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At Chicago’s Presence Health, Taking a Thoughtful Path Forward into Value-Based Care

March 9, 2017
by Mark Hagland
| Reprints
Sam Bagchi, M.D., CMO and CQO at Chicago’s Presence Health, describes the health system’s journey forward into value-based care

At the 11-hospital Presence Health, an integrated Catholic health system based in Chicago, Sam Bagchi, M.D. has several titles—and a lot of responsibility. Dr. Bagchi, who practiced internal medicine and hospitalist care for 10 years before moving into healthcare administration (he still practices limited telemedicine), is not only the health system’s chief medical officer and its chief quality officer; he currently is also interim president of Saint Francis Hospital, one of the larger hospitals in the system, while that facility, located in the Chicago suburb of Evanston, looks for a new facility CEO. What’s more, the corporate IT and informatics teams at Presence report to him.

As his current corporate bio notes, Dr. Bagchi “provides the vision and direction for a diverse list of system functions including: system quality/risk, care management, information services, telehealth, hospitalists, emergency medicine and clinical analytics. This broad area of focus has equipped Dr. Bagchi with uncommon insights into the challenges and opportunities facing today’s health systems as they move towards highly-reliable care delivery.”

Dr. Bagchi spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland about Presence Health Care’s journey into value-based and accountable care. Below are excerpts from that interview.

How would you frame your organization’s journey around population health?

It’s very much aligned with our mission, which is very much focused on the health of our communities and the patients we serve. So population health is a very nice fit for us, in terms of how we can take care of people outside the walls of the hospital. And because of our Catholic mission, we’ve focused on communities that potentially were not well-served, and also areas that other providers have abandoned or not focused on—behavioral healthcare, for example. In fact, we’re the largest inpatient behavioral health provider in the state. So from a pure clinical services point of view, we’ve been very interested in the full health and wellness of our communities, so it fits really nicely. In terms of our business, we’re still heavily dependent on fee-for-service revenues.

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Sam Bagchi, M.D.

You’re involved in one of the Medicare ACO [accountable care organization] programs, correct?

Yes, we’re in a Medicare ACO; we’re in Track 1 of the Medicare Shared Savings Program. We’re in the third year of our participation in that program. In addition, we have some value-based contracts with a few commercial payers, with Blue Cross Blue Shield of Illinois, with Humana—small amounts of Medicare Advantage with Humana. And we have a clinically integrated network, Presence Health Partners, for our affiliated physicians, who number about 3,000. Most of the physicians in Presence Health Partners are not employed. About 20 percent of our physicians at the hospital level are employed, and 10 percent at the network level are employed. The Chicago market remains a little bit underdeveloped in terms of physicians, compared to some other major metropolitan areas.

What types of technology are you using in order to perform health risk assessment across your covered populations in your MSSP and commercial risk contracts?

We’re using Healthy Planet, the care management system from Epic [the Verona, Wis.-based Epic Systems Corporation]. We transitioned over from another solution. We were part of the Medicaid ACO—we were one of those providers, but we’ve transitioned those lives to a third-party payer. Pretty much all the provider-based plans in Illinois have done that. But we do take the patients we’ve done the risk assessments for, and are trying to develop the best care management programs for the highest-risk patients. One thing for your readers to think about, in terms of ACOs and value-based contracts, then, outside those contracts, is how to how to manage those patients.

Whether you’re at risk through an ACO contract or value-based contracts or via the DRGs for your physicians, you need to find ways to analyze their health status and act on what you find. In our case, we’ve incorporated a high-risk screening process for all of our patients, called the LACE tool—a pretty traditional inpatient methodology for identifying patients at high risk for readmission. “LACE” stands for length of stay + acuity + comorbidities + ED visits. Using that tool, you take those factors into consideration, and create a score, and can determine which patients—those with higher LACE scores—are at higher risk for admission or readmission. And for those patients who are at a threshold score or above, we do a series of things, including specialized discharge planning, care navigation, home care if appropriate, and post-discharge follow-up appointments for them. In terms of care navigation, we’re looking at a couple of touchpoints—making sure people are getting to their appointments, filling their prescriptions, have transportation to follow-up activities, and we’re really tracking patients more than we ever did.

The fact is that we already have a lot of the information we need. For example, the LACE tool is a pretty basic tool that gives us information we can get easily; and its part of our admission assessment when we admit patients. It can have a real impact on readmissions.

Have you been able to measure any results of interventions yet?

