May 9, 2025 • 22 mins
Health Affairs' Jeff Byers welcomes Farzad Mostashari, founder & CEO of Aledade and the former National Coordinator for Health IT, to the pod to break down insights in the latest MedPAC report, quality measurement reform, and areas of opportunity for value-based care.
Health Affairs is hosting an Insider exclusive event on May 29 focusing on the FDA's first 100 days under the second Trump administration featuring moderator Rachel Sachs alongside panelists Richard Hughes IV and Arti Rai.
Related Links:
- Crossing the Chasm: How to Expand Adoption of Value-Based Care (The New England Journal of Medicine)
- 2025 MedPAC Report
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Jeff Byers (00:08):
Hello and welcome to Health Affairs This Week. I'm
your host Jeff Beyers. We'rerecording on 05/01/2025. Just as
a heads up, if you haven'talready heard, we have an
insider event happening on May29. It's on the FDA's first
hundred days under the secondTrump administration.
It's, gonna be moderated byRachel Sachs, and the panel will
include Richard Hughes thefourth and Artie Rye. Today, I'm
(00:32):
joined by Aledade cofounder andCEO, Farzad Mastashari. Before
starting Aledade, Farzad helpedusher in the use of electronic
health records in the healthcare setting as national
coordinator for health IT. He'salways had an active social
media presence from what I cantell, and I saw him reflecting
on the latest med pack report onvalue based care on X and
(00:52):
LinkedIn respectively. So itsounded like he had a lot on his
mind, so I invited him todiscuss these topics and more.
Farzad Mashashari, welcome tothe program.
Farzad Mostashari (01:00):
Glad to be here.
Jeff Byers (01:01):
Thank you. Yeah. Thanks for joining us. So this
is somewhat a Podestianquestion, but I have to assume
that every episode could besomeone's first, and every
episode could be someone's firstentry into health policy. So
when I was a business reporter,I never really saw any clicks on
this topic.
So I wanted to ask you, why isthe med pack report important?
Farzad Mostashari (01:20):
I mean, I'm always shocked at how good it is
and how full it is and what goodkinda honest, not not overly
fussy analyses, but but prettyhonest and and down the middle,
and they blend, the reporting ofwhat you can be observed and in
(01:42):
some cases using data that onlythey have access to with what
should be done. So I honestly,I'm mystified why everybody
doesn't read the med pack reportthe second it comes out. I can't
help you there.
Jeff Byers (01:54):
Yeah. Well, what what is the med pack report?
Farzad Mostashari (01:57):
Yeah. It's it's it's the Medicare Pain
Advisory Commission. They aretheir their job is to make
recommendations to congress,actually. It it one of the
things that I didn't understandwhen I was in the
administration, I thought theywere talking to us. Turns out
that that by law, by statute,they're not really talking to
CMS.
They're they're talking tocongress. But, obviously,
(02:18):
policymakers pay a a fair amountof attention to what they say.
And I gotta say, under Chernu,more so now than perhaps in a
decade ago. I think med pack hasspoken more clearly, and I think
that has helped actually, notkinda hiding the ball as much in
(02:42):
kinda technical ease, but butdoing mic drops like the, you
know, like, the stars, thequality program is broken. We
have no idea whether it, youknow, whether it it it measures
quality or not, you know, thatkind
Jeff Byers (02:59):
Mhmm. And then they just walk away.
Farzad Mostashari (03:02):
Exactly. Then they're like, fix it, congress.
Jeff Byers (03:04):
Well, you posted a tweet storm. I don't know if we
call them tweet storms anymore,but anyways, posted a tweet
storm. What are some about theMedPack report, the latest one,
what are some of the biggesttakeaways of that report that
you took from looking to futurehealth care policies?
Farzad Mostashari (03:20):
Yeah. So the the areas I mean, obviously,
it's a huge report. It covers alot of stuff that I have no
particular insight into. But theareas that I focus on is what
they say about primary care,what they say about alternative
payment models, what they sayabout Medicare Advantage, and
then competition consolidation.So those are the kind of the
four areas that I I knowsomething about.
(03:40):
And so I I kinda pay prettypretty close attention to. I
think on primary care, the thekinda key insight there was
around just how fee for serviceis is a losing game for primary
care. And they they keep tryingto help. Right? Like and now
they're trying to, you know, doa safety net add on policy, and
(04:04):
that's gonna help increase thefee schedule by 5.7% for primary
care clinicians.
