching dollars to compensate caregivers then obviously interoperability but one thing that struck me about that was the fact that not all data contain contained in the EMR or in what we think it's contained in that there's so much data out there the transdisciplinary versus multidisciplinary um and and what I loved also about this day was the emphasis on paliative care I mean you look at some of the cost measures that were shown in um the the slides on pallative care and you wonder why like everybody doesn't get pallative care right it's the right thing to do patients are happier families are happier it's a soft Landing and then you think about it and it actually saves the health system money so like why don't 100% of the people get it and so it's just one of those things that struck me as um an aha thing that you know everyone seemed to kind of speak to a little bit about why we need pallative care and so stop here and I I did like the CFO panel idea yeah I like that panel too uh lee thank you I certainly agree with um those things other members have already spok spoken to um reiterate some of those and perhaps bring in a few other threads things that stuck to me was really really going deep into just the for this population especially it's all about relationship and it's that relationship that drives engagement and this bigger theme of Engagement that you know perhaps paying that it's critical for having patients but caregivers and families being engaged because sometimes for this complex chronically ill population they're the source of more information Insight than the patients at times uh especially in facilities like where Walter's group practices but also that that even sometimes paying patients or caregivers to participate to to get them over the barrier of just saying yes I want your services is may be a very effective and cost- effective strategy so I think that was pretty bold um this issue of the centrality of of an Engaged primary care practice the other side of the engagement uh coin but and that outside that you know engaged owning longitude and primary care practice both care coordination and virtual telephonic care while valuable from a pure AIS perspective may actually just be fragmenting care and not actually deliver any returns um that made me resonate with something Dr Wayne said that never been he was talking about metrics but never been more humbled than seeing good intentions go arai and and virtual care uh you know care coordination we need more of it well maybe it's not always good if it's just thrown out of a vacuum and so I thought those were really valuable points um I think Eric really uh hit the nail on the head and talk about what's what's the Glide path um what's the template to try to get to the 2030 uh vision and he talked about just a tectonic shift in prospective payment for primary care if or when those practices have the capability to to step up to the plates and that that CL a theme we've had from multiple meetings over multiple years now in my term on PTAC of just continually making Fe for service an increasingly uncomfortable place to practice because it's not delivering as others said the pie is not feeding the right people at this time and so we need to not you know legislator mandate more piie we need to do something entirely different um then finally the some the conversations I loved the comment that uh you know trans we talked about primary care we talked about bringing in specialty metrics and how to engage Specialists and what's what's their relationship with the risk bearing entity and there's lots of Rich details there but this idea that trans Specialty Care is larger than the Physicians especially you know we are the PTAC and we're focusing on physician payment and yet we've got to remember that especially for complex chronic disease patients it often even more often than not perhaps it may be other community caregivers and organizations not the Physicians um in Specialties that are making very important and critical contributions to to the care and then lastly this idea about the Health Data utility again just very U very poignant having labor trying to implement you know new new pilots new measures macra same measures measured different ways for different payers it's just massive burden that we think is impacting uh patients and providers all the time and so the Health Data utility as an option to essentially revolutionize both the burden and the accuracy of measurements on a on a CommunityWide basis is really powerful and that CMS can Empower that partly just as they think about how to how to place and stand up new pilots so those were my coordinated thoughts thank you Lee Larry well I don't want to repeat what everybody else said but I'm going to frame reframe um last year we had a session and I walked away with the thought in my mind we have to make feif for service less desirable I think Mark mclen said that and it I built my comments around that but that's really a negative statement I'm coming away from today with a positive statement we need to make being a PCP a more desirable thing to do with your medical career because I don't think the system succeeds unless they succeed and this hurts me because I'm a specialist right so you know I'm supposed to be saying you know we're really important and everything but I I I listening to everybody they're all biting around the same thing and that is that we need to make primary care care doctors have more power over their decisions they have to be compensated for their outcomes not their volume taking a PCP and making them click or her click off CPT codes and visits and see five or six people an hour we're never going to get to where we have to be with that they have to have more control over their decision making and that and they have to have more control over their Specialists which means we've got to think of a way so that Specialists are more reliant on the primary care base they're receiving patients from so they can't make any primary care doctor really unimportant and and not focus