Trinity Health CEO Rick Gilfillan is what you might call an optimist. When asked what he believes the most under-reported story in healthcare is, Gilfillan's answer is unreservedly positive: That in his experience, patients are receiving better care in real time thanks to the myriad of transformative initiatives underway in the industry.
The one-time director of the CMS Innovation Center, Gilfillan has been a proponent of "triple aim" care since his med school education in the 1970's. Trinity Health, under Gilfillan's leadership, has become one of the cornerstone members of the Health Care Transformation Task Force, the group of big-name payers, providers and employers that have resolved to shift 75% of their operations to quality-based contracts by 2020. He has twice been named the most influential person in healthcare by Modern Healthcare.
Healthcare Dive caught up with Dr. Gilfillan to talk about the Task Force, payment reform, MSSP and more.
1. Tell me a little bit about Trinity Health’s participation in the Task Force.
We're involved in each of the work groups. We have staff with a lot of content knowledge and interest and practical engagement in the topics that those groups are working on.
We believe that there is a real opportunity to accelerate the course of transforming the way we deliver care and get compensated for care. We think if we create a simple, more direct path with certain timeframes, that people can plan better. The way we are trying to make this simple is to coordinate public and [private] payer approaches to some of the critical issues associated with the way we deliver and pay for care.
We started by working together to try to forge a consensus across the different parts of the Task Force on critical issues. The most obvious opportunity in that regard was commenting on the Medicare Shared Savings Program. We developed a set of shared principles and then responded to the specifics of the Medicare-proposed regulations for the program.
We think that's a great avenue to developing a consistent approach and an approach that is sustainable. By working on CMS-related policies and having providers and payers work together, we hope that we can develop some common approaches that are synergistic with government programs and private-sector models.
2. In the shift towards payment reform, some providers have expressed frustration with having to live with a "foot in both worlds" of fee-for-service and value-based reimbursement. Is there a tipping point for the percentage of value-based contracts that makes the model sustainable for providers?
I think most people would say if you have over 50% of your business being compensated for and delivering the triple aim, then you are starting to align your major operating activities with accomplishing that. If you're doing [less], you're not really changing the fundamental underlying operating activities that are delivering your results. Fifty percent is where it starts, but we thought 75% makes it unmistakable that everyone would be orienting their business and clinical activities towards delivering triple aim.
3. What are some of the specific challenges that Trinity Health faces in the shift towards value-based reimbursement, and how is an organization of its size navigating those challenges?
Every organization has their advantages and disadvantages.
Some of our advantages are that it's helpful for us to be able to learn within a large system and to spread best practices quickly. We can probably take more risks in doing different programs because we are more broadly diversified.
On the other hand, being large, sometimes it's hard to make decisions and move as rapidly as you would like. The challenge for us is to always make sure that we are able take advantage of opportunities and make change rapidly.
4. In the last couple of months, Trinity Health has announced a huge joint venture with Heritage Provider Network as well as a merger with Saint Francis. Can you comment a little bit on the strategy behind both of these deals?
We have an overarching strategy called People Centered 2020, building a people-centered health system together across our enterprise. That strategy has five major focus areas. Our first area of focus is to change the way we deliver care to deliver the triple aim, and with that we have to change the way we are reimbursed for care. The 75% goal [of the Task Force] fits squarely into that area of our strategic plan to change both our clinical model and our business model.
Our fourth area of strategic focus is about leadership nationally and strengthening and expanding our Catholic healthcare ministry. In that space, we look at each of our regional health ministries and identify opportunities to expand them and strengthen the regional health ministries, and over time grow them. The Saint Francis opportunity represents a strategic effort in that region to put together a larger set of care capabilities, outpatient facilities, hospitals... so that we can be an effective manager of the population in that market.
5. Speaking broadly, is consolidation an unavoidable reality of the industry now?
The industry is calling upon healthcare providers to produce something different from what we have in the past. They're asking us to deliver better health, better care and better costs. To do that, we need to be effective managers of not just episodic care—although that's still critical—but more broadly of [care] across populations. To do that, there's a whole new set of capabilities—whether they are delivery capabilities, IT capabilities or analytic capabilities—that we need to invest in.
