A: During my tenure at the Centers for Medicare and Medicaid Services, one of my many roles included serving as the Director of the Center for Medicare and Medicaid Innovation. It was an honor to lead the dynamic Center during a major health care shift in our country. I had the pleasure to direct and work alongside very talented leaders and staff to develop, test, spread and scale payment models and stand up key delivery system reform policies. CMMI was one avenue in creating a platform to test new approaches to health care payment and delivery while improving the value of care for Americans. We initiated major changes to make real progress in transforming the health care system during my tenure. We made it a priority to actively seek stakeholder feedback and utilized human-centered design approaches.

There are myriad accomplishments from my CMS career in which I take great pride, specifically from my CMMI tenure. Through dedicated efforts, we received CMMI’s first actuarial certifications to expand the Medicare Diabetes Prevention Program (DPP) and Pioneer Accountable Care Organization (ACO) model. The Medicare DPP model aimed to prevent type 2 diabetes for individuals with pre-diabetic indicators. We closely collaborated with the National Institutes of Health, Centers for Disease Control and YMCA to encourage lifestyle changes in people with high risk for the disease. This evidence- and community-based prevention program demonstrated that costs could be lowered and quality could be raised – and those improvements could be sustained. The Pioneer ACO model was very successful, allowing providers to transition from a shared savings payment model to a population-based model, separate and apart from the Medicare Shared Savings Program.

In addition, we partnered with the states of Maryland and Vermont to modernize the all-payer model for hospital services to improve patient healthcare and reduce costs. We also developed the Oncology Care model (OCM) to begin tackling the effectiveness and efficiency of specialty care for Americans. Specifically, OCM worked with physician practices and commercial payers to enhance care coordination and chemotherapy treatment for cancer patients. We also developed the Comprehensive Care for Joint Replacement model to begin addressing episodic care associated with hip and knee replacements in this country – the most common inpatient surgeries – to improve quality and coordination of care through recovery.

Lastly, we developed the Quality Payment Program, an alternative payment model to provide incentives to clinicians participating in high-quality, valuable care for episodic care or populations. In 2012, we had 0 percent of payments in alternative payment models, where providers were accountable for quality and total cost of care. By 2016, over 30 percent of provider payments were in alternative payment models like ACOs, bundled payments, or comprehensive primary care.

The shift toward these new payment models represented over $200 billion, which is a giant leap forward for value-based health care. CMS is now headed toward 500 ACOs in the public market, and even more in the private market. Under our Delivery System Reform efforts, we collaborated with a range of stakeholders to move from volume payment of care to value payment of care. We launched the Health Care Payment Learning and Action Network to improve care, lower costs and promote healthy populations.

A: The cost of health care is a fundamental problem facing the health industry. Collectively, we must address the prices we pay for quality health care.

Instead of creating a new health care system, we should focus on solutions that lower costs for all populations, including patients with multiple chronic conditions. It’s imperative that we collectively address rising prescription drug prices and actively work to lower these costs.

One area where we must make progress is in looking holistically at health, to include examining social determinants of health and sustaining healthy populations through focused efforts on primary and preventive care.

Americans have more personal choice in health care and insurance than anywhere else in the world. That range of options is fundamental to a health care system that offers affordable care with better health outcomes.

America’s health care system is a global leader in innovation and offers some of the world’s best hospitals and treatments. We shouldn’t give up on what’s good about our health care to build a new, unproven system.
I’ve had the pleasure of leading the country’s largest health payer and now leading North Carolina’s largest health insurer. Value-based care is crucial to a sustainable health care system that provides life-long quality care for Americans. And we all need to pick up the pace of change to bring about a value-based system.

A: Health care is delivered locally, personally. It’s not a one-size-fits-all proposition. Health insurance has to be just as focused on the individual.

The great advantage of the collective power of Blue Plans is our deeply embedded roots in the communities we serve. Nobody knows our markets like we do, nobody has the history and relationships we have with our provider networks. Simply put, we’re best positioned to lead the transformation toward value-based, consumer-focused health care.

BCBSA plays a critical role in facilitating communication and information sharing among Blue Plans, identifying what’s working and how those successes can be scaled and replicated across the country.

BCBSA is a central source for insurance claims information, taking the lead on utilizing big data to stay out in front of emerging trends. By collecting and analyzing claims information from Blue Plans across the country, BCBSA can identify trends and even help mitigate health crises before they reach a critical stage.

BCBSA sifts through its mountains of data for monthly Health of America analysis reports. These reports help payers, providers and consumers understand why health care costs have been rising so dramatically and by making the data public, we can provide insights on consumers’ role in moving toward value-based health care.

A: Mergers and alliances can create disruptive change and lead to innovation into the market. With change, there is opportunity. I don’t view these alliances or mergers as threats. They are a wake-up call for all of health care: Change must happen and it has to happen now.

With CVS-Aetna, time will tell. It will interesting to see how the companies integrate and maximize value throughout the partnership.

In terms of the Amazon-Berkshire Hathaway-JP Morgan Chase plans, my biggest takeaway is that they’re so upset with the current system that they want to disrupt it – and my reaction is, we should listen. They’re identifying a real problem; we want to be part of the solution, too.

At Blue Cross NC, we’re actively working to be the change for our customers. We are creating a value-based health care system committed to more choices, better access, lower cost and higher quality of care. We are keenly focused on primary care, social determinants of health, provider and beneficiary relationships, using human-centered design approaches to keep the focus on consumers.