With the market responding with a number of approaches to value-based care, one provider-led consultancy, Evolent Health (Arlington, Va.), is taking a multi-step approach to helping healthcare organizations prioritize high-risk patients, provide the right intervention and engagement, and align networks to provide economic incentives.
Evolent Health is an independently managed organization backed by capital, asset, and intellectual property contributions from the University of Pittsburgh Medical Center (UPMC) health system’s Insurance Services Division—the country’s second largest provider-owned health plan with 1.6 million members and a subsidiary of Pittsburgh-based UPMC—and The Advisory Board Company, a Washington, D.C.-based healthcare research, consulting, and technology firm.
In the path from volume to value-based payments, the market has responded with many approaches. On the public side, the Centers for Medicare and Medicaid has sponsored the Pioneer ACO program that include 32 ACOs, and the Medicare Shared Savings program (27 ACOs came onboard in Q2 and another 89 in Q3); and on the private sector side, organizations like Providence Health and DaVita have been acquiring medical groups to create their own ACOs.
Evolent’s approach to population health is “strategy first, then infrastructure” and acknowledges the many paths to value-based care, which are structured based on the level of risk ready to be assumed. This can range from minimal risk approaches like readmissions reductions strategies; toward more risk intense programs like patient-centered medical homes and federal-based ACO programs; and finally to maximum risk programs like provider owned health plans.
“We really believe in modeling this in a very in-depth way financially, so [clients] understand exactly what they’re investing in and what they can generate in a return over time,” said Frank Williams, CEO of Evolent Health, during an Advisory Board webinar.
It’s important for organizations to assess their current footprint and identify strengths and gaps, as well as evaluate payer and provider relationships. Evolent Health advises clients to look at complex case management, condition management, and pharmacy utilization management. “If you overinvest in certain areas, and under-invest in others, you’ll find yourself not generating the reduction in cost that you need to,” said Williams.
The consultancy also urges provider organizations to take a broader look at productivity through absence, worker’s comp, and medical leave, and then put into place comprehensive programs around employee health. The money saved from such endeavors can be invested back into care management infrastructure.
Evolent Health recommends five must-have ingredients for any value-based care approach:
- Creating a Coherent View: Evolent Health says organizations must integrate multiple sources of information, provide real-time alerts for ED admissions, and be able to transmit care manager notes to the appropriate providers
- Prioritizing High-Risk Patients: Williams noted that organizations could model their programs off the success of a UPMC team who has been assessing patients for years by collecting data and processing it through a rules engine to create predictive models for readmission risks and risk scores.
- Providing the Right Intervention by Building a Targeted and Tiered Intervention Portfolio: Evolent Health stratifies patients into buckets and creates a menu of interventions and care management operations to address particular patients. One key is to corral a team of R.N.s, social workers, and health coaches to create patient-centric workflows and prioritized outreach.
- Engaging at the Appropriate Intensity Level: Evolent Health says there are three levels of patient outreach.
-Routine care gaps can be addressed by social media, email, or conceierge ourtreach and scheduling.
-Medium intensity patients can be targeted with health coaches, social workers, nutritionists, pharmacy outreach, etc.
-High Intesity patients can be engaged by specialist care managers, home monitoring devices, chronic care clinics, or complex case management methods.
UPMC, for example, has designed a care management program from within their own provider network, rather than engaging R.N.s from outside organizations. “It’s actually a coach that is introduced by the physician,” said Williams. “It’s a coach from the health system calling, and what that’s done is created a much higher enrollment rate—nearly three to one engagement rate—in getting patients completed through the program, and it’s really a very different strategy. Through trial and error [UPMC has] built a pretty comprehensive system that we think can serve as a starting point for a lot of health systems across the country,” said Williams.
- Aligning Physicians through Innovative Model Design: Different resources should be provided to practices based on their volume and intensity, and careful consideration should be taken for the level of support given for each. “You want to have a platform in place that handles all populations, so that it can scale,” said Williams. “Really focusing on areas where you can generate a return, where you’re integrating with providers, and when you’re using central support resources in certain areas like pharmacy, social work, or support, so that you can get enough scale and focus across your care mangement organization to actually have an imact on your population.”