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In Arizona, the Ambition of “True Care Coordination” is Being Realized

June 20, 2018
by Rajiv Leventhal
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A care coordination platform is aiming to essentially relieve health plans from the responsibility of being “the keeper” of all patient data

When Equality Health—an Arizona-based integrated delivery system focused on improving care delivery for underserved populations—was formed in 2016, the goal was to look at addressing healthcare outcomes disparities through the lens of culture. “No one in the healthcare market was doing this,” says Mark Stephan, M.D., the medical director of Equality Health. "You see best practices at local levels around the U.S. among certain provider groups, but [they are] not of any scale.”

Stephan notes that the egregious differences in health outcomes based on race and ethnicity are well-documented. And so that is what Equality Health is setting out to do; narrow those gaps. To this end, senior officials of Equality Health—which is headquartered in Phoenix but has a network of providers that stretches throughout the state—say that the organization is able to care for these underserved populations through culturally-sensitive programs that improve access, quality and patient trust. “Through an integrated technology and services platform, culturally competent provider network and unique cultural care model, Equality Health helps managed care plans and health systems improve care for the Hispanic population while simultaneously making the transition to risk-based accountability,” its officials noted.

The IT platform that the organization’s executives mention is HealthBI, a Scottsdale-based company (and which is a subsidiary of parent company Equality Health) that was created by a team of industry stakeholders and physicians to fill the need for tools that enable healthcare payers and providers to reduce admissions and readmissions, automate care transition, and improve value-based care performance and HEDIS (Healthcare Effectiveness Data and Information Set) outcomes. HealthBI’s care coordination and care management platform for population health management, including CareEmpower, is used to accomplish these goals.

Stephan says that HealthBI, as a platform, serves two key purposes for payers today: to close quality gaps and to assist with care coordination, particularly around transitions of care. It’s a way to pass through ADT (admission, discharge, transfer) feeds on that front to the practice directly so that care can be better coordinated from the hospital system, he explains. “Most primary care isn’t going to the hospital anymore. So it’s a way to connect the dots for the average primary care practice, just to know where their patients have been and why they have been to the hospital.” 

Stephan points out that because Equality Health is a care delivery system that includes a physician network and an MSO (management service organization), it is leveraging the CareEmpower product for a more comprehensive view from a population health management perspective. “There is a need for the practicing physician to know what has been done, has not been done, and who is either overdue or eligible for certain test procedures, wellness exams, etc. So we have taken and expanded that concept beyond just HEDIS measures,” he says.


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For example, Stephan continues, there are process measures in disease management, and if “I manage a population with diabetes, maybe I have 500 patients with diabetes, and maybe 150 of those patients are uncontrolled. If it is left to work as usual, the patients either come back or don’t come back; they get tests and medications, or don’t, and I don’t know unless they show up again or don’t show up. My EHR [electronic health record] doesn’t do this for me. And that’s the great disappointment of the EHR—no matter the vendorit’s not a population health management tool. It is for documentation and billing,” he says.

Stephan says that Equality Health, as a delivery system that has a network, uses risk stratification in the HealthBI tool and CareEmpower to be able to divide up the work. There are nurse care managers, ambulatory call center care coordination teams, and there is a provider network. “And we divide up the work based on the risk of hospitalization, re-hospitalization, and the risk of future costs. Resources are limited by definition, so risk stratification becomes a practical way to sub-divide the population and reach out to them, engage them, and manage them in different ways with different services and tools. And you cannot manage an entire population with one strategy; so, risk stratification is key,” he contends.

How it’s Being Used

Stephan, when asked about the benefits of the platform, notes that it enables “true coordination of care.” He adds, “It’s one thing for a nurse or someone else to engage a member somewhere in the continuum, make a note and fax it to someone—but that’s not true coordination of care. The ability to communicate on one platform from a health system, hospital, provider network, care management team, and seeing the same set of information—including HIE [health information exchange] participation, which is part of that—is key to understanding in real time what the members need and where they are.”

