As we made our way through Washington, D.C. on Pearl Health’s Drive for Better Care, we enjoyed the opportunity to meet with Mara McDermott, CEO and Founder of Accountable for Health, Board Member at the Health Care Cost Institute, and one of Pearl Health’s Top 50 Value-Based Care Thinkers of 2023.
Join us as we discuss barriers and opportunities to increase adoption of accountable care models, the power of data and technology in enabling better patient care, the importance of sharing patient impact stories to advance healthcare policy, and more.
Steven Duque: I’m Stephen Duque, Chief Growth Officer at Pearl Health, and I’m thrilled to be here with Mara McDermott, CEO and Founder of Washington, D.C.-based Accountable for Health, a nonpartisan national advocacy and policy analysis organization based in Washington, D.C. that focuses on accelerating the adoption of effective accountable care.
Mara is an accomplished healthcare executive with deep experience in federal healthcare law and policy — including delivery system reform and physician payment models — and she serves as a board member at the Health Care Cost Institute. An attorney by training, Mara was previously the vice president at McDermott and Consulting, where she worked with clients to advance policies related to value-based care. As senior vice president at America’s Physician Groups, she also advocated for medical groups and independent practice associations working in capitated, coordinated care models.
I’m so excited to dive into the state of accountable care with Mara today, including discussing what’s being done in the policy space to help achieve better outcomes with lower costs.
Mara, thanks so much for stepping aboard the Pearlmobile on the Drive for Better Care. I know this is an unorthodox podcast recording setting, and we appreciate you taking time out of your busy day.
Mara McDermott: First of all, thanks so much for having me — I’m thrilled to be here. This is such a great opportunity and I love what you all are doing at Pearl to advance accountable care.
Steven Duque: I’d love to start with hearing about your journey, going back to the beginning when you were an attorney in the health industry practice at Akin Gump, focusing on health policy here in Washington. What first drew you to healthcare, and what experiences have shaped you?
Mara McDermott: I fell in love with healthcare and healthcare policy at UC Davis as an undergrad. I was a sociology major, and I had a professor in sociology of medicine who surfaced a lot of issues that I became very passionate about, including access to care, care coordination, gaps in care, and underserved areas. We’re still dealing with these issues today.
I ended up going to law school here in Washington, D.C. at the George Washington University, where I had amazing professors and the opportunity to continue to work on those healthcare issues including healthcare law and policy. I ended up at Akin Gump, as you mentioned, and from there I made my journey into the accountable care field around the time that the Affordable Care Act was being debated in Washington, D.C.
At the firm, we had a number of clients that were interested in the Medicare Shared Savings Provisions way back before that was a thing, before we had hundreds of ACOs. We were in the very early days of drafting what that legislation was going to look like and what it was going to mean for primary care providers, and for integrated systems, and everything in between.
I was fortunate enough to do a lot of work with the California Association of Physician Groups — which is now called America’s Physician Groups — as one of my clients, and I ultimately made a move over there. Through relationships with companies like yours when I worked at APG, and now at Accountable for Health, I got exposed to really passionate clinicians and business leaders who see what we all see in our daily life: the healthcare system, and interacting with it, is not optimized for people.
There are lots of gaps and lots of bad experiences, but there are also leaders who are really passionate about fixing that and tackling it in different ways, from bringing innovations and new technologies, to payment reform, which is perhaps the less exciting element, but still really important for driving that transformation.
Steven Duque: You started Accountable for Health just over a year ago. Huge congrats, by the way — we’re cheering for you.
We’d love to hear: what drove you to begin your own advocacy organization, and what was missing in the advocacy space that you’re seeking to fill with Accountable for Health?
Mara McDermott: Sure. I had been at a consulting firm where we ran a coalition of Accountable Care Organizations, and at the time of the transition between the Trump administration and the Biden administration, there was an advanced ACO model called Direct Contracting.
The Direct Contracting Model, which I’m sure is familiar to some in your audience, allowed participating ACOs to take capitation payments. It was new and innovative in that way, though in many ways similar to previous ACO experiments that allowed clinicians to take more financial risk and reward and more clinical accountability for their patient population.
