Q&A: How this medical group emerged stronger from the pandemic

Andis Robeznieks , Senior News Writer

Kaiser Permanente of the Mid-Atlantic States has achieved a standard of excellence with its Medicare Advantage plan by improving patient care and satisfaction. Beyond this traditional role, the plan has also served as a vehicle for Mid-Atlantic Permanente Medical Group physicians (the physicians who provide care exclusively to the members of Kaiser Permanente) to spur innovation, cut health care disparities and combat burnout amid the pandemic’s major challenges and a huge expansion in telehealth.

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The Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage with prescription drug coverage contracts on some 44 quality and performance measures. For the ninth straight year, the Kaiser Foundation Health Plan of the Mid-Atlantic States earned a perfect five-star rating from CMS.

The measures judge how well the plans help their members stay healthy and manage chronic conditions. They also assess member experience, customer service and pharmacy service. The ratings use data from the CMS Consumer Assessment of Healthcare Providers and Systems family of surveys as well as the Healthcare Effectiveness Data and Information Set (HEDIS) measures from the National Committee for Quality Assurance (NCQA).

The plan’s members live in the District of Columbia, Maryland and Virginia. Their care services are delivered by Permanente physicians, who are part of the AMA Health System Program.

The team of more than 1,700 Permanente physicians provide care at 33 sites to 780,000 Kaiser Permanente members—one of whom recently became the Kaiser Permanente Mid-Atlantic’s 1 millionth virtual visitor.

Leading this team is neurologist Richard McCarthy, MD, executive medical director for the Mid-Atlantic Permanente Medical Group and Kaiser Permanente. Dr. McCarthy also serves on Kaiser Permanente’s National Health Policy Committee and  National Telehealth Sponsors Steering Committee.

Dr. McCarthy recently spoke with the AMA about how the pandemic has affected his organization’s work, and how a Medicare Advantage plan helps drive innovation, value and health equity.

AMA: How has the pandemic affected care for Kaiser Permanente of the Mid-Atlantic States?

Richard McCarthy, MD
Richard McCarthy, MD, says Kaiser Permanente uses its Medicare Advantage plan to help drive innovation, value and health equity.

Dr. McCarthy: COVID sped up our focus on access and service, and really honed our telemedicine abilities. We have been able to improve patient satisfaction through delivering on-demand virtual care, 24/7. We also kept up with in-person demand as well—except for a temporary pause in elective care that was mandated by local government agencies in March of last year.

But we've been able to maintain the same high HEDIS, NCQA and CMS quality metrics. We've also added something that patients really enjoy, which is virtual, on-demand, 24/7 urgent care. And we've been able to do so while maintaining our cost position and without increasing budget.

Although it's been a really terrible year, and I don't think anyone would want to repeat 2020—including me—it really helped ignite us to do things in less than a year that, honestly, I thought would have taken us five, 10 years. COVID gave us some challenges and, in meeting those challenges, we were able to really improve our operations—not only for delivery of care during COVID, but ongoing after that as well.

AMA: How have the challenges and disruptions of the pandemic affected your patient volumes and quality scores?

Dr. McCarthy: We've maintained, or improved, our HEDIS and NCQA measures. We're still a five-star CMS program—the only one in the mid-Atlantic.

We are taking a look at quality, and quality oversight, in virtual care—because the scale of virtual care is new for all of us—to make sure that we're doing the preventative health care that we should.

Regarding physicians’ patient volume, what we did in the mid-Atlantic is we leveraged Permanente physicians who were able to pivot between in-person and virtual care.

We were able to provide care and promote innovation in specialties that—six months before, said, “Oh, no, I can't do that via video.” They were figuring it out with patients and really quickly delivering high-quality, patient-satisfying care via video.

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Because of the way we're capitated—we're a closed, integrated system—and we were able to regroup our physicians so that they could continue to see patients via video, and then also match demand for in-person care.

One of the things that we're concerned about, and we're watching very carefully, is the efficiency of video. We measure patient satisfaction of all different types of visits. We know that the highest patient satisfaction is with a familiar physician versus an unfamiliar physician. That's well established, both here and [with The Permanente Medical Group] in Northern California.

We also know that in-person visits are more favorable from a member-patient satisfaction perspective than, say, a telephone visit. But what we also found is that video visits are our most-satisfying visit type from a patient perspective—even when they're seeing an unfamiliar physician, which was surprising to us, but actually good news for telemedicine.

One of the things that we worry about in terms of that visit type are the follow-up rates, meaning the patient has a virtual visit which results in an in-person follow-up visit rather than resolution of their complaint. For some pretty common diagnoses, we are finding that an in-person visit is much more efficient. And it makes sense because a doctor can't do as much via video obviously, as they can in person. We have to be careful that the move toward telemedicine doesn't create inefficient care where patients have to be ‘seen’ twice, once by video and then in-person.

