 This is the Richard Perillo Family Professor of Health Care Ethics in the Department of Medicine and the Director of the Chicago Center for Diabetes Translation Research at the University of Chicago. He's also a practicing general internist and a national, I would say international expert in improving diabetes care for vulnerable patients and reducing racial and ethnic disparities in healthcare. Dr. Chen serves as the Associate Chief and Director of Research in the section of general medicine. He's an associate director for the McLean Center for Clinical Medical Ethics and is a co-director of the John A. Hartford Foundation Center of Excellence in Geriatrics. I'm just extremely thrilled and honored to be able to introduce Marshall. Want to come up? Thank you Monica. So I'm going to talk about what I think is one of the two cutting edge issues in health disparities. One is payment reform to reduce healthcare disparities and what I won't spend too much time talking about is the second cutting edge issue which I think is what Monica mentioned, intersectoral health, basically bridging the health and non-healthcare sectors to reduce disparities. So for disclosures, I have a variety of government and private foundation funding. The closest to a for-profit is the Merck Foundation, is a foundation funded by Merck Company. And then the other potential conflicts, I do a lot of committee and policy work for a variety of different national organizations, some of the especially organizations, safe and organizations, consumer groups, government groups including Medicare, and a co-chair, the National Qualified Forum Disparities Standing Committee. I'm also active in the leadership and advocacy of our major professional side for General Internist, Society of General Internal Medicine. So our learning objectives are first to recognize key trends and policies in the private marketplace in government reimbursement policy impacting disparities and then to identify opportunities to improve equity. I'm going to start with two case vignettes, give a brief history of health disparities, talk a little bit about cure transformation to reduce disparities, give a whirlwind tour of payment policy from the 60s to the present, then discuss payment reform to achieve equity, and then end with some early impressions from innovators in this area of payment reform to reduce disparities. So this is from maybe eight or nine years ago that at that time there was the Chief Financial Officer of the University of Chicago who had been in this job for a long time, I think it was like 15, 18 years or so, and each year he would go to each of the different departments and give his basically state of the finances talk about the medical center. And basically he said the same thing every year where the reality is that the what brings in the money is quaternary care at the university. It turns out it's only five percent of the patients at the University of Chicago that bring in the money that reimburses the rest of the operations. And so it's organ transplantation, orthopedic surgery, cancer chemotherapy, gastrointestinal procedures, there's relatively few of the different elements of the organization. And so maybe the third time I heard him give this talk I raised my hand and said no isn't it a little risky, basically the organization's strategic plan on only five percent of the patients, because basically the organization's plan was basically how do you increase the flow of these types of patients to the University of Chicago. And he said to me, well Marshall, you know, smart Alec, someone asked me this question every year and my answer was always the same. What has changed in the marketplace or health care policy that would make me change the strategic plan? And I had to basically shut up at that point that eight or nine years ago he was right that it made a lot of sense this in terms of the universities doing what is playing by the rules of the game and this is what would bring in the money. Second story, so Monica mentioned the Southside Diabetes Project and one of the things that it involves is working with six different clinics in the Southside Chicago and this is one of them on the right side, Chicago Family Health Center, Ashland Family Qualified Health Center, very mission-driven, really good people. And so we would check in them every every few months and at this particular meeting with a mental, Chief Mental Officer was there, he basically said well you know we love the program, we love the way that we're trying to transform care but we have our limits and he said that well because of the way we're paid there's only so much we can do to make what we think would be the logical type of change that would help reduce disparities. So I'll say that it's not just the University of Chicago, it's even some of the most mission-driven family qualified health centers that were in the same boat. So there are different definitions of disparities. The one I'm going to use for this talk is the one for the Institute of Medicine. Differences in the quality of health care that are not due to access related factors or the clinical needs, preferences of patients will be appropriateness of interventions. That's a lot sort of that's bundled in that definition. So I'm going to show it here graphically. This is one of Monica's slides that she was going to show. The vertical axis is the quality of health care. The big white bar is a non-minority population, say a white population. The lower darker bar is a minority population, say African-American population. The difference is the difference in the quality of care divided into three different aspects. The first box is what's thought to be perhaps okay. So if there's