Every year, the annual HIMSS Conference, sponsored by the Chicago-based Healthcare Information and Management Systems Society, offers its attendees a kind of conference-based snapshot of where the U.S. healthcare industry is with regard to the forward evolution of healthcare information technology adoption, as well as a sense of the overall policy and operational landscape of healthcare. Attendees can get a sense of the healthcare IT Zeitgeist through attending keynote addresses, educational sessions, association meetings, and networking-focused gatherings, as well as by wandering the exhibit hall and simply by having meaningful conversations with fellow attendees.
HIMSS15, held at the vast McCormick Place Convention Center in Chicago the week of April 12, offered perhaps the clearest portrait of the current moment that has yet been offered to date. Session after session focused on the shift beginning to take place from volume-based healthcare reimbursement to value-based payment, across a very wide range of mechanisms, between providers and both the public and private purchasers and payers of healthcare, and the implications of that shift for healthcare IT leaders.
Further, as part of the keynote session on Thursday, April 16 in the Skyline Ballroom at McCormick Place, Andy Slavitt, Acting Administrator of the Centers for Medicare and Medicaid Services (CMS), made the intentions of federal authorities crystal clear, when, referencing the statement of Health and Human Services Secretary Sylvia Mathews Burwell in January that she wanted the bulk of Medicare fee-for-service payments to providers to shift as quickly as possible over to quality- and value-based payment, Slavitt said, “Our priority is simple: to drive a delivery system that provides better care, smarter spending, and keeps people healthier. The success in the first five years since the Affordable Care Act has been very encouraging… Our agenda now,” he said, “is to get busy strengthening these gains. That will mean that more providers in more communities will need to be able to transform the care they provide so that they will benefit from value-based reimbursement. And they will need technology to help them get there.”
What’s more, in his keynote address two days earlier, Humana CEO Bruce Broussard had told HIMSS attendees, “We have to change the conversation on what we are doing in healthcare from a supply-based system to a system around demand, a system where we put the customer first as opposed to the system. Over the years,” he added, “healthcare has been built by creating more and more supply. I hope I leave today by convincing you that we have to change the focus towards how we improve health for our customers, members, and patients.”
The good news on the solutions side of this landscape is that vendors are rushing forward to provide population health- and accountable care-driven analytics solutions, at a time when such solutions are most desperately needed. Certainly, the hype at HIMSS15 was all around population health, care management, and accountable care solutions. The only question now, as the U.S. healthcare industry hurtles forward into the near future, is, is this a breakthrough moment for population health efforts? And if so, are provider and health plan leaders ready to effectively leverage the tools to make pop health really happen?
The long journey ahead
Leaders from all sectors of healthcare understand that the journey to population health and value-driven care delivery and payment success is going to continue to be a long, challenging one. Donald W. Fisher, Ph.D., president and CEO of the Alexandria, Va.-based American Medical Group Association (AMGA), says he and his colleagues are putting the vast bulk of their efforts into helping prepare physician group leaders for the transition. “We’re not quite there yet, and as we change to a new reimbursement system, even the large, sophisticated medical groups are going to need a few years to make the transition,” Fisher says. “You’ve got to put the infrastructure in place, and the large integrated health systems have been putting those elements in place—EHRs [electronic health records], alert systems, analytics systems, data warehouses—and some have teams of people mining the data to assess patient status.”
Donald W. Fisher, Ph.D.
Even more fundamentally, Fisher says, “You need a mindset for this. And we’re not all the way there yet. The problem is that we’re still being paid on fee for service, but also being asked to constrain our use of revenues and our utilization; and oftentimes, top-line revenue disappears.” In other words, he believes, it will take several years of transition, on the policy, business, and technology levels, before physician groups, the key executors of population health management, will be successful on a broad level going forward.
Coming from the payer side, Charles Kennedy M.D., chief population officer at Healthagen LLC, a subsidiary of the Hartford, Conn.-based Aetna, and a health insurer executive helping to guide dozens of accountable care organizations (ACOs), believes that “One of the most significant challenges to moving to value-based care is complementing the current approach to quality measurement, which is largely retrospective and based on post-hoc statistics about the aggregate cohort of patients. Many dashboards, quality measures, and electronic records today provide retrospective views and value,” Kennedy says. “What we need now is real-time insights on a patient’s health, including where they’re going for services and how compliant they are with their care plans so that we can act on information at the time it will most make a difference in the patient’s care.” Kennedy strongly supports intensive health plan-provider collaboration around data-sharing, data analysis and integration of data sets, for population health.
