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Assessing the Challenges and Opportunities for MD Groups That Are Taking On Risk

September 7, 2016
by Mark Hagland
| Reprints
Mark Werner, M.D. and Bob Schwyn of The Chartis Group share their perspectives on the plunge into risk-based contracting

Pioneering physician groups are helping lead the way in taking on risk-based contracts in a number of contexts—both in terms of federal accountable care organization (ACO) contracts, including the Medicare Shared Savings Program, Pioneer ACO Program, and Next Generation ACO Program, under Medicare, as well as in terms of commercial ACO participation—and in other contexts as well. Indeed, the September/October cover story of Healthcare Informatics will be focusing on the broad strategic and strategic-IT issues that physician group leaders are facing as they move more fully into risk-based contracting.

It was in that context that HCI Editor-in-Chief Mark Hagland recently interviewed Mark Werner, M.D. and Bob Schwyn, of The Chartis Group, the Chicago-based consulting firm. Dr. Werner is Chartis’s director of clinical consulting. In that role, he leads efforts around enterprise physician alignment and leadership, medical group performance, adoption and change management, performance innovation, population health, provider-payer relationships and the translation of strategy into clinical operations. Prior to joining The Chartis Group, he held a variety of executive positions in healthcare, including chief clinical innovation officer for Fairview Health Services, president and chief physician executive of Carilion Clinic and its associated hospital system, and chief clinical officer for Medica Health Plan. Schwyn, a director with The Chartis Group, has years of experience as an HIT executive leading teams in clinical transformation and the design and delivery of solutions for enhancing patient care quality, improving operational effectiveness and achieving excellence in customer service.

Indeed, it is in the context of physician organizations taking on risk and moving into new models of care delivery and payment, that The Chartis Group announced last month the creation of The Chartis Physician Leadership Institute. According to an Aug. 11 press release, “The Chartis Physician Leadership Institute brings together senior physician executives with unrivaled expertise from the nation’s leading health systems, academic medical centers, medical groups and health plans. It is dedicated to advancing health system and medical group performance through innovative solutions that drive physician alignment and engagement, and achieve the highest levels of organizational and operational effectiveness.”

Below are excerpts from the recent interview with Werner and Schwyn.

Dr. Werner, please tell me a bit about your clinical and administrative backgrounds that helped prepare you for the work you’re doing now at The Chartis Group, in the context of the risk-based contracting we’re talking about today.


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Yes; my clinical background is as a pediatrician specializing in adolescent health; I no longer practice clinically. And I’ve done a lot of work around various payer-provider strategies and arrangements. I’ve helped to build out multispecialty groups and IPAs that have had to develop risk management capabilities, as well as the IT, and the clinical, capabilities. And it is in that context that we’ve just created the Chartis Physician Leadership Institute. It was officially launched last month, but we’ve been putting it together for the past year. It involves a cadre of physician advisers within Chartis, most of whom have had senior roles in patient care organizations, working with leaders to make sure they have the right alignment and capabilities around their physicians, and have been able to prepare to go forward. I’m the leader, yes.

What has been learned broadly around risk, by the leaders of the most pioneering physician groups?

Mark Werner, M.D.: I think the more experienced and thoughtful medical groups are realizing a couple of things. One is that they have to fully understand what kind of risk they’re taking on, and to be able to distinguish what most people would call health management risk, versus insurance or financial. Health management risk is taking on the risk for creating the right kinds of outcomes, in terms of quality, for patient care and patient management, for clinical performance and outcomes. Then there’s a level around medical expense management risk. Then there’s the insurance-level risk. So it really is three levels. And the leaders are aware of those three levels, and are able to define specifically what they’re able to take on, early on taking on the health management risk, and then gradually taking on the medical expense management risk, and ultimately, the insurance and financial risk. So they have to understand what is driving both the outcomes and cost of the populations they’re taking on, at a high level of specificity that allows them to have an actionable level of understanding, and to develop interventions to address them.

Mark Werner, M.D.

Bob Schwyn: To tag onto what Mark is describing, that’s one of the largest differentiators between organizations that are doing this well, versus those that have more challenges from an IT perspective, meaning, understanding what my level of risk is, and my capabilities to manage different levels of risk. When you get into the health management risk, it’s all about care patterns and variations, and understanding those. There’s technology, there’s analytics, to help illuminate the drivers of variation and of sub-par outcomes. You need to be very clear in understanding that. Understanding the problem statement will help you align your technology objectives, per your stage of maturity. As Mark’s describing, organizations are at all levels of maturity. And it’s important to parallel that with your IT build as well. Often, organizations don’t have a good correlation between where they’re at strategically and what they need in terms of IT. So understanding what you’re trying to solve for and what capabilities are involved, is very critical.

Is there a strategic confusion or lack of clarity over what people are taking on, with some of these contracts?

Werner: I think you’re exactly correct. It’s a large and prevalent problem. People are reacting, and don’t even know adequately what they’re reacting to. They’re following some rather trite ideas, without really stepping back and asking themselves, what kind of problem am I trying to solve? And how can I solve this problem more effectively for my patients? And sometimes without even a tactical plan for how to go after the problem.