a clinically appropriate reason for the difference in care or patient preference issue. The latter two boxes are the ones which are problematic, so-called disparities. The middle box being the way we set up the way we organize care and pay for care. And the third box is various forms of discrimination or implicit biases. I'm going to be concentrating upon most of the second box here in this talk. So quick history of health disparities. So it's relatively new in terms of the national consciousness. So this is 1985, 31 years ago, Margaret Heckler, Secretary of Health and Human Services in President Reagan's administration. This report, Black and Minority Health, the first federal report showing disparities in the country. So the old-timers here will remember this article from Kevin Shulman, New England Journal of Medicine, 1999, that was entitled, The Effective Race and Sex on Physicians' Recommendations for Cardiac Catheterization. This is a vignette study where it basically had a patient that had clinical indications for heading cardiac catheterization. So the patient should have received cardiac catheterization. Randomized vignette study where the only things that differed in the randomized vignettes were the gender of the patient and then the race of the patient. You see the actual photos used in the vignettes. And what it showed was that there's disparities, so that even though all these patients should have been referred to cardiac catheterization, in particular, if you were a Black woman, you had the greatest under-referral then for cardiac catheterization. So this is the study that perhaps made the most impact in terms of the public, because it sort of, people can grasp it that it is sort of an overt discrimination or implicit bias in this particular case. Monica mentioned 2002, the Institute of Medicine Unequal Treatment Report, giving a lot of visibility to this. And then all I was going to say at this point is that up until maybe 10 years ago, most of what academia did was document disparities, so endless studies, documented disparities, and a lot of studies showing what the cause of disparities, very little on solutions. So we were fortunate in the University of Chicago about 12 years ago to become a National Program Office of one of Robert Wood Johnson Foundation's major disparities programs, finding answers to disparities for change. And about three, four years ago, we published this article that we call our roadmap article that ended up getting a lot of play. It was cited in a recent National Academy of Medicine report on best practices for based on disparities, and it's cited in the Medicare's equity plan. And so, and I think it's become like a common acceptance that this is the type of approach that makes sense for transforming care. And it basically devolves down to three principles. First, there's no simple magic bullet. And then second, it requires a systematic process. And this is one of the reasons why it's hard. It's not a magic bullet. A systematic process that involves numerous steps, including awareness and prioritization of achieving equity by both individuals as well as institutions like the University. Tailoring your solutions to the local organizational and patient context. It's an iterative quality improvement process. You're not going to get the solution right the first time. You've got to keep on adapting and trying again. And addressing the specific barriers of facilities to change. And then it's a little implementation of science. How do you get things to work in the real world? At the same time, though, if you just say, well, here's the process. Go ahead and do it. People don't like that. And so there is a menu of evidence based interventions that organizations and providers can use as a start, but that will have to tailor to their own particular setting. So it's a fair amount. We know it actually now in terms of reducing disparities. So some model slide addition to this reminds that there are multiple targets then for interventions, the community, the patient, the provider, the health care organization. I want to talk about the top part, which is the policy lever and particular financing, which is perhaps like the potentially one of the most powerful levers that it's not really being used right now. So payment reform from Lyndon Johnson to the president of President Obama. So in 1965, Medicare being passed and the AMA was initially against this. And the concern was basically depression of physician fees. So language was built in that Medicare had to pay the usual customary reasonable fees so that that the physicians would, from AMA's perspective, not be under reimbursed. If you fast forward to the 1980s, in 1989, what was passed was the resource based relative value scale. And what that was was a physician payment scale that was built upon research that tried to figure out what was the amount of work that was required to do something like a colonoscopy, to do something like a geriatric visit. And then payment was based upon that. It's actually one of the major problems right now in payment reform because it basically highly over reimburses specialists at the expense of the cognitive sciences like a geriatrician, for example. And politically, one of the reasons is that it's run by what's called the AMA Resource Based Relative Value Scale Update Committee of which I think like 22 out of 24 people are specialists. And so there's a lot of conflicts of interest there. In 1997, the Medicare Sustainable Growth Rate Act was passed, which said that physician payment could not exceed the growth in the gross domestic product that people were afraid about the Medicare budget ballooning. The rubber hit the rubber in 2002 