And they're just even thoughthey they recognize it, they're
just trying to patch whatfundamentally they recognize
doesn't really work for forprimary care. That primary care
is consistently paid less thanthe value there that they could
(04:29):
be creating in the system. Theother thing that they talk about
is the kinda average paymentsfor clinicians, and they say,
you know, clinicians are paid a40% of Medicare by commercial
plans. What's interesting isthat that's an average, and what
I wished they would actually dois look at the, price
(04:49):
transparency data that healthplans are now required to post
and just see how muchvariability there is around that
because there are plenty, let metell you, of independent primary
care practices who are paid ator below 100% of Medicare. And
so I think the the report doesfocus on the the adverse effects
(05:10):
of consolidation, but I wishthey would take it actually that
next step forward and break outindependent primary care
practices versus kind of thepayments that are made to health
systems for primary care, muchof which never flows down to
primary care.
Even if you increased primarycare fee schedules, it never
makes it to the primary carediocese. It gets kinda absorbed
(05:31):
by the system.
Jeff Byers (05:32):
And is that a kind of result of consolidation?
Farzad Mostashari (05:35):
Absolutely. It's not only a result of
consolidation, it's a driver ofconsolidation. Because when you
underpay primary care who'sindependent on the commercial
side, right, they then getbought up by health systems who
not only charge more for thoseservices, but it now they have
kinda the captive in terms ofthe referrals, the scans, the in
house services that furtherconsolidates and increases their
(06:00):
market power and their leverage.So I do think we have to take
competition consolidation veryseriously.
Jeff Byers (06:08):
Yeah. We've had a lot of episodes on consolidation
as well. There's a lot ofresearch from health the pages
of health affairs onconsolidation as well. You
talked about Medicare Advantage,and one of the things I wanted
to ask you about, there's a lotof, news, studies, just like
maybe potential criticisms ofMedicare Advantage these days.
What did what did you see inthat area in the med pack
(06:29):
report?
Farzad Mostashari (06:30):
Yeah. Again, I I really appreciated their,
like, very cool, balanced like,they're like, look. We we pay
more for when a when a seniorjoins a Medicare Advantage Plan,
the the idea had been that thatthe government saves money. In
fact, the government spendsmore. So that's that's a fact.
(06:51):
And and they go on to describethe portion of that that's due
to risk adjustment. The portionof that is due to selection
effects. But they also, like,very they're they're not trying
to be advocates. They're like,look. And seniors get more.
Right? Like, because of the theincreased payments, the MA plans
offer benefits that patients intraditional Medicare don't have.
(07:13):
And there is some evidence of,particularly in value based
models, of lower ER and acutecare, utilization and so forth.
So I think they're trying tostrike a a pretty good balance
in in talking about it. And Ithink it's, the the details are
where I think it getsinteresting.
(07:34):
Right? It's like, what should bedone for this? And so, for
example, one of the things theypoint about to is, that there
isn't guaranteed issue forMedSup once someone switches
from traditional Medicare toMedicare Advantage. There are
some states that have it, but,you know, if you if you wanted
to create more choice, perhapsyou would extend that guaranteed
(07:54):
issue for MedSup for so peoplego to the MA. They could go back
to traditional Medicare with theMedSup plan, make that more more
feasible.
They also talk a bunch about,risk adjustment. And and I think
it's a it's a super complicatedquestion of what to do. But I I
thought there were two points,that actually Abe Sutton, who's
(08:15):
now the CMMI director, made verywell, as well, which is one that
there isn't just a problem withoverpayment with risk
adjustment, but what MedPACcalls heterogeneity. Meaning,
some plans are a lot better atthan at this than others, and
then that creates downstreameffects that those plans that
(08:39):
are kind of the sharks againstthe guppies are able to offer
more benefits and grow more andhave higher margins and have
more consol right? So that isthe it's not just enough for the
government, for example, toincrease the coding intensity
factor and claw back, some ofthe overpayments on risk
adjustment.
If you simply increase thecoding intensity factor, you'll
(09:03):
actually exacerbate the sharksversus guppies. You'll drive
more of the clients who don'tfocus on risk adjustment out of
the market, out of business, andyou'll increase consolidation.
And so they're calling forthings like, you know, looking
at in home assessments assomething that might be a
specific policy that would helpin a sense level the playing
(09:25):
field.
Jeff Byers (09:25):
Yeah. I'm glad you touched on that because I did
wanna ask you about riskadjustment and quality
measurements. You had mentionedthat there's a window of
opportunity now to reformquality measurement. Can you
drill down into that? Like, whyis that window now?
And, like, what can be doneabout it? I mean, you kinda
talked about what can be doneabout it, but, like, why is the
opportunity now?
Farzad Mostashari (09:45):
Well, I I I do think that the Overton window
of what's possible is just widerwider today. And and I think the
opportunity now to substantiallyreform quality measurement, not
only to bring more meaning toit, but also to reduce the cost
and the burden of datacollection, to remove these
(10:06):
silly cliff effects, to focusmore on outcomes. That was
actually one part where Ithought the the med pack report
a little bit, they were like,they got tired. And at the end,
just kinda like mailed it in andthey were like, so anyway, what
we said before. And I'm like,no.
