Brian W. Powers

The digital phenotype

In the coming years, patient phenotypes captured to enhance health and wellness will extend to human interactions with digital technology.

ACOs and High-Cost Patients

Since a small percentage of patients account for the majority of health care spending, high-risk care management could substantially reduce costs and improve quality. But heterogeneity in clinical needs complicates efforts to develop integrated strategies.

Optimizing high-risk care management.

The most costly 1% of patients account for one-fifth of national health expenditures—accruing average annual expenses of nearly

Nonemergency Medical Transportation: Delivering Care in the Era of Lyft and Uber

90 000 per person.1 These individuals typically have several complex, co-occurring conditions for which they often receive poorly coordinated care, driving unnecessary utilization and poor outcomes. Given these characteristics, high-risk care management programs have potential to improve care and reduce costs for this population.2,3 The structure of these programs varies, but most involve care managers who work with panels of high-risk patients to coordinate care across clinicians, engage patients in setting and achieving health-related goals, and monitor and track health outcomes. Although these programs have traditionally been managed by payers or third-party vendors, clinicians and health care organizations are increasingly adopting programs of their own.2,4 High-risk care management is quickly becoming a cornerstone of health reform efforts. Over the past decade, Medicare has funded 6 rounds of demonstration projects aimed at improving care and reducing costs for high-risk patients.5 In the private sector, purchasers are seeking payers that provide these services; by this year, roughly 75% of large employers expect to contract with a health plan that offers disease management services.6 Within care delivery organizations, new payment contracts that tie reimbursement to cost and quality trends are prompting experiments with new delivery strategies for high-risk patients.1 Excitement over the growth and potential of highrisk care management programs are tempered by the unevenresultsofpreviousefforts.Despitesomeisolatedsuccesses, most evaluated high-risk care management programs failed to significantly affect the cost and quality of care provided to their targeted patient populations.4,5 This suggests that prevailing approaches to high-risk care management are not optimally designed. As activity continues to accelerate in this area, it is necessary to consider the optimal approach to organizing and financing these activities. Despite increasing evidence that programs led by clinicians and health care organizations are most effective, the majority of care management programs remain under the purview of payers.4,5 This is likely a key factor behind the lackluster results of previous efforts. However, prevailing regulations support this status quo. Payers are reluctant to cede control of care management programs to care delivery organizations. A frequently cited reason for such reluctance is that transfer of this responsibility would jeopardize National Committee for Quality Assurance (NCQA) health plan accreditation, which requires health plans to provide disease and complex case management services to beneficiaries. The NCQA has processes for delegating medical management responsibilities while maintaining accreditation. However, in discussions with payer colleagues, we have heard that current processes for delegation are cumbersome and could jeopardize accreditation. Continued efforts by the NCQA to simplify and streamline the delegation process are needed. While important, removing regulatory barriers to physician-led care management is only one element of the transformation needed to harness the substantial cost and quality opportunity presented by high-risk care management. Optimizing these programs will require a system-level approach that takes advantage of each stakeholder’s unique capabilities. Simultaneous initiatives from payers and care delivery organizations are unnecessary and wasteful. Drawing on our experience implementing these programs across a large, integrated health system, we propose 3 overarching principles to guide the design and implementation of high-risk care management services. Practice-based: High-risk care management programs are most effective when they are anchored in the practices where patients receive their care. Care managers co-located within practices are able to build strong, trusting relationships with patients that promote patient engagement through planning and adherence. The primacy of in-person contact and integration within clinical practices is underscored by the results of several studies. An analysis of the Medicare demonstration for high-cost beneficiaries found that programs in which care managers had direct, in-person interaction with patients and their physicians reduced expenditures by 7%, whereas those in which payer-based or third-party care managers interacted with patients via telephone had no effect.5 A review of both private and public programs reached similar conclusions, finding that programs that embedded in-person care managers into practices were more effective than those in which communication was outsourced to payers or third-party vendors.4 There is simply no substitute for person-to-person contact. Payer-catalyzed: As care financiers and plan administrators, payers have a fundamental role to play in creating an environment that enables and encourages the delivery of care management services. Most important is developing payment models that promote investment in high-risk care management capacities by clinicians and health care organizations. Traditional feefor-service reimbursement actively hinders experimentation with care management. On the other hand, shared savings arrangements, capitated payments, and per-member, per-month payments for complex longterm care management all afford care delivery organizations with the flexibility to reengineer care and create an environment where success improves financial perVIEWPOINT

Inter-animal variability in the effects of C-type allatostatin on the cardiac neuromuscular system in the lobster Homarus americanus

Reforms under the Affordable Care Act have reduced barriers to health care access by expanding insurance coverage to millions of individuals living in the United States. With primary barriers to access removed, secondary barriers, particularly related to transportation, have become increasingly important. In 2005, it was estimated that 3.6 million individuals failed to receive nonemergency medical care due to transportation barriers.1 These patients tended to be older, poorer, and ethnic or racial minorities. Patients with the highest burden of chronic disease typically have the greatest transportation barriers. Delays in treatment can cause chronic diseases to destabilize and progress, resulting in suboptimal outcomes and excessive use of resources.2,3 As a result, many payers ranging from the Centers for Medicare & Medicaid Services to state Medicaid programs to large commercial payers offer free or subsidized nonemergency medical transportation to beneficiaries. Nonemergency medical transportation services are

Delivery Models for High-Risk Older Patients: Back to the Future?