Charles Kennedy, M.D.
Provider leaders learn in the trenches
Those provider leaders helping to move their patient care organizations forward say that the only way to move forward is to advance step by step, not trying to boil the ocean while early on in the population health journey. “The focus for us has really been keeping it simple, meaning that, because medicine is so hard, we need to build gradually on a strong foundation,” says Benjamin Zaniello, M.D., medical director, population health informatics, at the Seattle-based Providence Health System, which encompasses 34 hospitals, 476 physician clinics, 22 long-term care facilities, and a health plan with 436,000 members, across Alaska, Washington, Oregon, California, and Montana. “Physicians have such busy lives, and medicine is so hard, that you really have to focus it on keeping it simple and making sure that any piece of data or information you share with the physicians is actionable. We always ask ourselves, what can we do with this? It either has to improve patient care or make their lives easier,” he says.
Benjamin Zaniello, M.D.
When asked about what to focus on with regard to data analytics, Zaniello says quickly, “Go to where the money is, and the money is with claims. And I think the biggest, shortest-term impact you can make on physician behavior and therefore patient health, is with claims data, because the claims data tells you what is actually happening in the system. And the payers have already gone through the process of normalizing that data through adjudication. And almost every physician is seeing Medicare, and can see it. And there’s a direct connection with financial incentives and outcomes. So what you’re doing,” he says, “is that you’re slowly educating your physicians.”
Similarly, Barbara Adams, vice president of the 800-plus-physicianTexas Health Physicians Group, the owned medical group of the Arlington, Tex.-based Texas Health Resources (which encompasses 24 hospitals, says of accountable care and population health work, “There are four different building blocks in our world. The first is the EHR [electronic health record]; the second is a data warehouse whose reach spans across all our EHRs in all our clinics; the third is analytical tools, including dashboards, and business intelligence tools. And the fourth, which we haven’t fully implemented yet, is a set of processes around population health management that includes outreach campaigns and processes to close gaps in care. The next step for us,” she says, “is to begin to close gaps in care. We’re beginning to do that on an ad hoc basis. We don’t yet have real-time data going into our data warehouse” or infusing decision support tools at the point of care, she concedes. “So a patient may have an appointment tomorrow, but we don’t know that they haven’t gotten a needed test, for example. But we’re looking to become real-time in terms of closing gaps in care and having [robust programs] for all the different disease states. We first have to get a strong sense of what’s going on with our higher-risk patients,” she adds.
And Scott Berkowitz, M.D., medical director, accountable care, at the five-hospital, Baltimore-based Johns Hopkins Medicine, says, “We’re still in the developmental phase. But we use the data in a lot of different ways, first, in terms of executing on care management interventions. We determine who the high-risk members of the population are, and we bring in the care managers in real time. We’re trying to develop expertise in terms of determining who the patients in our population are who do not have primary care. In fact, in an academic medical center environment, a lot of patients are actually attributed to us through specialists. We’re also doing dashboarding.” Given that their physicians are working in diverse EHRs, Berkowitz notes that, “At what point in care you share that information, becomes important. We provide registry information to physicians, high-risk lists. There are certain things we’re able to do in real-time. We’re focusing on quickly collecting information and sharing it after the fact.”
Scott Berkowitz, M.D.
Readmissions, accountable care, pop health work: they’re all connected
Not surprisingly, provider leaders who been plunging into any of three related areas—population health management, accountable care organization development work, or avoidable readmissions reduction work—are finding how intricately connected the three phenomena are, and how strongly each phenomenon is connected to the other two, conceptually and practically.
John Carew, who this spring left his position as assistant vice president of analytics at the Charlotte-based Carolinas Health Care, an integrated health system with 42 hospitals, to become senior manager in Accenture’s health analytics practice, says, of his Carolinas team’s work, that “We mined our data, and put together a readmissions risk model to predict readmissions for 30 days, looking at all readmissions for all conditions, not just the CMS conditions. So we built a capability with our care management team—they deploy readmission risk scores—within an hour of admission, a patient’s risk for readmission was automatically calculated, pulling from data in our EMR system, looking at about 50 different variables, updated on an hourly basis, and updated per condition, which can change quickly.”
