The Case for Vertical Integration: Do Replicable Models Exist?
Friday, April 13, 2018 - 10:30 AM - 11:30 AM
Vertical integration between payors and providers is increasing and evolving, taking shape in models that span the range from full to partial allocation of risk. Large, integrated health systems have existed for decades in a few markets and some have demonstrated the ability to provide high quality services while controlling costs. More recently, accountable care organizations have formed to internalize financial risk within a provider network while seeking to maintain quality. Novel partnerships between insurers and health systems are also emerging, offering alternatives to full integration that nonetheless attempt to align incentives and reallocate risk. Can vertical integration keep costs down and quality up? Which models work, and how can they be scaled? After a brief overview of trends in value-based care and integration, panelists will detail their organization’s approach to integration, results, and potential replicability. The implications of vertical payor-provider integration for broader health system reform will be examined.
Tom Bulleit, JD
Ropes & Gray
Tom Bulleit represents a wide range of clients in all sectors of the healthcare industry, from academic medical centers and companies engaged in biomedical research and development, to large and small manufacturers of medical devices and pharmaceuticals, to HMOs and other healthcare payors, to hospitals, hospices, physicians, physician practice management companies, physical therapists, and other hands-on providers of healthcare, to niche companies offering unconventional services such as e-health connectivity. Tom's practice focuses on legal and regulatory compliance, coverage, and reimbursement, especially under Medicare and other federal healthcare programs but also under state licensing and regulatory regimes, as a counselor, a business lawyer, and an advocate. A primary focus of Tom's practice has been compliance with health regulatory requirements, especially the healthcare fraud and abuse laws. He strives to provide counseling that allows clients to meet legal requirements while still engaging in competitive business arrangements. His counseling practice includes internal client audits and the development of compliance plans, policies, and standard operating procedures. Because the fraud and abuse rules often dictate or heavily influence the permissibility of financial relationships in the healthcare industry, Tom’s regulatory experience has led his healthcare and investor clients to engage him extensively for strategic analysis, development and negotiation of business deals, including academic affiliation agreements between medical schools and their teaching hospitals, and between academic medical centers and community healthcare providers, contracts for healthcare professional services and employment, medical product purchase and sale, discounts and rebates,asset purchases, and regulatory “due diligence” in both the public and private company arenas. Tom also advises in other key areas of health regulation, including coverage and reimbursement, provider payment sunshine laws, digital health and information privacy, and clinical research. He also represents clients who are under investigation by the U.S. Department of Health and Human Services Office of Inspector General, the U.S. Department of Justice, and state Attorneys General, including the negotiation and implementation of Corporate Integrity Agreements and Deferred Prosecution Agreements.
Sanjay Doddamani, MD
CMO, Keystone ACO, Geisinger
Dr. Sanjay Doddamani is the Chief Medical Officer of the Geisinger led Keystone ACO, and a Senior Director, in Population Health, at Geisinger Health System. In this capacity, he works with the executive leadership to accelerate improvement of performance metrics across the system, working closely with the service line medical directors, platform leaders, and operational leadership, to improve integration of population health initiatives. He is also the System-wide Chief of the Advanced Cardiac Disease – Heart Failure program for Geisinger Health System. His background as a heart failure cardiologist has kept him interested in chronic disease management aspects of heart failure. Additionally, he oversees the LVAD program for mechanical circulatory (heart pump) support. Dr. Doddamani is board certified in Internal Medicine and Cardiology, as well as in heart failure and cardiac transplant. He has served on numerous panels and committees, as well as delivered lectures, both nationally and abroad, related to heart health and disease.
Joe Scheidler, MBA
Vice President, National Accounts
Joe Scheidler is Vice President, National Accounts for Kaiser Permanente. In his role, Scheidler leverages over 25 years of expertise in healthcare, health and management consulting and financial services to lead account management and sales for the organization’s national employer group business line with primary focus on contributing to the organization’s sustainable membership growth. Among previous roles at Kaiser Permanente, Scheidler most recently served as the Vice President of National and Multi-State Sales where he successfully led multi-disciplinary sales teams and served as a Senior Executive Account Manager where he drove accelerated growth with large, complex customers including Walmart, The Home Depot and United Auto Workers VEBA Trust, among others. Prior to joining Kaiser Permanente in 2006, Scheidler held senior brand and corporate strategy positions with the Blue Cross Blue Shield Association. Earlier in his career, Scheidler served in a number of roles in compensation, management and strategy consulting at the Mitchell Madison Consulting Group and Watson Wyatt Worldwide. Scheidler holds a Master’s degree in business administration from Yale University, completed an executive program at Harvard Business School and received his Bachelor of Science degree in Business and Finance from Northern Illinois University. He is an active participant in several influential industry organizations including the National Business Coalition on Health.
Al Kurose, MD, MBA
President & CEO
Al Kurose, MD, is President and CEO of Coastal Medical, a primary care driven Accountable Care Organization (ACO). Coastal Medical provides care to 120,000 patients in more than 20 medical offices across Rhode Island.
Dr. Kurose has led Coastal Medical since 2008, and has been a driving force behind Coastal’s transition to accountable care. He is a member of the Policy Committee for the National Association of ACO’s (NAACOS) and the Healthcare Executive Advisory Council for UnitedHealth Group.
Dr. Kurose is a graduate of the Washington University School of Medicine in St. Louis, MO; the Brown University Internal Medicine Residency Training Program and the Yale MBA for Executives Program. He is one of the founders of Coastal Medical, and practiced primary care internal medicine in a community-based office for 20 years. He is a Clinical Assistant Professor of Health Services, Policy & Practice at Brown University.
Cassandra Toscano, MBA
Executive Director of Joint Venture Clinical Transformation
Cassandra currently serves as Aetna’s Executive Director of Joint Venture Clinical Transformation. In this role, she is responsible for the clinical and financial performance of three Joint Ventures, accounting for approximately 300k members and $1 billion in medical spend. At Aetna, she has also led ACO clinical transformation from DC to Maine.
Cassandra has always worked in roles which blend financial, clinical, and innovation acumen. Before joining Aetna, Cassandra was Director of ACOs for EmblemHealth, led value-based contract implementation and clinical design at PwC, and worked in hospital finance and administration for Partners Healthcare System.
She is dedicated to transforming healthcare delivery into a financially sustainable, clinically reliable, and customer-friendly environment. Cassandra received her bachelors of arts in Biology from Boston University and her masters of business administration from Yale University.