when, because this act was followed, physician reimbursement would be cut by 5%. Then it was a lot of concern then that if physician payment was cut, people would just believe the Medicare program and that there would be access problems. So this is succeeding 12 years then, Congress then passed a variety of the so-called DOC fixes where basically they overruled that particular rule. And then this basically happened again and again and again. And then last year, this sustainable growth rate was repealed. And you can hear more about this in the policy environment, but something called MACRA was passed that we placed the SGR. So we'll talk more about MACRA in a moment. But what happened though is that this is basically the shift from paying for volume to so-called value-based payment. So the current Secretary of Health and Human Services, Sylvia Burwell, 2015 Nijim editorial, she talked about like the two different sort of forms of delivery. So this Medicare fee for service, payment by volume. So by this year paying, tying 85% of that payment to quality measures or value measures as opposed to this purely paying based upon just having it done by 2018-90%. Then the second bullet here is then alternative payment models. We're hearing about things like accountable care organizations, bundle payments, basically various forms of putting payment into a global amount. And the money comes from that. But under these systems, providers being comfortable again for the quality and now the cost of care. By this year, the goal was to have 30% of Medicare payment through these alternative payment models by 2018-50%. So the threshold shifters saying, this is my story that I had this sort of chance meeting with Secretary Burwell just by chance. And so it's only situations where you had, I had like 30 seconds to make a pitch, in terms of basically seeing her. And so basically the pitch I made was that you got to basically explicitly use your payment reimbursement mechanisms to explicitly try to reduce disparities. That was my 30 second message to her. So MACRA, it's an acronym for the Medicare Access and Ship Reauthorization Act. So again it eliminates this STR, there's a 0.5% annual rate of increase in physician payment through 2019. 2019 becomes live. Something called the Quality Payment Programs where all physicians and organizations need to choose one of two pathways. Something called MIPS, the Merit-Based Incentive Payment System, and the second called Advanced Alternative Payment Models. What's MIPS? Well, a physician's reimbursement can either grow by up to 4% or decline by up to 4% based upon these measures, these basic quality measures, composed of four different elements which are a lot of four bullets here. 60% of the calculation is based upon your performance on six quality measures that you report. 15% will be based upon your quality improvement, clinical improvement activities. 25% will be based upon your use of electronic health records, these five different measures for that. Note that at present 0% is allocated to how cost-efficient you are. By 2021, 30% of the formula will be based upon the cost and resources. Advanced Alternative Payment Models is the other pathway. So the advantage for this is that off the top you get an automatic 5% additional bonus payment to incentivize people or physicians going to this particular pathway. You have to use certified electronic health record. Payment is based upon quality measures and then as we mentioned before, the provider needs to be more than a nominal amount of financial risk. So it's idea about the global payments, ACOs, patient and mental homes, episode-based payments. So I've just spent about five minutes talking about some of these arcane details of payment policy, which I think are going to be important to realize. But you may have noticed that where's equity? And that's the problem that basically it hasn't been in anything I've mentioned in terms of these major directions that Medicare and the payors are going into at this point in time. So this issue of motivation and so that especially for McLean audience, I think we talk a lot about professionalism and doing the right thing and having more values. Extrinsic motivators are also powerful though. So money can be a powerful motivator and non-monetary financial or rewards also. So we had another sort of major piece come out this year, creating the business case for achieving health equity, which again has already started to achieve a lot of traction. National Academy of Medicine sites in that report. There was an equity leadership forum sponsored by the American Hospital Association and Joint Commission, which talked about the six principles I go over. Families USA, major consumer advocacy group, is adopting these principles as well as the national quality forum. So there's six different aspects that we're basically arguing for in terms of things that this was going to be probably more likely if there was a Clinton presidency, but those have to be introduced and sort of pushed forward under the President Trump's presidency. So first, requiring public reporting of stratified disparities data. So in other words reporting performance quality data stratified by race, ethnicity, or insurance status for example. Once people see the light, in some ways it's like a sanitizer, that when people see the data, people are motivated then to take action. Strengthening incentives for prevention and primary care. I mean right now money is in quaternary care, so that there need to be stronger incentives for prevention and primary care. Most of the current global payment systems right now, like the current ACO systems, actually the amount of money at risk is relatively small, so