As chief population health officer at UW Health and president of the UW Health Accountable Care Organization in Madison, Wisconsin, Jonathan Jaffery, MD, MS, MMM, FACP, has had a front-row seat to one of academic medicine’s biggest challenges — how to increase access to high-quality, equitable, affordable care while ensuring that providers are adequately compensated for that care.
Under his leadership, UW Health implemented multiple innovative care models that have resulted in significant savings while still providing top-notch care to populations across the UW Health system.
Now, as the AAMC’s new chief health care officer, Jaffery hopes to help other academic medical centers adopt those same types of value-based programs, while continuing to innovate and fulfill their tripartite missions of medical education, research, and clinical care.
“If we take a step back from thinking that we have to do things the way we’ve traditionally done them, it opens up all sorts of possibilities for us to broaden the reach of academic medicine,” Jaffery says.
A nephrologist by training, Jaffery first became immersed in the health policy world as a Robert Wood Johnson Health Policy Fellow, working with the Senate Finance Committee, right after the passage of the Affordable Care Act in 2010-2011. He has also served as chief medical officer for the state of Wisconsin’s Medicaid program.
Jaffery recently sat down with AAMCNews to discuss some of the biggest challenges facing academic medicine today, as well as what he hopes to bring to his new role as chief health care officer.
Before coming to the AAMC, you were chief population health officer at UW Health and president of the UW Health Accountable Care Organization. Can you tell me a little about your work in those roles and how you envision using those skills at the AAMC?
When I returned to UW in 2011 after having spent a year in Washington, D.C., as a Robert Wood Johnson Foundation policy fellow working for the Senate Finance Committee, I was tasked with starting up our accountable care organization, our ACO, and really all of our health system population health capabilities. When I started it was really just a department of one, but over time it’s grown significantly and the department now encompasses three different areas. There’s the ACO, which is how we interact with CMS [the Centers for Medicare and Medicaid Services] and other payers as well as other parts of the community that deliver parts of the health care continuum that UW Health doesn’t necessarily deliver. Second is the population health care model. These are all the internal care model programs that we develop, implement, and evaluate in order to achieve value-based care. And then the third area is community health improvement. This is how we collaborate with other parts of the community to address the social determinants of health in order to improve care for all populations. So throughout my career, I would say I’ve consistently worked to align really two things. One is our care models — how we deliver the care — with the payment models — how do we get paid to deliver that care. And the fee-for-service system doesn’t always allow those models to be in alignment.
With that in mind, one of my goals in coming into the chief health care officer role at the AAMC is to help academic medicine continue to innovate and to navigate the shift from fee-for-service to taking financial risk under value-based care. I’ve been able to demonstrate how an academic medical center can do those things not only at the same time, but actually synergistically to provide both the cutting-edge specialty care that we do throughout the region and … also the high-quality, full-spectrum care to a medically homed population in a local community. And we’ve been able to do that while [having] some of the lowest total costs across the country. In my new role, I’m looking forward to working with health systems all across the country to help academic medicine build on its many strengths and seize those opportunities that exist today in order to really continue to thrive.
Do you think ACOs are the solution to improving access and cutting costs?
They are part of the solution, and what we’ve seen over the last decade, since the passing of the Affordable Care Act and the establishment of the CMMI [Center for Medicare and Medicaid Innovation], are a whole lot of innovative care models that aim to engage lots of different providers that serve many different populations of beneficiaries. As it moves into its second decade, CMMI is trying to narrow down a lot of those programs to focus on a smaller number that can actually move the needle. At a high level, those things fall into two buckets: population-based payments, which include ACOs, where a group of providers takes accountability for the total outcomes and cost for a population of patients over a period of time, usually a year; and then episode-based payments, also sometimes called bundled payments, where a group of providers takes accountability for episodes around a more select set of outcomes and activities. Those often are around procedures, but not always. And they are often for a shorter period of time than a year, maybe 60 or 90 days. What I would say is that together these can really encompass all the care that health systems provide for their patients, and I think that the biggest opportunity is for systems that can deliver that entire spectrum of care, from primary and preventive through specialty on to tertiary and quaternary.
Improving health inequities is a major focus of the AAMC. Health inequities also have been a focus of your work at UW. How do we begin to move the needle on health equity?
