Vox medical directorae

What I Wish the Other Side Could See

The chief medical officers at health plans and provider organizations often see the world through different lenses. Here, chief medical officers from both sides of the divide share their views.

Lola Butcher

They are all physicians. They all want to take care of people. But the chief medical officers at health plans and provider organizations often see the world through different lenses.

Here, chief medical officers from both sides of the divide share their views.

Wish they’d think before submitting that claim

Richard Seidman, MD

Richard Seidman, MD

“The most common prior authorization denials are for services that the plan is not financially responsible for, services for benefits not covered by the plan, and for the complete absence of—or inadequate—information to meet the clinical criteria for the requested service.”

Richard Seidman, MD, CMO, L.A. Care Health Plan, the largest publicly operated health plan in the country. L.A. Care—technically, the Local Initiative Health Authority of Los Angeles County—covers more than 2 million Medicaid beneficiaries, uninsured children, and other vulnerable populations. Before this position, Seidman served as CMO for one of the nation’s largest federally qualified health centers.

A little logic, please

Joe Kimura, MD

Joe Kimura, MD

“If we view payer measurement of quality as a means to incentivize and reward providers for improving quality of care…we should start with a shared construct accepted by both payers and providers that logically and realistically links how we expect outcomes to improve.

“We can then anchor our metrics and measurement to that construct. We can meaningfully assess how our delivery structures and our clinical process reliability can lead to those value-based results within an accepted timeframe. And, in doing so, we can help create a shared understanding between payers and providers around how they can collaborate to improve clinical medicine.”

Joe Kimura, MD, CMO, Atrius Health, a not-for-profit group of large medical practices serving nearly 750,000 patients across eastern Massachusetts. Board certified in internal medicine and clinical informatics, Kimura serves as co-chair of the Office of National Coordinator for HIT Policy Federal Workgroup on Advanced Health Models and Meaningful Use.

That test you’re questioning—it’s money well spent

Laszlo Mechtler, MD

Laszlo Mechtler, MD

“Investing in aggressive therapy for a patient experiencing migraines every day or spending just $250 for an MRI to rule out a potentially devastating neurologic disorder is money well spent in the long run. Payers only seem to ‘justify’ expenses once the disorder becomes so severe you cannot help but spend money, resulting in huge expenses for emergency department visits, hospitalizations, or lifelong disability care.”

Laszlo Mechtler, MD, Medical Director, DENT Neurologic Institute

You’re not the only one with regulations

“The biggest challenge of my job that health system CMOs probably do not realize is the extent to which health plans are required to focus efforts to achieve and maintain compliance with regulatory and accreditation mandates.

“The Centers for Medicare and Medicaid Services, multiple state agencies, and the state [ACA] exchange board—each have their own mandates. And the National Committee for Quality Assurance adds additional requirements intended to enhance the quality and safety of care provided to health plan members.

Richard Seidman, MD, CMO, L.A. Care Health Plan

Who will take care of the patients?

“Many physicians are experiencing burnout from documentation burden and hyper-scrutiny and ‘scoring’ of their work by nonphysicians. Alarmingly, over 50% of neurologists would ‘not do it again.’ Given the current shortage, this is devastating to the future of medicine.”

Laszlo Mechtler, MD, Medical Director, DENT Neurologic Institute

You can’t even imagine...

“As I found out in my first six months, the simple act of paying a claim or not paying a claim is incredibly challenging. And the relationship between the health plan and the member—or the health plan and the employer—is really complicated. Managing those relationships—the benefit designs and everything else— is important to ensuring patients don’t have artificial barriers to care.”

Thomas Graf, MD, CMO, Horizon Blue Cross Blue Shield, New Jersey

I’m caught in the middle here

“The most challenging part of my job is dealing with the huge chasm between the expectations of our customers (members, employer groups, and benefit consultants) and the expectations of the provider community.

“As our health care system migrates toward a value-based payment methodology, each stakeholder defines ‘value’ in very different ways, and that creates certain tensions between all parties.

“Our customers, both individual and group, want their total cost of care to decline while improving quality. Providers want to deliver high quality care, but they also want to maintain or increase their margins or revenue. Every dollar that we pay to a provider comes from charging a customer and is reflected in increased premiums. Health care reform legislation failed to deal with the critical issue of cost.

“I suggest we need to be candid, transparent, and open as we move toward value-based payment systems, keeping the interests of customers front and center.”

Brian Caveney, MD, CMO, Blue Cross and Blue Shield of North Carolina. Board certified in preventive medicine with a specialty in occupational and environmental medicine, Caveney practiced and taught at Duke University Medical Center before joining the insurer.

Old claims data ain’t cutting it

“The pragmatic utility and clinical validity of quality metrics is highly dependent upon the source data used to calculate the metrics. Hence, the exclusive use of lagged administrative claims data for quality measurement limits the ability of health plans to meaningfully measure in a way that helps provider groups improve.

“The combined use of administrative claims data, electronic health record (EHR) data, and patient-reported data would enable more comprehensive and meaningful measurement.

“The lack of EHR data semantic standards is a real and major barrier to health plan trust and adoption of provider EHR data in measurement. However, to align and partner together to improve patient care, health plans and providers can build the trust by working closely to measure the right things together.”

Joe Kimura, MD, CMO, Atrius Health

EMRs are no fun for insurers, either

“Every provider knows the massive expense, time commitment, and impacted productivity of electronic medical record implementations. But most do not realize that it is similarly enormous to change claims payment.”

Brian Caveney, MD, CMO, Blue Cross Blue Shield of North Carolina

This is why we seem hard to work with

“Providers are so heterogeneous—from primary care to specialists, from small practices to large integrated systems, from aggressive to conservative doctors, and variable commitments to quality—but yet we need to have consistent and fair decisions on what we cover.”

Brian Caveney, MD, CMO, Blue Cross Blue Shield of North Carolina

Hit the pause button, please

Thomas Schenk, MD

Thomas Schenk, MD

“There is a lot of very rapid handing off of patients from primary care to specialists and superspecialists who are very specific in their scope of work. I don’t know that primary care always contemplates the effect that a referral has on the course of care for a patient.

“If a patient is referred to, let’s say an orthopedic surgeon or a neurosurgeon, the chance that that person is going to have surgery goes up significantly” even if the patient was not referred to the appropriate specialty.

Thomas Schenk, MD, CMO, Blue Cross Blue Shield of Western New York

Finding those few bad apples creates hassles but it’s worth it

“When I was at Geisinger, I would get frustrated with CMS for all these regulations that are designed to manage out that tiny fraction—you know, that .05% or whatever it is—of doctors and hospitals who are the bad actors, the people who are actively committing fraud. And that creates all this busywork for everyone else, the 99% of doctors and hospitals who are trying to do the right thing.

“Then, when I got to the health plan, I recognized how much of our time we spend trying to find those people and keep them from hurting our members. Yes, I agree that it’s a tiny fraction but they have a disproportionate impact on total medical spend, and it’s money that’s going to no good cause, and it is true waste.

“We talk about 25% to 30% of the health care dollars being spent on things that either provide no value or, in fact, harm patients. This is in that ‘harms patients’ space. So the rules, although they can be difficult, challenging, annoying, frustrating—whatever word you like—they are there for a reason, and in fact, have been proven to be necessary.”

Thomas Graf, MD, CMO, Horizon Blue Cross Blue Shield of New Jersey


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