In this episode Chess Vice President of value-based operations, Josh Vire, has a conversation with JP Sharp, one of the original architects of the Next Gen ACO model at CMMI and current Chief Growth Officer at Rippl Care, about what it was like at the infancy of the value movement.
JP Sharp welcome to the move to value podcast
Thanks! pleasure to be here!
I want to start you have had an interesting path in getting into the healthcare you are a lawyer by training, and you earned your JD from the University of Michigan also received your Master of Public Health from there as well was there a particular moment or experience that got you interested in in healthcare and moving away from the law?
Yeah, excellent question. I won’t pretend to give universal career advice on how to go about this, so I could tell a little bit about how I got started, which is I went into law school kind of with healthcare in mind. I have a healthcare family from different angles, a veterinarian, oral surgeon, and a pathologist all kind of in the in the family. And I was a little bit of the black sheep and didn’t go in directly into the clinical side of things but was still fascinated by it and also just the complexity of it. So, as I was thinking about you know grad school that’s when the ACA passed and lots of effort and attention on that unique window of opportunity there. So, I went in thinking I hey let’s be a lawyer for a little bit and focus on healthcare and then see what happens. And the see what happens happened most sooner while I was in school and just realizing that great experience, but I wanted to start doing things and being part of this transformation sooner rather than later. So that’s kind of where I took that turn to say alright how do I get on the front lines and really start being an actor in this space.
That’s great. Interesting to sort of hear your thought process there and glad you moved over to healthcare. You’ve had an expensive career been in a number of places including CMMI, Blue Cross Blue Shield, Optum, recently you’ve moved over to the provider side of the house. But I’d like to start with your time at CMS. You were there in the in the early days of CMMI and payment transformation and redesign, tell us a little bit what was that experience like being there in those early days?
Yeah, it was a lot of fun it was pretty unique. Some people described CMMI as the little innovation group inside you know the government bureaucracy, and a little start up inside the government and it’s actually like that both with the people, the mission, and mostly like how we worked physically. It was set in a separate building which, one of those like nondescript you don’t know it’s a government building from the outside, but you know inside they’d like colored it you know bright colors and had treadmill desks and stuff and so it was like they set it up to actually be a little bit more exciting. And they brought in people who otherwise probably weren’t going to be super attracted to government jobs like that you stereotypically think of, you know the bureaucratic of regular day-to-day stuff, but they’re able to because of the mission here and the attention that this is getting is just a major off opportunity and moments in healthcare transformation. They brought in people of all walks of life and different backgrounds. So, we had people with Health Sciences, health services researchers with pH D’s and MD’s and MBAs and MPHs and a few folks with like me with random other degrees just all like get around the table and figure things out from end to end. And so, it was really just like a very mission driven place with this big task ahead of ourselves and you know it’s something that you quickly learn too, is that the funding behind it it’s actually pretty big. You’re thinking about how to build a portfolio over 10 years which was the first kind of funding cycle of CMMI $10 billion over 10 years and to really ramp that up from zero to how are we actually going to be distributing these dollars, paying differently, and getting out the door to actually learn things in a reasonable time frame. So that then the end goal of all of this is to say what actually reduce costs and improve quality or some combination of the other and then expands those things to actually make a scaled national level impact.
And so you see the kind of evolution from the early days was let’s just try to get money out the door like and like start things happening, to getting a little bit more refined still alright let’s think about the a rigorous evaluation before you know the models start going you know so it’s like set up to evaluate more properly how you refine and tweak all of those little ACO levers and policy points, just doing it a little bit more iteratively than you often see the government doing uh kind of with one big program launch. And so that was that was a lot of the both exciting but a little scary you know components of being there in those early days.
It sounds like a good and interesting time a unique time for sure yet your description of the building is not what I would have in mind for building.
Yeah Woodlawn, Maryland out there you know that you see the big CMS building which looks like a big government building out there and then you don’t realize that like down the street there are a few other like expansion parts that you know you wouldn’t know that the CMMI is operating inside there.
That’s great so tell us a little bit about where you were in in the path of CMMI. So you and your team I believe were heavily involved in in the design of the NextGen ACO model. What other big the items were you working on in terms of payment design your days at CMMI?
Yeah so, they had you know various different groups. I was in what they called the seamless care models group and that had ACO programs as well as other primary care related initiatives and the first of the kidney care initiatives which have since all of which have evolved recently. And so those were all kind of the first and second iterations of those programs focused on the broadest based risk distribution to responsible provider partners out there. And so I went on back row legislation passed so that a big part of that is if folks recall was payments and setting up a new program which we ended up calling the quality payment program and about half of that was the new MIPS program, which I’m like no comment on other people love it or hate it or you know or ambivalent, but the other half was designed to accelerate the adoption of alternative payment models. And so, I led that work of basically writing that first rule and launching that first program under the quality payment program which was just a phenomenal experience and spanned everything we were thinking about as far as APM’s go and I you know got my probably lifetime fix of writing like large federal rules like that. But it was pretty cool I mean the number of comments on this thing like broke records. It was just one of these things that was also a pretty potentially big shift in broad based payments across CMS, Medicare, Medicaid. And so, it’s kind of grappling with all these key decision points. Of course, the legislation’s tricky. As an agency you have to operate within what Congress passed, and so there was just a lot of that’s when kind of the legal stuff like actually came in handy and like to say like how do you read this law are the degrees of freedom that the agency has to be able to actually just execute the intent of this or make sure it’s as successful as possible or gets that kind of intended effect through you know all these different little levers inside the big kind of legislative language that they placed in our way. Yeah, that was that was most of my time there at CMMI and spent a little time in the front office doing a general strategy portfolio strategy work as well.
