Hello, and welcome to our second general session exploring COVID-19's impact on health care and quality in particular. My name is Ty Gluckman and I'm honored to be the moderator for today's discussion. I currently serve as medical director of the Center for Cardiovascular Analytics, Research and Data Science at the Providence Heart Institute in Portland, Oregon, and also chair the American College of Cardiology Solutions and Oversight Committee, a group dedicated to developing clinical policy and tools aimed at closing gaps in care. To get us started, it is my pleasure to welcome our esteemed panelists for today's discussion. I'd appreciate you introducing yourself, telling us a little bit about the role that you play at your institution and your particular areas of interest. I'm going to start in alphabetical order. Kathy, would you please get us started? Hey, thank you, Ty. It's an honor to be with this great group to talk about a very important topic. My name is Kathy Bega. My day job is with 90 cardiologists in Chicago across 14 acute care hospitals that we are cobbling together a great service line. My night job is being on the board of trustees for the American College of Cardiology as well as chairing our MedAxium board. My goal and my passion is change. I think COVID has given us a opportunity to really enhance a lot of things and do things differently. I'm looking forward to our discussion today with the panel so we can all leave with some new ways of doing older things. Harwin? Hi. Thanks, Ty. Harwin Krumholtz. I'm a cardiologist and a professor of medicine at Yale School of Medicine, and I've had the privilege of working with members at the American College of Cardiology around these COVID issues, and very pleased to be here and appreciate the opportunity to join. Thanks so much. Tom? Hi, I'm Tom Maddox. I'm a cardiologist and professor of medicine at Wash U School of Medicine. I'm also the executive director of the Healthcare Innovation Lab there. In the college, I currently serve as the chair for the Science and Quality Committee, and in this regard, in relationship to COVID, that committee has been charged with helping think through and understand the science of COVID and cardiovascular disease. Fantastic. And finally, Cheryl. Great to be with everyone. Hi, my name is Cheryl Pegas. I am the president of Consumer Health Solutions and the chief medical officer of Cambia Health Solution, which is a large insurer on the West Coast. We cover Utah, Idaho, Oregon, and Washington. I'm also a cardiologist. I currently sit on the board of the American Heart Association. I'm the past chair of the Association of Black Cardiologists, and I work with ACC on our health equity as well as our payer committees. Great to be with everyone today. Thank you all so much. This is fantastic. I really appreciate you taking time out of your busy schedules to participate. So I'm going to try and set the stage. And in contrast to a lot of other talks like this, there are no set presentations during this session. Rather, the goal is to have a conversation about the varied impacts of COVID-19 with a particular focus on cardiovascular quality. Before beginning, I'd like to go over some basic facts. As of today, there are nearly 33.8 million COVID-19 cases worldwide and 7.2 million cases in the United States. And this has resulted in just over 1 million deaths across the globe and 206,000 deaths in the U.S. alone. Beyond the morbidity and mortality that has resulted from the SARS-CoV-2 virus, COVID-19 has had a devastating impact on noncommunicable diseases as well. We've seen substantial drops in emergency department visits and hospitalizations that have been accompanied by partial or complete disruption of ambulatory care services. In addition, and we've talked about this in other sessions, COVID-19 has shown a bright light on the longstanding problem of healthcare inequality. Current data from the CDC notes that compared to white non-Hispanic individuals, American Indian or Alaska Natives are 5.3 times more likely to be hospitalized and 1.4 times more likely to die from COVID-19. And similarly, Black non-Hispanic individuals are 4.7 times more likely to be hospitalized and 2.1 times more likely to die from COVID-19. Lastly, COVID-19 has dealt a devastating impact to hospital finances with the American Hospital Association projecting $323 billion in losses this year. And so I'm going to run through a couple of individualized questions and then we're going to take it more as a broader panel. But Tom, we have several thousand individuals listening today who have dedicated their careers to cardiovascular quality. You chair the college's science and quality committee and have also led an amazing effort to educate clinicians about the pandemic through the ACC's COVID-19 hub. Can you tell us a little bit about that effort and where things are going with the hub knowing that the pandemic unfortunately is far from over? Sure. So one thing that I think not everybody may know about the American College of Cardiology is it's a global organization and that about a third of our members actually are from other countries besides the U.S. And obviously that includes China and Italy, which were the first two countries to get hit by the outbreak. And so as that was starting to rev up and the world was starting to take note of what was happening, we started asking those members in those countries about what was going on and wanted to provide that information to the college. So we did two things. We generated a clinical bulletin in conjunction with those members, along with experts in virology and cardiovascular disease in our membership. And we were able to provide at least some early information about the apparent risk that cardiovascular disease had in more severe COVID illness. We also talked a little bit about what appeared to be some cardiovascular effects of infection, including acute heart failure and what appeared to be an increased thrombotic risk. And we also got some information from our frontline colleagues about potentially effective ways to protect care teams from infection and transmission of the virus as well. In addition to providing that written information to our membership, we also hosted several webinars moderated by Harland actually, and were able to really get some important insights from the frontline care teams, particularly in China, that would inform what we knew would eventually impact us in America. So as we got that information and put it on the ACC website, the demand was frankly just overwhelming. So today we've had over 7,000 downloads of the bulletin. We've had over 18,000 views of the web or the webinars. And so we realized that there was a real hunger and need for a hub, if you will, an information hub to help us all collectively both inform and learn about what was coming, particularly because it was such an evolving and fast-moving pandemic. So over the past four or five months now, we've had that hub up and running as part of the website. We've included clinical information as we've continued to learn about the sequela of COVID on cardiovascular disease. We've also included practice protocols, information about how to manage both COVID and non-COVID patients, both in-person safely as well as virtually. We've started