on the needs of their patients so they have to have more control over their decisions have their income has to be based on their out out comes they have to have control over the specialist they got to be paid differently we need a different bu and chenny brought up a good point and I think it was it was affirmed by several of our speakers there's money in the system we don't have to be saying that the physician fee schedule is the pie and if we want to pay pcps more it's got to come out of Specialists probably some does but there's waste in the system elsewhere that should be able to we should be able to find to be able to compensate the primary care doctors better um we I heard we we have to have a longitude we can't have a transactional focus on patients we have to have more of a longitudinal focus with them because these outcomes are longitudinal um meaningful prospective transdisciplinary team-based payments so the second thing that hurt me being funny here but you know I spent the last 10 years of my life with care coordination with sonar heard very clearly that care care coordination cannot exist on its own it has to be linked with responsibility for the patient population's outcome so I think the positive uh take from today is we got to make Primary Care More appealable a lot more appealing not tweaking on the edges we got to make it a lot more appealing thank you Larry Jay I'm just going to reemphasize what Larry just said we've been talking about paying Primary Care Providers more for the last 15 20 years right okay so it's enough already the money is there in the system and we have to pay them accordingly and then we'll get the the results we want and then we'll have less of this fragmented care and more holistic care that's number one number two in terms of virtual versus hybrid and care coordination healthc care is about trust end a story that is the foundation of health care if it's coming from the primary care provider that has the relationship with the patient virtual is going to work at times if it's coming from an outside entity or even a land that the patient has no relationship with it's not going to work so I think if you make Primary Care the focus and you make the care coordination come out of it it'll follow and it'll work and the other point I want to make because everybody else has made every other point is I I think we've got to get the major EMR companies to the table okay whether it's through CMS or cmmi or us because when we talk about data and performance measures they're part of the solution right now they're part of the problem but we've got to make them part of the solution and we've got to make them see that they're part of the solution and again Walter and the PCD team great job today thank you great thanks everybody for all that the only thing lots of Lindsay you got I didn't see your card up you need some go ahead no problem hard to follow Larry or Jay after that because I I don't know what else is more important than uh paying Primary Care appropriately but um a a couple I think things that did get called out today that are I think we've heard in previous sessions that I wanted to punctuate here around payment specifically for people in um you know as we think about new models so I think rais the idea that as we think about models and total cost of care models we we can't think about reducing Baseline payment after one or two years years when we heard about people planning for especially patients with complex chronic illness and serious illness that is a big investment um and an upfront investment that has to be done in advance and when um the payment gets changed uh that's just when the overhead costs have started to to dive in so getting a finance uh team member or colleague to buy in on some of the real investment that's needed on this population to change outcomes um it it has to be um has to be more stable Baseline payments um another way to kind of get at that same thing is the idea of protecting people who are maybe not in a large organization from downside risk in the first few years if they're going after caring for patients with complex chronic illness this is an important thing to do and I heard something interesting that I hadn't heard before or maybe didn't listen well enough before but the idea that it could be helpful to think of a ready template of what it takes to manage risk if you want to get into um you know what that downside risk is going to look like um but incremental adjustments are not enough so um I think the most of the other points were were mentioned by my um faster to draw colleagues here I I think the last one I'll make is maybe a theme that I heard throughout many of the sessions which is and the voice of the patient is important um we heard this theme in the what matters most comments that were already emphasized we heard it in thinking about what incentives we can offer to patients and caregivers to potentially participate um and we heard it in thinking about um creating the right measures that that take into account what matters to patients and to caregivers um with that I'm going to see to Angela thank you thank thanks to everybody for those great comments um so I want to thank everybody for participating today uh had a great presenters and panelists today very engaging thank my Pac colleagues and those listening in we'll be back tomorrow morning at N9 o'clock Eastern time uh our day two agenda will feature a listening session with experts on optimizing the mix of paliative care and end of life care and total cost of care models a special panel discussion with CMS staff a listening session on best practices for incentivizing improved outcom comes for patients with complex chronic conditions or serious illnesses and total cost to care models as well as an opportunity for public comments tomorrow toward the end of the day we'll hope you uh will join us tomorrow thank you uh for all your contributions and we'll end the meeting today and see you tomorrow thank you produced by the US Department of Health and Human Services