When a provider can increase the amount of time he spends with a patient through longer, more frequent visits and can see the results of his efforts through measurable outcomes and patient satisfaction scores, that’s the sweet spot of medicine — “why we all went to medical school,” says Roy A. Beveridge, MD, Humana’s senior vice president and chief medical officer. To implement those ideals on a broad scale, he points to Humana’s success with Medicare Advantage plans, where hospitalizations are down, HEDIS scores are up, and technology enables the company to provide new services to patients, such as transportation and better follow-up care. Humana is innovating on the commercial side of its business with incentive programs for members, and it expects to see gradual changes where service is provided. An oncologist, Beveridge cites a growing role for clinicians as health care in the United States evolves and new payment models emerge. “It is crucial that physicians are engaged in business decisions,” he says. Beveridge previously served as CMO at McKesson Specialty Health and as executive vice president and medical director at US Oncology. He was codirector of the Bone Marrow Transplant Program at Inova Fairfax Hospital in Falls Church, Va. The author of numerous articles on a wide range of medical topics, he is a member of the American Society of Clinical Oncology and the American Society of Hematology. He serves on the board of Med Fusion, a laboratory and clinical trials services company based in Lewisville, Texas, and previously was on the boards of the American Cancer Society and the National Patient Advocate Foundation. Beveridge earned a bachelor’s degree at Johns Hopkins University and a medical degree at Cornell University. He completed a residency in internal medicine at the University of Chicago and a fellowship at Johns Hopkins University. He spoke recently with Managed Care Editor John Marcille.
Managed Care: As chief medical officer of Humana, what’s the main thing that’s on your mind every day?
Roy A. Beveridge, MD: Quality is front and center. As large an organization as we are, I want to ensure that we are consistently bringing the best, most appropriate treatments to our members everywhere. There’s a lot of emphasis on that process, the review of data, and engagement with our members.
MC: Is there much conflict with people in other parts of the company who are more concerned with cost?
Beveridge: No. Humana is in the process of evolving from a traditional insurance company to a health company. Our entire emphasis in the past year to 18 months has been fundamentally about a consumer-centric model — and our consumers are not just our members, but people we work for, including CMS [Centers for Medicare & Medicaid Services] and all of the physicians and providers we work with. So there is really great alignment at this point in terms of direction of the company.
MC: Was there a key moment that signaled the new direction?
Beveridge: Our board looked at where the company was going and hired Bruce Broussard as our CEO. Bruce has a very deep understanding of the provider world. One of his first hires was Jody Bilney, Humana’s chief consumer officer, whose focus is on consumerism and looking at things through the members’ eyes. One of the very first exercises that we did was to work with members who were just signing up for our plan and look at the entire process from their point of view. We counted the number of mailings and telephone calls and, from the consumer standpoint, really began to home in on “Know me, show me you care, make it easy, and help me,” and we began to simplify things. If that’s the mindset that you’re taking, then you are always looking at it from the standpoint of the member, the provider, CMS, et cetera. That is where we are collectively at this point.
MC: That must strike a chord with you, with your background in provider organizations.
Beveridge: I am a medical oncologist, and I was in a practice for more than 20 years. I was very active in taking care of thousands of patients and then became the CMO for a provider organization. The switch to Humana fits in exactly with where I think clinicians need to be involved — at the C-suite level. And if a big company like Humana is transforming from an insurance company to a health company, you have to engage an increasing number of clinicians. That includes nurses, pharmacists, and others in addition to the chief medical officer. That’s why this job was appealing.
MC: Has the greater emphasis on health increased staffing levels at Humana?
Beveridge: I don’t know if the staffing ratios are the same, but the services are fundamentally different. Say a Medicare Advantage patient is going to one of our Miami practices and doesn’t have transportation to an appointment. We have a sophisticated system that will help pick her up. If she needs to see a specialist, before she leaves the clinic an appointment is made for her to be seen by someone. We link her up with educational programs for her diabetes. Our electronic health record works across a very large platform so that no matter where this lady goes within hundreds of miles, she’ll be on the same health record. When she is hospitalized, we have people in the hospital who work with her physicians to ensure that she is discharged to an appropriate place, and if we need to arrange for food or other social services, we do that. And then we ensure that she is seen within 48 hours by her primary care physician. We are taking care of the patient from soup to nuts. A lot of that is done by very sophisticated technology, and a lot of it is done telephonically, by text, and by e-mails.