Another example of the platform being used is at the Mesa, Arizona-based behavioral health provider Partners in Recovery, an organization that is using HealthBI to close gaps in physical healthcare for its members with various behavioral health issues, including severe mental illness.

Leanette Henegan, M.D., chief integration officer for Partners in Recovery, recalls the case of a member who needed state hospital care, which is challenging due to the outpatient resources needed to be utilized in order to enable that care. But Henegan says she was able to pull the member’s cost analysis out of the platform and show that for the frequency she was going to the ED, as well as the regularity of inpatient stays, it would have been cheaper for the member to be at the state hospital. “I have never been able to present that data when trying to justify a level of care. That was paramount; we got excited because the state hospital was denying her, but we showed them the cost variance,” Henegan boasts.

What's more, Stephan notes that social determinants data can also be integrated in HealthBI in one of two ways: they can be incorporated into a person’s risk stratification by using traditional public health data. But, Equality Health also surveys its members. “When you think of the SF-12 [survey that measures functional health and well-being] as a traditional health survey, that’s in CareEmpower, but we also have our own that [includes] cultural preferences and other social determinants. That’s our own standalone risk score for us, and in the software is the ability to embed our survey and score it so that we can begin to share it, use it, and take action on it when we engage members based on their preferences, risks and so forth,” he says.

Speaking more broadly about population health, Stephan says that a true population health management solution should be agnostic of vendors, payers and hospital systems. “You have to be,” he attests; “otherwise, everyone remains in their defensive position and hoards their own data.” He adds that by taking a look at what is happening right now in healthcare, one would notice that there is an absorption of independent practices into ever-larger medical groups. “And that’s been the solution today—well, if we all just get on the same EHR and I employ all the physicians around my hospital system, for instance, that’s [people’s] definition of an integrated system.”

But Stephen says he would argue that there is a tremendous population health need—particularly in primary care around the U.S., in rural areas, in underserved zip codes, and in smaller towns and cities. “You just can’t employ the entire system. So we see a real opportunity, and we need to be able to aggregate through technology and data sharing so that a population can be managed without having to be all under one roof,” he says.


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NCQA Moves Into the Population Health Sphere With Two New Programs

December 10, 2018
by Mark Hagland, Editor-in-Chief
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The NCQA announced on Monday that it was expanding its reach to encompass the measurement of population health management programs

The NCQA (National Committee for Quality Assurance), the Washington, D.C.-based not-for-profit organization best known for its managed health plan quality measurement work, announced on Dec. 10 that it was expanding its reach to encompass the population health movement, through two new programs. In a press release released on Monday afternoon, the NCQA announced that, “As part of its mission to improve the quality of health care, the National Committee for Quality Assurance (NCQA) is launching two new programs. Population Health Program Accreditation assesses how an organization applies population health concepts to programs for a defined population. Population Health Management Prevalidation reviews health IT solutions to determine their ability to support population health management functions.”

“The Population Health Management Programs suite moves us into greater alignment with the focus on person-centered population health management,” said Margaret E. O’Kane, NCQA’s president, in a statement in the press release. “Not only does it add value to existing quality improvement efforts, it also demonstrates an organization’s highest level of commitment to improving the quality of care that meets people’s needs.”

As the press release noted, “The Population Health Program Accreditation standards provide a framework for organizations to align with evidence-based care, become more efficient and better at managing complex needs. This helps keep individuals healthier by controlling risks and preventing unnecessary costs. The program evaluates organizations in: data integration; population assessment; population segmentation; targeted interventions; practitioner support; measurement and quality improvement.”

Further, the press release notes that organizations that apply for accreditation can “improve person-centered care… improve operational efficiency… support contracting needs… [and] provide added value.”

Meanwhile, “Population Health Management Prevalidation evaluates health IT systems and identifies functionality that supports or meets NCQA standards for population health management. Prevalidation increases a program’s value to NCQA-Accredited organizations and assures current and potential customers that health IT solutions support their goals. The program evaluates solutions on up to four areas: data integration; population assessment; segmentation; case management systems.”