Love to hear as you were there in developing and designing those models, what stuck with you in terms of principles that that you learned that were important to alternative payment models and value-based care?
Yeah, and um I certainly won’t be able to recite them, but I like the use of principles and I’ve kind of carried that everywhere I go and that’s also something that our director at the time, Dr. Conway, also used you know it was like what are the what are the guiding principles? And so again I won’t be able to recall exactly what we’d written down on paper, but we did actually have that while we were creating these new payment models is writing it down and putting up on the screen in all of our meetings and conversations, these are our principles for this model and the purpose of what we’re doing. But actually part of the like preambles if you ever read the requests for application for the CMMI my models, they still do this too, is usually a purpose section at the top and it’s like it gets like written in kind of obscure legalese but it is it is something that’s like tailored to the models to say this is what we’re trying to test here and why. And so as a center there are a couple parts like there were technical things we were trying to figure out and so as like this is very early days of ACO and all the things we now take for granted on how to do attribution and how to benchmark and how to like exclude people or cart people in or out, all of this like what time periods you’re doing stuff and if you know what you do with the ESRD population relative to the general population and all the things that like happen under the covers now when you sit down with actuaries and contracting stuff and like look at what has been learned in this ACO space, those were still like evolving.
So, there’s a lot of like technical learning on just how does this program mechanically work in a way that’s going to be fair to providers, something that’s going to actually attract people or provider organizations that want to apply participate in this see this as an opportunity, both financially and clinically to do better and do good things. And then really just overall broadly there’s like gain adoption and experience and learn. And so, there’s also there’s a whole group at CMMI called the learning and diffusion group that kind of span the models. And so that was that was a bit of just the indicator of what we thought was important at CMMI, which is all of these models need to have a learning component, they’re evolving both the government and the participants and the providers in these programs need to learn from each other and kind of across all those streams. So, kind of having that infrastructure was really key. And then of course having a certain number of successes that could be quantified, meaning OK these models actually, through evaluation rigorous evaluation met the criteria for reducing costs, keeping quality the same or improving quality, and keeping cost the same and proving both. So, getting things that actually crossed that threshold in which CMS could recommend, that it would expand the program more broadly. And so that having some programs actually accomplish that which they did and then actually expand them was a big goal to say alright like you know we’re learning a bunch of stuff but there’s also savings that are being generated by the center.
So, after CMMI you went to a private payer, Blue Cross Blue shield of North Carolina, where we worked together in designing alternative payment models there. What are the differences you know going from the largest payer in in the country being Medicare and then going to a private payer? What was more challenging or what worked better or just different?
It was a lot of fun making that shift and I think it was a good mix of things that were pretty similar and things are very different and so it was a nice transition and challenge and that was the kind of mission of going and doing that was hey we did a bunch of this stuff at the federal level, we started to get the ball rolling, what does that look like in the private market if we were to really make this a top priority somewhere, which is what Blue Cross did and which was what made it exciting as to say alright if we get all the energy behind this at a private payer, what’s the you know how big of a swing can we take? So, I think similarities were hey these are both big bureaucratic organizations certainly federal government the biggest most bureaucratic organization but they’re also like pretty good at it but also very rigid so we were working through like deep operational issues there that were not fun or cool but there were just part of what like doing health policy transformation is. Like, how do you change the coinsurance you know variation or variable or like the counter on it for a beneficiary if they’re going to provider A versus provider B because ones in an ACO and one isn’t. And make sure the beneficiary isn’t harmed and they’re paying you know no more than they were going to before, hopefully less. And so like all of that stuff on a claims operating system that was decades old and good at moving like a trillion dollars but not good at changing.
That’s actually not far off from the where like Blue Cross was also which is a billions of dollars flowing through that on an annual basis, how they could accurately do you know fee-for-service claims in a certain way because that’s what the systems over decades have been built to do, not super good at doing all kinds of creative flexible things that we were wanting to test and do with providers, especially if you know we had five different we wanted to launch a year that all did things a little bit differently. So, that was like pretty similar across them. I think the you know fun part and different part is thinking about the different parties more. Where you know federal government gets to create a program in a box certainly with a bunch of input over time, so a lot of learning research goes into these things but then they say here is the monolithic model. Come apply to it and everybody and it comes and participates in the exact same program under the same terms. At a private payer it’s all like a bunch of negotiated contracts at the end of the day. And so you try to make it as you know consistent as possible for the sake of not having wasteful customization all over the place and things that that break, so you try to try to keep things as close as possible but each party is going to have different interests, different negotiations, different like elements that are just important to each party in each of their conversations. And so, thinking about all those different variables all the time was a lot of fun. Plus, there’s also you know less prescriptive regulation around what those contracts can look like at CMMI like this is your mission, these are the types of programs you could launch, this is your waiver authority so you can move these levers in these different ways and pay people differently in these prescribed ways. At a private payer the regulatory window is a lot wider in which you can pull a lot of different levers without having to go back to Congress and ask them to you know change something so that was a lot of fun too yeah stop I’ll stop with that I could go on…