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Accountable Care News: July 2015

Catching Up with… David Fairchild, MD, MPH is a Director and Senior ACO Advisor at BDC Advisors, specializing in physician organization and engagement, clinical quality improvement, and shared-risk contracting in academic health systems. A former Chief Medical Officer and Senior Vice President in major academic health systems, and president of a Medicare Shared Savings Program (MSSP) ACO, he has extensive experience in the development of ACOs, clinically integrated physician networks, and population health management strategies. He talks about his ACO experience, hospital-physician relationships, the current medical school curriculum, recent CMS ACO policy, patient-centered medical homes, and himself.

Accountable Care News: During your time as president of the UMass Memorial Health Care’s MSSP ACO, did you think you all would be ready to accept some risk after the three-year period?

David Fairchild: Many institutions talk of a “glide path” to taking risk. Not many institutions actually take this path however. When there is no real pressure to change care models to prepare for population-based reimbursement, it is tempting to stick with the current systems of care that work well for fee for service. Starting a MSSP ACO in January 2015 created the needed pressure and mandated a time frame for the UMass Memorial Health Care System to migrate to accepting risk. I have since stepped down from my role as President of the ACO, but I believe we— the ACO— will be ready to take risk after 3 years. We took seriously the need to invest in care management infrastructure. We established a preferred provider network of skilled nursing facilities, and we applied our sophisticated quality collection and reporting system- honed in the Blue Cross Blue Shield of MA Alternative Quality Contract (AQC)-to the ACO quality metrics. I think the ACO is on the right glide path.

Accountable Care News: The American Medical Association and the American Hospital Association recently released a set of guiding principles for hospital executives and physician leaders to work together in leading new healthcare delivery efforts such as ACOs. In your mind, what are the keys to making this relationship successful?

David Fairchild: All good relationships are based on trust. This sounds obvious and simplistic, but creating trusting business relationships between hospitals and physicians is never simple, as it requires an organizational architecture that engenders alignment of goals and operational congruity. One of the keys for a successful health system relationship is to have a strong physician organization that can truly be the equal partner to the hospital. Bringing together employed and independent physicians or aligning community and academic physicians- who often come from significantly different clinical cultures- requires careful attention to the balances of governance so that no one constituency feels underrepresented. To be successful in risk contracts requires true clinical integration that can best be achieved by a well- functioning hospital – physician partnership. Integration of information systems makes data collection, analysis and reporting more robust. In turn, good data- that doctors truly believe is credible!- will create the foundation upon which process improvement is based, and will propel both quality and financial performance.

Accountable Care News: You have been on the faculty of two medical schools. Are today’s medical students getting enough training in the non-clinical areas that are critical to health care reform, e.g., information technology, team care, interprofessionalism, leadership, incentives?

David Fairchild: I have been on the faculty of three medical schools, and I can certainly say that over time, these topics have been increasingly emphasized in each school. That said, I think most practicing physicians would say that no trainee is really prepared when they enter the real medical world. Leadership development in particular is an area where I feel medical training still falls short. We need more physician leaders who feel comfortable working at the interface of business and medicine. Many health systems have leadership development programs to fill this gap. The one area that the young providers have an advantage is in the use of information technology. From running medical apps on their phones to finding their way around the EMR they frequently outperform us older physicians…I am not sure they learned this in medical school, however.

Accountable Care News: What is your take on CMS’s recent changes to the MSSP program and the introduction of the new Next Generation ACO model?

David Fairchild: CMS has made a move in the right direction with its new rules for the MSSP. However, the shared-savings ACO, even in this new iteration, remains a transition step on the risk continuum. For accountable care organizations that want to develop competency in managing Medicare beneficiaries, the MSSP offers a low risk (but not low cost) point of entry. While the new rules make some improvements, the MSSP shared savings model will likely continue to have limited appeal as ACOs skilled at care management will continue to be more attracted to Medicare Advantage contracts. In the new track 3 model, the retrospective attribution methodology, that has so frustrated providers, is now replaced by prospective patient assignment, so that providers will know who their patients are at the beginning of the risk year. In addition, the risk and reward range is increased in model 3 which will appeal to high performing organizations. Overall, the new rules are advantageous to providers, but I don’t think they have gone far enough yet to make the ACO more appealing to providers.

Accountable Care News: Putting on your academic/researcher hat as editor-in-chief of Physician’s First Watch, which goes daily to some 160,000 primary care clinicians worldwide. how do you assess the performance of the patient-centered medical home model in meeting the Triple Aim?

David Fairchild: I love the concept of the patient centered medical home. I believe that it can improve care. However, the data is mixed on how effective it is in achieving the triple aim- particularly in reducing costs. Implementing the medical home model is expensive. Therefore, we probably cannot afford to provide PCMH services to all patients. Better segmentation of the patient population will allow PCMHs to target patients who are most likely to benefit from intervention.

Accountable Care News: Finally, tell us something about yourself that few people would know.

David Fairchild: My career has followed what I call the physician-administrator track. Blending clinical, academics and administrative/operations roles I have had a very exciting career trajectory. The truth is that getting on this career path was completely serendipitous. Here is the brief story: After residency I joined the Indian Health Service as a primary care physician. After the first year the clinical director of our 60 bed hospital left and none of the other physicians were interested in the job. So, a family doc and I agreed to split up the responsibilities. This is how I became the Chief of Staff of Chinle Hospital in AZ one year out of my residency. I found I loved the blend of administrative and clinical work, and all of my subsequent jobs and roles have been variations on that theme.

David Fairchild, MD, MPH

  • Director and Senior ACO Advisor at BDC Advisors Miami, FL

  • Former Senior Vice President for Clinical Integration and President of the, MSSP ACO, UMass Memorial Health Care, Worcester, MA

  • Former, Chief Medical Officer and Division Chief of General Medicine, Tufts Medical Center, Boston, MA

  • Former Director of Primary Care Services at Brigham and Women’s Hospital and Assistant Professor of Medicine at Harvard Medical School, Boston, MA

  • Editor-in-chief, Physician’s First Watch, an e-publication of the New England Journal of Medicine (NEJM) Group

  • MD degree, Pennsylvania State University; MPH degree, Harvard School of Public Health


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