No, we just went live with this tool in December and January, so we haven’t measured it yet, but there are demonstrated results in the literature, so we’re confident it will have been helpful. For us, the basic approach is more pragmatic and less sexy than what other people are doing, but we’re trying to focus our efforts on things that work, rather than getting too involved in preparing for a future state that may not happen. A lot of health systems have built architectures for capabilities they think they may need. That worked well in California with Medicare Advantage, and in Massachusetts with global HMO payments; but in the Chicago market, we don’t have the same levels of payer pressures to manage the entire cost of care. So that’s something that’s been a change here at Presence; a couple of years ago, there was a focus on building capabilities for a future state that may not yet happen.

So, essentially, you’re taking a practical, measured approach to this evolutionary process, then?

Yes. We know that the things that affect our hospital book of business will be helpful in any future state scenario, so we’re focused on things that can drive down the cost profile and improve quality of care and outcomes. In any scenario, when you’re managing costs, the hospital always comes up top of list. And that’s where we’re focusing our efforts, and not getting too caught up with the regulatory landscape that’s changing.

You’re young for a health system CMO, correct?

Yes; I’m 41. I’m on the younger side for a CMO. I think the traditional CMO has been one who’s this champion who’s there to be a liaison. It became clear to me very early on that I was very interested in management; I’m interested in systems and process, and trying to help lead change more broadly. We have about nine CMOs in the different business units and hospitals—to be more operationally integrated, to be true executive leaders, and not just being liaisons, though that is important as well. And I’m passionate about quality, and that’s where I would say that we’re trying to drive the physician culture, with them as key stakeholders in driving outcomes, not just driving volume, but driving excellent results for patients. Generally, physicians can get behind that, and it resonates for them, particularly younger physicians who haven’t become jaded by the FFS model. But physician culture is critical.

Shifting physician culture to match the objectives of value-based care delivery and payment and of population health definitely is critical. What are you and your colleagues doing in that regard?

One of the more unique things we’re doing is around the credentialing process. If you think about all the raw ingredients that go into health outcomes, physicians are key stakeholders in that, along with nurses, with capital, etc.—physicians are top-of-list in my opinion; yet there’s been very little done in the industry to vet physicians from a quality and capability perspective. We’ve brought to bear a technology system to consistently credential physicians across the system; we’ve implemented a monitoring system to instantly know if someone’s board certification status has changed, or anything else. And physician-specific quality outcomes are hard to come by and hard to collect. As much as we get a lot of data, a lot of that data does not give us meaningful information about physician performance.

Have you provided your physicians with clinical performance dashboards yet?

Probably not as much as we’d like to have. We do have a variety of physician-specific data elements. We struggle more with our outpatient-focused physicians, where we have less access to their quality data. With our employed physicians, we’re on the same EMR, so we have capabilities to pull HEDIS measures, and have crated quality improvement projects around hypertension management and diabetes management, and raised those to the system level. Put simply, with our employed physicians, we have a lot more data to work. We are working in those areas with hypertension and diabetes, focusing on those two areas. Initially, we just focused on whether we had a blood pressure measure or a hemoglobin a1c measure for patients at risk. So there’s been some crawl-before-you-walk-type work that’s been done. And for our employed, we’re able to incentivize them, with a percentage of pay tied to care management.

And with our larger integrated network with our affiliated physicians, we’re beginning to explore incentivizing our physicians to focus on various care management elements, but it’s a tougher row to hoe, because of the inability to drive all the payment incentives. I will say, though, that while incentives are good and can be a part of the story, as a CMO, I’m constantly trying to reconnect our physicians at the emotional hook of the story, in terms of their relationships with their patients. Part of the struggle is that they may have meaningful interactions with their patients, and yet I tell them that they may not be getting credit for all of those, if we can’t measure their outcomes. I think that that resonates with physicians if it’s framed for them in a positive way and not used punitively as a weapon. Sometimes, with the HEDIS measures, sometimes if you focus too punitively, you lose your physician audience, and we all forget why we’re trying to do this in the first place. So I try to connect emotionally with them around what’s at stake here.

One challenge is going to be around MIPS/MACRA [the Merit-based Incentive Payment System for physicians under the Medicare Access and CHIP Reauthorization Act of 2015], correct? Many physicians still remain woefully ignorant of what’s involved in MIPS/MACRA.

It’s scary—and especially in Chicago, because we still have a lot of these onesie-twosie practices, and they said they would retire rather than do an EMR, and then rather than be measured, and now they’re saying that they’ll retire over MIPS/MACRA.