We're all learning what the best type of care is for each problem—and, ultimately, the patient needs to decide that—but telemedicine can be very high quality, offer high patient satisfaction and can be an efficient form of care.

AMA: Dr. Ezequiel Silva has described the telehealth boom as “the largest pilot study in the universe.” He also noted that there is more significant data emerging on outcomes and satisfaction. What’s your experience so far?

Dr. McCarthy: We've seen dramatic improvements in patient satisfaction with good telemedicine access. What we also learned is that, when it comes to on-demand, urgent-care telemedicine, the sweet spot is less than two hours. The net promoter—or customer experience—index for a visit where the patient can see a doctor within two hours is about twice the score than when they have to wait eight hours or more for a physician. So, particularly with on-demand, urgent care, time to be seen is really important.

For the other specialties, what we learned is that there is a place for telemedicine for every specialty and they can all provide patient-pleasing care. The key to quality of care in telemedicine is making sure that there's a reliable, high-quality, in-person delivery system to back it up.

The future world will be one where we will know what the most efficient venue of care is for each complaint or condition, and offer that choice first. But then, also, give patients the other venue options too, because I really do think that patients intuitively know what they need.

AMA: Do you have problems with broadband access in some of your areas?

Dr. McCarthy: We're lucky that we're in a pretty metropolitan area—Washington, D.C., Baltimore, and then the suburban areas in Maryland and Virginia. We're lucky in that we, especially  Permanente physicians, have excellent broadband access. Also, all our buildings are wired with broadband, which really helps—both guest broadband and also internal broadband. That makes a big difference.

For some patients, there is an issue of technology challenges and/or broadband access. For those patients, telephone is a necessary option for them. The most important thing for all of these new tools is that we make sure, as physicians, that they're patient-centric, meaning that we have to meet the patient where they want to be met and in a venue that they're comfortable with.

What we've found is that a lot of people—including elderly people—really enjoy video. Some people don't. Some people want in-person care. To be effective as clinicians and to deliver the best outcomes for patients, it’s critical that we respect that and that we continue to offer choice for patients.

We're committed to that. At Kaiser Permanente, we continue to focus on access to those choices and work on them—even offering IT training for people who don't know how to use video and technical support for video care.

We have great leaders in the mid-Atlantic, who—even prior to COVID—focused on telemedicine capabilities. Kaiser Permanente in the Mid-Atlantic States was ahead of the game when COVID-19 struck and we needed to pivot quickly from less than 10% of our visits being virtual to more than 90% at one point, and now about 40% of our visits being virtual,

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AMA: After adoption and integration, what can a Medicare Advantage plan do to optimize telehealth use?

Dr. McCarthy: Medicare Advantage helps promote innovation, helps inspire physicians to think outside the box to figure out different ways of providing great outcomes for their patients without the constraints of “OK, what's the billing code for that? Oh, I can't do that because I can't bill for it.”

That’s really important because the solutions in health care will be determined by the people giving the care, which are physicians. Giving them the incentive to innovate—which I think Medicare Advantage does—is the right strategy to move the country forward and to, ultimately, create a better health care system for everyone.

AMA: Can operating under Medicare Advantage reduce physician burnout, especially during the stress of a times like these? 

Dr. McCarthy: Medicare Advantage spurs innovation and that innovation has to come from physicians. And I think that physicians are, by their very nature, inquisitive, intellectually curious folks who love innovation. In that way, Medicare Advantage does help them deliver more creativity and innovating and, therefore, does decrease physician burnout.

AMA: Do you think Medicare Advantage plans and value-based care models advance health equity, defined by the AMA “as optimal health for all”?

Dr. McCarthy: Value based models have advanced health equity tremendously, because we can look at populations and compare outcomes across populations.  We're also able to create systems of care that are personal, but also organized in a way that we can deliver consistent outcomes for all our patients. I think that value-based care—prepaid-capitated care, Medicare Advantage—promotes that and makes it easier to think about population-based care, which is really important.

It focuses physicians more on data—outcomes data, quality data, patient satisfaction data—that continues to drive improvement. At least for us, it has helped us continue to focus on health care disparities and eliminate health care disparities in important ways.

For example, year after year, we have one of the highest—usually the top one or top two in the country—hypertension-control rates. And we have that for all our patients. The Mid-Atlantic, by the way, has the highest percentage of African American patients in the Kaiser Permanente system. And as you know, African Americans have a higher rate of hypertension. So, I think we've proven that our data-driven, population-based care model that focuses on efficiency, patient satisfaction, and really focuses on outcomes, also works to eliminate health care disparities.