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At the D.C. Department of Health Care Finance, Digging into Data Issues to Collaborate Across Healthcare

November 22, 2018
by Mark Hagland, Editor-in-Chief
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The D.C. Department of Health Care of Finance’s Kerda DeHaan shares her perspectives on data management for healthcare collaboration

Collaboration is taking place more and more across different types of healthcare entities these days—not only between hospitals and health insurers, for example, but also very much between local government entities on the one hand, and both providers (hospitals and physicians) and managed Medicaid plans, as well.

Among those government agencies moving forward to engage more fully with providers and provider organizations is the District of Columbia Department of Health Care Finance (DHCF), which is working across numerous lines in order to improve both the care management and cost profiles of care delivery for Medicaid recipients in Washington, D.C.

The work that Kerda DeHaan, a management analyst with the D.C. Department of Health Care, is helping to lead with colleagues in her area is ongoing, and involves multiple elements, including data management, project management, and health information exchange. DeHaan spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding this ongoing work. Below are excerpts from that interview.

You’re involved in a number of data management-related types of work right now, correct?

Yes. Among other things, we’re in the midst of building our Medicaid data warehouse; we’ve been going through the independent validation and verification (IVV) process with CMS [the federal Centers for Medicare and Medicaid Services]. We’ve been working with HealthEC, incorporating all of our Medicaid claims data into their platform. So we are creating endless reports.


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Kerda DeHaan

We track utilization, cost, we track on the managed health plan side the capitation payments we pay them versus MLR [medical loss ratio data]; our fraud and abuse team has been making great use of it. They’ve identified $8 million in costs from beneficiaries no longer in the District of Columbia, but who’ve remained on our rolls. And for the reconciliation of our payments, we can use the data warehouse for our payments. Previously, we’d have to get a report from the MMIS [Medicaid management information system] vendor, in order to [match and verify data]. With HealthEC, we’ve got a 3D analytics platform that we’re using, and we’ve saved money in identifying the beneficiaries who should not be on the rolls, and improved the time it takes for us to process payments, and we can now more closely track MCO [managed care organization] payments—the capitation payments.

That involves a very high volume of healthcare payments, correct?

Yes. For every beneficiary, we pay the managed care organizations a certain amount of money every month to handle the care for that beneficiary. We’ve got 190,000 people covered. And the MCOs report to us what the provider payments were, on a monthly basis. Now we can track better what the MCOs are spending to pay the providers. The dashboard makes it much easier to track those payments. It’s improved our overall functioning.

We have over 250,000 between managed care and FFS. Managed care 190,000, FFS, around 60,000. We also manage the Alliance population—that’s another program that the district has for individuals who are legal non-citizen residents.

What are the underlying functional challenges in this area of data management?

Before we’d implemented the data warehouse, we had to rely on our data analysis and research division to run all the reports for us. We’d have to put in a data request and hope for results within a week. This allows anyone in the agency to run their own reports and get access to data. And they’re really backed up: they do both internal and external data reports. And so you could be waiting for a while, especially during the time of the year when we have budget questions; and anything the director might want would be their top priority.

So now, the concern is, having everyone understand what they’re seeing, and looking at the data in the same way, and standardizing what they’re meaning; before, we couldn’t even get access.

Has budget been an issue?

So far, budget has not been an issue; I know the warehouse cost more than originally anticipated; but we haven’t had any constraints so far.

What are the lessons learned so far in going through a process like this?

One big lesson was that, in the beginning, we didn’t really understand the scope of what really needed to happen. So it was underfunded initially just because there wasn’t a clear understanding of how to accomplish this project. So the first lesson would be, to do more analysis upfront, to really understand the requirements. But in a lot of cases, we feel the pressure to move ahead.

Second, you really need strong project management from the outset. There was a time when we didn’t have the appropriate resources applied to this. And, just as when you’re building a house, one thing needs to happen before another, we were trying to do too many things simultaneously at the time.