We were very excited about that opportunity and felt like it was a great way to continue to advance the ball on coordinated, accountable care. Unfortunately, there was a lack of understanding on Capitol Hill about the model, which led to a lot of pushback. As we were making the rounds on Capitol Hill, talking to offices about the Direct Contracting Model and Accountable Care Organizations overall, it became clear that there was a disconnect between the enthusiasm for accountable care from people who were doing it and who are coming up with these solutions and the knowledge base on Capitol Hill.
Hill staff have hundreds of issues on their plates — they often handle healthcare and other portfolios — and we all know that these accountable care models can be super wonky. It felt like there was a big gap that still needed to be filled around understanding the models, why they’re important, and why fee-for-service contributes to fragmentation and this brokenness that we all experience in healthcare delivery.
Accountable for Health was launched to fill that gap. We need to be having more conversations with Hill staff, the administration, and everybody in Washington, D. C. I like to talk about it as the “surround sound” in Washington, D.C. around what accountable care means for people and how to help make it resonate. Accountable for Health was born with that in mind.
We have a great number of leaders that came together to start the organization, including Adam Boehler, Dr. Dick Merkin, and others who were passionate about this effort in the policy space. Today, at just one year old, we have close to 50 members across a broad range of participants in the accountable care space, including ACOs, of course, but also consumer organizations, data and technology companies, and specialty care organizations.
Our goal was to create a big tent to express the enthusiasm for accountable care we all have here in Washington, D.C. I think we’ve held true to that and are continuing our work into year two.
Steven Duque: That’s wonderful. Thank you so much for sharing what you’ve been working toward at Accountable for Health. You alluded to it earlier, but we’d appreciate hearing more about the challenges you’ve faced in advocacy. You spoke to the fragmented mindshare that folks on the Hill have, and we’d love to hear more about what it’s been like as you’ve led Accountable for Health.
Mara McDermott: One of the biggest challenges is the language. We all know the term “value-based care” means something to us, but maybe it means something different to other people. So, even in the naming of Accountable for Health, we have been trying to really focus our audiences on the concept of provider accountability for care quality and cost.
While that’s what we mean when we’re talking about value-based care — transforming the accountability for financial and clinical performance — the term “value-based care” is still used by other elements of the healthcare industry to mean different things. I think that communication issue is perhaps our biggest barrier.
The other challenge is trying to make the idea of care coordination and payment reform resonate with people. Why should it be important to them? It’s something that we continue to wrestle with today, as do all of our member companies. If you just arrived here with no prior knowledge of how the healthcare system works, a lot of what accountable care is doing is fixing problems that never should have existed in the first place. Take smooth handoffs, for example. You don’t want to be readmitted to a hospital if you don’t need to be there, but that would be your expectation.
So our biggest challenges have been communicating why this work is important, what gaps that we’re trying to close, how to reset expectations around healthcare delivery, and how to make sure that there are no gaps in the first place as we move forward.
I find that once people understand what we’re talking about — once they have time to focus on it and really dig into it — they are passionate about it, too, because many of them have experienced those very gaps we’re talking about, either themselves or through a friend or a family member.
Another challenge is that it’s hyper-technical, right? A lot of the issues that we are talking to policymakers about relate to financial models, and benchmarks, and things like that — not really the things that you see on headlines in the New York Times.
In summary, capturing people’s attention and then really getting deep into that policy space have been our biggest challenges.
Steven Duque: It’s interesting to hear this juxtaposition between the human aspect of what we’re talking about here and the hyper-technical components and characteristics of these models.
I’d love to hear your thoughts on the current accountable care models — including the Medicare Shared Savings Program and ACO REACH (formerly Direct Contracting) — and how they’ve been able to improve care quality and reduce costs in the healthcare system.
Mara McDermott: Sure. I am so excited about where we are with ACO policy. The ACO portfolio over the last 10 years has pretty consistently demonstrated shared savings, which means it’s returning funds to the government. But perhaps more important than that, it has really transformed the way that care is delivered in those communities. What we see in our review of the data and the literature on ACOs — and you’re going to hear from clinical folks on your journey who can explain this better than I can — is that they’re expanding access to care.
Lowering Costs through Value-Based Care
Interested in learning more about the impact of accountable care models? Download this recent report from Berkeley Research Group.
I get so frustrated when I can’t get my kids a doctor’s appointment after four o’clock. With accountable care, doctors have extended office hours and added weekend hours, creating access where there traditionally has been none for primary care. They’re making sure that appointments are coordinated, so when somebody is discharged from the hospital, they’re really wrapping services around them to make sure the patient has that next primary care appointment; that they know what medications to take; that the medication has been filled and picked up from the pharmacy.
