Q & A with Lisa Dulsky Watkins

Since 2009, the Fund has supported the Multi-State Collaborative (MC), a group of states committed to transforming the primary care delivery system through payment reform across all payers. Most of the 18 member states that are part of the collaborative participate in either the MAPCP demonstration or the CPC initiative.

Lisa Dulsky Watkins, MD, is the former Associate Director of the Vermont Blueprint for Health at the Department of Vermont Health Access, and one of the founding members of the Milbank Memorial Fund-supported Multi-State Collaborative. A former primary care pediatrician in Vermont, she is the author of the 2014 Milbank Report, Aligning Payers and Practices to Transform Primary Care: A Report From the Multi-State Collaborative.

What progress has the Multi-State Collaborative made so far this year?

This is an important moment in the work of states transforming primary care. We have moved from testing the results of experimental state collaboratives with limited implementation to getting real data about their impact. We know what we have learned thus far—and now the question at the federal, state, and local levels is what we will do with these lessons. We are no longer asking whether we should do this work, but how we can refine and expand it.

What basic lessons have these states learned about primary care transformation?

Some of the basic principles of this work are outlined in the report mentioned above—and they still hold true. We can see that you need local leadership; you need to be flexible or even unconventional in how you create and sustain your implementation strategy; you need to have multiple payers involved. There needs to be a consistent mechanism to analyze information about costs and quality of medical and nonmedical services. Having said that, we are starting to see variation in the performance of some of the collaborative members.

What type of “momentum” are you seeing?

The federal programs run by the Innovation Center will be releasing the second year results soon. Their first, and really preliminary, reports were largely positive. At the same time, the US Department of Health and Human Services Secretary Sylvia Mathews Burwell announced her agency’s intent to enact new federal policies to change physician payments from encouraging volume to those that promote better care. The repeal of the Sustainable Growth Rate (SGR) legislation in April indicated a shift. This bill, which was signed into law as the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA), not only repealed SGR, but also focused on the new way of valuing medical care, especially patient access to team-based, high-quality primary care.

What do we need to do better?

We need to resist shying away from asking the hard questions. Looking critically at the connection between the interventions and their impact on quality and cost (“value”) means moving in the direction of factual rigor and methodological transparency.

The emerging outcomes information is pointing to an ever-clearer need for accurate and timely access to data. The most compelling results we have seen are from organizations that took this charge seriously and in a highly organized way—good examples are The Patient-Centered Medical Home’s Impact on Cost and Quality, Annual Review of Evidence, 2013-2014, which looks at multiple programs, and individual reports such as Vermont’s Blueprint for Health 2014 Annual Report.

What are next steps for the MC?

We are at an exciting crossroads this year. The future of Advanced Primary Care and multi-payer reform is being debated and designed, as we speak. Our individual programs (state and regional), as well as our collective Collaborative experiences, should be able to provide a wealth of important information to policymakers.

To that end, MC members are working together to supply accurate information about the impact of our work. The Fund commissioned Mathematica Policy Research to create an independent report assessing the MC projects and their internal evaluations. We are brainstorming and creating a consensus set of recommendations for consideration by state and federal policymakers on the next evolution of multi-payer primary care transformation. We are convening the payers in these projects to collect their perspectives and assessments. Later this year, we are planning on bringing the MC states together for an annual in-person meeting. Our common goal is to take a hard look at our outcomes, identify successes and challenges, accelerate learning and to grapple with the question of “sustainability,” or what happens next. The value of being in the same room, even briefly, is extraordinary. Spending time face-to-face creates and fosters solid working relationships, making us more nimble and effective.