To clinically align and engage its medical staff, Covenant Health System created a clinical integration program to deliver improvements in quality and cost of care. Some key results of this program have been a reduced average length of stay by 1.1 days and the elimination of incidence of ventilator-associated pneumonia cases for 18 months.
Four years ago before healthcare reform, Covenant Health System, a five-hospital system in Lubbock, Texas, embarked on a clinical integration program to effectively collaborate with its physicians. Covenant Health Partners (CHP), a physician-hospital organization, was formed in 2007 to deliver improvements in quality and cost of care in return for incentive payments for these improvements achieved via enhanced collaboration. CHP includes more than 300 community-based physicians, half of whom are employed by Covenant Medical Group and half of whom are independent physicians in the community.
“Those 300 physicians came together and began to look at their quality and how to integrate closely with Covenant Health System and how we could integrate our technologies and understand what we could do to raise quality and lower cost,” says John Grigson, CFO of Covenant Health System and CEO of CHP.
Quality Improvement Metrics
Michael Camacho, COO, Covenant Health Partners, says that Covenant focuses on 109 quality improvement metrics in 11 categories across 46 different specialties. Some quality improvement categories include administrative efficiency, hospital readmission, preventative care, pharmacy cost reduction, and patient satisfaction. Physicians produce the pool of savings as a group and then the savings are distributed based on individual quality performance.
“Quality has always been in the physicians’ minds, we’re just not accustomed [to thinking] in terms of group objectives for the benefit of a system,” says David Gray, D.O., CMIO, Covenant Medical Group. “So our challenge is to portray the benefit to the system at a level where the patients are also a part of the conversation.”
David Gray, D.O.
Camacho says that Covenant’s business intelligence software (CHS was a beta site in 2007 for Crimson, from the Washington, D.C.-based The Advisory Board Company) provides detailed cost and quality data, inpatient and outpatient, across the continuum of care. The software offers a 45-day retroactive dashboard for physicians to review individual and aggregate measures and see how they stack up against their Covenant peers, as well as peers around the country. Hospital quality, cost, and efficiency data is loaded into the repository on monthly basis from multiple sources including inpatient and outpatient billing, ICD-9 codes, and a charge master file. Currently, there is a monthly submission of data from hospital and physician offices for Physician Quality Reporting System (PQRS) requirements. Covenant’s business intelligence software doesn’t interface with its electronic health record yet, but that is a future goal. The hospital operates on Meditech (Westwood, Mass.), while its physician group operates on Allscripts (Chicago).
Grigson says that Covenant has been engaging several insurance companies to sign shared savings contracts with the health system. Currently, there are three active shared savings contracts. Through its hospital efficiency agreement providing a P4P contract involving quality metrics jointly negotiated between CHP and Covenant Health System, 83 percent of metrics were met last year for a savings of $802,000. A contract with FirstCare, an Austin, Texas-based healthcare plan, created $1.3 million in shared savings over three years, while a contract with the Nashville, Tenn.-based HealthSpring resulted in $133,332 of savings for fiscal year 2010.
Bridging IT Gaps
Grigson admits that Covenant physicians still have room to improve on metrics, but he hopes to open up this clinical integration program to more physicians. To do so, IT infrastructure gaps, must be bridged. Gray says that the employed group has been on an EHR for seven years and is moving toward meeting meaningful use this year. On the other hand, the independent physicians that work with Covenant have to use their own resources to purchase EHRs. CHP has budgeted $500,000 to provide a 75 percent subsidy for these physicians to purchase EHR systems. The selection process is currently underway to set up 20 physicians per year over the next 2 years. Last year 40 physicians took advantage of the subsidy. “One of our strategies is we need to have all our physicians in CHP have electronic medical records and reaching meaningful use, so that is one of our longer term goals,” says Grigson. “From a health information exchange standpoint we need to make sure all this data will connect seamlessly between each other and the medical center, so that’s something we’re working really hard on.”
Gray says that eventually Covenant would like be able to share information with non-affiliated practices in its region. “The informatics leadership from all the different players in our community have been meeting for quite some time to establish a foundation that will allow us to share information which is critical to enhancing the quality of care for all our patients,” he adds.
Next steps for Covenant include using its business intelligence software as a platform for population management next year with the purchase of some other tools. This will then be a springboard for accountable care organization (ACO) development and value-based purchasing participation. Covenant submitted its intent letter to Medicare in November to participate in the bundled payment initiative and will seek ACO and medical home certification next year.