No. No. Now is the time becauseI do think that they they just
(10:29):
say, like we said in June oftwenty twenty, congress should
replace the current MA qualitybonus program with a new MA
value incentive program thatscores a small set, please small
set, of population basedmeasures, evaluates quality at
the local market level, andestablishes a system for
distributing rewards with nocliff effects. So, yes, but
(10:53):
let's get more specific. And Ithink in particular, you know,
this is the time where delete,delete, delete might make sense
to folks in the administration.
And if there are measures wepublished a a a an article
talking about, the medicationadherence measures. And it just
they don't make sense anymore.Like, we have a we have blood
(11:14):
pressure control. We don't needa medication adherence for blood
pressure control measure that istriple weighted, that that is
topped out, that, is franklyroughly uncorrelated with actual
blood pressure control. Like, wedon't need that measure anymore.
Delete it. So I I I thinkthere's a lot of the the
(11:35):
window's open now to make morebigger changes than would
normally be possible.
Jeff Byers (11:40):
Well, thanks for laying that out for the med pack
report. That that that helps melearn a lot. Again, I I didn't
know that much about it, sohopefully, the listeners learned
something as well. You publisheda piece on LinkedIn outlining
some thoughts on value basedcare in an article published in
New England Journal of Medicine.And it made me wonder, you're
(12:01):
instrumental in crossing thechasm for EHRs.
There are financial incentivesthere. But for value based care
and the adoption of AI in healthcare, what are the similarities
and differences between theadoption of EHR and value based
care?
Farzad Mostashari (12:16):
So when I joined the administration in
02/2009, it was pretty rare fordocs to be on electronic health
record, like one in five wasusing it. And by the time I left
five years later, one in fivewas not using it. So we got this
kind of fundamental, like, flip,right, from only only early
adopters to basically only lateadopters not having it. What
(12:39):
happened there? And we took somelessons from that with the
author of actually the the kindof seminal business book,
Crossing the Chasm, JeffreyMoore.
And, one of the things some ofthe things that we outlined in
that one was, it's not justabout financial incentives. I
think I was actually talking tosome doc who said, yeah. You
know, well, we were there was amandate to switch to EHRs. And I
(13:02):
was like, well, do do youremember what the what the
dollar amount was? He was like,no.
I I don't. I was like, it was$9,000 a year. This is a this is
a doc who's getting a a checkfor over a hundred thousand
dollars from us for value basedcare. Right? The for the size of
the financial incentives forprimary care to adopt value
based care is so much biggerthan what the financial
(13:23):
incentives were for EHRadoption.
So it's not that. Right? It waswe created a sense of
inevitability. We spoke reallyclearly about we want, like,
paper kills. Right?
EHR is better than paper. Right?And I and I think there's a
little bit of opportunity in CMSwho controls both the fee for
(13:45):
service side and the alternativepayment side to say, we think
unmanaged fee for service isbad. We think it's bad. We think
everybody should get out ofthat, and and we want all
primary care docs in analternative payment model.
I mean, Congress kinda said thatin MACRA, and I think CMS didn't
really follow through with that.There were no penalties really
(14:06):
for the low performers, and theydidn't really make fee for
service uncomfortable. So I Ithink there's an opportunity
there. The other thing that wetalked about is don't keep, you
know, shipping bells andwhistles. Like, the more new
programs you have, in a way, themore you confuse the issue.
There was one meaningful useprogram, period. We want you to
(14:26):
do meaningful use. And rightnow, every time, honestly, CMMI
introduced, you know, a a newmodel, it confused people as to
what they're supposed to bedoing. And our strong
recommendation is focus on theMedicare shared savings program
as the chassis and encourageeverybody to join that for
primary care at least and focusCMMI on specialty models. That's
(14:49):
where we need moreexperimentation.
Great. When it comes to primarycare, we have the chassis. It's
the Medicare shared savingsprogram. And then, you know,
removing the the obstacles, butalso simplifying it. And in the
case of the electronic healthrecord, it was pretty
complicated making thatdecision.
And cofounder, actually, MattKendall, set up 60 regional not
(15:10):
for profit extension centersthat helped primary care docs
That's right. Adopt thetechnology. 33,000 primary care
docs made the switch,successfully to meaningful use
through those regional extensioncenters. We spent a billion
dollars on that in the federalgovernment, and that was money
extremely well spent. Right?
That's what essentially Aledateis trying to do. We and other
(15:31):
enablement partners are tryingto be the simple button for this
transformation where the docsdon't have to try to figure out
the technology and the data andthe rules and the policies and
the regulations and theplaybook, and we just say, hit
the easy button, and we'll helpyou get there. But there isn't
really a program the way therewas with EHRs for CMS to
explicitly acknowledge andenable and empower those
(15:55):
enablement partners.