All of the things I mentioned above result in cost savings, but also in a better experience for human beings touching our healthcare system. Those are the things that we’re excited about with Accountable Care Organizations, and now that you’ve had organizations in these models for a longer time, we’re seeing the savings and other benefits increase. I’m super thrilled.
You also probably know that the CMS Innovation Center has recently announced a new model — the ACO Primary Care Flex Model — which is going to allow for more changes to cash flow. One of the problems that we work on is that the dominant way physicians are paid in our country is fee-for-service: a payment for everything they do.
What Primary Care Flex and ACO REACH are saying is that we can transform that payment. We can create a different kind of cash flow: paying more money up front to enable investment in services like longer office hours and more staff. Those investments will then translate into better care.
We’re excited about ACO Primary Care Flex, and I’ve heard a lot of interest in that model from our membership. The request for applications just came out yesterday, so we’re still diving into that, but I think the ACO portfolio is on really good footing, and we’re excited for what comes next.
Steven Duque: You spoke a bit to these improvements in cash flow — namely capitation — for making those critical investments around the clinical operations of practices. What are some of the opportunities for improvement in these models based on what you’re hearing from your membership and what you’ve observed to be successful?
Mara McDermott: In federal government programs, there is a constant ebb and flow between participants in the models (the provider organizations that are participating or, in the case of Medicare Advantage, the Medicare Advantage plans) and regulators. We are constantly going back and forth about how to get the right incentives for the right behaviors, and I see that opportunity in the ACO models, too. The opportunity to continue to talk back and forth about what is working and what’s not working from each of our perspectives. That’s really the role that Accountable for Health plays — bringing that “doer” focus from people who are on the ground. People who are saying, for example, “this waiver is working, this waiver is not working,” or “this element of the benchmarking rule you thought would have this effect is having that effect instead,” and then bringing that to the Centers for Medicare and Medicaid Services to have a dialogue about what they’re trying to achieve and what we’re trying to achieve. There are always opportunities to continue to drive improvement.
One thing that we’ve been very focused on is the longevity of these models. If your model is built on saving based on what you have historically done, and you’ve historically been a high spender, that works great. If your model is based on what you’ve historically done, but you’ve now been in a model for 10 years, and your utilization and spend are lower, it starts to work less great. We need to have strategies in place both for people who have been at this for a long time, and those who have never done it before. Creating those policy differentials is going to be important.
We’re constantly thinking about new ways to bring beneficiaries more into accountable care. 10 years ago, when I was still working on the early days of the Medicare Shared Savings Program, the policy decision was made that the ACO would happen around the beneficiary, meaning that beneficiaries don’t enroll in an ACO. They are attributed — or aligned — to an ACO based on where they get most of their care. That decision worked fine at the time, but 10 years in, what we see in the policy environment and on the ground is that there’s a hunger in the beneficiary community to know more about these models — to know more about what they mean, how they improve care, and how a beneficiary could engage.
That has been a huge policy focus for us, in very close coordination with organizations that represent beneficiaries and their families and caregivers. How can we think about the next generation of accountable care policy that really brings the beneficiary into a more active role in making those choices and having information at their fingertips? How can we help beneficiaries learn where local ACOs are if they want to participate in a model like that, or with a clinician that’s participating in one of those models? Those are some of the big issues on our plate.
I will just wrap by saying that, not specific to the models, but I am super passionate about Medicare payment policy because that’s been my entire career. We are seeing Congress and other folks start to turn their attention back to the Medicare Access and CHIP Reauthorization Act, MACRA.
MACRA had some incentives for clinicians who participate in what they call advanced alternative payment models, which would include ACOs that bear risk. Congress is revisiting those incentives and saying, “Okay, we’ve learned a lot since MACRA first passed in 2015. How can we rejuvenate those efforts to create more enthusiasm and more urgency around the movement to ACOs and other models where clinicians are taking risk?”
We’ve seen some hearings on that topic. We’ve started to see some early thinking in the form of white papers and other policy documents. And I am just really thrilled to dive back into that because it takes me back to my law roots. I think the federal government can so much set the tone for where we’re going, and these conversations help to set that tone.
Steven Duque: Thank you, Mara. In your work, what have you seen as the most significant barriers to adoption of accountable care models?
