Interview with Dr. Gerard Livaudias, Hawaii Pacific Health

Dr. Gerard Livaudais is vice president at Hawaii Pacific Health (HPH), responsible for the overall development and strategic leadership of the organization’s accountable care organization, (ACO) Hawai‘i Health Partners (HHP). Through HHP, HPH has partnered with HMSA to create a new model of care that emphasizes clinical integration and care coordination.

Karianna Wilson: How has HPH worked with HMSA in the process of this payment transformation, and how have you led this charge internally?

Gerard Livaudais: It goes back to both the payer and provider understanding that a new relationship was needed. This relationship manifested with a new shared savings agreement. This is fairly typical now, but was the first in the market and it did have the provider agreeing to take risks. There was some key emphasis or dependencies on quality, as well as shared savings, both included in the agreement explicitly, so that the behaviors and interests were aligned.

The mechanisms for calculating quality and metering shared savings participation according to quality basically laid the foundation for what subsequently became HMSA’s statewide payment transformation effort. You can see the same methodology that was worked out in the agreement between HPH and HMSA sort of being re-used in a broader sense to figure out if the new physician or new provider is achieving any degree of shared savings with the payment transformation model.

We had a different starting point than the rest of the community in the statewide payment transformation program. We began a little bit earlier and, as a system, have invested quite a bit in the infrastructure to manage the risk responsibly.

KW: Why did HPH start earlier? Was that an internal goal prior to the work with HMSA, or was that due to your partnership?

GL: We started in concert with HMSA. HPH has been a very successful entity in the fee-for-service payment model, but we understood that couldn’t go on forever. We knew we wanted a partner on the payer side. Not surprisingly, HMSA was feeling the same pressure, so we found a connection there and developed our agreement. That was in 2014, before the rest of the community. That was the first and I believe remains the only risk-sharing agreement with a provider that HMSA has here in the market.

KW: How have you worked internally to align the incentives? That’s a major shift if there’s risk involved, instead of a fee-for-service based arrangement. I’ve been involved in a lot of risk-sharing agreements here in Washington, so I’m familiar with full risk and partial risk, but culturally it’s a shift in thinking.

GL: It’s not finished by any stretch of imagination. I would say we’re still in the early stages of it. The starting point was introducing the whole notion of an accountable care organization, inviting considerations of what that would mean and introducing a distribution methodology that awarded points for participation in the ACO – effective participation, not just showing up for a CME, but actually doing things that contributed in some measurable way toward quality or shared savings. This includes things like participating in clinical workgroups that are trying to figure out appropriateness for ordering of high-intensity diagnostic imaging or use of the emergency department. If the providers are active and do things that make it visible and measurable, they earn points. If there are bonus dollars at the end of the year, those points are how we distribute that money.

That was the first time that doctors here were able to see their entire panel and be introduced to the idea of a panel in any kind of quantified sense and know how many are in there, what they’ve got, the per-member per-month costs, where those costs are occurring, the percentage of avoidable ED visits , quality performance on diabetes, etc.. All of that’s integrated, and they’re one click away from the actual records, so they can do things like, “Here’s a patient with a very high complexity score. I can refer them to the complex care services program,” which is one of the programs that was created under the ACO. That program comes alongside and helps go to the home and address a lot of the social determinants of care. We’ve set up a quasi-experimental design to try to gauge the effectiveness of the program, and it has a very healthy return on investment, which is great. It’s gratifying.

KW:  You know physicians do love data, so when they were introduced to the dashboards, was there pushback or just excitement? Was there any of that competitive, “Well the benchmark is x and my number is y, so I want to get it closer to x”?

GL: I think there was sort of a question of, “Why am I getting this?” These are a lot of new concepts that are being introduced to really busy physicians. We didn’t create the competitive charts and other things that would pit one doctor against the other, like a lot of organizations do. We simply gave them information about their practice. We did provide a comparison against their specialty, but not against the individual doctors within the specialty, so they can see how they fare on those various metrics. In the beginning, the reaction was a little nonplussed, but those who took the time were very intrigued and excited. I remember a comment in particular: “This was the first time I have ever known anything about who considers me to be their doctor.” So, that’s pretty cool.

We’ve been monitoring the traffic, and it’s been a very steady increase, but I think we’ve plateaued now. We had about 87 to 90 percent of all the eligible users in that dashboard at one point about two months ago. I think now it’s at 87 percent. We might have dropped off a couple of points. We wouldn’t expect 100 percent. People are on vacation and what have you. But you can see a very dramatic increase in the use, and we would like to believe there’s a causal attribution that the quality scores have also improved.

We hit the high-water mark – 94.2 percent of available points in our ambulatory quality program. This is yet another program that we have with HMSA. That’s kind of an unbelievable success, and I would like to imagine that there’s a connection between those two things. We didn’t set up a study to prove that, but it’s pretty interesting that they both occurred at the same time.

KW: What’s involved in that ambulatory program?

GL: This is a program that has been in place for a long time with HMSA across the state. There are about 27 measures of ambulatory quality – typical things like blood pressure control, preventive measures, cancer screening and so on and so forth. Good scores are rewarded with dollars for either performance or improvement, and the amounts can be substantial in a primary care practice, somewhere in the neighborhood of $30,000 or so. The doctors pay attention to it; it’s an important part of their revenue. As the ACO, we recognize that that this is the work we want them to do well because that is population care. We have a team of people here that support those efforts and ensure their great performance and quality.

KW: How has HPH achieved success in terms of engaging and getting support behind this new partnership with HMSA?

GL: The relationships are key. We have set aside our historical positions and started anew with fresh relationships. We have at least five joint working groups with HMSA on everything from analytics to back office operations, medical management and marketing and community affairs. This is not just the executive level, this is the people who do the work getting together, talking to each other and often meeting for the first time. It’s building a different level of trust and cooperation that I think will prove very important in going forward with this relationship.

The other key thing that I think is becoming apparent is that we want the physicians to lead this transformation. We really are trying to avoid an administrative solution to solve the riddle of escalating medical costs, and, if we can find a way to effectively have physicians own that appropriateness and utilization activity, we’ll all be better for it. It’s a hard sell because it’s not what doctors are trained to do, and many times it’s not well received. So, what we’ve found to be very successful, and it’s probably not very surprising, is that if we just create space and time for physicians to talk with one another and give them the problems to solve in a non-threatening way, really good things start to happen. We started observing that and are playing more and more to it now.

We recently had a clinical forum – we had about 150 doctors give us an evening where we presented four different scenarios, little video vignettes where a physician is talking about his/her experiences, and then the doctors were invited to just have a free-form discussion at their tables, which we shuffled. It was kind of a progressive dinner where they would be at different tables, play another video, and talk about a new topic. The feedback was tremendous. It was great because you heard it that evening over and over, “Oh this is so good to put a face to a name. I’ve never had the chance to actually meet you.” That level of relationship and familiarity of community I think is equally important to the relationships and trust that are being built between the provider and the payer. I think within a provider community, playing to the strengths of the physicians and giving them some room and space and the information to start the transformation will be key.