Jeff Byers (15:56):
Yeah. Well, I'm glad you brought up your work with
Alidade with that because I andalso the regional extension
centers, which also reminded meof, like, how much of a
coordinated effort that is. Howdoes that work getting people to
take the journey with whetherit's technological advancement
or how payment is changing inhealth care?
Farzad Mostashari (16:15):
Yeah. I mean, look. We we bring in more people
into the Medicare shared savingsprogram than anybody else. We
added 500 new practices lastyear into the Medicare shared
savings program, and 80% ofthose were new to the program.
They weren't coming from onegroup to the to to us.
And so we we know a lot aboutwhat those practices, are are
(16:41):
looking for, and one of thethings they're looking for is
stability. And they're lookingfor the the proven solution.
Right? And so the fact thatwe've been around ten years, the
fact that we we have ademonstrated track record and
they can find others in in theirneighborhood who have joined and
have been successful, I think,is a is a big part of it. But
(17:02):
it's also kinda the feeling oftrust.
And, being an independentpractice is hard and getting
harder. And when there aredisruptions like COVID, like the
change health care attacks, likea hurricane, those are the times
when both people realize fee forservice is not a great way to
run a business, when thosedisruptions happen. But also
(17:25):
that they are they feel alone,that there's no one advocating
for them. There's no one ontheir side. There's no one
looking out for them.
They're not part of anythingbigger, and they don't wanna be
consolidated. Right? They don'twanna have someone else take
over their clinical autonomy,take over their schedule, take
over their you know, push themon RVRUs. And, it was there was
(17:46):
actually a very interestingsection in the med pack report
that talked about why they sellthem themselves to practices.
And they basically say they sellthemselves to hospitals because
the payer rates are low, butthey don't get more pay.
They see fewer patients. Theyhave less autonomy. They don't
like being unproductive, andthey hate being micromanaged.
(18:07):
That's the summary of theevidence of consolidation as it
affects these independentpractices. And I think what we
offer them is a way to stayindependent but be part of
something bigger.
Jeff Byers (18:18):
I remember back in the day, I can't remember if it
was an ACO. Yeah. Talking aboutACOs, I think there was
something like, you've seen oneACO, you've seen one ACO. So
have we come to a centraldefinition of ACOs and how do
they actually save money?
Farzad Mostashari (18:32):
There there actually was a recent article in
JAMA that they did a follow-upstudy on ACOs in in the Medicare
shared savings program, and theevidence is strong and getting
stronger every day that theythey are saving money. And the
the more independent ones, thenonhospital ones are saving
more, and it it is billions ofdollars that that are being
(18:53):
saved. And in terms of, like,how they're doing it, there
there are some differences, butthe one commonality is primary
care access. And I appreciatethe MEDPAC for trying to say,
like, look, seniors can accesscare in Medicare. But according
to the data they showed,Medicare beneficiaries, fifty
(19:16):
two percent of them said theyhad a problem finding a primary
care provider who would treatthem.
Fifty two percent. So the medpack compared that to commercial
and said, hey. It's not bad. AndI'm like, yeah. Well but for a
senior like my mom, know, who's80 years old and has multiple
(19:36):
chronic conditions, like, towait many weeks to see twenty
two percent had to wait morethan eight weeks for their next
primary care appointment.
Like, that is a that is a bigproblem. And if there's one
commonality between differentapproaches for accountable care
that work, It's just access.Just elderly seniors with
(20:01):
multiple chronic conditions needto be able to see a primary care
doc who knows them, who knowstheir conditions, who knows
what's happening with them, andcares about preventing them from
ending up in the hospital andsays to them, look, call us
first before you go to the ER,as opposed to when you call the
number, it says, go to the ER.You got a problem. And I think
(20:23):
that is it's it's like the bigdifference in how more
prevention, more primary careleads to better chronic disease
management and fewer acute carecomplications.
Jeff Byers (20:36):
Great. So Farzad Masashari, as we wrap up, you're
a physician, a researcher. Youwere the national coordinator
for health IT and now businessowner with Alidade. Had a
question. You mentioned thatAlidade has been around for ten
years now.
Coming out of government serviceand physician and research,
people like to say, you know,making a business in health care
(20:58):
is hard. You've done it. Howhard has that been building a
business? What was harder thanwhat you expected? What's been
easier than you expected?
Farzad Mostashari (21:07):
I guess I would say the continuity for me
from ten years as a publichealth person in New York City,
Five Years as a federalpolicymaker, eleven, twelve
years running this publicbenefit corporation, Aledade,
the commonality has been morethan the differences. It's it's
about setting the vision for howdo we save the most lives, has
(21:29):
been the kind of the animatingtheme and finding different
approaches to that. But at theend of the day, setting that
vision, inspiring and andmotivating people to climb on
board, believe in in thatpostcard of the future, and then
using honestly technology andcreativity and financial
(21:52):
alignment, to to to to try tofind our way there. It's not a
straight path, but it is themost meaningful work we could
do.