that the at-risk amount probably needs to be increased to basically create the stronger incentives for investing in infrastructure for preventive care. We talked about the RVU problem in terms of the payment schedule being weighted towards proceduralists, and we talked about encouraging intersectoral partnerships. The third one is what I still don't know why it's not being done already, which is pay for reducing disparities. Right now there is the so-called rising tide lists all boats perspective that if you improve quality in general, so you do something like the general quality improvement initiative, the assumption is that it's going to help everyone. Whereas this increasing evidence that you basically have to tailor to the specific needs of different populations, different individuals. And so besides we're worrying for overall quality, why not reward for reducing disparities? Aligning these quality measures across public and private payers so that if all the payers of the place that you know Chicago have the same metrics, then we're more motivated to basically meet them. And then taking care of the safe net providers, and some of that thing I want to sort of alluded to, that there's a relatively small number of the hospitals and providers that take care for the majority of the at-risk patients. And so they again need to have special help, adequate payment. Right now there was something called dish disproportionate share hospitals that was greatly reduced when the Obama Act was passed. The problem was that it was assumed that increased insurance expansion would then compensate for that because so many different red states did not expand, those states are being killed. A risk adjustment to create a level playing field, so adjusting, for example, for the social factors involved, that are part of the patient. So actually Dean Polanski makes this point that, and that was his major suggestion when I showed him a draft of this paper, that a place in the University of Chicago would penalize because of the high number of Medicaid patients we take care of unless there was risk adjustment to better create a level playing field. So the place in the University of Chicago had more incentive to care for Medicaid patients, demo projects, but the main point is having an explicit equity lens of thinking about up front, how we design our payment and care systems so that we reduce disparities. So we are already a program that's morphed into one that now looks at payment and delivery system reform. So we're giving out grants and evaluating this. Most of our grantees do a combination of payment reform, it ends up something like a global payment scheme. And we want to share now this the last couple minutes now. So some of these are some of the research questions that are cutting it. So what are the best payment models with cheap equity? How do you optimize intrinsic and extrinsic motivation? How do you overcome payment reform implementation barriers? I'm going to share some quotes from some of our current grantees that sort of crystallize some of these issues. So about intrinsic motivation, one organization says, I think even if it was presented as goals only, no financial attachment, I think just the fact that we are certain things that we need to meet, I think that's a push enough for everyone. So it's professionalism. One payer says money helps. Just like with everything else, what gets monitored gets done. So yeah, I mean, they should be doing it, but having that additional incentive, I think does serve as a very good reminder. And the fact that it's sort of team-based, I think makes it somewhat effective in linking the two, the behaviors, that incentive and hopefully the positive outcomes. This issue of maybe it's not sort of money for the provider, but having a good infrastructure so we can deliver good care. So it's not about the financial incentive. It's about the non-financial incentive, right? It's about not only you get to do the right thing, but that you have the resources to do that. So we thought the primary part of the study was that it's going to be most impactful was this extra resource and making it easier for clinicians to do the right thing. So for example, being able to hire community health workers or care managers. I think that the amount of money it costs to actually budge them providers, if it was based on the financial interest would be just too high. If you really want to change behaviors, then give them each a ton of money for each postpartum visit. I am sure they would do it, but that amount would be something that no one could afford. Coercion. But you know, at times we felt like we had been coerced, you know. If you don't do this, then you don't get it, okay? So there was that fine line, you know, incentive versus coercion and money. So difficult issues to sort out. 10-hole issues. So number one, does it get to the right person? X, I don't know that. And number two, if it doesn't get to the right person, you know, what can we do? If it does get to the right person, how can we make sure that person pays attention to it and evaluates that opportunity for the practice? So the money goes to the right person. And then who do you incentivize? And the challenge I think is making it meaningful to the individual providers when these incentives are paid at the practice level. Having the practices figure out how to tie those payments back to providers and how they want to organize the practices around that type of performance incentive. So a lot of unresolved issues. So and then that a couple of years ago I had an editorial in the New England Journal of Medicine that was how to achieve health equity. And it devolved down the four things. Looking at