Schwyn: I would echo that. I think there is a confusion out there, and then a tendency to feel like there’s some urgency and therefore, one needs to react. Our experience tells us that, rather than reacting—certainly in our work with our clients, we try to direct that activity, to make sure that you’re building the tools you need, commensurate with that roadmap; and two, make sure you’re mitigating that risk—because these tools are expensive to buy and costly to stand up. So making that alignment between the strategic and the tactical is critical.

Bob Schwyn

Werner: I often tell clients, start with the end in mind. Understand what your goals are. And I find that when they try to start at the end, the medical groups are somehow trying to preserve today’s practice environment, and find a way to keep the revenue coming. And they haven’t really realized that the marketplace is trying to get you to fundamentally transform your practice. They’re not just trying to help you find new and creative ways to get you revenue. People don’t always understand what the end state is going to be. And that’s particularly challenging for medical groups, and as Bob says, it causes problems.

What would you say about the need to move patients upstream, to less-acute care interventions?

Werner: I agree with the point that that CEO was making. I think it’s very difficult to approach transforming healthcare and it get to some kind of risk-based arrangement, through the prism of a hospital-based model. You simply can’t get there. And it’s proving very difficult for hospital operators to make that transition. At the same time, medical groups need a lot of the resources that a hospital system can provide. The medical group leadership needs to very clearly articulate its goals and strategies, what it wants to accomplish; and it needs to approach the health system very thoughtfully, so that they come to these conversations with a level playing field. I worry about the medical groups that are only being passive recipients of requests from health systems. Back to the Physician Institute—that’s one of the key tenets of how we’re trying to help hospital systems and medical groups work together—that it has to involve bidirectional, strategic thinking.

Schwyn: I think that along those same lines, when I look at it from an IT-programmatic perspective, folks have to make the same kind of pivot around their IT capabilities. For instance, when you get into analytics, it’s not about reports that count beds filled or throughput; as Mark Werner put it, it’s understanding the key drivers that are leading patients to become inpatients—and what the insights are that I can gather around that data, that can help the leaders of the medical group or organization to understand what the challenges are. So that pivot is also challenging in terms of thinking about what they’re looking to do, analytically.

What should CIOs and CMIOs be doing right now, in this context?

Schwyn: IT leaders need to be in this interstitial space between the strategic and the tactical. And this is an opportunity for senior IT leaders to really help make an investment, and to work with their peers and with the business leaders, to really help understand the types of risk they’ll be entering into, the kinds of drivers they’ll be helping to measure, and find ways to really bridge that gap. We’ve found that it involves developing use cases, thinking about the capabilities we’re trying to develop from an IT perspective, and developing the interventions involved. It’s really walking through all that; and I think the IT folks don’t always have the level of sophistication to do that. So per what Mark Werner was saying, these IT leaders need to help develop competencies.

It seems clear that there will be a need to bring in a lot of data analysts and data scientists. We’re hearing that organizations are bringing together teams of individuals with experience from outside and within healthcare. What are your thoughts on that?

Werner: There’s no doubt there’s a shortage of good analysts of all types. I think team-based approaches are probably one of the better ways of going forward. That said, everyone on the team has to come in with an interest in learning how to walk in the clinicians’ shoes. I need people who are willing to spend time with me as a clinician, to develop a sense of the kinds of clinical challenges I’m facing—who can take the raw analytics, and put it into a clinical framework. I think that’s critical. The other piece that’s missing, particularly in healthcare, is people with an actuarial background. And I think that actuarial capabilities will be very important going forward.

Schwyn: Yes, that’s certainly a challenge at virtually every client we talk to. And it’s two-fold: one, how do I develop and acquire these competencies? And there’s a speed issue, too; I need to develop these capabilities very quickly. So there’s a sense of urgency about it. And there are ways to temporarily get people quickly. And as Mark said, some organizations are bringing in people who can understand the care process and the documentation and how things get recorded; so that’s one element. The second element is how you build the back-end data algorithms that mesh all this data together, and correlate all the data in order to derive insights. That’s a challenge, too. And many organizations are looking at some of the new graduates coming out of school. And this new generation is more adept at all this. And we’ve seen that happening.

Do you have any last thoughts?

Schwyn: We didn’t talk about data management and governance. And you and I have talked about that before. And we can’t be silent on that issue. There’s such a lack of understanding of good, strong data, and how it’s captured and recorded and aggregated. And there are a lot of organizations really straining with that. And it’s hard to do that in the rearview mirror. So the challenge is to get organizations to look forward, and say, how do we design our care delivery processes and care management processes, and clinical documentation processes, so that we’re capturing the right data in the right way, to begin with.

What will happen in the next couple of years, in all this?

Schwyn: I think some organizations will emerge as leaders, and there will be people who clearly are able to do this. And that will create more of a sense of clarity around best practices. If you just look at the vendor solutions available in this space, it is staggering. And the number of folks who claim to have a piece or portion of this is incredible. And that to me is a sign that organizations haven’t yet clarified what they need. So I think there’s going to be a lot of sorting out in the next years.


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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
| Reprints
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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