Jeff Byers (22:03):
Well, that's a fantastic place to wrap up.
Farzad Mashashari, thanks forjoining us today on Health
Affairs This Week. And if you,the listener, enjoyed this
episode, please send it to afriend. With that, have a great
rest of the week, and we'll seeyou next time.
Hello and welcome to Health Affairs This Week. I'm
your host Jeff Beyers. We'rerecording on 05/01/2025. Just as
a heads up, if you haven'talready heard, we have an
insider event happening on May29. It's on the FDA's first
hundred days under the secondTrump administration.
It's, gonna be moderated byRachel Sachs, and the panel will
include Richard Hughes thefourth and Artie Rye. Today, I'm
(00:32):
joined by Aledade cofounder andCEO, Farzad Mastashari. Before
starting Aledade, Farzad helpedusher in the use of electronic
health records in the healthcare setting as national
coordinator for health IT. He'salways had an active social
media presence from what I cantell, and I saw him reflecting
on the latest med pack report onvalue based care on X and
(00:52):
LinkedIn respectively. So itsounded like he had a lot on his
mind, so I invited him todiscuss these topics and more.
Farzad Mashashari, welcome tothe program.
Farzad Mostashari (01:00):
Glad to be here.
Jeff Byers (01:01):
Thank you. Yeah. Thanks for joining us. So this
is somewhat a Podestianquestion, but I have to assume
that every episode could besomeone's first, and every
episode could be someone's firstentry into health policy. So
when I was a business reporter,I never really saw any clicks on
this topic.
So I wanted to ask you, why isthe med pack report important?
Farzad Mostashari (01:20):
I mean, I'm always shocked at how good it is
and how full it is and what goodkinda honest, not not overly
fussy analyses, but but prettyhonest and and down the middle,
and they blend, the reporting ofwhat you can be observed and in
(01:42):
some cases using data that onlythey have access to with what
should be done. So I honestly,I'm mystified why everybody
doesn't read the med pack reportthe second it comes out. I can't
help you there.
Jeff Byers (01:54):
Yeah. Well, what what is the med pack report?
Farzad Mostashari (01:57):
Yeah. It's it's it's the Medicare Pain
Advisory Commission. They aretheir their job is to make
recommendations to congress,actually. It it one of the
things that I didn't understandwhen I was in the
administration, I thought theywere talking to us. Turns out
that that by law, by statute,they're not really talking to
CMS.
They're they're talking tocongress. But, obviously,
(02:18):
policymakers pay a a fair amountof attention to what they say.
And I gotta say, under Chernu,more so now than perhaps in a
decade ago. I think med pack hasspoken more clearly, and I think
that has helped actually, notkinda hiding the ball as much in
(02:42):
kinda technical ease, but butdoing mic drops like the, you
know, like, the stars, thequality program is broken. We
have no idea whether it, youknow, whether it it it measures
quality or not, you know, thatkind
Jeff Byers (02:59):
Mhmm. And then they just walk away.
Farzad Mostashari (03:02):
Exactly. Then they're like, fix it, congress.
Jeff Byers (03:04):
Well, you posted a tweet storm. I don't know if we
call them tweet storms anymore,but anyways, posted a tweet
storm. What are some about theMedPack report, the latest one,
what are some of the biggesttakeaways of that report that
you took from looking to futurehealth care policies?
Farzad Mostashari (03:20):
Yeah. So the the areas I mean, obviously,
it's a huge report. It covers alot of stuff that I have no
particular insight into. But theareas that I focus on is what
they say about primary care,what they say about alternative
payment models, what they sayabout Medicare Advantage, and
then competition consolidation.So those are the kind of the
four areas that I I knowsomething about.
(03:40):
And so I I kinda pay prettypretty close attention to. I
think on primary care, the thekinda key insight there was
around just how fee for serviceis is a losing game for primary
care. And they they keep tryingto help. Right? Like and now
they're trying to, you know, doa safety net add on policy, and
(04:04):
that's gonna help increase thefee schedule by 5.7% for primary
care clinicians.
And they're just even thoughthey they recognize it, they're
just trying to patch whatfundamentally they recognize
doesn't really work for forprimary care. That primary care
is consistently paid less thanthe value there that they could
(04:29):
be creating in the system. Theother thing that they talk about
is the kinda average paymentsfor clinicians, and they say,
you know, clinicians are paid a40% of Medicare by commercial
plans. What's interesting isthat that's an average, and what
I wished they would actually dois look at the, price
(04:49):
transparency data that healthplans are now required to post
and just see how muchvariability there is around that
because there are plenty, let metell you, of independent primary
care practices who are paid ator below 100% of Medicare. And
so I think the the report doesfocus on the the adverse effects
(05:10):
of consolidation, but I wishthey would take it actually that
next step forward and break outindependent primary care
practices versus kind of thepayments that are made to health
systems for primary care, muchof which never flows down to
primary care.
