As He Prepares to Step Down, APG’s Crane Shares His Perspectives on the Policy Moment
On June 3, the Los Angeles-based APG (America’s Physician Groups), an association representing some of the most advanced physician groups in the country, announced that president and CEO Don Crane was announcing his plans to leave the organization, once APG’s leaders could find a successor. As Crane had told Healthcare Innovation Editor-in-Chief Mark Hagland the day before, he was leaving APG on a high note, after having helped to build the association to its current prominence in the policy sphere, and was simply looking for his next adventure. He will remain in place until his successor is found.
The association posted the announcement on its website. It began thus: “After 21 years of leading America’s Physician Groups (APG), the national association representing more than 340 physician groups practicing risk-based coordinated care, APG President and CEO Don Crane has formally announced his plans to step down.
“It has been an honor and a privilege to lead APG through many years of change and challenges in an ever-evolving healthcare landscape. But after two decades of growing APG from a small California-based organization into a national organization, it now feels like the right time for me to take a bold step, both personally and for APG. This is a bittersweet time, but I’m excited about the next chapter that lies ahead for me and for the organization that I have served for so many years,” said Crane, in a statement included in the press release. “We are committed to finding a successor to continue building on the success of the value-based care movement.”
“Don is a highly-respected thought leader in the value-based care movement and his departure will be deeply felt by APG members,” said Bill Wulf, M.D., APG Executive Committee Chair, and CEO of Central Ohio Primary Care Physicians, in a statement. “Those of us in the trenches providing coordinated and accountable care owe a debt of gratitude to Don for his incredible leadership over the past two decades. His impact in moving value-based care forward in the U.S. has been immense. He will be greatly missed…his successor will have big shoes to fill.”
“The APG Executive Committee will form a search committee for a successor,” the press release concluded. “Crane will continue serving as APG President and CEO until a replacement has been selected.” APG describes itself on its website thus: “America’s Physician Groups is a national association representing more than 340 physician groups with approximately 195,000 physicians providing care to nearly 45 million patients. APG’s tagline, ‘Taking Responsibility for America’s Health,’ represents our members’ vision to move from the antiquated, dysfunctional fee-for-service reimbursement system to a clinically integrated, value-based healthcare system where physician groups are accountable for the coordination, cost, and quality of patient care.”
On June 2, Hagland interviewed Crane to get his perspectives on a different development: following U.S. Senate confirmation, which had been delayed for months in Congress, Chiquita Brooks-LaSure was able to assume her position late last month as the new Administrator of the Centers for Medicare and Medicaid Services (CMS). Brooks-LaSure will be facing a number of issues at CMS, including the path forward for accountable care organizations (ACOs), two-sided risk for providers, and other key issues. Below are excerpts from Hagland’s interview with Crane.
Tell me just a bit about your coming departure from APG? You’ve been at the helm from the start.
I’m leaving once a successor is found. For sure, I’m hanging in until my successor starts; it will be an orderly, staged process. It seems appropriate; I’ve done this for 21 years. It’s just time for me to move on to a new adventure. It will be a very orderly process.
You’ve obviously built up something important over the years. How do you see the state of APG in this moment?
In a very strong place. We have a stronger, more talented past than we ever have in the past. Our membership held during the pandemic. And the staff is what’s really strong. There are no planned changes. So I think the organization is poised to continue to help lead the value movement. There will be a multitude of really great candidates; I have no doubt that they’ll be great, and will bring fresh thinking and new energy.
What do you think of the current policy environment, as Chiquita Brooks-LaSure takes the reins at CMS?
In a word, much remains unknown and uncertain. It’s only now that the new CMS Director has landed; it’s a new Congress that’s just getting going. We have more to learn, and will know better. Preliminarily, there are some issues of concern. The leading single one is suspension of some aspects of the Direct Contracting program. We advocated for it; it happened under Adam Boehler and Brad Smith, and it seems to have been paused, as CMMI continues to evaluate the alternative payment models and make decisions as to what goes forward and not. They’ve fully eliminated the geographic model; it’s produced a pause in the execution of the second cohort. They let the first cohort go, and left the second, the professional model. And now they’ve sandwiched the two into a merged model.
So the first cohort of 51 or so organizations got in. Then they closed the door. They’re allowing those that deferred their applications to go forward. They cancelled the Next Gen program, which was expected; the good part is that they allowed the Next Gens into the Direct Contracting program.
So how does one interpret that? Does it indicate a reevaluation, or does it suggest some lost of faith in the value movement? There’s the 64-dollar question. We don’t know. There’s clearly expressions by Liz Fowler of unstinting commitment to value. That’s caught our attention and involves a bit of concern.