Ultimately, where is this going for your organization in the next few years?

What we’re hoping is that this would be incorporated into our health information exchange. We have a separate project for that, utilizing the claims data in our warehouse to share it with providers. We’d like to improve on that, so there’s sharing between what’s in the electronic health record, and claims. So there’s an effort to access the EHR [electronic health record] data, especially from the FQHCs [federally qualified health centers] that we work closely with, and expanding out from there. The data warehouse is quite capable of ingesting that information. Some paperwork has to be worked through, to facilitate that. And then, ultimately, helping providers see their own performance. So as we move towards more value-based arrangements—and we already have P4P with some of the MCOs, FQHCs, and nursing homes—they’ll be able to track their own performance, and see what we’re seeing, all in real time. So that’s the long-term goal.

With regard to pulling EHR information from the FQHCs, have there been some process issues involved?

Yes, absolutely. There have been quite a few process issues in general, and sometimes, it comes down to other organizations requiring us to help them procure whatever systems they might need to connect to us, which we’re not against doing, but those things take time. And then there’s the ownership piece: can we trust the data? But for the most part, especially with the FHQCs and some of our sister agencies, we’re getting to the point where everyone sees it as a win-wing, and there’s enough of a consensus in order to move forward.

What might CIOs and CMIOs think about, around all this, especially around the potential for collaboration with government agencies like yours?

Ideally, we’d like for hospitals to partner with us and our managed care organizations in solving some of these issues in healthcare, including the cost of emergency department care, and so on. That would be the biggest thing. Right now, and this is not a secret, a couple of our hospital systems in the District are hoping to hold out for better contracts with our managed care organizations, and 80 percent of our beneficiaries are served by those MCOs. So we’d like to understand that we’re trying to help folks who need care, and not focus so much on the revenues involved. We’re over 96-percent insured now in the District. So there’s probably enough to go around, so we’d love for them to move forward with us collaboratively. And we have to ponder whether we should encourage the development and participation in ACOs, including among our FQHCs. Things have to be seen as helping our beneficiaries.

What does the future of data management for population health and care management, look like to you, in the next several years?

For us in the District, the future is going to be not only a robust warehouse that includes claims information, vital records information, and EHR data, but also, more connectivity with our community partners, and forming more of a robust referral network, so that if one agency sees someone who has a problem, say, with housing, they can immediately send the referral, seamlessly through the system, to get care. We’re looking at it as very inter-connected. You can develop a pretty good snapshot, based on a variety of sources.

The social determinants of health are clearly a big element in all this; and you’re already focused on those, obviously.

Yes, we are very focused on those; we’re just very limited in terms of our access to that data. We’re working with our human services and public health agencies, to improve access. And I should mention a big initiative within the Department of Health Care Finance: we have two health home programs, one for people with serious mental illness issues, the other with chronic conditions. The Department of Behavioral Health manages the first, and the Department of Health Care Finance, my agency, DC Medicaid, manages the second. You have to have three or more chronic conditions in order to qualify.

We have partnerships with 12 providers, in those, mostly FQHCs, a few community providers, and a couple of hospital systems. We’ve been using another module from HealthEC for those programs. We need to get permission to have external users to come in; but at that point, they’d be able to capture a lot of the social determinants as well. We feel we’re a bit closer to the providers, in that sense, since they work closely with the beneficiaries. And we’ve got a technical assistance grant to help them understand how to incorporate this kind of care management into their practice, to move into a value-based planning mode. That’s a big effort. We’re just now developing our performance measures on that, to see how we’ve been doing. It’s been live for about a year. It’s called MyHealth GPS, Guiding Patients to Services. And we’re using the HealthEC Care Manager Module, which we call the Care Coordination Navigation Program; it’s a case management system. Also, we do plan to expand that to incorporate medication therapy management. We have a pharmacist on board who will be using part of that care management module to manage his side of things.



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