to take action when we've seen issues in the public health sphere like people being scared of coming into our hospitals, and started issuing public service announcements telling our cardiac patients that if they do have acute cardiac symptoms to not delay seeking care and assuring them that they could be safe in doing that. And then finally, reaching out to our research community and really encouraging them to start to study and think deeply about what's underpinning the intersection of COVID and cardiovascular disease. So as we've been learning and developing that content, we continue to maintain the hub. At its peak, the hub was being accessed 300,000 times a day, and we were updating content daily. At this point now, over 2.5 million people have visited the hub, and we're really proud of the fact that it has served, at least in our community, as an organizing point for our collective knowledge. So as we go forward, we'll continue to provide information. We're certainly hopeful that the anticipated wave in the winter won't be as severe as the first wave, but we want to be prepared for any eventuality. We also have a COVID task force being chaired by Harlan that he can speak to that I think will provide some important efforts. And then finally, good quality research does take time. And so as those studies are starting to produce results, we want to serve as a platform to share what we learn and figure out the best way to manage both patients in this pandemic, and then be prepared with the infrastructure needed if other pandemics hopefully don't emerge, but be prepared if they do. So that's been a bit of what's been going on, and we've been excited to contribute in that way. Tom, kudos to you, Harlan, and the entire team. I know it takes a village to be able to do all this work, and you guys have pivoted so quickly. So appreciate it as a member, and I know all of those who have not yet seen the hub. It's a phenomenal resource that's constantly being updated. Kathy, I wanted to turn to you. You manage a large provider group, a very large provider group, and have been integrally involved in healthcare operations and finance your entire career. Although the early impact was dramatic, not to say it's not today still, but COVID-19 is likely to have a lasting influence on how we deliver care. And I wondered if you could share a few thoughts about what you're seeing from an operations perspective, et cetera, in light of COVID. Hey, thanks, Ty. And I think much like Tom, just kudos to the entire team. The one thing about COVID is it pulled us all together as a team. Our CV team really was highlighted through this entire area, from administrators all the way through the entire workforce. Communication was key, knowing that we could go to the ACC COVID hub for the clinical information, and then we could turn right around and go to the MedAxium COVID hub for the business and financial perspective, really allowed us to work together. And from a quality perspective, and I know we've already had a talk on this, telehealth, oh boy, how quickly did that change on a dime? And how quickly we needed to get information out, both to ensure really some of the financial stability of our practices, but also more importantly, to ensure access to our patients. And so I think COVID taught us a number of things, and I am afraid that just a few months into it, we have forgotten some of those already. And that is that our speed to execution is proven. It was proven that we could deliver quality to our patients during a pandemic, and yet how quickly we have reverted to some of our own comfort zones. So part of our quality summit, I think here, would be that challenge to remember some of that, and to remember that our team-based care is critically important. And as we learn how to marry our face-to-face as well as our virtual visits, how we can take care out to our patients in rural areas, but also our sicker patients in our urban areas that may have difficulty getting to the office, is really, really important. And how that evolves, I think, is a critical component. The continued access to virtual visits, we all know that that's both an advocacy and administrative and a clinical component. So again, the whole team coming together as it relates to the virtual nature of everything. The patient access, we really need to remember. You identify quickly, we shut our offices down in 24 hours. Coming back up was much, much more difficult. And so if we do have, as Thomas talked about, we have the second wave that may be facing us as we get the flu and COVID, especially in some of our urban areas and such, we will never shut down as tightly as we did. We have learned to live with COVID. And I think that's a really important message, that our patients and our staff feel safer in the office than we do at Target or the grocery store. And I think that's kudos to the entire health care team as we come together in protecting our patients. And quality, I think the one thing both from an NCDR perspective, specifically from a Pinnacle perspective, we have two pathways of quality in our world. One of them is office-based and one of them is hospital-based. So the PCI action, the registries are all on the hospital side. But I want to talk for a second about the practice side, because this is where COVID taught us an awful lot about quality. So as we are running our device check reports, as we're running our INRs for our Coumadin patients and such, these are the types of things that practices and service lines need to pay attention to, so that we deliver care in a different way. Drive-by Coumadin clinics, who would have ever thought? And yet what an excellent opportunity for our patients and how much easier it is for their family to receive health care that way. So what is wrong with integrating that into our system and how we deliver that care? So from a quality perspective, I would just leave us with the thought that communication is critical during the height of COVID. Thanks to Tom and his team, every day we'd be heading to the hub to see what was going on and what we could do for our patients, because we really didn't know. And same on that administrative perspective, really keeping that ongoing communication. And I hope we don't need it quite as much in our second wave, but may we never forget how it really impacted us. And our patients are sicker right now, at least that's what we're seeing in Chicago. They waited long for their care, so they infarcted at home in many cases, and so we're getting them now in that secondary stage. I think that's also a lesson learned from a quality perspective, that we need to make sure that whether it's face-to-face or virtual, that we are connecting with our patients on a daily basis. Thank you. Really poignant points. Cheryl, I'm going to turn to you. You bring a great perspective as a cardiologist who's helping to transform health care delivery. The company you work for does so many things, including develop solutions for more than 80 million Americans and more than 3 million individuals that are enrolled in your regional health plans. And sometimes in these meetings, we don't get the payer or health care delivery other side or perspective. What's top of mind right now for you and your colleagues as it relates to COVID-19? Thank