There seems to be a bit of a schism among provider leaders over, at a deep level, support of ACOs versus direct contracting?
Thus far, we’re talking about CMMI [the Centers for Medicare and Medicaid Services, a division of CMS] and Medicare. But let’s not forget that there’s a lot of healthcare outside of those programs, in the United States, right? There are commercial, self-insured, fully insured, Medicare Advantage; and there’s a lot of commitment to value outside of Medicare. So the new administration comes in with Liz Fowler, a really smart, really capable person whom we like a lot. And her first job is to assess Next Gen, MSSP, Direct Contracting, etc. And she’s hearing from some people that the Direct Contracting will be competing with the ACO programs. So she’s seeing some organizations saying, you’ve got to protect the ACO program! And, parenthetically, their revenues, right? To some extent, there will be some competition between the two. We love the Medicare ACO program as an important pathway or bridge to higher levels of risk, to which we aspire for the good of the nation. And it’s not a bad idea as a baby step to retain upside-only risk in MSSP. But there’s no question that we believe that downside risk is necessary to transform the delivery system for lower levels of cost. The more important model long-range will be the directly contracted, capitated model. The MSSP program, ultimately, is still built on a modified FFS model. Nobody thinks that that’s the long-term solution for the healthcare system.
Open-network, upside-only: the shortcomings of that program are clear. And it’s important that we graduate. The capitated model is so good, for so many reasons.
Do you have any thoughts about Chiquita Brooks-LaSure as the new CMS Administrator?
I don’t know her personally, but I know her by reputation and resume. We’re talking about a very smart, very capable, very well-trained person, for sure. We’re justified in having very high hopes in her. She’s got the chops to do a great job. But next, what really is the administration’s agenda that she’s being asked to execute? So let me shift my gaze to the Administration. We completely applaud expansion of coverage; we fully believe in universal coverage, provided that we simultaneously fix the leaky boat. It’s conventional wisdom that 35 percent of the spend in the HC system is associated with unnecessary and avoidable care and waste. And adding more people into a boat that’s filled with holes, only causes the boat to sink even faster.
So we applaud the expansion of coverage, but the absence of delivery reform has us concerned. As of this hour, the leaks in the boat don’t seem to be the highest priority of the administration. So her mandate may or may not be what the situation requires. There is that terrible choice between massive provider cuts and fixing all the leaks and moving towards quality. And, holy smokes! No one wants the massive provider cuts. We need a pipeline of medical students who see a reasonable future for themselves. So if the policymakers in Washington try to strangle the costs out of the system, that’s a bad approach. And we see, across our membership, that they’re doing very well for their patients and in terms of their finances. It’s a proven model.
Perhaps one challenge, though, is multiple perspectives and voices among providers, in this case, with regard to whether their energy should be focused most on supporting ACO development, or supporting participation in direct contracting. What are your thoughts on that issue?
None of this is new. We’ve had a multiplicity of voices out of the healthcare world, in the past. Most of them, with all due respect, are always saying, pay me more, faster, better—the guild approach. If you ask most physicians what they want out of the AMA [American Medical Association] and the specialty societies, it’s, protect my revenue. But that’s not true of some other associations that are supporting the value movement, and are saying, don’t pay me more, pay me differently. Give me the population, and we’ll make it healthier.
So we are not in the “pay me more” group; we want to be a part of the solution. And Chiquita’s going to have no problem distinguishing between those supporting value versus just wanting to protect their revenue streams.
There are kind of different positions out there in terms of direct contracting versus ACOs, though, correct? NAACOS is, understandably, very focused on support for ongoing ACO development.
NAACOS is concerned that Direct Contracting will impinge on the forward movement of ACOs. They may be right to an extent. Here, we view the Medicare ACOs as something transitional, leading to something better. We’ve always viewed the MSSP program [Medicare Shared Savings Program] as a pathway. So yes, the expectation is that you will perhaps decline in numbers in the MSSP, as we move forward into risk. We shouldn’t be protecting pedestrian pathways as we build freeways. And look at the portfolio of APMs: there will be groups that will want to be primary care-capitated-only; they typically combine that with shared savings and shared risk with regard to specialty care and hospital care. I think there will be 30 different ways to get to goal here, which is true risk. There are a lot of ways to skin the cat. And to the credit of CMMI, they’ve offered a couple of different ways to get there. And you see slightly different variations on the theme, within the value movement.
As the policy, payment, and operational landscape evolves over time, where does APG fit in?
Bigger and stronger over time, as the value movement moves forward. Nobody wants to move from sequester to sequester. And since we’re synonymous with the value movement, we’ll get bigger and stronger over time; that’s what I think.
