Member Login: Your login username is the email you signed up with.

Log in


Report from the WA State HealthCare Symposium

18 Oct 2017 11:05 AM | WSMTA (Administrator)

Notes on the "A Commitment to Value" Conference

(Day 1: Purchaser Conference)

by the Health Care Authority

On October 18, 2017, the Health Care Authority hosted a 2-day conference aimed at Payers/Producers, Purchasers/Employers and Providers regarding "Value-Based Purchasing".  If you didn't know, the Health Care Authority (HCA) is the WA State government organization that purchases health care services for medicaid (Washington Apple Health) and PEBB (Public Employees Benefits Board), which makes it the largest purchaser of health insurance in WA State.  They spend roughly $10 billion a year.  Their contracts with producers/payers is available online, with redactions for confidentiality.

Currently, our health care is based on "fee for service", the provider is paid for each procedure performed.  This can create over treatment or evaluation as providers earn more money by performing procedures.  Medicare has been pushing the healthcare industry to switch to "Value-Based Purchasing".  In Medicare speak, this means adding payment from the value added to care of patients by improving measurable outcomes.  When Medicare implemented this, hospitals reported metrics and received additional payment for medicare patients for high or positively improving metrics.  Some aspects of the healthcare chain in different geographic regions of the United States have taken this concept and run with it to create "integrated care systems" that go beyond their own medical organizations to provide "value-based care".

Value-based purchasing, is about purchasing insurance plans that provide medical service that improve the value of the health care by determining a correct diagnosis, plan of care and follow through to make sure the patient is managed through the system in a way that solely benefits the patient and reduces unnecessary care that can be both expensive and harmful.  An example of this is how doctors and clinics are now treating diabetes patients.  Instead of the patient showing up for an annual checkup, providers within the organization regularly follow up with the patient with diabetes to make sure that their A1C numbers and other indicators are staying within normal ranges throughout the year, providing opportunities for education on managing a lifestyle that reduces variability in daily glucose readings, arranging for check-ins with pharmacists to ensure the type of medication being used remains effective and is being correctly used.

The Conference organizers brought in large and small purchasers to present and also had producers/payors participate as well.  Day 1 was meant to provide education on value added purchasing, perspectives from a variety of participants with an eye towards creating some solutions between payers/producers and purchasers.   Day 2 was meant to create small groups to try and brainstorm solutions to some of the issues.


The following sections are snippets from the various presenters.


Sim Grants -- The State Innovation Models (SIM) initiative provides federal grants to states, under cooperative agreements, to design and test innovative, state-based multi-payer health care delivery and payment systems. The distinctive purpose of the SIM initiative is to test whether new models with potential to improve care and lower costs in Medicare, Medicaid, and CHIP will produce better results when implemented in the context of a state-sponsored plan that involves multiple payers, broader state innovation, and larger health system transformation to improve population health.2 A premise of the SIM initiative is that states have important policy and regulatory authorities and the ability to convene a broad array of public and private stakeholders – means that can be used to leverage the development of initiatives in which multiple payers participate, potentially enhancing their effectiveness. -- verbatim  https://www.kff.org/medicaid/fact-sheet/the-state-innovation-models-sim-program-an-overview/ -- Note:  only roughly 1/2 of the states participated.


Resources Purchasers should use in order to make wise choices in the plans they choose or help to create:

  • Community Checkup -- rates clinics, medical groups and hospitals -- https://www.wacommunitycheckup.org/

  • Bree Collaborative -- The Dr. Robert Bree Collaborative (Bree) was established in 2011 by the Washington State Legislature.  

“…to provide a mechanism through which public and private health care stakeholders can work together to improve quality, health outcomes, and cost effectiveness of care in Washington State.”

Information about our legislative authority can be found in the bill that established the Bree.  Members are appointed by the Governor and include public health care purchasers for Washington State, private health care purchasers (employers and union trusts), health plans, physicians and other health care providers, hospitals, and quality improvement organizations.  Verbatim from website.  http://www.breecollaborative.org/

  • WA State Common Measures Committee -- Legislative Language:  ESHB2572, Section 6 "there is created a performance measures committee, the purpose of which is to identify and recommend standard statewide measures of health performance to inform public and private health care purchasers and to  propose benchmarks to track costs and improvements in health outcomes -- verbatim from slide 7 http://crhn.org/pages/wp-content/uploads/2015/06/Common-Measure-Set-Release-12-08-2015_FINAL-DRAFT_PDF-for-review.pdf.  The direct link is: https://www.hca.wa.gov/about-hca/healthier-washington/performance-measures.


Consumerism is the primary driver for improvement in goods & services:  

  • Consumer Directed Healthcare -- By allowing patients to control and manage their own health care dollars, consumer-directed health plans help individuals become more conscientious consumers of health care.  Consumers are able to shop around, compare prices and providers, and select the medical services that are best for them.  Doctors are able to repackage and reprice their services, competing for patients based  on price and quality.  -- verbatim http://www.ncpa.org/about-cdhc/

  • castlighthealth.com  -- Castlight connects with thousands of health vendors, benefits resources, and plan designs. Through our partner ecosystem, you can purchase pre-integrated vendors on a single contract. But you're not limited to our ecosystem—we can create truly seamless user experiences with nearly any vendor, utilizing our flexible integration architecture. -- verbatim  https://www.castlighthealth.com/

  • accountable care organizations -- ACOs are groups of doctors, hospitals and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.  The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. -- verbatim https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html.  WA state has ACOs that are not medicare related, such as the UW Medicine Accountable Care Network.


John Espinola, MD, aka "Espy" is the Executive Vice President, Healthcare Services, Premera Blue Cross:  In his talk "Espy" put forth the idea that change requires time.  Annual health plans as they exist may not be able to accomplish change in the most "timely" or effective way as they are reactive to the whims of regulatory, payer and purchaser organizations.  Perhaps, there could be an alternative method to having an "annual" plan.