you, Tyne. I really want to echo some of the comments of the previous speakers about communication. We are in, I mentioned, Cambia Health Solutions. We cover Oregon, Washington, Utah, and Idaho. For everyone who now remembers, we had the first cases in Washington. And at that time, really required us to look not only at our members, our 3 million members, but all of our employees as well. We were one of the first companies in Washington to go virtual 99.5% within 48 hours before health systems had begun making those changes. We were able to do that because we had the infrastructure already built to allow us to share data, PHI privately well, and allow us to communicate with our health systems. That for us became a really key component in the early days of COVID-19. Our site, and it's been cited by the Washington Health Authority as well as Oregon and in Utah, it was the place to collect information. We convened the leads of every health system across our four states, and we utilized our own resources to help them coordinate, share different resources, where to find PPEs. A lot of offices closed at that time. Our nursing staff began managing for a number of practices, their patients. We knew who were the most acute because we have the data of those patients, and we've already had relationships with those practices. That team-based approach that it can occur amongst all clinicians caring for a population was really meaningful. That we are continuing today. I think the ability to remember that patient, that member, and the care they need, however we're able as a team to provide it, has really prevailed, I think, for everyone involved. We've also spent a lot of time not just expanding telehealth services, but we're continuing to train and teach providers on utilizing telehealth and submitting claims for it. We're in a place where we've got a lot of rural providers. I think a lot of large health systems have infrastructure, have support for many other providers as they look to their viability. We are the ones who are helping to support that for them. I think we're also learning that many of the needs that occur between a physician and patient as it relates to care, as many of us are aware, multiple more social determinants of health come into play, not just during COVID-19, but just in addressing health equities. We have gone as far as our providers reaching out to share that, hey, we've got a lot of our own patients who have needs. We've been providing everything from individual food gift cards to ensuring that we're bringing in-home care if a provider does not have the telehealth platform or the resources to set that up today. I know, Tai, you live in our part of the country. There are many people who still have those needs. That collaboration with providers has been really meaningful for us. I would be remiss to not talk about behavioral health and how that's really impacted not just patients, but providers as well. Those needs really are in ensuring that people feel confident in returning to work in any of the facilities that they work in, but if they do have questions and needs that we're providing services. We've partnered with the large health systems in our areas to be a resource for providers to provide solutions, be they online telehealth solutions for providers, to provide other vendor programs that we may have in partnership with health systems. It's really a great time to remember that we all contribute to the care and improving quality within our communities and leveraging our resources to be able to do that and do it in a continuous manner. Kathy mentioned a number of patients who have delayed care or delayed treatment. We actually initiated a data analytics poll of high-risk members for cardiac and other conditions and not only did a direct mail order of all of their medications to them, We began a seven day rotation between our physicians, our nurses, and the practices who care for them to be able to let them know that if there was a problem, though the office may be closed, they could still call us to really help to, we hope, ameliorate some of these higher risk sequelae that may occur with people delaying care. That has continued for us, and we continue to see people really wanting to reach out right on a Saturday afternoon at 4 p.m. And when you're doing that, the one place that we're, again, we've gone fully virtual, we're able to support providers who do not have an infrastructure in place to care for these people. So that partnership and that communication, we are seeing it continue and we're really thrilled about that. This is phenomenal. Absolutely phenomenal. So thank you. And lastly, Harlan, we're going to delve into some other deeper topics in a moment, but you've dedicated your entire career to use some data to identify care opportunities and ways in which we can really transform the health of our patients. Obviously, beyond the development of a safe and effective vaccine, what are you seeing as the biggest unmet needs as it relates to COVID-19, at least right now? Thank you, Taya. And I was just saying, listening to my colleagues here, I'm so humbled because their accomplishments are just really breathtaking in so many different ways. And they and the communities around them really rallied. And it was just something to hear and something to see. What I'm thinking is that a lot of the ways that we were forced to think to respond to COVID uncovered for us a lot of the vulnerabilities and inadequacies of our current system. And as we were driving towards solutions that would meet people where they live, that would provide services, that would make it easy for them to receive care, that would, as Cheryl just said, proactively reach out to those who are most vulnerable and at most risk. This is both a challenge and opportunity for us to start thinking in this direction. And how do we use data to be smarter and better in which we're trying to find who really needs our help? When you look at the disparities that existed, it was no surprise that the communities of color were disproportionately hit. But where could we have been smarter with data to be able to not just pick up and describe it, but to be able to develop the kind of proactive interventions that would help both shape the way in which care could be delivered as well as to address the structural problems, which, by the way, aren't unique to COVID, but we know that these same groups are bearing a disproportionate burden of risk factors and of disease. And so what I'm hoping is that this sort of opens our eyes to a world of possibility, that what if we saw the suffering of the people around us as always saw it in terms of a public health urgency and emergency, and the kind of solutions that we were seeking were ones that were going to be very patient-centered and specifically identifying where are those places where people are falling through the cracks? Where are those places where our current systems are asking people to take off a half day of work to come see us or be inconvenienced as hourly workers, this is actually a very big sacrifice for them to be able to miss or they simply don't have the flexibility to do that without risking losing the job altogether. So, you know, this is, I think, going to sensitize us in ways that we should