In that regard, what plans do you have around engaging MDs around MIPS?

We’ve been educating all the physicians in our clinically integrated network around MACRA and MIPS, and really pretty quickly settled on focusing on MIPS. We saw some of our competitors messaging their physicians early on even before the final rules were in, to join our CIN or ACO because we can help you avoid MIPS and stay in a value-based plan; we purposely did not do that. We said, we can be your value-based partner and educate you. There is a real question now, and this comes back to credentialing—we will soon have the quality data we’ve always wanted, to make a more meaningful credentialing process.

In that context, we’ve linked our hospital-based credentialing process, which physicians use to get privileges in our hospitals (and physicians have to have membership on a medical staff to participate with third-party payers), to help our physicians get third-party payer credentialing. And what we’ve all wanted is physician-specific quality data, in order to make better decisions about whom we allow on our medical staff. And health systems aren’t going to want every physician in their network.

Have you chosen already not to credential individual physicians?

Yes. It’s partly based on the high priority our board has placed on this. We’re taking a strong stance on this because of our focus on quality and safety and not wanting to have physicians who aren’t equally aligned. Unfortunately, we don’t have the strongest elements yet, so it’s still primarily based on licensing, board certification, and malpractice history, things that are less appealing. We don’t have anything yet as rigorous as what we’re going to see with MIPS, in terms of the rigor of the quality data. But as physicians get further down this MIPS pathway, essentially, we’ll have physician-specific fee schedules, based on performance and participation, and it will become quickly evident to physicians who don’t perform well, that they won’t fit as nicely into the programs of the payers here, unless they do better on quality. So it will be a “yes, and”—we need the quality programs, the participation in reporting. So I think you’re right, it’s an unprecedented opportunity to engage physicians around outcomes.

We’ve already been on the hook for value-based purchasing readmissions reduction, and healthcare-acquired conditions penalties, under the ACA, and we’ve had to persuade the physicians to engage with us on this. Going forward, I think it will be harder to advance the ball if you don’t involve credentialing in this. And if you have rubber-stamped, paper-based, routine processes, which many organizations do, you’re going to have a lot harder time navigating this. So even though we’re not all the way down to measuring the physician-specific dashboards that I’d like, yet, we are moving around, around credentialing decisions.

In terms of helping individual physicians with their MIPS measurement work, is that something that you might offer them?

Absolutely. We don’t have it in place yet, but it’s in our plans, particularly with physicians who either are in our employed group or are on Epic with us. And down the road, I think that’s absolutely a service that will resonate with physicians as they decide which multi-hospital system to partner with. But to your point, what we’ve found is a lot of willful unawareness of MIPS awareness, or as I like to put it, some doctors are in a ‘pre-contemplative’ state around this. A lot of physicians aren’t yet as interested in having discussions around this, as they should be. The ones who are most interested are already the most engaged in providing value-based care and the most involved in managed care contracting. Those physicians are ahead of the curve; but that’s probably 20 or 30 percent of physicians, and the lion’s share are either still head-in-the-sand around this, or are overwhelmed by issues in their day-to-day practice, or are saying they’re going to retire. I’ve had a lot say that this is it, that they’ll retire—or they’re saying they may go into concierge practices.

There’s not enough of a market for massive numbers of physicians to go into Medicare-free, concierge practices, though, correct?

True, but in some areas like Dallas, in markets with shortages of doctors, some are stopping seeing Medicare patients. So yes, while commercial payers will eventually get there, some of our physicians are going to try to circumvent even more for a couple of years.

What’s next in the next couple of years at Presence?

The focus will be on the health and wellness of our communities and on being good stewards of resources—really making sure we’re the best possible resource we can be to our communities. That’s where all of our focus is. And for me and for many of us, it’s where we can deliver the best possible quality outcomes. We’re very much dependent on our FFS, hospital-based payments. We are focused on increasing our ambulatory offerings; but if we do that at the expense of operational effectiveness of our hospitals, we really risk our core businesses. So we’re trying to provide our best, highest-quality, lowest-cost care at our hospitals, because that will be critical to how population health unfolds; and those organizations that don’t focus on their highest-cost patients, will potentially lose out in terms of the big picture. Right now, our payer mix is about 40 percent Medicare, 20 percent Medicaid, and the remaining 40 percent commercial.

And we’re trying to partner with others who are interested in the same types of community outcomes we are, whether that’s physicians, multi-specialty groups, or health retailers—we’ve been creative about joint venturing and partnering, where it makes sense, and not competing just for the sake of competing.

 


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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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