Even if you increased primarycare fee schedules, it never
makes it to the primary carediocese. It gets kinda absorbed
(05:31):
by the system.
Jeff Byers (05:32):
And is that a kind of result of consolidation?
Farzad Mostashari (05:35):
Absolutely. It's not only a result of
consolidation, it's a driver ofconsolidation. Because when you
underpay primary care who'sindependent on the commercial
side, right, they then getbought up by health systems who
not only charge more for thoseservices, but it now they have
kinda the captive in terms ofthe referrals, the scans, the in
house services that furtherconsolidates and increases their
(06:00):
market power and their leverage.So I do think we have to take
competition consolidation veryseriously.
Jeff Byers (06:08):
Yeah. We've had a lot of episodes on consolidation
as well. There's a lot ofresearch from health the pages
of health affairs onconsolidation as well. You
talked about Medicare Advantage,and one of the things I wanted
to ask you about, there's a lotof, news, studies, just like
maybe potential criticisms ofMedicare Advantage these days.
What did what did you see inthat area in the med pack
(06:29):
report?
Farzad Mostashari (06:30):
Yeah. Again, I I really appreciated their,
like, very cool, balanced like,they're like, look. We we pay
more for when a when a seniorjoins a Medicare Advantage Plan,
the the idea had been that thatthe government saves money. In
fact, the government spendsmore. So that's that's a fact.
(06:51):
And and they go on to describethe portion of that that's due
to risk adjustment. The portionof that is due to selection
effects. But they also, like,very they're they're not trying
to be advocates. They're like,look. And seniors get more.
Right? Like, because of the theincreased payments, the MA plans
offer benefits that patients intraditional Medicare don't have.
(07:13):
And there is some evidence of,particularly in value based
models, of lower ER and acutecare, utilization and so forth.
So I think they're trying tostrike a a pretty good balance
in in talking about it. And Ithink it's, the the details are
where I think it getsinteresting.
(07:34):
Right? It's like, what should bedone for this? And so, for
example, one of the things theypoint about to is, that there
isn't guaranteed issue forMedSup once someone switches
from traditional Medicare toMedicare Advantage. There are
some states that have it, but,you know, if you if you wanted
to create more choice, perhapsyou would extend that guaranteed
(07:54):
issue for MedSup for so peoplego to the MA. They could go back
to traditional Medicare with theMedSup plan, make that more more
feasible.
They also talk a bunch about,risk adjustment. And and I think
it's a it's a super complicatedquestion of what to do. But I I
thought there were two points,that actually Abe Sutton, who's
(08:15):
now the CMMI director, made verywell, as well, which is one that
there isn't just a problem withoverpayment with risk
adjustment, but what MedPACcalls heterogeneity. Meaning,
some plans are a lot better atthan at this than others, and
then that creates downstreameffects that those plans that
(08:39):
are kind of the sharks againstthe guppies are able to offer
more benefits and grow more andhave higher margins and have
more consol right? So that isthe it's not just enough for the
government, for example, toincrease the coding intensity
factor and claw back, some ofthe overpayments on risk
adjustment.
If you simply increase thecoding intensity factor, you'll
(09:03):
actually exacerbate the sharksversus guppies. You'll drive
more of the clients who don'tfocus on risk adjustment out of
the market, out of business, andyou'll increase consolidation.
And so they're calling forthings like, you know, looking
at in home assessments assomething that might be a
specific policy that would helpin a sense level the playing
(09:25):
field.
Jeff Byers (09:25):
Yeah. I'm glad you touched on that because I did
wanna ask you about riskadjustment and quality
measurements. You had mentionedthat there's a window of
opportunity now to reformquality measurement. Can you
drill down into that? Like, whyis that window now?
And, like, what can be doneabout it? I mean, you kinda
talked about what can be doneabout it, but, like, why is the
opportunity now?
Farzad Mostashari (09:45):
Well, I I I do think that the Overton window
of what's possible is just widerwider today. And and I think the
opportunity now to substantiallyreform quality measurement, not
only to bring more meaning toit, but also to reduce the cost
and the burden of datacollection, to remove these
(10:06):
silly cliff effects, to focusmore on outcomes. That was
actually one part where Ithought the the med pack report
a little bit, they were like,they got tired. And at the end,
just kinda like mailed it in andthey were like, so anyway, what
we said before. And I'm like,no.
No. No. Now is the time becauseI do think that they they just
(10:29):
say, like we said in June oftwenty twenty, congress should
replace the current MA qualitybonus program with a new MA
value incentive program thatscores a small set, please small
set, of population basedmeasures, evaluates quality at
the local market level, andestablishes a system for
distributing rewards with nocliff effects. So, yes, but
(10:53):
let's get more specific. And Ithink in particular, you know,
this is the time where delete,delete, delete might make sense
to folks in the administration.