have always been sensitized to the specific needs of people, to the social determinants, and the power of reengineering the way in which we're delivering care. And then ultimately holding ourselves accountable. Your question was about data, and I think data is about how can that support us in the targeted interventions that we may need to make, informing us and our patients about the options ahead of them, and being accountable, not just claiming that we're providing services, but actually seeing whether or not we can eliminate these disparities, promote greater equity, and improve the health and quality of lives of people who are at risk or suffering from cardiovascular disease and others. I'll just say one other thing, too, which is that, you know, this has pushed all of the cardiologists to be thinking both about what the implications were for patients with chronic and acute cardiovascular disease, but also the vulnerability of our patients to a disease that had yet to be fully defined. And so I've also been heartened by the fact that so many of my colleagues have contributed both to the knowledge and efforts around COVID itself, its diagnosis and treatment, but also then around how to help for the collateral harms, like the avoidance of care issues, that we needed to take into account. Our community, our healthcare professional community, shown immense agility and resilience. And what I'm hoping to do, as I think Kathy alluded to, is how can we make this the new norm? That is, that we're constantly searching for ways to make this kind of difference, and we're constantly asking ourselves whether the way we've always done things is really the best way. And is it really in the best service of the people that we seek to help? And what can we do to strengthen ourselves? And again, I do think that technology, both in terms of telehealth services, remote monitoring, and the way in which we're analyzing the data and having it fed back to us so we can preempt problems before they occur, we can intervene to try to help people make the choices that are best for them, and that we can deliver the services in ways that are most convenient and affordable for people, taking into account the specific challenges that they're facing in their lives. So yeah, I'm excited that we may be able to start accelerating our progress toward this learning health system, which is ultimately existing, to be able to ensure that every single person has a chance to live the best life they can, and the healthiest life that they can, and we're here to support that. Harlan, that's fantastic. Thank you. Thank you all for these great insights. I'd now like to actually ask us to maybe dig a bit deeper into some of the issues that may be top of mind for our audience. Today, many of our hospitals in the U.S. and outside the U.S. participate in a number of registries. We're going to be talking about just cardiovascular ones, but it exists across the entire broad portfolio of service lines where data is abstracted, submitted, benchmarked, and reported back. And as Kathy had said, NCDR is a home for many of us to do that. There are multiple drivers for registry participation, including clinical or research interests, a requirement for reimbursement, or part of certification or another form of recognition. Tom and Harlan, I'd like to start with you. While there's always been a motivation to do this more efficiently, the economic impact of COVID has begun to accelerate this. And I guess I would ask you both, in short, how do we begin to think about doing this better, smarter, and faster? Tom, I'm going to let you kick things off, but then pass it to Harlan afterwards for some thoughts. Sure. Yeah, I agree with you. I think all of us recognize the real power that comes with data collection and registry use and informing the care that we provide. And in my opinion, some of its greatest uses are in telling us how we're doing, how we can do it better, and then on the research side, to figure out what's next, what are the insights that we can gain to further the science and care of cardiovascular disease. So I think there are two things that were already in play, but the sort of economic crunch you talk about, Ty, from COVID will likely, hopefully, accelerate things. One is the use of electronic data as a really important assist in making sure that the registry data we get is both comprehensive and complete. And I do feel like that some of the growing tools that are embedded in some of the smart health systems, electronic health systems that we're seeing, clinical decision support, there are logic checks now for data to make sure there's sort of internal consistency, even some direct assist as clinicians are completing forms or documenting the care they're providing. I think all of that can help sort of create a more accurate record of the care that's being provided and the quality inherent in that, while at the same time, hopefully, decreasing some of the documentation burden that our frontline clinicians currently feel. So I think with that will come sort of the follow-on effects of improved quality and completeness of our data. I think the other thing that's a big accelerant is the implementation of the 21st Century Cures Act, and in particular, its call out for greater data interoperability, transparency, and access by our patients directly. And I think all of that is going to have really good impact on our ability to benchmark the care that we're providing for our patients across the healthcare delivery system. We know that our patients often interact with multiple places for care. And if we have the data liquidity to kind of see what their journey is, regardless of where they receive that care, it'll better enable us to track the quality they're receiving or opportunities to improve that. So I think all of that's really promising. I think it also, if I put myself in the shoes of somebody extracting that data, it's going to change my role going forward as these mature. And I think it'll move somebody whose primary role may have been chart abstraction and really making sure that the registry forms match the clinical record to one of still doing some of that spot checking to ensure data quality, but then moving more into a consumer and user of that information. So I can imagine that folks who are based at a given hospital or health system will now to be able to more rapidly interact with that data, take those insights, see opportunities for quality improvement and immediately start working with our quality teams and frontline care teams to address those quality gaps, ideally in a very rapid cycle and closed loop fashion. So that if we identify a quality issue within a matter of, you know, hopefully days, if not hours, we can start to close some of those gaps so that the next person to come to our door doesn't face the same problem. I think it'll also enable us to start building a more rapid research capability where we can even do small studies, even in a single center and use our EHR and registry data to both find patients for those studies and then follow them along for the outputs that we're interested in seeing, the outcomes we're interested in seeing. And I think all of the builds to that vision that Harlan talked about of a learning healthcare system. So