The first rule of improvement is [that] you can’t improve what you don’t measure. And so we have to ensure that we can capture so-called REaL data — race, ethnicity, and language data — in order to measure how we’re doing. … At the same time, health systems need to really thoughtfully pick where there are high-impact areas for improvement that not only address some of the important health gaps in their communities, but that can close equity gaps as well. Under the Affordable Care Act, hospitals have been required for over a decade to complete CHNAs — community health needs assessments — and then implement the Community Health Implementation Strategies. And I think there’s a real opportunity to use this process to help everyone zero in on the most important areas for their systems locally. There are a lot of themes that emerge in CHNAs across the country, but there are also local nuances. … One of the advantages of this is it really speaks to the need for teaching health systems to build those community collaborations to move those ideas from thought to expression. These are things that ... traditionally have not been a focus for academic medicine, but I do believe they are what enable systems to make those meaningful and sustainable changes that are needed if we’re going to decrease disparities in our communities.
Is there anything else that teaching hospitals or teaching systems should be doing to reduce health disparities?
In addition to approaching the CHNA differently, hospitals can really structurally embrace their roles as anchor institutions in the community. As typically one of the largest employers in the community, and one that regularly interacts with the public, hospitals are uniquely positioned to do things that influence the health of the community in ways that really go beyond just delivering high-quality care. So not only starting to directly address social determinants of health through the CHNA process, but … by supporting historically underserved groups through things like local hiring, procurement, and investment practices. And I would say that this isn’t just a way to try and reduce disparities. It’s also good business. Local support across communities is ultimately how systems are going to thrive. And making these kinds of investments helps lead to a more diverse workforce that reflects the populations that the local health care providers serve. You end up having more trust in the system, better outcomes, and all those things that I think will really help us stay strong and relevant for generations to come.
One of the biggest challenges facing academic health systems today is staffing. What are your thoughts about how to solve the staffing problem or, if not solve it, maybe take steps to improve it?
This is absolutely a top concern of every single health system today, and with good reason. This problem really exists across roles, it’s not just physicians, but it’s nurses, it’s across the board. There is a lot of innovation going on to increase the pipeline. Things like internal staffing agencies that systems are creating, programs to bring in local community members and giving them support while … they work toward their degrees and also work within the systems providing clinical care. These are great things, and they’re going to be part of the solution. They’re also incidentally things that can help diversify the workforce to make it look more like your local community. That said, it really is more than a pipeline issue. … We’re also seeing an exodus of the workforce out of health care and, again, that’s across the board. So efforts to retain people are just as important as bringing in the new people. … It’s important to realize that this is about more than just money. It includes helping people to manage what really is a growing amount of bureaucratic and administrative tasks. It’s giving folks a platform for their voices to be heard, for shared governance for decision making, and things that really impact them most and help them maintain some sense of agency and control of their day-to-day lives. So we need to be careful not to reduce the conversation to only pay. … At the end of the day, this is really a universal problem, and so these solutions are going to have to be holistic and multifaceted.
Academic health systems have a lot of obligations: teaching the next generation of medical students, researching treatments for disease, and providing clinical care to some of the most medically complex and vulnerable patients. With those obligations come financial pressures. What are your thoughts on this, and is there a role for the AAMC to play in helping our constituents through some very difficult times?
There’s no question that it’s an ongoing challenge to fulfill multiple missions, although it’s also why we all went into academic medicine in the first place. … So one piece is for us to continue to demonstrate just how vital academic health systems are both to our local communities and to the nation as a whole and to continue to advocate for the necessary resources to support these missions. I think the public health emergency showed us just how much our systems are really part and parcel of the public health infrastructure in this country, providing not just COVID care but testing and vaccinations, along with public education to help combat misinformation and disinformation. … Another thing we saw is just how important it is for hospitals to have the capacity to manage a large number of patients, which means you’ve got to maintain some of that capacity even when there are fewer patients. And then I think the other thing we have to keep reminding policymakers of is that there’s a whole host of other … unique but critical services that our members provide, the things like burn care and trauma, transplantation. The infrastructure to keep that capacity and to maintain those capabilities is costly.
Now, all that said, I think there’s also a real opportunity for academic medicine to create its own destiny, if you will, and to create a more sustainable financing system by embracing value-based care. … Patients often get a lot of unnecessary care in the United States but unlike a lot of these capacity issues, avoiding unnecessary care is very much in our control — through things like better care coordination, access to ambulatory care, greater provision of home-based services, and things of that nature. The problem with all that work is that historically, the cost of investments to eliminate waste have fallen on the health care providers, and the benefits have all accrued to the payers. So by entering into more of these value-based care arrangements, health systems can capture some or even all of that waste. There’s a reason that the large insurers are so focused on Medicare Advantage, but payment mechanisms like we were talking about before — bundles, ACOs, or other kinds of episodic or population-based payments — can enable providers to keep that value and then, in turn, reinvest it and continue to support all those other missions. That includes providing care to historically disadvantaged populations, which often underutilize the health care system.