Mara McDermott: That’s a great question. There are many different barriers, including policy barriers. One that is very striking for me right now is the number of model options available. Within MSSP there are different levels — A through E, and then Enhanced, and possibly a new level — and then there’s REACH, and then there’s Primary Care Flex.
I think that it can be hard for mere mortals to parse those options to figure out, “which of these models should we be most focused on?” My day job is to dive into those models. I think about a clinician trying to understand them, and their day job is not that. It has been a good problem to have — more options are good — but a problem nonetheless. We need to help folks understand where they need to go and how to get into those models.
Another barrier we hear about all the time has been data: how do you move from a fee-for-service mindset and data orientation to a coordinated care, capitated care data orientation? And how do you get the CMS systems to cooperate and collaborate with that setup?
Another huge barrier has been COVID recovery. People have been focused on other things, and rightfully so. Now I’m seeing a return of focus in Washington, DC — and with members that I talk to — to delivery system reform after, I don’t want to say a lull, but a focus on other things during the pandemic. Again, rightfully so, but the focus on other things did slow progress as we think about where the energy was pre-pandemic versus where we are now in the environment.
Steven Duque: Mara, you shared some of the challenges that provider organizations and Accountable Care Organizations face as they seek to integrate data, and obviously there’s also a big opportunity there that you highlighted. I’m curious to hear what you’re observing as provider organizations and Accountable Care Organizations leverage technology to solve some of these problems.
Mara McDermott: We’re seeing technology used in a lot of different ways. To me, the secret sauce of accountable care has always been the ability to find data tools that support stratification of the population, which is just not done in a fee-for-service environment.
So we are diving into our population. We are finding the sickest patients. We are finding out how sick our population is, what their specific conditions are, and then building care management programs to match those conditions. That creates a ton of opportunity that just doesn’t exist in a fee-for-service environment. It creates the ability to align care management programs to your population’s specific needs. That is one element.
Another element we’re seeing is the use of all kinds of other tools, like telehealth and remote patient monitoring, that can have a really profound effect on managing patient care and keeping people healthier, keeping them out of the hospital if they don’t need to be there, and aligning care management resources to the specific need of our patients. I see a ton of potential there.
You also asked earlier about different issues or new concerns that have been coming up. I would say AI is a huge one that we hear about all the time. Obviously the provider community, along with everybody else, is still figuring that out, but I see a lot of potential there as well.
There’s tons going on with technology, and the common theme is finding new ways to support patient populations and their health, and to meet people where they are to increase convenience, which I think is a huge element of what accountable care can do in the future — just making healthcare easier to access for folks.
Steven Duque: What are some of the more important and impactful opportunities to increase the reach of accountable care, both for Traditional Medicare and for private Medicare Advantage payers?
Mara McDermott: This may not answer your question, but I think the most impactful thing for our audiences is to share their stories. Storytelling is the way we advance policy. We need to get folks to resonate with what we’re trying to do, where the barriers are, and why our work is important by telling the stories of clinicians and patients who have experienced value-based care.
I hear on the road all the time — as I’m sure you do, too — that value-based care creates new opportunities and enthusiasm for primary care clinicians. Reshaping the way that they practice medicine is creating more longevity in their careers and more joy. We need to share the stories of patients who would previously have fallen through the cracks, but because of accountable care, they do not and are able to live more fulfilled lives with better healthcare experiences.
That, for me, has been particularly true in some of what we hear about our accountable care members in the kidney models. If you think about a person who’s living their life on dialysis in a facility versus in the home, there are real, substantial opportunities to transform people’s lives through that model of care delivery that’s driving innovation and all the better things that we talked about.
So, sharing those stories is perhaps our most important work from a policy perspective. And then, of course, we need to dive deep into the weeds and get those policies right.
Steven Duque: I love that insight and recommendation to share the stories. I imagine in your seat you hear a lot of powerful stories and I’m curious whether you’d be willing to share any of them with our audience.
Mara McDermott: Sure. I think for me, the most impactful stories are always the more routine ones. When I first fell in love with accountable care, a story one of our clinicians shared with me was that they had a patient who kept being readmitted to the hospital, and they were trying to figure out why.