I think there's a lot of exciting things in place. Even though the economic hardship is a real thing, I'm hopeful that from it, we can use it as an opportunity to further accelerate these efforts. So those are some of my thoughts, but I'll look forward to hearing Harlan's insights too. This is great. And Harlan, you spent a lot of time thinking about this. So I'll let you pick off where Tom left off. Well, look, if you're going to give me license to tell you where I think we should go, I'm glad to do it. And let me just say ACC pioneers, we've done extraordinary things leading about what the value and potential is for registries, but we're still now at this point in 2020 using 20th century approaches. Look, the current registries are in general too labor intensive, they're too expensive, they're too slow, just like our national quality measures. And we've got to make a switch. We're a decade, a little more than a decade into the digital transformation and yet we're still working in analog approaches. And so what we've got to do is one, we've got to begin to have a vision of bringing together, as Thomas suggested, accountability, improvement, and discovery needs to come together. They should not be separate lanes. They shouldn't be a lane where we're collecting information for accountability. And then the quality improvement teams have to collect their own information and then discovery is on a whole third lane. The registries have tried to be that, but the data comes back too late. Real improvement occurs with almost real-time feedback. And so you've got to be able to have data that is actionable and meaningful at the point of care. The reason we made such great progress in door-to-balloon time, I believe, is because so many institutions initiated a real-time feedback. Somebody came through with a STEMI, they got treated in a certain amount of time, at least in my institution, emails went out within hours. Somebody just came through, here were the times, here were the time intervals. When we hit the mark, everyone celebrated. When we didn't, we did root cause in almost real-time. And it created a cycle time of improvement that was very tight and short and enabled people to feel a sense of it. Just take a look at so many of the things. That's not just the registries. The CMS measures are often three years out of date. By the time I get feedback on mortality or readmission, honestly, it's meaningless. And I've been involved in developing these. I think it was in advance that we started looking at measures, but the honest to goodness truth is it doesn't help in improvement. The only way we're going to do that is to ride the digital wave. Two things need to happen. One, on the health system side, we need to not wait for anyone else to do this. We need to control our own destiny. We need to move into common data models like OMOP. We need to be able then to be interoperable so that we can send out queries in a federated fashion, then we can combine them centrally, we can learn together rapidly, and we can overcome the current inertia that is holding us back. We need to be able to learn from each other. And that means that whether you've got Epic or you've got CERN or whatever your system is, it needs to be translated into something that when I send something to Tom, he sends something to me, it can all be understood. The data is there. There may be some last mile manual data collection that will still need to persist, but in general, we want to need to dispense with it. We need to be able to get into a position where we can provide that information back to frontline providers and can also be aggregated and organized centrally so that we can then learn about how we're progressing vis-a-vis others and how we can encourage each other and how we can find out who's doing things best. And then I also would like to see us be able to engage our patients in ways that we can start to collect information. So on outcomes, we know about function, we know about symptoms, we know about this kind of information from patient-reported outcome measures that are feeding into our system. They're being able to be used clinically. We're using them as assays to be able to track our progress in terms of treating people, but they're also feeding into quality improvement. When we've got people who are symptomatic, how successful are we at helping improve their function and decreasing their symptoms? Are we being responsive to their needs? These kind of assays, like the Seattle answer question or KCCQ and a wide range of others, you know, stand as standardized reproducible measures that then it doesn't matter whether I'm seeing a patient today and you're seeing a patient next week and we may be asking different questions. We're using tools that are enabling us in quantifiable ways to be able to assess burden to patients and see whether or not we're making progress. These can feed into our data information systems. And then we also need ways for patients to link so that when they go to other health care systems outside of ours, we're able to in real time know what's going on with them and with their permission, we're able to work with them so that we can provide unified care. It's not like they ended up somewhere else and then someone had to repeat all the testing because they didn't have access to the data. Every time I'm on the wards, you know, a third of the patients have critical information somewhere else and nobody wants to spend a half day tracking it down and find, you know, it's a pain. So these are things we need to overcome. And finally, I think that some of this is around the documentation too, that you're saying, well, the medical record may be missing key data. That's a quality issue. I mean, we shouldn't say that's a problem for the registry. That's a problem for people taking care of the patients communicating with each other. So I'm excited. I think we need to move quickly. This is moving us faster into a digital age, but we need to now pivot. We need to start creating demonstration projects where we can show that this can be done. We need to show the value of it and we need to begin this movement to re-engineer the way that we're using, generating the data and feeding it back in the role that ACC and the institutions can play in making sure we're getting real-time feedback. Because otherwise we're not nearly going to make the progress that we're capable of. That's great. This is great. So I know we could talk about this topic for for hours overall, and you've given us a lot to think about and certainly our audience too as well. Kathy and Cheryl, I'm going to pivot to you on a different topic. And in 2015, the Medicare Access and CHIP Reauthorization Act, affectionately known as MACRA, was passed, also known as the Quality Payment Program. And a major goal was to shift the way that providers are paid or better reward value. Given a major portion of this is based on improved healthcare quality at a lower cost, what impact do you think COVID's going to have on this program in the near term and long term? And I'm going to throw in also, do you think that this will accelerate or will it decelerate some of the push to participate in value-based arrangements? Cheryl, I'm going to start with you first, just from your thoughts about where