SUMMARY Although the global effects of many modulators on pattern generators are relatively consistent among preparations, modulators can induce different alterations in different preparations. We examined the mechanisms that underlie such variability in the modulatory effects of the peptide C-type allatostatin (C-AST; pQIRYHQCYFNPISCF) on the cardiac neuromuscular system of the lobster Homarus americanus. Perfusion of C-AST through the semi-intact heart consistently decreased the frequency of ongoing contractions. However, the effect of C-AST on contraction amplitude varied between preparations, decreasing in some preparations and increasing in others. To investigate this variable effect, we examined the effects of C-AST both peripherally and centrally. When contractions of the myocardium were elicited by controlled stimuli, C-AST did not alter heart contraction at the periphery (myocardium or neuromuscular junction) in any hearts. However, when applied either to the semi-intact heart or to the cardiac ganglion (CG) isolated from hearts that responded to C-AST with increased contraction force, C-AST increased both motor neuron burst duration and the number of spikes per burst by about 25%. In contrast, CG output was increased only marginally in hearts that responded to C-AST with a decrease in contraction amplitude, suggesting that the decrease in amplitude in those preparations resulted from decreased peripheral facilitation. Our data suggest that the differential effects of a single peptide on the cardiac neuromuscular system are due solely to differential effects of the peptide on the pattern generator; the extent to which the peptide induces increased burst duration is crucial in determining its overall effect on the system.

Aligning incentives for value: The internal performance framework at Partners HealthCare

Current care models and delivery systems frequently fail to meet the needs of high-risk older patients. Medicare beneficiaries with multiple comorbid conditions often receive poorly coordinated care, leading to frequent hospital and emergency department visits, increased rates of readmissions, and suboptimal outcomes.1 Improving care for high-risk older patients has been an area of health care system and policy-maker attention for nearly 2 decades. Despite widespread use, outpatient care management interventions focusing on care coordination, medication adherence, and selfmanagement have produced mixed results.2,3 Within this population, programs focusing on transitions among inpatient, postacute, and community sites of care are often more successful. For example, the transitional care model4 at the University of Pennsylvania successfully reduced inpatient utilization and improved select outcomes, such as readmissions, hospital days, and charges for health care services. However, replication and widespread adoption of these and other related programs have failed—adding another layer of care simultaneously

Three members of a peptide family are differentially distributed and elicit differential state-dependent responses in a pattern generator-effector system.

Abstract • Incentives that reward performance at the intersection of organizational priorities and physician motivations are well positioned to spur behavioral change and accomplish organizational goals. • Metrics associated with financial incentives should be limited to those that are clinically meaningful and easy to understand. • Health systems must support physicians in the journey to value-based care. Placing physicians at financial risk for controlling health costs and improving quality—without equipping them with the tools to do so—leads to frustration and disillusionment. • Incentives that reward all levels of performance between baseline and a specified goal are effective at engaging physicians and promoting improvement.

Engaging small independent practices in value-based payment: Building Aledade's medicare ACOs

C-type allatostatins (AST-Cs) are pleiotropic neuropeptides that are broadly conserved within arthropods; the presence of three AST-C isoforms, encoded by paralog genes, is common. However, these peptides are hypothesized to act through a single receptor, thereby exerting similar bioactivities within each species. We investigated this hypothesis in the American lobster, Homarus americanus, mapping the distributions of AST-C isoforms within relevant regions of the nervous system and digestive tract, and comparing their modulatory influences on the cardiac neuromuscular system. Immunohistochemistry showed that in the pericardial organ, a neuroendocrine release site, AST-C I and/or III and AST-C II are contained within distinct populations of release terminals. Moreover, AST-C I/III-like immunoreactivity was seen in midgut epithelial endocrine cells and the cardiac ganglion (CG), whereas AST-C II-like immunoreactivity was not seen in these tissues. These data suggest that AST-C I and/or III can modulate the CG both locally and hormonally; AST-C II likely acts on the CG solely as a hormonal modulator. Physiological studies demonstrated that all three AST-C isoforms can exert differential effects, including both increases and decreases, on contraction amplitude and frequency when perfused through the heart. However, in contrast to many state-dependent modulatory changes, the changes in contraction amplitude and frequency elicited by the AST-Cs were not functions of the baseline parameters. The responses to AST-C I and III, neither of which is COOH-terminally amidated, are more similar to one another than they are to the responses elicited by AST-C II, which is COOH-terminally amidated. These results suggest that the three AST-C isoforms are differentially distributed in the lobster nervous system/midgut and can elicit distinct behaviors from the cardiac neuromuscular system, with particular structural features, e.g., COOH-terminal amidation, likely important in determining the effects of the peptides. NEW & NOTEWORTHY Multiple isoforms of many peptides exert similar effects on neural circuits. In this study we show that each of the three isoforms of C-type allatostatin (AST-C) can exert differential effects, including both increases and decreases in contraction amplitude and frequency, on the lobster cardiac neuromuscular system. The distribution of effects elicited by the nonamidated isoforms AST-C I and III are more similar to one another than to the effects of the amidated AST-C II.

The residency-MBA program: A novel approach to training physician leaders.

• Financial resources are necessary but not sufficient to engage small independent practices in value-based care delivery. Strategies must also focus on workflow improvement, behavior change, and engagement. • Supplementing delayed returns (i.e. annual shared savings payments) with more immediate rewards can help promote engagement in alternative payment models. • Aligning performance metrics and financial rewards with a core set of performance drivers and clinical delivery competencies spurs behavior change and promotes attention to issues that matter most. • Small independent practices feel increasingly burdened by regulatory and policy changes. The prospect of financial rewards alone is not enough to motivate engagement. Efforts must also focus on making practices change as frictionless as possible through technical solutions, coaching, and guided clinical process redesign. • Sharing non-blinded performance data within (but not between) different accountable care organization (ACOs) seems uniquely effective. This delicate balance taps into physicians natural competitive tendencies, but bounds these tendencies in shared goals and joint commitment.