PROVIDENCE – One of the safe harbors amidst the ongoing storm and crashing waves of health care reform under the Affordable Care Act and the transformation of health care delivery is Healthcentric Advisors.

The nonprofit organization, founded in 1994, and headquartered in Rhode Island, is currently the Medicare Quality Innovation Network-Quality Improvement Organization serving the six New England states, under a contract with the Centers for Medicare and Medicaid Services.

Healthcentric Advisors’ elevator speech goes like this: “We don’t provide health care. We provide education and technical assistance to those who do so they can deliver higher quality health care.”

The competitive advantage that Healthcentric Advisors has achieved has been its ability to serve as a neutral convener, earning the trust of different stakeholders, while championing the need for patient engagement.

In addition to its quality work for Medicare, Healthcentric Advisors is about to be named the quality consultant for the Physician Transformation Network contracts in Maine, Massachusetts and Rhode Island.

H. John Keimig, president and CEO of Healthcentric Advisors, is one of the stakeholders appointed to serve on Gov. Gina Raimondo’s new working group on health care innovation.

And, Healthcentric Advisors has been “invited” to harmonize the data measures and metrics under the State Innovation Model plan.

“We have been invited to participate in the SIM grant to take a look at the data measures and metrics, to try and make sure there is harmonization,” Keimig told ConvergenceRI during a recent conversation at Olga’s Cup and Saucer. “You’ve got a long list of very smart, educated people, but at the end of the day, you’ve got to make sure that you talk to the analytical people. My chief analyst is going to work on this.”

Here then, is an in-depth interview by ConvergenceRI with Keimig, who foresaw three trends: a lot of money being pushed out by the federal government under the Affordable Care Act to reinforce the legacy of health reform; the coming tsunami as a result of the changes in the way that Medicare reimburses providers; and his view that, as much as the legacy systems are transforming themselves as fast as they can, there is still no clear picture of what the end game is going to look like.

ConvergenceRI: What were the reasons behind your success in winning the contract as the Medicare quality improvement organization for the six New England states?
KEIMIG: We attribute our success to what we’ve been able to accomplish here in Rhode Island over the past [20] years. It really put us in a nice position when CMS decided to completely restructure the quality program nationwide.

We were well positioned to be one of the survivors that were welcomed into this new program, which gave us the opportunity to work in all six New England states. We’ve engaged the former QIO contactor in Connecticut, to help us get off on the right foot.

We believe that CMS was able to see what we were able to [accomplish] in Rhode Island, serving as that neutral convener and neutral facilitator of different types of health care innovation projects, such as the leading the care transitions initiative here in Rhode Island.

We were able to bring all of the various stakeholders together – hospitals, patients, nursing homes and payers – and get them to agree on standards for best practices in transitioning patients from one care setting to the next.

ConvergenceRI: Can you talk about the apparent difference between patient-centered care and patient-directed care, and how that is playing out in the reform of the health care delivery system?
KEIMIG: This goes back to our mission statement. We have an elevator speech that goes something like this: we don’t provide health care; we provide solutions, assistance and resources to those that do, so that they can provide health care that is higher quality, safer and need-centered.

We focus on patient engagement; that’s the term that we have been using instead of patient-centered or patient-directed care. Patient engagement – making sure that the patient is engaged with their care.

For example, with our last contract with CMS, when we were the QIO contractor just for Rhode Island, we received a supplemental contract from CMS for two initiatives with advanced care planning. One was developing patient engagement – we called it “My choice, my voice, my care” – to create a palliative care initiative for nursing home residents that involved families in that decision, that was very successful.

We are now in negotiations with CMS to basically take that work and develop it further in Maine and Massachusetts as well as Rhode Island, to expand it and make it scalable, so that CMS can take it nationwide.

ConvergenceRI: Can you be a bit more specific about what you mean by the work around patient engagement?
KEIMIG: We are working with a number of Medicare beneficiaries in all six of our New England states, with targets that CMS has asked us to meet, in terms of interfacing directly with disparate populations and with those that are in rural census tracks that have a diagnosis of diabetes.

We’re providing one-on-one education focused on self-management for diabetes.

ConvergenceRI: How does what’s happening in Rhode Island – and in New England – fit in with the national trends of health care reform?
KEIMIG: Right now, CMS is like a fire hose. With the Affordable Care Act, there are only so many months left in the current administration. There is a legacy that they are trying to develop in terms of health care reform nationally. There is a lot of funding left in the Affordable Care Act that has not been spent, and CMS is pushing that out and trying to move the needle in health care transformation.

What’s happening is that there is money being pushed out to transform the system at a very rapid pace, not only with the QIO contract program but with money coming out of the Centers for Medicare and Medicare Innovation for care transformation projects, and money coming out of the office of the National Coordinator for health information technology.

There’s money flowing to fund hospital engagement networks, and money going to physician transformation networks.

A lot of these programs are overlapping providers and markets. There’s a great risk of too many transformation and quality improvement initiatives at once, causing fatigue among the providers.

ConvergenceRI: Here in Rhode Island, where there are a limited, small number of providers, has that kind of fatigue set in?
KEIMIG: CMS is looking to the QIO contractors to be a neutral convener to bring all these entities together, so that they can successful [and not get overwhelmed]. That’s how we see our role in Rhode Island, and in Massachusetts, where there are so many more entities.

Once the Physician Transformation Network grants are awarded, we will be working with the grantees [in Maine, Massachusetts and Rhode Island] to do a baseline assessment of where the physician practices are; then we will monitor the performances of the PTN network, providing assistance, technical support and guidance.