COVID's impact will have in terms of how we're shifting and how we pay for healthcare. Thanks, Ty. And so Kathy mentioned this, right? A significant hit to many who are in current FIFA service contracts when COVID-19 hit, and they closed their practices. For physicians and practices who had value-based arrangements, not so much, because they're managing populations not based on volume. So I think it has a significant impact if we look at the existing data and how practices have been impacted. But I'll look at it in a couple of different ways and use some of our own experience at Cambia Health Solutions. So we're about 40% in of all our total payments in value-based arrangements. This is before looking at episodes of care, which look at specialty care like cardiology, and I'll talk about that a little bit separately. I want to build on something that Holland said, and I think I said this before with Holland. Holland's one of my mentors, probably the reason why I'm so embedded in epidemiology and biostats. So we've got about 40% of our total payment in value-based arrangements. And what we do is we analyze it, right? Because it's not just that you've got a payment model, is it working? And so we've got about a 200% higher patient satisfaction score with our value-based physicians as compared to those who are not. We've got a 17% higher quality care gap closure, 33% lower catastrophic spend, about a 15% lower in opioid scripts, and overall about 6% in lower cost. Now, why is that important? Because there are incentives tied to this. And we are going back out to our practices and systems, significant dollars, millions in being able to look at this. But what I talked about earlier is really important here. There is a partnership here in sharing data. There is data that we see that a single physician may not. And so our ability to ensure that they have the right amount of data, not a data dump, the right amount of data to help them close a care gap creates a relationship where we're partnered in doing this. And that's how we're seeing these results occur. Same thing with episodes of care. It's interesting that we launched our episodes of care program during COVID. And we've had major health systems and provider practices across our four states immediately sign up. They understood the program prior, but they also see the benefit as COVID has shifted payment programs, and we are providing some of that data backbone and infrastructure to help support them. A key piece of this for us as we look at this work, it's in looking at all of the needs of our members, of our physicians' patients, and they're not just medical. It's ensuring that we're providing them with data that they may not be aware of. They're not aware of the challenges sometimes that a patient have in getting to their office. We're able to say, and by the way, unless there's something that you immediately need, they would benefit from having a telehealth visit, something that patients are still not willing to sometimes admit. We are also addressing some of the concerns that people have in where they're being asked to come back in to a practice, but they themselves don't feel ready. And so making sure that they understand the trust and communication with their physician and talking about that. And why is it? Because they've got other sick members of their family at home. So that communication, empathetic relationship necessary for a patient to be able to be adherent to treatments and to be able to want to follow up is really critical. And the last piece that I would say that we've really learned is the relationship matters. And so we've got a lot of work that we're doing across our network of physicians to look at cultural match with our patients to make sure that people have the right hours and availability for patients so that they can see them when they can see them around their family and work obligations. And we're going to be listing that publicly within our database because it matters for these members. And so work that we've already started, I think we've accelerated it. This is no longer us saying, hey, this is a great way to go. We are getting more calls from our physician practices saying, one, we've spoken to those you're working with. Two, as we look at models, we know that this is one that allows us to have viability. And the third piece of this, right, is we are willing to invest in that data infrastructure for sharing data, which is an investment, one that we believe and I think many believe is necessary that investments have to be made in this area for us to be successful going forward. Without the right data, you're kind of hoping you're doing the right thing. The data matters and then being able to measure it on the back end. That's great. Fantastic. Kathy, you spent a lot of time thinking about this as a deliverer of care. What are your thoughts? I mean, I've listened to you for years at the CV Summit and talking about our shifts in terms of how we're going to get paid. Clearly, quality is that much more important. So what we've been measuring and for many of the people listening who have fed our registries, helped us identify gaps in care, leading quality improvement initiatives. It matters. It seems like that much more now. What impact do you see COVID having on this? Well, you've hit my favorite topic, so I could go on for hours, but I'll try to be succinct. And I think Cheryl hit a couple of really key points. Relationships. The one thing my physicians have said about telehealth is how awesome it was, how it brought back some of the joy of practicing medicine. To see the patients in their own surroundings really adds that whole perspective of treating them differently. So I think that's number one. Number two, if COVID taught us nothing else, fee for service is broke. If all of a sudden we can't deliver care anymore because we have some socially distanced or a pandemic going on, tells us that there's something inherently wrong in how we're delivering health care. So much as Cheryl said, and I wish she was in Illinois, but our bundle payment initiative just sort of skyrocketed. Because as we were caring for patients, adding a telehealth visit is not about adding another cost to the health care system. It's about taking care of that patient across the whole continuum. And we were one of the first things we did with COVID, which I hadn't really expected, was because we have a very active post-acute care program because we're in several BPCI bundled initiatives. And so we had to communicate with our patients in the nursing homes. And so utilizing telehealth, I mean, I thought we were a little bit crazy when we said, hey, we'll drop off a phone. We need you to FaceTime. We need to set up this time with our patients in order to make sure that they're doing OK. So COVID accelerated us once again, much to what Harlan is talking about, into a environment that we need to embrace and we need to not forget how it happened. And then my last comment, which is the one I could go on forever, is I think COVID also said to us, we have to deliver care in different sites of service. And I think we saw that in the fee schedule rule that has come out and the HOPD, the hospital outpatient rule that's come out. You know, where are we with our office-based labs or