Inland Empire Health Plan, based in Rancho Cucamonga, is a not-for-profit health insurer that covers 1.25 million members in Southern California, primarily in Riverside and San Bernardino Counties, in the eastern part of the vast Los Angeles Basin metroplex, and with additional members in Palm Springs, the high desert, and other areas.
The health plan’s membership includes 1.2 million MediCal members—MediCal is California’s uniquely named Medicaid program—and 23,000 dual-eligibles—that is, individuals who are eligible both for the Medicare program and the MediCal (Medicaid) program.
A lot is happening at Inland Empire Health Plan these days, and much activity is being led by its CEO, Bradley Gilbert, M.D. Dr. Gilbert, who practiced as a board-certified general preventive medicine and public health specialist before joining the health plan 20 years ago, joined the organization as medical director and CMO, and was promoted to CEO nine years ago. Gilbert has led numerous advances at the health plan, including in the context of the health plan’s support for health information exchange (HIE). It is in that context that Gilbert serves as chairman of the board of the San Bernardino-based Inland Empire HIE (IEHIE).
And it is in that context that Gilbert was one of the leaders participating in the January 10 announcement of the planned merger of IEHIE and the San Francisco-based California Integrated Data Exchange (Cal INDEX). Gilbert and others spoke at a press conference held simultaneously at the Sir Francis Drake Hotel in downtown San Francisco, and via telephone. The merger, once approved by federal authorities, is expected to create one of the nation’s most comprehensive not-for-profit HIEs.
It was announced that Claudia Williams, former White House technology senior advisor, will lead the new organization as CEO, effective February 1, 2017. The merger, subject to regulatory approvals, is expected to be completed in the first quarter of 2017 and will operate as a tax-exempt public benefit corporation under a new name.
And, according to a press release published at the same time as the press conference was taking place, “The new HIE will combine the 11.7 million claims records from Cal INDEX founding members Blue Shield of California and Anthem Blue Cross with the 5 million clinical patient records of IEHIE and its 150 participating partners. HIEs help improve the quality of the patient experience, support collaboration and coordination and improve efficiencies by making it easier for doctors, hospitals and other care providers to securely review, analyze and share medical information across the healthcare system.”
And the press release quoted Dr. Gilbert as stating that “The creation of this new statewide health information exchange by IEHIE and Cal INDEX is an important milestone in transforming California’s healthcare system into a coordinated system that delivers higher quality and more efficient care to all Californians.”
Two days after the press conference, Dr. Gilbert spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding all these developments. Below are excerpts from that interview.
Based on your experiences, what do you believe are the biggest challenges in evolving HIEs forward these days, and in sustaining them in the current operating environment—one in which many HIEs have been failing?
I believe that the biggest single challenge is getting the participants involved in HIEs. At Inland Empire Health Plan, we already have good access to pharmacy data and claims data—but the claims data is older data. In that regard, the key is getting the hospitals and medical groups involved; they have clinical data that is more timely. The IEHIE has been pretty successful—we have every single hospital in the Inland Empire either actively participating in the HIE, or contracted to participate. We’ve got multiple medical groups participating as well. So the key is getting the data, and the second is the financial model that makes it self-sustaining; we’ve doing both.
Bradley Gilbert, M.D.
It’s not just the medical elements, it’s the social determinants of health and other factors that have to be considered, in order to engage in effective care management, correct?
Yes, it’s not just the medical elements at all. It’s the behavioral elements, too; and also housing, food, transportation, everything. Having done this for 20 years, and having spent my medical career caring for this population—if we can take care of dual-eligible and disabled MediCal members, we can take care of everyone.
And getting a handle on all of those factors is especially important for the Medicaid/MediCal population, especially the disabled Medicaid/MediCal population, and the dual-eligible population, correct?
Yes, I agree, it’s even more important to make sure that we can get current, up-to-date data on members of certain populations, because many of our members really are very transient and are moving around a lot. It is a more transient and fragmented population. That’s why we’re so engaged—why I’m the chairman of the board of IEHIE, why we support it financially, because it holds so much potential for our population.
What are the key practical challenges facing HIE leaders in this context?
There are a couple of challenges; the barrier getting just to the medical data alone is tough. And the behavioral health system data is very fragmented, so that can be a challenge. Now, Inland Empire Health Plan does cover behavioral, so we do have some data. Substance abuse is a carve-out under federal law, and that’s a challenge. And then you get to housing and other challenges. So we very tightly connect to the housing services in the two counties and other social services, but the actual movement of the data is a challenge, a big challenge. And ultimately, if we can get the medical and behavioral data integrated, that would be a big step.
Let’s talk about a typical member of Inland Empire Health Plan, and what that member’s challenges might be. That member is probably older and fragile, with social-determinant challenges, correct?