ConvergenceRI: In Rhode Island, by my count, there are six separate initiatives and studies focused on statewide health care delivery, including the recent working group on health care innovation that you are a member of. I have been struck by what appears to be the lack of, to use your term, patient engagement in the decision-making. Is that a good question to ask? What are the questions that you think should be asked?
KEIMIG: When you read the reinventing Medicaid report, it’s extremely well written. It offers a roadmap for how Medicaid – and even how health care needs to be transformed. What it lacks are the details, and the devil is in the details.

I don’t think you’re wrong about asking where the patient is in this whole discussion.

There are a lot of legacy providers in the current health care delivery system. We don’t need as many legacy providers as we once had. We don’t need the size.

I just think that’s make a lot of sense to take that approach. The system can’t continue the way it is, so let’s start to make the big changes.

ConvergenceRI: Is there the research that backs up those kinds of policy changes? Do we know if the policy changes are going to work, or not? Where is the quantitative or qualitative data?
KEIMIG: I felt that, after reading the [reinventing] Medicaid report, it was saying: We’re trying this. I’m not an expert about how the state government is organized, or how the Medicaid program is organized, but I believe that there’s got to be some major changes in the infrastructure of how Medicaid services are provided.

The big picture stuff needs to be out of the way, and once these hurdles have been removed, you can change [the system]. The issue of how behavioral and medical services can be better integrated…

ConvergneceRI: There are existing models of delivery that have done a good job of integrating behavioral health, such as the community health centers…
KEIMIG: I’m not an expert on community health centers. We’ve worked with them over a number of years on a number of different projects. They provide the bulk of services to Medicaid recipients in the state.

I know they have their trade group and everything. But to really reform Medicaid, they need to come together in some sort of umbrella entity, so that they can take advantage of the scale of such an infrastructure. And, with analytics, focused on how you are going to integrate the work of case managers, by bringing them together, so that they can share these specialized services to keep the Medicaid patients out of the ER. There is a silo now.

ConvergenceRI: I’m not sure that’s an accurate description about whether there is a silo or not. From my perspective, the problem is not with the community health centers, but with the structure of the reimbursement system at the state’s Medicaid office and the shared saving contracts with the state.

If, for example, a community health center saved $16 million in 2014 in its managed Medicaid program, how much of that money goes to the insurer, how much goes back to the state’s general revenue fund, and how much comes back to the community center to support your innovative work?

Currently, most of the money saved is going back to the state’s general revenue fund, and very little is going back to the actual providers.

What are the measurements and analytics in quality that you are using in your Medicare work?
KEIMIG: We are working with nursing homes, under the CMS QIO contract, on very specific quality improvement initiatives – reduction in the use of anti-psychotics, reductions in the use of restraints, things of that nature.

ConvergenceRI: You don’t move forward unless the metrics are in place, is that correct?
KEIMIG: We have a pretty solid staff of analysts and folks with MPH training. That’s something we’ve grown up with, that we’re not going to motivate any sort of change or quality program unless you have the data, and the data is solid and there is integrity with it. We just really focus on that.

We’ve been invited to participate in another group, the SIM grant, to basically take the data measurements and metrics, and try to make sure that there is harmonization. My chief analyst is going to be working on this. I’m hoping that we can lend some guidance and expertise to the group in terms of how the measures are developed.

My measure to the group is this: let’s not reinvent the wheel. The federal government pays the biggest portion of the health care dollar. And, those federal measures need to be the starting point. Then, we can take a look and see if there’s a way to refine them or amend them that is unique to Rhode Island.

But, if we try and go in and say, here are the measures, but they don’t align with what the federal government is doing in terms of how they’re measuring performance of hospitals or value-based purchasing, [there will be a problem].

I don’t think the medical community is aware of the tsunami approaching them in terms of the changes of how Medicare is going to be reimbursing them over the next five years.

The greatest portion of physicians’ reimbursement from Medicare will be dependent on performance measures. [Medicare] is going to merge all of the physician quality reporting system reports plus the value-based purchasing; they’re all going to be combined.

It’s a zero sum game. So there are going to be physicians who will lose a substantial portion of Medicare reimbursements if they are not meeting performance standards in order to reward other physicians that are meeting and exceeding performance standards.

ConvergenceRI: Within that context, the importance of population health analytics keeps growing. How do you think that the rapid growth in mHealth, in wearable bands, in cloud-based data analytics in real time will change the equation? Will the health IT systems have to be rewired once again?
KEIMIG: Health information technology is often compared to the international banking system, where it has been the business goal for the banks to be talking the same language in terms of interface.

There hasn’t been that same business imperative in the health care industry.

ConvergenceRI: What’s the right question to be asking about health IT?
KEIMIG: What we don’t know, going back to the legacy systems and how they are transforming themselves, we don’t what the end game is, in terms of what things are going to look like.

Here in Rhode Island, there are many different players. CharterCARE and Prospect Medical, for instance, are not prescribing one health IT system over another. What they have done is taken their California model and transplanted it here in Rhode Island. Their model is to go into the physician practices and, whatever their systems, extract the data and send it back to California, where they amass the data and do the analytics, then send it back to Rhode Island. Their model has been successful in other areas.

Lifespan and Care New England have chosen Epic systems. We just don’t know where the dust is going to settle in terms of where the medical community is going to land. Are they going to get into bed with a hospital-based ACO, with a physician-sponsored model like Coastal Medical.

Tim Babineau [at Lifespan] and Dennis Keefe [at Care New England], they have invested in Epic for proprietary reasons, because they want their organizations to succeed and prosper under this new environment of population health and accountable care.

The other side [of population health management analytics] is public health, where we can use health IT to improve the social determinants of health.

We have a long way to go in terms of making health IT efficient and really responsive to the provider’s and to the patient’s needs.