The patient kept saying, “I’m taking my medication the way that I’m supposed to,” so the Accountable Care Organization sent somebody into her home to find out what’s going on. To understand, “why does this person keep ending up back in the hospital?” And it turned out that the patient had poured all of her medication into a large jar. Where the medication instructions said, “take two or take three a day,” she was just going into the jar and taking two or three a day. So she was doing what the paper said, right? Take two. But the effect of that was a mixing of medications. That was not what was intended by the instructions that were given to her.
But for that presence in the home, the care team may never have known about that. If you think about a fee-for-service environment, that could have continued on and on and on with potentially really bad results.
So that was one of the early stories that was most powerful for showing me the benefits of accountable care. A story that showed the impact of having somebody who is paying attention and getting access to the data, seeing that this person is being readmitted over and over again, and then having the tools and wherewithal to go into the home, spot the problem, come up with solutions, and send that person on a better path for their healthcare journey.
Steven Duque: Thank you for sharing that story with us, Mara. I’m curious, what are some of the most common issues that you’re observing at Accountable for Health across your members? What are they thinking about and focused on?
Mara McDermott: I was just on the road with some members and friends talking about what’s top of mind for them, and the biggest one that we have not yet talked about in this conversation is the workforce. I hear about it at every talk I give, from every audience that I speak with: concerns about the physician pipeline; concerns about early retirements; concerns about the continuing flow of people who are able to do this important work, starting from medical school all the way through.
And I am now very concerned about those workforce issues. I don’t have a great solution to share with you today — I wish I did — but that is very top of mind. The other thing that has been top of mind for our group and for the federal government is bringing clinicians who are still in fee-for-service today into the value-based care movement.
If clinicians have observed models go by for 10 years, or have sized them up and decided they’re not for them, what can we do to bring those clinicians into the fold of accountable care? What are changes to the models, or the communication style, or the data — what are different things we could do to bring later-stage adopters into accountable care?
Steven Duque: Thank you for sharing that, Mara. You work deeply with primary care and provider organizations on accountable care and advocacy. From your perspective, what have you seen to be the impact of advocacy alongside provider organizations? Why is that important to them, and why should they care?
Mara McDermott: The impact can be huge. We’ve seen everything from legislation like MACRA that creates the incentives for moving more clinicians into accountable care, to smaller model changes like the transition to ACO REACH and the ability to weigh in with CMS to get some of the changes that participants want.
The clinical voice in the work of advocacy is critically important. We can’t get things done without it. We see the most success when we can work closely with our member companies to identify problems and coalesce around solutions.
One thing I’ve observed is that if you have a model — for example, one with 100 participants that each bring 100 ideas to the federal government and say, “we want you to do this” — it is very easy for the government not to incorporate those ideas because they cover too many things that are too disparate. But, if we can bring folks together and have them coalesce around two or three things, we have a much better opportunity for impact. That’s the work that Accountable for Health is doing: bringing folks together, identifying those ideas, prioritizing them, and then finding the right folks, the right data, and the right information to bring those ideas forward. That is where we see a ton of success with our accountable care advocacy.
Steven Duque: That notion of synthesizing all of these disparate ideas — of bringing them together and prioritizing the key issues — is really powerful. I’m curious if there are other things that you’d recommend provider organizations do to enhance their advocacy capabilities.
Mara McDermott: Yes, I like to give this homework assignment every time I talk to people. My homework assignment for provider organizations out there listening to this is: identify your member of Congress and communicate with them.We have to share those stories much more regularly than we are. We have to make those local connections. We have to make accountable care a local thing that people care about. There’s a lookup tool you can Google for those wondering how to execute.
Look up your member of Congress on their website. There will be contact information. You can say, “hi, I’m a constituent. I would like to share with you this video, this story, this data.” Whatever it is you’d like to share.
The extra credit on that assignment? Have the staff visit you. Show them accountable care in action. Help them fall in love with it the way that we are all in love with it and are so passionate about it.
I think that is the most important thing that folks can do, and Accountable for Health is happy to help with that if folks want to engage in that way. It is so important that the communication is happening much more frequently than it does today.
Steven Duque: Mara, we are so grateful to have had this conversation with you today. Thank you so much. We’re honored to sit here with you, and we are just huge fans of the work that you’re doing at Accountable for Health. We encourage our listeners today to engage with you and to increase their advocacy capabilities going forward.
Mara McDermott: Thank you. We’d love to continue to connect — folks can follow Accountable for Health on LinkedIn if they want to learn more.