Yes, that’s right; our typical member is a relatively complicated patient. They probably have diabetes and CHF [congestive heart failure] possibly CAD [coronary artery disease] and COPD [chronic obstructive pulmonary disease]. But certainly, our typical member has coronary vascular disease and diabetes. They may have transportation issues, so we have to provide transport for them. They may be so sick that they need ADL [activities of daily living] help, with cooking and cleaning, things like that. So the care manager has to be sensitive not only to their diabetes, but also to their depression; we’ve got to get them transported to their various appointments, including specialty appointments; and IHSS—in-home supportive services—MediCal will pay for a personal care aide. It’s a person the member chooses, often a family member who’s paid a very modest wage to do shopping, cleaning, transportation. We pay for it, but it’s administered by the counties.
And that’s an example of the continuum of services that have to be coordinated for that kind of person. Our care manager has to be connected to all those services, including IHSS, transportation services, and referrals to specialty appointments. That’s our typical “MediMedi dual” or MediCal member. And I didn’t add substance abuse to that, and I could have. So it’s not one thing, it’s five to ten things that our typical member is faced with.
Care management for many of these MediCal and dual eligible plan members is very complex stuff, obviously then, correct? And can require broader solutions—even such actions as paying to install handrails in members’ houses, that kind of thing.
Yes, exactly. Take the extreme example of if they’re homeless; until we manage they’re housing, they won’t be able to manage their medications or get to their appointments, etc. So the care manager has to look at the plan member across the entire continuum of their lives. And home modification is not covered by MediCal, but, for example, in one recent situation, we bought a washer and dryer for one of our members, because she had such bad COPD that having to go out to the laundromat was terrible for her and worsened her condition, so it made sense to do that. And your example of the hand railings in the house made sense, because a hip fracture is devastating for everyone. And that goes back to the data. You have to figure out that a member is being hospitalized often for COPD, and she tells us that she goes out of her house and gets sick. And this is taking it well beyond what we’re required to do; but we do these kinds of things to improve the health status of our members.
And even among the disadvantaged population, Americans travel and move around a great deal and obtain their care in many locations, correct?
Yes, that’s right; we definitely have members traveling a lot. So for me, next year, what’s really key is to integrate the two different entities with their different strengths. Claudia [Williams, the new CEO of the new merged HIE, who will join the organization formally next month] got to integrate the staffs, the different activities, goals. And we’re both on Orion, but on different platforms, so that has to be integrated. And what is our value proposition for the providers? You’ve got five big health plans [involved in the new merged HIE], and so we have a really good story to share with potential participants. Particularly in this age around alternative payment mechanisms and bundling; people need data.
What kinds of alerts are live already at Inland Empire HIE?
We alert the doctors when there’s an inpatient admission; we also are reporting ED visits, in report format. Now one thing is that there’s alert fatigue. So it’s talking to the doctors and medical groups and asking them, how best do you want to consume data? And sometimes, it’s analysis of which of their patients were in the ER. So working out whether it’s an alert, a report, an electronic notification, we have to figure that out.
Do the physicians in your area understand what you’re trying to accomplish on behalf of your members who are their patients, as we move into the emerging arena of population health?
Yes and no, we have to show them the value, that it helps them take better care of their members, versus it being a burden. And being a doctor and working with many doctors, I think people are getting it, they’re understanding the concept of population health versus just focusing on the patient ahead of them. It’s to some extent a generational change.
Population health is a game-changer, but hard to actually execute on, right?
Exactly. And we’ve got to deliver the data to them that is usable and actionable—hey, I’ve got all these diabetics who have uncontrolled blood sugars. Hey, I’ve got to have Mrs. Smith come in and see me. And if we don’t deliver the data to them, they won’t know, until that member shows up and is in their presence. A lot of docs and medical groups and ACOs [accountable care organizations] are doing these things. But in the inland Empire, we’ve got some work to do, in a good way.
This offers the potential to keep them at a higher level of health status, yes?
We cover a quarter of the population of the Inland Empire. Yes, there’s been a good drop in unemployment, but a lot of those jobs are low-income jobs without health insurance, so they’re getting IEHP through MediCal. There are a lot of individuals who are at risk because of their low income level are at IEHP. So it’s not just the diabetes, it’s everything, all the factors. So that’s exactly our mission, to organize the care and bring people to …
What would you say to the CIOs and CMIOs and patient care organizations whose organizations might be partnering with you, about this HIE development work?
I think they need to become participants, and start actively sharing data through interfaces. And then they’ve got to consume the information. It’s got to be bidirectional, with the HIE. Classic situation: patient arrives in the ED, doesn’t recall all their medications. You want that ED doc to have that list immediately. And he says, here’s the list I see, and are you taking those? And by the way, I’m not going to prescribe this one medication, because you’ve got this other one. Some complex patients will bring lists with them, others don’t.
And they might not even remember all the medications they’re on.
Yes, that’s right. My mom is a classic example of that; she’s on a ton of medications, and can never get it straight. And there are two doctors in the family, and that helps. But her situation illustrates the typical kinds of situations facing ED doctors when patients come into the ED for care. Having data at hand and available in situations like ED visits is extremely important.