OBLs? Where are we with ambulatory surgery centers or ASCs? Where are we in that continuum of offering care in a less expensive environment and better patient outcomes? Not to get into the debate of what is clinically appropriate for doing patients outside perhaps of a hospital setting or a hospital campus setting, but definitely identifying an environment that now is maybe pandemic safe as well as clinically safe. And I think it has taught us, COVID being that specifically, not to mention the quadruple aim, which we've all been trying to figure out how exactly this fits in, but really how do we deliver care to our patients in a different, less costly environment? Because we can't be so beholden on our fee-for-service basis. It just really is very, very difficult. And I think the timely data is also so important, that we need to make sure that what we get data that can be actionable and deliverable. And Harlan's exactly right. If you give me my fourth quarter report in July, that's not going to help me change processes that I need to really do. So I think COVID has been that energizer, that stimulator that we need to really start to look at episodic care. And you started your comments with MIPS and the fact that now MIPS has added yet more bundles of care. And I have to tell you, when I saw the field-tested reports that just came out, I'm thinking, this isn't cardiology. I'm not going to have a bunch of COPD or diabetic patients. I don't need to look at it. Wrong. We found that we had been attributed a number of our patients because, again, our patients have comorbidities and therefore they're going to be in episodic payment. So the last comment is, we haven't talked about this yet, is risk factors. Making sure our documentation is sufficient to identify how sick our patients are. Making sure that we're doing clear, specific diagnosing, very specific diagnosing. Making sure that we're actually adding on our billing list the number of CPT, the ICD-10 codes that our patients have. How sick are our patients? Because that's the only way Cheryl's database is going to have the right information in order to do some comparisons and get us to that stage we need with high-quality outcome. So I hope that helped. That's a really important topic. No, this is great. Fantastic. You know, I think we could go on for quite a long time, and we have a limited time together. You know, some of the topics I wanted to touch on that we'll have to save for another day is, you know, the impact that COVID has had on research trials and a lot of new knowledge that allows us, that is built off of, as Tom had put, gaps in care and where we need to do better for our patients overall. We were fortunate, and I would welcome everybody to view the keynote by Quinn Capers that was given about health care disparities and how we begin to address inequities in health care. I would say, and I'm going to ask you a final question to help round out the session here. There are some silver linings to COVID. You know, we have seen devastating impacts in terms of deaths, hospitalizations, and morbid events. We have seen, obviously, the economic impact and people's loss of income, loss of their jobs altogether, loss of insurance. So it's had a devastating impact. But I'm going to ask you, as we move into the next phase in thinking about this, and Tom, I'm going to start with you. What do you see as one silver lining? We didn't compare each other's silver linings today, so maybe we'll all have the same silver lining. But what do you think is the silver lining that you take away from COVID that you think will accelerate our advances in health care going forward? Yeah, I wish I could go last because I want to hear about everybody else. But I do think, maybe I'm being a little optimistic here, but I do think, in general, the public has a greater awareness of the importance of science and public health and how critical it is when our society faces an issue like COVID. And even though, like everything in a big group of people, it gets a little politicized, I think the majority of people recognize that the importance of having good scientists, good doctors, and good public health officials able to do their job, work together, and think quickly and effectively about how to manage a pandemic like COVID has been a really good reminder. We've been fortunate as a country to not have to face this, at least in my lifetime. And hopefully, it'll be another lifetime before we do again. But I think a silver lining is a reminder of how important that is. I think another thing is recognizing really how much we can do remotely. I don't love working with people exclusively remotely. But it is clear that I can get a lot done without having to travel across the country or even across town. And I think it'll help us think about creative ways of balancing the needs to do our work, whatever that work may be, and also balance it with other professional and personal obligations to family, et cetera, and to take full advantage of the technological world in which we live to facilitate that. And then the final thing, and Kathy actually mentioned this earlier, the power of collaboration, being able to do what we've needed to do in COVID and all the myriad things that needs to happen. No single person is able to do much. Collectively is how it works. And it really is striking that when there is a huge need, people put their lives on hold, come together, and get stuff done. I, anyway, was really struck and impressed by the collective efforts of everybody I've worked with. So those are some of the silver linings that occur to me. Fantastic. Cheryl? So I will say there are a couple of them. The adoption of telehealth by everyone is huge for us as a healthcare community. And I think we all have to recognize that in those communities that don't always have access to care, we sometimes talk about the disparities of broadband access. They have mobile health. They have smartphones. 80% of underserved populations have smartphones. There are a lot of solutions that can be delivered so that creativity, innovation, to making sure we can provide care to everyone utilizing technology, I think is a key, key benefit that came out of this. And by the way, that physicians will adopt it. And that patients, be they Medicare or others, will use it. I'd say the second thing that has come out of it is this conversation around health equity. And if there's one ask that I would hope is that in every EMR going forward, you can't move forward on any screen unless you've filled out race and ethnicity. So we can do sub-analyses going forward. That would be a life-changing event in how we look at data. And I, you know, like Tom, I'm really positive about those two. Lots of heartbreak to get to some of these places, but they're really good places for us as a healthcare community to align around. Thank you. Kathy? Hey, thanks, Ty. And I think I have a couple, much like Cheryl, and I'm going to start with team. I think our team was always important to us. It became even more important to us watching us adapt into different work schedules and different work environments, having our physicians work with their medical assistants so they could be home with their kids if they needed to be, and yet still have chart prep and the things that