MC: That is very different from the past.
Most of our patients, particularly in Medicare Advantage, stay with us more than seven and a half years.
Beveridge: In the ’90s, it was, “let me cut rates,” whereas in today’s integrated world, we are looking for ways to keep patients out of the hospital and improve their health, because most of our patients, particularly in Medicare Advantage, stay with us more than seven and a half years. We truly have skin in the game. And the patient has that same incentive, so it goes even further. For example, we have a national partnership with Walmart to incentivize people to eat better by offering savings on healthier foods. So when this lady in Florida — or Texas or Virginia or wherever — goes shopping and wants to buy healthy foods like vegetables and low-fat milk, she gets a discount because she’s a Humana member.
MC: How are the commercial programs evolving in comparison with the Medicare Advantage programs?
Beveridge: The fundamental difference is that one is a fee-for-service model and one is a global fee model. With a global fee, there is accountability, and we can invest quite heavily early on in the life cycle of the patient. In an accountable methodology where we are seeing the patient for a fairly long period, it’s OK for us to ensure that the patient gets a colonoscopy and a lot of treatment up front because over seven or eight years, this is going to be a dramatic benefit to the patient and everyone. On the fee-for-service side, there is no accountability, so the clinician is just being paid for a service and not the quality of the care. On the accountable side, it is, “Are your quality scores high? Are you monitoring the patient in terms of her glucose? Is she getting a mammogram?” In terms of linking things, on the commercial side we are trying to work with employers to improve their employees’ health. We have HumanaVitality, which is a program where employees get incentives for exercising, for stopping smoking, for losing weight. It’s very effective. Of course, you can see how that can port over for improvement of health on the Medicare Advantage side, so those tools can be used on both sides.
MC: Should companies be looking for these types of contracts with you?
Beveridge: I can speak from a quality standpoint. At Humana, we have a plan that says if I do so many steps with my pedometer, if I do a biometric screen, if I do all of these different things, then I get a reduction in my gym membership fee or various other benefits. Those incentives have been shown to drive good behavior. Incentive programs help people cut back on tobacco use and exercise more.
MC: Do you tell employers that the fee-for-service model isn’t working?
Beveridge: Employers want the health of their employees to be as good as it can be for as long as it can be. There are multiple ways of getting there. When one looks in various populations, primary care HEDIS or Medicare Star scores in the fee-for-service model tend to be lower than in models where there is accountability. The accountability can be held by the hospital or by the physician group or by other entities. The data suggests that when people are held accountable for the health of their patients, there is greater engagement. There is an active debate going on in the medical community about the best methodology for paying providers. On the commercial side, there is a feeling that if you could have more providers in accountable relationships then we would hopefully increase the quality metrics afforded to the employee — you and me.
MC: What has the feedback from providers been as Humana becomes a more care-based company?
Beveridge: We have thousands of physicians who work with us in accountable relationships. Let’s start with the group that is primarily accountable — primary care physicians. They view this in a very positive light. The reason is that in most of our accountable groupings, the amount of time they spend per patient isn’t 8 or 12 minutes as it can be in fee-for-service. It’s more like 30 or 35 minutes. And the number of visits for their elderly patients is higher. At one clinic I visited, the average number of visits was 13 per year. That’s significantly greater than it is in a fee-for-service model. So the doctor is feeling much more in control. They also realize that metrics are transparent to all, and this is kind of exciting. Now there is a way of proving that you are helping patients because their hemoglobin A1c levels or their hospitalizations are lower. The patients are happier. So particularly in the Medicare Advantage world, where there is accountability, the appreciation for the care of their patient is high.