Julie Sylvester, Vice President, Business Development, Virginia Mason:   Health care is a complicated thing to explain at the member level, let alone the purchaser level.  Terms are not always easily translated.  Need to make it easy for the purchaser to understand.  Messaging is key.


Community-based organizations will be key in getting info to the public.

Providers are using social workers to help manage high risk patients in their community.


From Karen Wren, Benefits Manager, Point B (approximately 1400 employees):  If you are a smaller employer:

  • talk directly to the producer -- get educated, find out how to manage your plan, what tools you need to do so.

  • find out from the producer how your employees are using their benefits.  Figure out how to improve the quality of care or provide knowledge of how to use benefits more effectively to improve care and reduce the employer costs.  For example, if your employees are using the ER a lot, find out why and educate them on alternative options if the ER really isn't an appropriate choice.

  • find out if it's possible to work with payors/producers to mirror the state's health plan for smaller purchasers.

As a smaller company, if you create a self-funded program for your employees, you can use existing organizations to manage your needs instead of getting rejected by the insurance companies because you're too small.  Here are some options that Option B uses:

  • RxBenefits:  Small and mid-sized companies lack the negotiating clout to wrangle competitive pharmacy contracts.  But not with us.  We leverage our collective database for deeper discounts, smarter terms and more significant savings.  All supported by our high-touch service model.  -- verbatim www.rxbenefits.org

  • CarrumHealth:  Carrum Health directly connects progressive self-insured employers to top-quality regional healthcare providers through the industry's first comprehensive bundled payment solution.  Our innovative platform reimagines how care is paid for and delivered, improving the value of health benefits for employers and their members. -- verbatim  currumhealth.com

  • "Choosing Wisely Campaign" -- "Choosing Wisely" aims to promote conversations between clinicians and patients by helping patients choose care that is:

  • supported by evidence

  • not duplicative of other tests or procedures already received

  • free from harm

  • truly necessary

In response to this challenge, national organizations representing medical specialists asked their providers to "choose wisely" by identifying tests or procedures commonly used in their field whose necessity should be questioned and discussed.  The resulting lists of “Things Providers and Patients Should Question”  are intended to spark discussion about the need--or lack thereof--for many frequently ordered tests or treatments. -- verbatim  www.choosingwisely.org -- there is more to it than this, but you can go to the website to find out more.


Susie Dade, Deputy Director, Washington Health Alliance

Washington Health Alliance --  The Washington Health Alliance services to build a strong to alliance among patients, doctors, hospitals, purchasers, health plans and others to promote health and improve quality and affordability by reducing overuse, underuse and misuse of health care services. -- verbatim www.wahealthalliance.org

Seven things every purchasing executive should know about the problems with healthcare:

  • health care quality varies widely

  • significant portions of healthcare spending is waste -- 30% ($1 trillion is wasted every year)

  • no provider is good at everything

  • financial incentive are misaligned

  • businesses generally buy health care based on cost

  • wellness programs are important but not sufficient

Seven things you can do about it:

  • understand your data (know what works, who has successful outcomes, etc)

  • focus on value, not just cost

  • demand transparency of information (metrics, etc)

  • insist on value in contracting

  • manage your healthcare costs like the rest of your supply chain

  • educate your employees

  • Build momentum and join with other purchasers to drive change.


Center of Excellence (COE):  ACOs and other health care networks are identifying and creating "centers of excellence" were the quality of care and outcome of procedures is high -- and predictable.  Within a plan, if you choose a COE, then the expense might either be lower or there might be no cost (after deductible) and if you choose to go elsewhere the expense will be at a set rate.  

An ACO (Accountable Care Organization) is supposed to be the accumulation of the best of medical care in certain areas by bringing together organizations and providers that offer integrated services.  These are put together through the analyzing of the quality and outcomes of care with the thought of cherry picking what is available to create great health care.  From the producer/payor standpoint, they've worked hard to provide affordable and quality care but the general public views this is as narrow options, a limitation of choice.  Producers/payers want to work with purchasers to figure out how to bridge this gap of education for members to buy in that these networks are in the member's best interests.


David Lansky, PhD, CEO, Pacific Business Group on Health.

Pacific Business Group on Health:  Rapid and complex changes are occurring in healthcare, creating unprecedented opportunities for purchases of healthcare services to come together and drive improvements in quality and affordability.  PBGH is a purchaser-only coalition, representing 60 public and private organizations across the US that collectively spend $40 billion a year purchasing healthcare services for 10 million Americans.  PBGH functions as a convener, administrator and advocate for dramatic change and delivers value to its Members in the following ways:

  • Implementing practical purchasing programs that return value.

  • Providing access to a network of like-situated professionals.

  • Convening Health Plan User Groups to address plan-specific issues and organizing Work Groups to tackle current issues.

  • Building platforms for the public release of cost and quality information so Members can form value-based networks.

  • Advocating with both national and state policymakers.

  • Disseminating timely information and alerts via newsletters, webinars, Twitter feeds and a Member-only LinkedIn Group and web portal.

-- verbatim  http://www.pbgh.org/

Good News:  David mentioned in his speech that Payers/Producers, Purchasers/Employers and Providers coming to together like this is leading edge, that there are very few geographic locations in the US that are trying to work together like WA state is.

Bad News:  He also mentioned that he heard a quote from the expected, soon-to-be new secretary of health (whose name I did not catch, if it was mentioned) who stated something to the effect that he only believed in "fee for service" health care and that value-added purchasing was a waste of money.

Email Contact

Copyright © 2016-2017

Website Disclaimer

Powered by Wild Apricot Membership Software