For many healthcare organizations nationwide, patient engagement efforts are focused around healthcare consumers being more involved in their own care by setting clinical goals such as losing weight or controlling blood sugar. The idea is simple in that, if these goals are met, health outcomes will be improved. For leaders at the Des Moines, Iowa-based Mercy ACO (accountable care organization), however, proper patient engagement involves drilling down multiple more layers to truly find out what motivates patients.
Formed in 2012, the Mercy ACO is part of the Medicare Shared Savings Program (MSSP), but with a number of commercial contracts also. According to David Swieskowski, M.D, chief accountable care officer at Mercy ACO, in the first year in the Shared Savings program, it had 27,000 lives at risk, and the ACO saved 3.3 percent, or about $10 million dollars, while receiving a $4.5 million dollar payment for those savings it generated. In year two, Swieskowski says, the lives at risk grew to 60,000, and while Mercy saved another $10 million dollars, the organization didn’t receive any payment due to not hitting the minimum savings of 2.2 percent.
Swieskowski chalks this up to Medicare wanting to make sure that payments given are not a random variation, meaning that it wants a significant improvement in cost reduction. “We’re in a one-sided [risk] model where you don’t ever have to give anything back to Medicare,” he says. “Medicare now has a [two-sided risk model] where with one of their tracks they will let you choose your savings rate, but it goes both ways. So if you lose a half a percent, you have to pay it back rather than having to lose 2 percent before you have to pay anything back,” Swieskowski explains. As such, it’s “just very difficult to bend that cost curve,” he adds. “You have to change patients’ behavior and change physicians’ behavior. That’s difficult to do. It’s something that takes a long time—you can’t do it in a year or two. But I think we have an effective strategy for doing that, at least for patient behavior,” he says.
That strategy was actually developed 12 years ago, Swieskowski says, when Mercy leaders were invited to a pilot program on self management support funded in part by the Institute for Healthcare Improvement. “[The program] got involved in self management support and teaching patients to manage their own diseases. Part of the program was about motivational interviewing and goal setting as well,” he says.
To this end, a key component of Mercy ACO is its health coach program. Mercy health coaches are licensed, registered nurses stationed within the Mercy primary care clinics. Health coaches work in conjunction with primary care physicians to provide personalized, one-on-one care to help patients set and achieve their healthcare improvement goals. Health coaches are also responsible for following up with patients who may be at higher risk for developing chronic illnesses and will also work with healthy patients to provide reminders for regular health care screenings. Swieskowski says when Mercy’s patient engagement strategy began in 2003, there was one coach employed; now there are 80 of them, located physically in physicians’ offices.
The concept behind the health coaches is broadly to help people achieve their goals. But there is nothing “broad” about the coaching itself, notes Swieskowski. “The goals are personalized and they are not necessarily clinical goals. That’s what is unique about this strategy,” he says. “It’s not about controlling blood pressure or losing 10 pounds, because we don’t think that’s what patient goals are about. Patients want to control blood pressure or lose weight to achieve something in their lives. That’s what you have to figure out. What do you want to achieve by doing these things? What motivates them?” Swieskowski asks.
He adds there are anecdotal results about improving outcomes, recalling a story a Mercy coach just told him a few weeks ago regarding a patient who was in with diabetes. The patient had been talking about weight loss for a long time, and finally the patient contacted the coach to start working on it, Swieskowski says. “She set goals to lose weight, and the coach said ‘Why do you want to lose weight?’ The coach then drilled down to the reasons, to which the patient said she wants to feel stronger and walk better. The coach drilled down even more, and found that the patient was very worried about losing her independence and being dependant on other people. Maintaining your independence is the goal that will be motivating someone; it’s a much deeper goal than feeling stronger. Drilling down like that is the key,” Swieskowski says. “We are not imposing our clinical goals, but instead finding out their goals. For them to achieve their goals, they always have to improve their health anyway,” he adds.
More Than Just Tech
Interestingly, while Swieskowski feels that patient portals are a big part of engaging patients, the infrastructure at Mercy isn’t currently conducive for working portals. “Unfortunately we don’t have patient portals in our ACO practices right now as we have run into a lot of problems with our EMRs and getting them working,” he says. In Des Moines, Mercy is connected with Colorado-based Catholic Health Initiatives (CHI), so its EMR is a large project that is part of CHI’s national implementation. “We have to rely on what they give us, and they haven’t given us a patient portal yet,” he notes. Similarly, Mercy is also connected with Catholic Health East/Trinity Health, located in the mid-Atlantic region. “They are changing their EMRs, from NextGen to Cerner, so it’s the same deal,” Swieskowski says. “We just don’t have our EMRs installed in a way that allows us to change the way we practice medicine at this point.”
Swieskowski adds that he in “no way happy” with the data systems to measure and track what the ACO is doing. “It’s not anywhere near what I think we could be doing. By this I mean with our data warehouse, we’re getting the billing information well, but we’re not getting clinical information, such as ‘Is your blood pressure or blood sugar controlled?’ We just are not getting the data in the way we wish we were. If we were, we’d be able to feed it back to the physicians and offices, and make an impact on performance improvement. If you don’t have the metrics to see if you’re making any progress, it’s hard to make progress,” he says.
As such, Mercy has built disease registries. It has a data warehouse where clinical data from EMRs and billing data are married together in one database to try to understand clinical quality and cost for the patients the ACO is taking care of, Swieskowski explains . “The warehouse is used to measure ourselves and improve quality. We probably have 15 EMRs across our ACO, so we get an electronic feed from those, and we then standardize them so we all have a standard measurement across the entire ACO. So we use that for our quality improvement, not the meaningful use reports that come out of the EMRs.”
Another challenge that leaders at Mercy face is engaging physicians to engage patients. Swieskowski says that when a patient comes in the office, it’s easy for a physician to literally walk him or her three down to the health coach. While that can be a powerful approach, some clinicians remain hesitant still, he says.
“Not everyone wants to buy in. But we tracked the data on the physicians, and we found that those who utilize health coaches had better quality outcomes and higher productivity. There were also increased revenues in the practice because you are doing all these ancillary tests and medically-necessary tests that don’t get done. Due to the way offices are designed, you can’t address them in a 10-minute visit,” Swieskowski says, adding that the increased revenue came out to more than $600,000 per coach per year that is generated in the office setting when you have a coach in there. “Quality scores also got better, so based on that physicians have accepted this strategy, and are even paying for the coaches out of their pockets.”