And if there are measures wepublished a a a an article
talking about, the medicationadherence measures. And it just
they don't make sense anymore.Like, we have a we have blood
(11:14):
pressure control. We don't needa medication adherence for blood
pressure control measure that istriple weighted, that that is
topped out, that, is franklyroughly uncorrelated with actual
blood pressure control. Like, wedon't need that measure anymore.
Delete it. So I I I thinkthere's a lot of the the
(11:35):
window's open now to make morebigger changes than would
normally be possible.
Jeff Byers (11:40):
Well, thanks for laying that out for the med pack
report. That that that helps melearn a lot. Again, I I didn't
know that much about it, sohopefully, the listeners learned
something as well. You publisheda piece on LinkedIn outlining
some thoughts on value basedcare in an article published in
New England Journal of Medicine.And it made me wonder, you're
(12:01):
instrumental in crossing thechasm for EHRs.
There are financial incentivesthere. But for value based care
and the adoption of AI in healthcare, what are the similarities
and differences between theadoption of EHR and value based
care?
Farzad Mostashari (12:16):
So when I joined the administration in
02/2009, it was pretty rare fordocs to be on electronic health
record, like one in five wasusing it. And by the time I left
five years later, one in fivewas not using it. So we got this
kind of fundamental, like, flip,right, from only only early
adopters to basically only lateadopters not having it. What
(12:39):
happened there? And we took somelessons from that with the
author of actually the the kindof seminal business book,
Crossing the Chasm, JeffreyMoore.
And, one of the things some ofthe things that we outlined in
that one was, it's not justabout financial incentives. I
think I was actually talking tosome doc who said, yeah. You
know, well, we were there was amandate to switch to EHRs. And I
(13:02):
was like, well, do do youremember what the what the
dollar amount was? He was like,no.
I I don't. I was like, it was$9,000 a year. This is a this is
a doc who's getting a a checkfor over a hundred thousand
dollars from us for value basedcare. Right? The for the size of
the financial incentives forprimary care to adopt value
based care is so much biggerthan what the financial
(13:23):
incentives were for EHRadoption.
So it's not that. Right? It waswe created a sense of
inevitability. We spoke reallyclearly about we want, like,
paper kills. Right?
EHR is better than paper. Right?And I and I think there's a
little bit of opportunity in CMSwho controls both the fee for
(13:45):
service side and the alternativepayment side to say, we think
unmanaged fee for service isbad. We think it's bad. We think
everybody should get out ofthat, and and we want all
primary care docs in analternative payment model.
I mean, Congress kinda said thatin MACRA, and I think CMS didn't
really follow through with that.There were no penalties really
(14:06):
for the low performers, and theydidn't really make fee for
service uncomfortable. So I Ithink there's an opportunity
there. The other thing that wetalked about is don't keep, you
know, shipping bells andwhistles. Like, the more new
programs you have, in a way, themore you confuse the issue.
There was one meaningful useprogram, period. We want you to
(14:26):
do meaningful use. And rightnow, every time, honestly, CMMI
introduced, you know, a a newmodel, it confused people as to
what they're supposed to bedoing. And our strong
recommendation is focus on theMedicare shared savings program
as the chassis and encourageeverybody to join that for
primary care at least and focusCMMI on specialty models. That's
(14:49):
where we need moreexperimentation.
Great. When it comes to primarycare, we have the chassis. It's
the Medicare shared savingsprogram. And then, you know,
removing the the obstacles, butalso simplifying it. And in the
case of the electronic healthrecord, it was pretty
complicated making thatdecision.
And cofounder, actually, MattKendall, set up 60 regional not
(15:10):
for profit extension centersthat helped primary care docs
That's right. Adopt thetechnology. 33,000 primary care
docs made the switch,successfully to meaningful use
through those regional extensioncenters. We spent a billion
dollars on that in the federalgovernment, and that was money
extremely well spent. Right?
That's what essentially Aledateis trying to do. We and other
(15:31):
enablement partners are tryingto be the simple button for this
transformation where the docsdon't have to try to figure out
the technology and the data andthe rules and the policies and
the regulations and theplaybook, and we just say, hit
the easy button, and we'll helpyou get there. But there isn't
really a program the way therewas with EHRs for CMS to
explicitly acknowledge andenable and empower those
(15:55):
enablement partners.
Jeff Byers (15:56):
Yeah. Well, I'm glad you brought up your work with
Alidade with that because I andalso the regional extension
centers, which also reminded meof, like, how much of a
coordinated effort that is. Howdoes that work getting people to
take the journey with whetherit's technological advancement
or how payment is changing inhealth care?
Farzad Mostashari (16:15):
Yeah. I mean, look. We we bring in more people
into the Medicare shared savingsprogram than anybody else. We
added 500 new practices lastyear into the Medicare shared
savings program, and 80% ofthose were new to the program.
