In the proverbial journey of a thousand miles that begins with the single step, when it comes to leveraging healthcare IT to support value-based reimbursement models, provider leaders are still just steps from the beginning of that journey. That was the consensus of a group of industry experts participating in a panel discussion on March 4 entitled “Supporting Value-Based Reimbursement Models With IT,” held on March 4 at the Hyatt Fisherman’s Wharf, as part of the Health IT Summit in San Francisco, sponsored by the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics under our corporate parent, the Vendome Group LLC).
The panel was moderated by Deanne Primozic Kasim, director of research at IDC Health Insights. She was joined by Davin Lundquist, M.D., vice president and CMIO, Physician Integration, Dignity Health (San Francisco); Howard M. Landa, M.D., CMIO at Alameda Health System (Oakland, Calif.); Arien Malec, vice president, strategy and product marketing, at Relay Health (Alpharetta, Ga.); and Steve Shihadeh, senior vice president, North America sales and customer operations, Caradigm (Bellevue, Wash.).
Panelists (from l. to r.): Kasim, Malec, Lundquist, Shihadeh, and Landa
To begin with, as Alameda’s Landa noted, some organizations, like his, are going into the value-based purchasing arena with limited resources. “We are very involved in value-based purchasing and in PQRS,” he said, referring to both the mandatory Medicare value-based purchasing program and to private health insurer-based programs, as well as Medicare’s mandatory Physician Quality Reporting System; “it’s going to be hard to participate in other things,” he noted. “We have a panel for sickest patients, something called the Hope Program,” he reported. That program focuses on optimizing care coordination for “frequent flyer” patients, something that Landa noted has already reaped rewards. Meanwhile, he added, “We’re looking to population health on a broader level.”
Dignity Health’s Lundquist, speaking of a recent announcement from the Department of Health and Human Services in January around value-based payment goals, that federal health authorities announcement “that they will be moving to value in a few years, “signaled to us that we shouldn’t hold off long” on preparing for that shift. “We do have tons of accountable care in the Sacramento area,” he said, referring to Dignity Health’s accountable care organization (ACO) involvements in that region. Meanwhile, he added, “Down in Ventura [in Southern California] where I am, probably half of our contracts are capitated. And many of our hospitals have co-management programs.” What’s more, his health system is involved in an Arizona-based Medicare Shared Savings Program (MSSP) ACO. The bottom line, Lundquist said, referring to the full spectrum of possibilities, is that “We’ve been trying just about every [payment and delivery] model possible. And we definitely believe that the proportion of at-risk patients in every market will continue to rise.”
Asked about some of the core data challenges facing organizations plunging into a variety of value-based payment and delivery models, Caradigm’s Shihadeh noted that the key thing is “getting the different data types onto one data platform. We’re doing bundled payments in St. Louis,” he noted, and that his company’s customer organizations there “need all that data available to them in order to be able to bid, and then manage disbursement,” in a complex operating environment.
Asked by IDC Health Insights’ Kasim how patient care organization leaders can get physicians on board, Relay Health’s Malec said that one key is “helping them to understand their true risk profile and patient population. All providers have a long way to go,” he said, relative to their being able to fully understand their patient panels in a comprehensive way.
Still, Lundquist said, “Physicians practicing now are much more accepting of technology. Most who said they would retire before they got onto an EMR have since retired. So I think we’re there,” in terms of physicians’ acceptance of using information systems and information technology in their practices. “But there are still a lot of challenges,” he said. “We kind of went through this with meaningful use. We wondered, how can we get them engaged with this process? How do we create workflows that allow them to accomplish this, without adding a lot of burden? And some of my data informatics partners are always wanting physicians to check more boxes, so we have better data to report on.”
In fact, Lundquist said, referring to the informaticists he and his colleagues work with on clinical performance improvement and other initiatives, “I’ve always told them, we have to align our incentives with what we’re asking our physicians to do. Physicians will find the most efficient way to do their jobs, and if checking boxes doesn’t align with what they need to do, they won’t be checking boxes. But the minute you align incentives so that they will be incented to check boxes, particularly around reimbursement, they will be asking for boxes to click. So you have to align incentives.”
What’s more, said Landa, “Physicians are actually primed to receive accurate information. But instead of being transparent in bringing them the information, we hide it and disguise it. But if there’s one thing we physicians are good at, it’s working with ambiguity and complexity. So we need to get physicians involved in the data creation process. And if the incentives are aligned, and physicians are involved in creating the data processes, that will work. And getting all the clinicians involved is critical, because if you ask a physician to do something he considers menial, you will get data that is useless or misleading. So aligning incentives, and being transparent in delivering data, will move things forward.”
What’s more, Shihadeh said, “Physicians have become more sophisticated, and the data has become better. It’s become cleaner. So the conversation has become better on both ends, getting and giving,” when it comes to working with data under risk-based contracts.
Importantly, Lundquist said, “You need to achieve a virtuous feedback cycle, and you need to make sure the physicians know that the data is originally coming from them. If you start by saying the data is terrible, you’ll never get there.”
Responded Landa, “ You have to say, this may not be perfect, but working with you, we can get it better.”
Lundquist said, “Meaningful use is a good example of this, in terms of putting data in front of physicians that’s not accurate. One of the requirements in MU is your ability to report data on certain metrics. But it’s patient data as opposed to provider data, and sometimes there are multiple providers involved in a situation. And so I’ve had multiple discussions with providers about that. The purpose is to build a highway, I’ve told clinicians. And I’m glad you’re looking at the data and seeing it’s not quite right, but it will improve, and we need feedback. It’s still hard for them to comprehend, but it’s getting better.”
Lundquist added that “Smoking cessation is an example, in terms of physicians typing into the EMR that they’ve provided smoking cessation counseling. We had a physician ask me, well, how do you know that I’ve actually provided that counseling? And I said, well, there actually is a CPT code for that, and she really liked that. So that was a win, as she realized she could indeed code for it. And that was an example of where physicians were already practicing appropriately. The care was already quality care, but you just needed to find a way to document/reflect that.”
Asked by Kasim about the long journey towards interoperability, with interoperability being a facilitator of collaboration in risk-based, value-based contracting, Malec noted that “I sit on the [federal] Standards Committee. There are some hopeful trends” emerging now, he reported. “We’re working very closely with Congress on incenting interoperability around our access as people to access the consolidated record, as well as delegating authority to our clinicians, our care providers and health team, to use the totality of our health record.
Further, Malec added, “I think we’re in a transitional period. There’s been some talk about the high cost of interfaces; we calculated a cost of $10,000 per interface, which is absurd, because if you have 500 physician practices to interface, that’s $5 million just to get started. We’ve got to get to a place where interfacing is built in,” he said. “In my experience at ONC [he was formerly an official at the Office of the National Coordinator for Health IT], policy is a blunt object. It’s useful for putting out goalposts and milestones; it’s a terrible tool for helping to promote the scaling of behavior, and we need to make sure to drive incentives in the marketplace so that EHR vendors, for example, are competing on interoperability.”