RICHARD GILFILLAN, M.D., chairs the Health Care Transformation Task Force, a group of providers, payers, purchasers and patient groups that debuted in January to align private and public sector efforts to advance value-based purchasing. Gilfillan is president and CEO of Trinity Health in Livonia, Mich. Previously, he launched and led the federal Center for Medicare & Medicaid Innovation, which oversaw the creation of accountable care organizations and bundled payments for Medicare. | Interviewed by Jan Greene
Why not just let the market push value-based payment, spurred by Health & Human Services payment incentives?
Gilfillan: We felt there was a real opportunity to bring together a group of organizations from multiple segments and work together to try to develop a consistent timeline and a consistent approach that simplifies the path toward this different way of delivering care. We think it’s critical to align the efforts of both the public and private sectors. By working together, we could actually accelerate the timeline and become more successful.
What are your specific goals as well as general philosophy of value-based payment?
Gilfillan: We set a specific aim to have 75 percent of our respective businesses operating under Triple Aim alternative contracts by January 2020. We all agree that it’s essential that we get people focused on delivering better health, better care at reduced cost. We think that shared savings models based on a total cost of care target provide lots of incentive for people to do that, and certainly risk provides more incentive, but we’re not ready to say that we should be requiring everyone to actually go to risk under this time frame.
Should more organizations be taking on a greater percentage of risk?
Gilfillan: The aspirational goal is actually to get providers of all types focused on delivering the Triple Aim and really restructuring their business and clinical models to accomplish that. All of that is in pursuit of actually improving outcomes and decreasing the increase of costs.
There are different mechanisms that help people to accomplish that. A bundled payment arrangement will accomplish that for one episode of care. Some ACOs are accomplishing that today under a straightforward, one-sided shared savings program. Some people are doing it under two-sided risk. And while policymakers may believe it would be nice if everyone accepted risk, there are practical realities and experiences people have had that make many providers uncomfortable with accepting risk at this time. It takes some time for us all to learn how to do this well — to deliver care and to change how we pay for care. We need time to design and implement new care models, payers need to adjust their payment systems, and we all need more experience with the financial arrangements — adjusting benchmarks and targets. Clearly, there are significant uncertainties we need to address before we mandate that everyone has to expose themselves to downside risk. We believe our approach will get many more providers to engage actively in the effort to deliver the Triple Aim. This is a marathon, not a sprint.
Remember, people who are doing this work, even if they don’t have downside risk, are making an investment; they are committing dollars and resources to do this work. They want to see a return on investment.
What is next for the Medicare ACO model?
Gilfillan: It’s still very early [in the shared savings model] and we’re just beginning to receive data on what works. It’s amazing that we’ve had as much progress as we have in such a short period of time. This is a radical change in the way we all operate. It’s the nature of innovation and entrepreneurship; you never get it just right the first time. It’s to be expected that we learn as we go. It’s way too early to say whether ACOs are working, but the good news is that some are working, in some markets, with certain approaches.
How do you bring physicians along?
Gilfillan: There are a lot of different things that give physicians concern … electronic health records, changes in regulatory requirements, competitive pressures, deciding whether to be employed. It’s a complex world for physicians and care teams, and that creates frustration and concern. But, when you redefine the way we deliver care and you put care managers in their offices ... with information that allows them to see their populations of patients and how they are doing and where they can improve care … all of that stuff is very positive.
What do you think about where we are on quality measures?
Gilfillan: We’ve come a long, long way in the last 20 years. We have many, many, many measures. And there’s more we can do to simplify that and automate information collection. From a payment perspective, we are advocates of reducing the number of overall metrics for payer purposes, making them broader and more reflective of patients’ functional status and outcomes, and grounded in the person’s experience of care and how he or she actually felt as a result. That’s the most powerful way to incent providers to deliver the Triple Aim.
What can your group contribute that the Centers for Medicare & Medicaid Services or others can’t?
Gilfillan: We have an opportunity to forge a common perspective and recommendation on the different policy approaches and payment models. Helping to forge a consensus about good principles and payment policies for us to follow, whether with CMS or private payers, is a big impact opportunity. We think we can work together and develop some specific models that people can use … we could try different models and see what works and whether people could agree to use common approaches, always being mindful of not violating any regulatory constraints about working together.
Another opportunity is to share best practices from both the payment side and from the clinical side. And we hope we can encourage other payers, providers and others to step up and say, ‘We are going to commit to changing the way we deliver care and pay for care.’ It’s hard for people to operate in uncertainty. We think this is a way to get through that and make it clear that we are all committed to moving to a world in which we are focused on delivering better care and reduced costs.
What has been the reaction to your group?
Gilfillan: We have had inquiries from another 50 organizations that are interested in participating. There’s an emerging commitment and excitement about making this transition. Virtually everyone I spoke with [whether they joined or not] agreed with the basic notion that we need to find a way to accelerate the transition and make it simpler and clearer. The exciting thing is that most providers in America, and I suspect most payers, are interested in moving toward a system focused on people-centered care and the Triple Aim.
The Gilfillan File
He began his career as a family medicine physician, later getting an MBA from the Wharton School of the University of Pennsylvania. He has held executive positions at Independence Blue Cross, Coventry Health Care and the Geisinger Health System.
What are you reading?
Right now, I’m reading Anti-Fragile by Nassim Nicholas Taleb, How the Mighty Fall by Jim Collins, America’s Bitter Pill by Steven Brill and XLR8: Building Strategic Agility for a Faster-Moving World by John P. Kotter.
What are your greatest career influences?
The biggest influences on my career are people, especifically my wife, Carmen Caneda, my parents and all of my bosses!
What are your hobbies?
Grandchildren, guitar playing, golf and sailing small boats.