MC: What kind of financial arrangements enable physicians to spend more time with a patient when all of the pressure seems to be on reducing costs?
Beveridge: With a fee-for-service model, the more services physicians provide to their patients, the more they get paid. This system does not reward the doctors who achieve the best outcomes. In an accountable world, one has metrics and one is being paid based on the score that one is achieving. There are standardized scores CMS has developed that primary care physicians are well aware of. They include not just process metrics, but results metrics, so not just what you do, but the results for the patient — the clinical outcome. And then there’s a survey back to the patient. How do they feel they are doing, and how was the interaction with the physician and the practice? HEDIS scores and Star scores are very reproducible, very well defined. And to engage with the patient takes some time. But the result is that the patient is hospitalized less, is healthier and does better. That’s why the physician can spend more time with the patient. Fee-for-service has been the norm for a long time, but it should not be the way health care is run in the future.
MC: In your Medicare Advantage plans, are you effecting a shift from specialists to primary care, something that has been advocated by a lot of health care thinkers?
Beveridge: I am a specialist myself. Certainly in the risk arrangements, or in the accountable arrangements — which I think is the more appropriate word — if someone has cancer, they are still going to be seen by the medical oncologist. In accountable relationships, your patient has to have a colonoscopy and a mammogram and all of the appropriate screenings. If you look in the fee-for-service world, lots of patients never got screened for colon cancer, never get their mammograms, never get a whole bunch of screenings. In the accountable world, what you see is the entire population of patients being screened for all of these things. The only one who can do a colonoscopy is a gastroenterologist, so in this system, what you find is a higher proportion of better-used specialists, and I see that as I tour the country.
MC: How do you talk about the need to reduce hospitalizations with the hospitals in your network?
We’re fairly agnostic in terms of where care is given, as long as we have high quality.
Beveridge: Hospitals are an integral and important part of the health care system, just as outpatient centers are, just as office-based physicians are. In this world that we are all moving into, we want to have high quality care, but we want to spend less money for it. One needs to allow for the innovation that leads to more cost-effective ways of doing things. In 30 years, everything is going to look fundamentally different. When I was an oncologist in training, all chemotherapy was given in a hospital. Now, because our anti-nausea medicines and other supportive care medicines are so powerful and so strong, it’s rare that chemotherapy has to be done in a hospital. It can all be done — and should be done — in the outpatient setting. That’s the natural evolution of improvement in care. We just want the natural evolution to be: Where do you get the highest quality and the best value? We’re fairly agnostic in terms of where care is given, as long as we have high quality. Everything is going to continue to evolve.
MC: How will CMOs at health plans influence how things evolve?
Beveridge: What you are seeing in the role of the chief medical officer is that more people who have taken care of patients and who have some business understanding are participating in the process. The health care system is incredibly complicated, but the clinical voice has to be there. Just like the question you asked in terms of hospitalization: Everyone wants the hospitals to survive and do well. When I get sick, I want my local hospital to be there and to be doing just great. But if I have cancer, I don’t want to have my chemotherapy there, because it can be given in an alternate place. I believe that chief medical officers and clinicians can continue to bring that clinical viewpoint into decision making.
MC: As a clinician, you were instrumental in Humana’s effort to educate consumers about the Affordable Care Act. Why was that important?
Beveridge: At the beginning of enrollment back in the fall, there was not a great understanding of what the ACA was or who was eligible. We took a very active role in working with the YMCA, CVS, WebMD, and a multitude of organizations to try to educate people about the ACA. In December, we placed a full-page newspaper ad where we said, “Call this number. We’ll answer questions on any plans.” On our website, we gave approximate costs on not just our plans but other plans so people could begin to understand as consumers what they would be responsible for. This was very well received, and at this point we believe the population is better educated. Remember, a lot of people who have joined through the ACA have not had insurance before, or haven’t had insurance for years, and they are confused about what copayments mean or what the process is. Our call centers have increased sevenfold just trying to answer questions that members and other folks were having. It was a big educational opportunity.
MC: Thank you.