The leaders at Lancaster General Health in Lancaster, Pa., which in August became part of the Philadelphia-based Penn Medicine system, have been moving ahead on population health management initiatives recently. Their two main areas of focus have been the organization’s participation as an accountable care organization (ACO) in the Medicare Shared Savings Program (MSSP) for ACOs, and its universalization of the patient-centered medical home (PCMH) model across all of its medical clinic sites. Among those helping to lead the charge in Lancaster are Douglas Gohn, M.D., physician executive for population health at Lancaster General Health, and Michael Ripchinski, M.D., Lancaster General’s chief quality and medical information officer. With regard to ACO development, LGH is managing the care of 18,000 in the MSSP program and 70,000 in some sort of risk-based contract. LGH is also participating in the Bundled Payment Pilot Initiative out of the Centers for Medicare & Medicaid Services (CMS), doing cardiac stents, bypass surgery, pacemakers, hip and knee joint replacements, and some spine procedures as well, Gohn reports. Gohn is a cardiologist who continues to practice one day a month.
Drs. Gohn and Ripchinski were among the healthcare leaders interviewed by Healthcare Informatics Editor-in-Chief Mark Hagland for the upcoming September-October print issue of HCI. Below are some excerpts from Gohn’s interview with Hagland. Excerpts from Dr. Ripchinski’s interview will appear at a later date.
Tell us about Lancaster General Health’s MSSP participation, and about its private-insurer ACO involvements.
Our MSSP ACO is called the Lancaster General Health Community Care Collaborative.This is our second year: we started in January 2014. And we have private contracts. We have about 18,000 in our MSSP, overall, about 70,000 in some sort of risk-based contract. We’re also participating in the Bundled Payment Pilot Initiative. We’re doing cardiac stents, bypass surgery, pacemakers, hip and knee joint replacements, and some spine work as well.
Douglas Gohn, M.D.
Which private insurers are you working with, in the ACO context?
We have contracts with Highmark, Aetna, Coventry, Humana, and UPMC. All are shared-savings contracts.
Is Lancaster General Health managing everything, in the private contracts?
The way we have our contracts set up, the patients are attributed only to our primary care physicians. We’re trying to engage some independent physicians into the MSSP, trying to get them loaded into the MSSP for 2016. We have two medical groups with salaried physicians.
What lit the spark for you and your colleagues around population health management efforts?
The starting block for our work has been the patient-centered medical home. All 28 of our primary care practices are Level 3 PCMHs. We’re trying to upgrade to the 2014 standards for PCMHs. There are some changes, not real substantive ones, but that require tweaks. So the PCMH and team-based care are in my mind the foundation for population health. Then you need to connect the physician IT infrastructure to all of that. A lot of the challenge for us has been a data challenge. The goal here is to aggregate claims and label data from disparate sources and put that into an analytical tool and derive appropriate risk. Claims, EHR, and some form of social determinant, all need to be added to that, and now we’re also beginning to look on patient-provided data, such as from wearables and implanted devices, though we haven’t even done that yet. You need a care management platform that that sits on.
Everyone is having to trudge forward on several fronts at once in order to make all these initiatives successful, correct?
Yes. I grew up in the old school where as a doctor, you treated one patient at a time, and you dealt with that patient as best as you could and then hoped they’d do well until the next time. And we’re shifting towards team-based, panel-based care, and so we have to teach people to do that. And how do you transmit that to an extremely busy primary care provider? We’ve been successful—we’ve done some optimization courses with Epic, and we’re including the courses for the doctors around panel management. So we’re trying to give people education around how best to use the technology, the tools, to facilitate care management. We have a Care Transformation Team trying to standardize practices—the real goal is to get standardization in workflows across all our practices. And we, like everybody else, have basically acquired independent physician practices along the way.
And, I’m certain, like every other patient care organization trying to move forward on the standardization of clinical practices and processes, you’ve experienced some pushback?
Correct. It’s really difficult to get buy-in. And that’s our challenge, to be able to say, here’s the proof that this really works. And physicians only believe double-blinded, randomized clinical trials, so there’s always a challenge in sharing data with them.
So what is the essential element of success, in this context?
Engaging the key stakeholders, understanding who the key stakeholders are, acquiring champions in each practice, those are vital. We’re realizing that coming in top-down is not going to work. The key physicians need to understand and spread the word.
And you and your colleagues are using dashboards to help the physicians in their practices, correct?
We are, yes. There’s a dashboard in Epic. The one a lot of folks look at is very complex. But we have ten separate registries, for ten disease states, but there’s a roll-up dashboard that looks at metrics in those registries.
How long has that dashboard been live?
It’s been live for about a year. It continues to get refined and tweaked.
What kinds of learnings have taken place so far, broadly speaking?
When we tried gap closure through just cold-calling patients, in terms of things like calling them and saying, you haven’t had your colonoscopy yet and you’re 55. The action on that isn’t good, we get about 20 percent action on calls. But one of our best practices is having a morning huddle: we identify actions that need to be taken: “Mrs. Smith needs her colonoscopy, Dr. Jones, please remind her.” That kind of process. So with regard to gap closure, there’s clear benefit through the huddle process.
Are you sharing outcomes results on their panels with them yet?
Yes. We look at quality metrics down to the provider level, and share them with the physicians. Most recently, there were nine key metrics we were tracking, with them.
Where are the physicians with all this right now, given where you are in this broad initiative?
I think we’re in that transition phase from people ignoring it to them starting to look at it, but they still see the red dot with the exclamation point in the middle of it and don’t know what to do about it yet. So, if hemoglobin a1c [control] is our major deficiency system-wide, if the a1c is greater than 9 for a certain number of months, do you send them to the diabetes clinic? So we’ve begun focusing on hot-spotting. And it’s taken some time to get there. Open discussion about site-based and overall deficiencies and how to correct them, is really important. So we’re just starting to roll through an organized approach to this, but we do have numbers on the board, and are working our way forward.
What will happen in the next year at Lancaster General Health?
Our care management approach has been evolving. First, we decentralized, then re-centralized, our care management team. At this point, we think we need a hybrid approach—centralized, in that everyone sits in the same room and works from the same workflows, but decentralized, in that the team has the ability to customize approach for the individual practices. From the physician standpoint, we just need to build awareness of the need to be successful with this. Population health management is the wave of the future. You can’t survive without being successful with these care management approaches and still be successful on these value-based contracts, and that’s where things are going.
What advice would you like to share with healthcare IT leaders?
As an industry, we lack embedded evidence-based clinical guidelines. Epic doesn’t have very robust clinical decision support. So structuring standardized documentation with clinical decision support that gets us more onto standardized ordering with the evidence-based clinical decision support is key. And one of the projects we’re working on is celiac disease, where there’s a contingency ordering algorithm pathway possible to create that we need to do. We’re a little behind in that respect.