make an office actually flow. So it indeed, it took a village as we came through that. And I hope we never lose that. I think we had a hard time getting to it, but I think it is critically important. And the resiliency, it is just amazing to me how resilient we are, not just our frontline workers, but really from our patients and our communities all the way down and through that. And with that resiliency really came a speed to execution. And that if we could only retain one thing, I think that knowledge that we really can't execute, we really don't need things tied up in committees ad nauseum and forever and ever, but that we could really get things done. I think the college proved it, that without hurting the core element of science, that we really could get some information out and good information. And we're not saying that maybe it was research validated yet, but it gave us that ability to treat patients when we didn't know really what to do that was best for our patients. And I think the last is the healthcare spend. I think to Cheryl's point, I think we know that there are ways we can deliver healthcare differently. And although there was a lot of heartbreak as to how that can happen, I think that's a critically important lesson to learn. And the issue with disparity in care is so bothersome. And I think it's so core to what's going on in our country today and exemplified in a lot of different day-to-day elements that as healthcare leaders, we need to lead that way. So to Cheryl's point, I was so glad to hear her say that. I don't want one more patient to tell me they don't want to tell me their ethnicity because they're afraid that it'll be biased against them. As opposed to really helping us move forward and identifying how we really can deliver care better to each of our patients. It was a tough period. I don't know that I want to go through it again. But I think it gave us a lot of valuable life lessons and healthcare lessons. Thank you, Kate. And Harlan. Well, it's hard for me to talk in terms of silver linings when we've lost over 200,000 people that communities of color were disproportionately affected, that we were slow to respond, that science was undermined at every turn, that our confidence in our national institutions is at all-time low, that we can't be confident in CDC or FDA, that they've been highly politicized, that political people have written memos that have filtered the information that made it into the public, that our leaders knew about the harm, but openly said that they didn't want to panic the population, so weren't honest. And that's just of the record that's out there. I mean, look, I'm not proud of what we did because, look, despite all the accomplishments, we should have done more about masks and we should have done more to make this not about political, are you Republican, are you Democrat? There's science, there's evidence, there's public health emergency. And honestly, on our watch, the United States has done the worst job in the world. And we are still at risk. I mean, it's not over, Kathy. I mean, we are in the midst of it and there are places in the country where that inflection point is going up. It's not going down. It's just that it's traveling around the United States. And we still have a lot of lack of consensus around the best way for us to do this. And waiting for a vaccine is a pipe dream. We have within our grasp the means to get this under control. As we wait for a vaccine, you know, God willing, the vaccine will be here soon and it will be effective. But right now, because of all that's gone on, there's a historic low trust in whether to take the vaccine. A large number of Americans are not interested in taking the vaccine. So, look, it's important for us to take a good hard look at the society that we're part of and what's happened. With regard to the thing, yes, the health care system is re-architected. We've accelerated the use of remote and digital and we need to continue to push that, right? And there's no question about it. We talk a lot about disparities, but we also have to embrace the idea that a lot of this is stemming from structural racism. It's not from an individual, but it's from the circumstances. And by the way, we're trying to talk about testing, inadequate testing still to today. But you tell an hourly worker that you should be tested. All you're doing is putting them in a position that they're going to have to quarantine for two weeks. Honestly, they don't want to know because if they're asymptomatic, they feel that they've got to put food on the table and their jobs are at risk, especially in a bad economy. We've got to be able to be starting to think systematically about these problems and the challenges that individuals face and the incentives that are in front of them. And whether or not we are making it such that people can be tested, feel safe, guaranteed not to lose your jobs, and that we can help support people through what's going to be a very difficult future. And it's possible that this pandemic could be with us for a decade if we don't get ahead of this. So, yeah, I mean, there are some things that have happened and teamwork and the digital revolution and all this, but I am still very unsettled by the current situation that we're in and feeling that we have to roll up our sleeves. And this is a marathon, not a sprint. And we're not nearly through it. I just don't know whether we're only through 10% of it or 50% of it, but I can tell you we are not 70% through of it. And so we've got to be prepared for what this fall is going to bring, what the spring is going to bring. And even if we get through the pandemic, the economy now is going to be a major risk factor for a large segment of our population. And the question, how are we going to make sure people can get access to care, can afford it? If the Affordable Care Act is overturned by the Supreme Court after the election, what are we going to do to make sure that our patients aren't suffering? These are all things that are going to be continuing challenges to us. And we, as a health care professional organization, have to be activated so that we're trying to find solutions that are proactively seeking to ease the way for people who are far from through what has just occurred and maybe at just the beginning of what they're going to have to endure. And we've got to be sure the health care system is as supportive as possible. Thank you. And I appreciate all of you sharing all of your thoughts, some of them sobering, some of them in terms of the positives that we've had. And the reality is we do have a long way to go. And Harlan, much like you said, this is a marathon, not a sprint. In wrapping things up, I just want to say that this has been a great conversation for me. The insights shared have been fantastic. And I suspect our audience would feel this could have gone on for hours. I do want to extend special thanks to our panelists for taking time to participate, as well as everyone watching. As there continues to be uncertainty on the timing of a vaccine, please stay safe and enjoy the rest of the summit. Thank you.

COVID-19

healthcare

quality

telehealth

team collaboration

data collection

healthcare equity

patient-reported outcome measures

value-based care

health disparities