your own data, if you have disparaging practice, talking to your patients and telling me to care for them, align the incentives and assisting the safety net. And so I'll just end the University of Chicago. We're actually, since Dean Polanski came on board, we've made a lot more progress. I think part of it is his background from South Africa where he saw apartheid and the spares up front. So I think part of it is sort of morally driveling. But I'm not so naive to believe that it's the full thing that's driving the University of Chicago. And because now the environment has shifted then my initial story eight, nine years ago where we now have, I think it's fair, it's fair that global payments and ACOs are coming. Actually, we'll be entering our first ACO contracts I think in 2017. More at-risk contracts, population health is becoming more important. Paper reform is the community needs assessments required for a non-profit like the University of Chicago to maintain its non-profit tax status does now finance the census to start looking at disparities. The last slide here, I have the leadership of our center here. So I think this needs material by saying that leadership matters. It is a professional responsibility as clinicians, administrators and policymakers to improve the way we deliver cure to the diverse patients. We can do better. And I think as Monica eloquently said at the end of her talk that this is going to be an environment where we all need to basically make sure that advocacy is a priority and that we work on these concrete ways that we can help improve the way we deliver and pay for care. Thank you very much. Time for a few questions. I see a few people making their way to the mic. And then, Marge, did you have a question? Ask a question. I'm wondering if there will be any policy in place for reimbursement with a harm reduction framework. I work with patients who drink up to six two liter bottles of soda a day and smoke five to six packs of cigarettes. When we get them down to a pack a day or one liter of soda every other day, we get the hemoglobin A1C down to eight from 14. Those are achievements. But from the goals that the government has, we're still not succeeding with the numbers. So I'm wondering if there's a voice for people that have a different lifestyle than most of us in the room. Because a lot of the numbers are wonderful. But really, it's about a harm reduction model. That is the success. There are a couple of potential areas that can come into play. One is that the more that there are these global contracts, then people are looking at the so-called high utilizers, the high cost patients. And so some of the folks that are like the multiple community patients that it be, maybe substance abuse, behavioral health, frequent visits to the emergency department, these are the folks that places like the University of Iowa are starting to design systems to basically pour more resources into trying to keep people healthy and not in the emergency department in the hospital. The second strand is that there are some thoughts about can you give more reimbursement to the cure that is evidence-based. So if there's evidence-based practices for harm reduction in terms of like mental health treatment, for example, or substance abuse treatment, or outcome space in terms of rewarding if you're able to have the end results of people with better risk factor control. So those are the potential two different strands that may help with what you're talking about. What you talked about is AX, okay, so it's back on. Did you hear the beginning of the question? So it's interesting that the Institute of Medicine takes access out of the disparities equation, but it looks like that you put it back in, which I think is probably important. Do you really think that incentivizing people not to practice disparate medicine is the way to go with this? Because it seems that incentivizing something like that sort of goes against sort of the moral sort of fiber of doctors taking care of patients. And I think this whole move towards incentivizing things is really a move away from sort of practicing ethical medicine. Yeah, come a point. Thanks Dan for those comments. So first in 2010, the IOM revised their definition of qualitative care. So AXS is now one of the dimensions of qualitative care. So that has been elevated to a more prominent in the IOM's overall view of quality of care. I think in terms of this issue of the balance of professionalism, individual incentives to physicians and then resources to reduce disparities. It's got to be a balance. And I feel like my quotes I gave at the very end show that it'd be simplistic and wrong based on trying to emphasize one over the other. So for example, that is core. It's got to be professionalism. That this is some of the things that are involved in believing great care to patients. That it has to be driven by doing the right thing for patients. But at the same time, at the margin, it probably makes a difference. So for example, one of our grantees is incentivizing teams, not just the physician, but like the nurse, and the front office person and all. And some of the early evidence teams have been showing that, well, for things that then require the whole team, then that can make a difference at the margin. And then the overall institution, you're going to have to make it so that it makes sense for a big battleship like the University of Chicago to work in equity. So there's only so much that goodwill and the overall ideals the university can go if the famous system is stacked against putting a lot of resources in equity. So it's going to require all three of those things, I think. Thank you so much. Okay, thanks. All right.