They weren't coming from onegroup to the to to us.
And so we we know a lot aboutwhat those practices, are are
(16:41):
looking for, and one of thethings they're looking for is
stability. And they're lookingfor the the proven solution.
Right? And so the fact thatwe've been around ten years, the
fact that we we have ademonstrated track record and
they can find others in in theirneighborhood who have joined and
have been successful, I think,is a is a big part of it. But
(17:02):
it's also kinda the feeling oftrust.
And, being an independentpractice is hard and getting
harder. And when there aredisruptions like COVID, like the
change health care attacks, likea hurricane, those are the times
when both people realize fee forservice is not a great way to
run a business, when thosedisruptions happen. But also
(17:25):
that they are they feel alone,that there's no one advocating
for them. There's no one ontheir side. There's no one
looking out for them.
They're not part of anythingbigger, and they don't wanna be
consolidated. Right? They don'twanna have someone else take
over their clinical autonomy,take over their schedule, take
over their you know, push themon RVRUs. And, it was there was
(17:46):
actually a very interestingsection in the med pack report
that talked about why they sellthem themselves to practices.
And they basically say they sellthemselves to hospitals because
the payer rates are low, butthey don't get more pay.
They see fewer patients. Theyhave less autonomy. They don't
like being unproductive, andthey hate being micromanaged.
(18:07):
That's the summary of theevidence of consolidation as it
affects these independentpractices. And I think what we
offer them is a way to stayindependent but be part of
something bigger.
Jeff Byers (18:18):
I remember back in the day, I can't remember if it
was an ACO. Yeah. Talking aboutACOs, I think there was
something like, you've seen oneACO, you've seen one ACO. So
have we come to a centraldefinition of ACOs and how do
they actually save money?
Farzad Mostashari (18:32):
There there actually was a recent article in
JAMA that they did a follow-upstudy on ACOs in in the Medicare
shared savings program, and theevidence is strong and getting
stronger every day that theythey are saving money. And the
the more independent ones, thenonhospital ones are saving
more, and it it is billions ofdollars that that are being
(18:53):
saved. And in terms of, like,how they're doing it, there
there are some differences, butthe one commonality is primary
care access. And I appreciatethe MEDPAC for trying to say,
like, look, seniors can accesscare in Medicare. But according
to the data they showed,Medicare beneficiaries, fifty
(19:16):
two percent of them said theyhad a problem finding a primary
care provider who would treatthem.
Fifty two percent. So the medpack compared that to commercial
and said, hey. It's not bad. AndI'm like, yeah. Well but for a
senior like my mom, know, who's80 years old and has multiple
(19:36):
chronic conditions, like, towait many weeks to see twenty
two percent had to wait morethan eight weeks for their next
primary care appointment.
Like, that is a that is a bigproblem. And if there's one
commonality between differentapproaches for accountable care
that work, It's just access.Just elderly seniors with
(20:01):
multiple chronic conditions needto be able to see a primary care
doc who knows them, who knowstheir conditions, who knows
what's happening with them, andcares about preventing them from
ending up in the hospital andsays to them, look, call us
first before you go to the ER,as opposed to when you call the
number, it says, go to the ER.You got a problem. And I think
(20:23):
that is it's it's like the bigdifference in how more
prevention, more primary careleads to better chronic disease
management and fewer acute carecomplications.
Jeff Byers (20:36):
Great. So Farzad Masashari, as we wrap up, you're
a physician, a researcher. Youwere the national coordinator
for health IT and now businessowner with Alidade. Had a
question. You mentioned thatAlidade has been around for ten
years now.
Coming out of government serviceand physician and research,
people like to say, you know,making a business in health care
(20:58):
is hard. You've done it. Howhard has that been building a
business? What was harder thanwhat you expected? What's been
easier than you expected?
Farzad Mostashari (21:07):
I guess I would say the continuity for me
from ten years as a publichealth person in New York City,
Five Years as a federalpolicymaker, eleven, twelve
years running this publicbenefit corporation, Aledade,
the commonality has been morethan the differences. It's it's
about setting the vision for howdo we save the most lives, has
(21:29):
been the kind of the animatingtheme and finding different
approaches to that. But at theend of the day, setting that
vision, inspiring and andmotivating people to climb on
board, believe in in thatpostcard of the future, and then
using honestly technology andcreativity and financial
(21:52):
alignment, to to to to try tofind our way there. It's not a
straight path, but it is themost meaningful work we could
do.
Jeff Byers (22:03):
Well, that's a fantastic place to wrap up.
Farzad Mashashari, thanks forjoining us today on Health
Affairs This Week. And if you,the listener, enjoyed this
episode, please send it to afriend. With that, have a great
rest of the week, and we'll seeyou next time.
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