After going live with the program between January and November 2013—staggered across the health system’s various facilities—Carew reports that “We saw moderate improvements, as well as more consistency in our overall are admissions rates, with lower fluctuation, and it also helped us understand what patients have benefited from which services.”
Broad learnings from a nationwide Blues program
Even as individual provider organizations and health plans are documenting early successes in leveraging data for population health initiatives, some nationwide population health programs are providing proof of concept on a broader scale. One example of this is the Blue Distinction Total Care program, an initiative sponsored by the 37 health plan-member Blue Cross and Blue Shield Association, the Chicago-based association of all Blues plans in the United States.
Antonio Linares, M.D., regional vice president and medical director at the Indianapolis-based Anthem Blue Cross, gave a presentation at HIMSS15 on April 12, in which he described the BCBSA’s nationwide initiative. Under that program, Linares explained, “We require that physician groups participate in four areas. First, they have to agree to take on a financial model [involving some risk]; second, they have to guarantee enhanced access to care for their patients,” such as evening and weekend hours third, they must provide improved communication” with patients; “and fourth, they must participate in population-based coordinated care management.”
Importantly, Linares noted n his HIMSS15 presentation, BCBSA has given physician groups participating in the Blue Distinction Total Care program access to two years of claims data, and with tools to help physicians identify high-risk members, as well as sending to every participating medical group “a patient-centered care consultant, a community collaboration manager to develop learning collaborative content based on best national practices, and a provider clinical liaison to help practice s develop care management skills.”
The results after just one year have been impressive, including gross cost savings of $9.51 per member per month, or 3 percent of gross plan member costs nationwide (net cost savings have amounted to about $6.00 PMPM); 7.65 fewer acute inpatient admissions per 1,000, 5.4 percent fewer inpatient days per 1,000, a 3.9-percent decrease in acute admissions for high-risk patients with chronic conditions, and a 4.8.percent PMPM decrease in outpatient surgery costs; and significant improvements in patient/plan member satisfaction.
Advice: step by step, realistically
All of those interviewed for this article agree that healthcare IT leaders will need to proceed strategically and thoughtfully going forward. Texas Health Physicians Group’s Adams offers several key pieces of advice. “First,” she says, “bring IT and governance in early. IT needs a seat at the table so they can partner and strategize with the business on developing ACO plans based on realistic expectations for application and system integration.” Second, she says, “If you are pursuing population health via an ACO contract, identify ACO patients in the EMR by flagging them, develop an ACO manual with screen shots identifying EMR fields for ACO Measure capture, and educate providers on ACO EMR documentation. “ More broadly, she adds, “Don’t be afraid to be vulnerable: ask questions. You are not expected to be the ACO expert; we are all learning. No one has solved it yet and it is still evolving.”
Nancy Beran, M.D., chief medical officer at the Katonah, N.Y.-based Westchester Health, a 120-physician multispecialty group that is participating in both the federal Comprehensive Primary Care Initiative and the new Healthcare Payment Learning and Action Network launched on March 25 of this year, says this: “When you start out, it’s as though the EMR is the alphabet, and you’re just learning to write. And population health is really using the EMR to do aggressive chart review. And we’re at the point where if you track things right, you can do aggressive chart review from the EMR, but it requires that you standardize processes across your practice, whether it’s big or small. Because if everyone’s recording mammograms the same way and not just scanning documents, you can really leverage check- boxes; then the check-box has meaning.” In other words, Beran and all those interviewed for this article agree, start with realistic goals, make early gains, engage the clinicians, and most especially the physicians, and build resilience for the long journey ahead.
Key Takeaways on Population Health’s Moment
- Whether one’s organization calls it population health, accountable care, value-based delivery and payment, readmissions reduction, or care management, the population health journey is inevitably a long, complex one, and the healthcare industry is still very early in that journey.
- Those involved in leading population health efforts in their organizations are taking a very wide range of approaches, but all involve harnessing data from clinical and claims sources, implementing data analytics programs, and linking data and analytics processes to core clinical and operational improvement processes.
- Healthcare leaders moving their organizations forward agree that part of the key is to plan strategically, begin carefully, and build on early successes.