Many organizations are finding that given the size of the investments and the amount of change that's required that it makes sense for them to be part of a larger system in order to be successful at managing the health of a population versus just managing episodic care for a limited number of individuals.
There are many ways to do that. Some of them are partnerships; some of them are putting together our respective networks and working as partners but not necessarily integrating. In some instances, it's a matter of actually consolidating.
6. Trinity Health has obviously invested heavily in the MSSP, with current participation in 13 Shared Savings Plan ACOs and an additional eight under CMS review. The program has been criticized for forcing ACOs to compete against their own best performance. Is that a fair criticism, and if so, how can the model be altered to address that problem?
We have had several of our regional ministries involved and have had good results to date. Most of our ministries are just getting started this year.
We do believe that to make the program sustainable, it's important that there be a reasonable expectation that folks can achieve shared savings that allow them to continue to make the investments needed to be successful. Trinity Health [provided feedback to the Centers for Medicare and Medicaid Services that] speaks very clearly to the need to establish benchmarks that do not result in the continuing whittling away of opportunity.
[The document] explains what is referred to as "rebasing." Say your target this year is a thousand dollars a month for each patient, and you have to do better than that. It turns out the care ends up costing $800 on average over the next three years. If [CMS] then sets my target at $800, now that opportunity to achieve savings that was there before—savings that I obtained and used to invest in making care management possible—that opportunity is not there any longer. We argue is that Medicare should see themselves benefiting each time from the savings as well as from the reduced trend that is occurring, and not take the savings out of the benchmark for future periods. Leave the savings in.
7. So, bottom line, is MSSP a sustainable program? Is it a model that works?
I think it's important to have some perspective. We're just seeing the result of a year or two's efforts by people who are attempting to make an incredible change. It's too soon to say whether the program is successful. Some people are having success, so it's clearly possible to do a good job.
What we want to be sure of it is that CMS establishes a policy approach that allows it to be sustainable for the long term. We think it can for sure be a sustainable program, if they make those kinds of adjustments. The belief that they will is why we're investing in the program.
8. What have you learned about the successful execution of an ACO?
At the end of the day, patients need to be treated differently. What needs to be different in the community, in a physician's office, in a patient home? Putting care managers, or nurse navigators or community health workers into doctors' officers. Putting systems in place, giving [providers] IT infrastructure that allows them to find patients, and analytic tools to allow them to track whether or not patients are getting all the services they need, if they're taking their medicine.
There are very real changes in how we deliver care that have to be the focus of our efforts. There's lot of things you can do, but at the end of the day, you have to change a patient's experience and improve their health.
9. What is the most under-reported story in healthcare today?
It would be the point I just made.
People ask, "Is this going to happen on the payment side?", "Are ACOs a model that can succeed?" I think what's being missed is the reality that all these changes are actually taking place. There's millions of patients for whom there is suddenly a nurse care manager who is coordinating their care.
All the infrastructure behind that is kind of upstream. But the critical piece that I would urge folks to think hard about is, if it was your mother or father years ago and you had the experience where their care wasn't coordinated, now you have a nurse coordinator to call in your physician's office or at the ACO.
There's all these investments being made in care vehicles that weren't there before. That's a giant story that people aren't focused on.
10. How would you demonstrate that positive impact of care coordination efforts?
I would make the connection with what's happening with Medicare expense. If you look at the last four or five years, we've had the lowest trend in the history of Medicare in terms of increased medical expense. And I would look at the rate of readmissions, which is going down. I think that's reflective of the fact that people are getting better care as a result of all these initiatives. It's tough to get your arms around that, and tough to see it, but there's a story there.
It's interesting, but we don't have a single vehicle to ask people if they think their care is being better coordinated. It would be great to see some sort of effort to measure that, but I have not seen that report.
This interview has been edited for clarity and length.