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A Clinically Integrated Network Forges Success in Southeastern New Jersey

March 25, 2018
by Mark Hagland
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Shore Quality Partners is proving that clinically integrated networks can be successful at a very practical level

As the U.S. healthcare system shifts from volume to value, provider leaders are finding that there are many different ways to advance, and that in particular, there are many different ways to participate in ACO (accountable care organization) arrangements; but that one irreducible critical success factor is physician engagement.

That certainly has been a core awareness at Shore Quality Partners CIN, a clinically integrated network based in Somers Point, New Jersey, just south of Atlantic City. Formed in March 2014, Shore Quality Partners is owned by Shore Medical Center, a freestanding community hospital, and encompasses about 240 primary care physicians and about 190 specialists, 65 of whom are employed by the hospital, with the rest in independent practices.

Shore Quality Partners was formed as a network of providers aligned to support quality improvement and cost efficiency. The CIN is governed by a board of directors and several physician committees, who are responsible for developing and implementing clinical integration initiatives and dealing with all matters affecting the organization. The CIN’s board consists of a total of 12 directors, of whom nine are physician directors (a mix of primary care and specialist physicians), and three hospital directors.

As articulated on its website, “Shore Quality Partners brings independent, contracted and employed physicians – whether primary care, specialist or hospital-based-physicians, together with Shore Medical Center to form a network of providers aligned to support quality improvement and cost efficiency. The Clinically Integrated Network (CIN) is governed by a Board of Directors and several physician committees, who are responsible for developing and implementing clinical integration initiatives and dealing with all matters affecting the organization. The CIN performs various functions and activities: developing and managing arrangements with payers for payment of bonuses, care management fees and other incentive compensation; developing and implementing care guidelines, policies, procedures and protocols; gathering and analyzing data; designing and implementing care management initiatives; aligning with additional providers; managing IT infrastructure implementation and operations; and measuring performance and distributing incentive funds based on performance.”

With regard to the CIN’s founding, the organization’s website also notes that, “In collaboration with its Physician Leadership Council, SMC [Shore Medical Center] identified the need to respond to the changing market while allowing community physicians to retain their practice independence and autonomy. Shore Quality Partners emerged as a dynamic model designed to engage and align interests among community providers and SMC. This effort brings together physicians and SMC to enhance collaboration and achieve clinical integration with the support of Shore Medical Center’s resources and infrastructure. By proactively seeking opportunities with interested payers, Shore Quality Partners positions its participants for success under new payment and care models.”

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In terms of the data analytics and population health needs involved, Shore Quality Partners has been partnering with the Piscataway Township, N.J.-based HealthEC, in order to achieve success in leveraging data analytics to support its intensive clinical transformation work.

Since the outset, Cliff Frank has been Shore Quality Partners’ interim executive director. Frank spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland about his organization’s push into value-based healthcare. Below are excerpts from that interview.

 

Tell me about the origin of the impetus for formation of the clinically integrated network?

At the end of 2012 and in early 2013, we realized that we didn’t have enough money to employ our way to a big medical staff; it just costs too much to employ physicians and cover their overhead. So we knew we needed some other vehicle. And a lot of medical staff didn’t want to be salaried, and in any case, we didn’t have the money. Same canoe.

Are you an MSSP?

We are part of an MSSP [Medicare Shared Savings Program], Track One. We have a direct shared savings contract, commercial, with Horizon Blue Cross, and a separate one with MJ Health for Medicaid; and we have a pay-for-quality contract with a Medicare Advantage program, Clover, which up in northern New Jersey and active here. They’re owned by the same organization up in northern New Jersey.

What is the name of the MSSP?

Allegiance ACO, and they’re based in Trenton. They have about 5,000 patients over there, and we have about 75,000 patients over here.

And what is the size of your commercial ACO population altogether?

About another 30,000 lives.

When did you join Allegiance ACO? And when did your commercial contracts begin?

Commercial ACO started about April 2014. The Medicaid ACO with M Health started in January 2016. And the Medicare ACO started in January 2017.

So you’re in the second year with the MSSP?

Yes, that’s correct.

What are you hoping to achieve overall?

Well, the first thing is, we’d like to earn a bonus for our doctors; and that’s easier said than done, believe me. But we’re certainly about improving the quality of care for the patients, and we’ve got a good track record of having done that on any number of metrics, and earning a bonus. And how we get there is important. One of the things that ACOs across the country have, is a lot of care that leaks out of the network and goes elsewhere. We have a lot of that—60-70 percent leakage. And as a hospital, we only have 30 percent market share in our country, so you’d expect leakage. And we don’t do open-heart and certain other procedures. And we’ll never eliminate leakage, never; but if we could go from 70 percent to 50 percent, that would be wonderful.

How have you been able to get physician buy-in, and what have the results been?

Our experience has been that, once they trust us, it’s not so hard. Getting them to trust us was really hard. And it wasn’t so much an issue of trust per se, as it was, getting us to fit into their workflow. Yes, you’re right, they did not want us messing with their workflow. For example, for nine months, I had a social worker working with us, and the phone wasn’t ringing. And I said, what’s the matter? Give us your most difficult cases. And nothing happened. Well, it turns out, making a phone referral is not how they do business. As soon as we invented a fax-based referral form, boom, 50 referrals a month. In other words, so much of this is not about any intellectual or emotional resistance, but about finding the workflow-based path that fits their patience; and as soon as we do that, boom! They’re with us. We help simplify their quality metrics—what’s in their nominator? What’s in their denominator? Helping them identify patients who should be de-attributed. Otherwise, it’s overwhelming. And Medicare, Medicaid and commercial, we will only talk about one of the three types in a meeting, which means that we’ll be there three times. Otherwise, they get totally overwhelmed. They get overwhelmed anyway. At least this way, they can keep it a little bit straight.

And what have some of the results been?

One of the things we did early on was to identify our diabetics, as other organizations have done. We actually went out and found a certified diabetic counselor, and she is floating around to all the practices. And we’ve taken our diabetic spend down to half, from $3,000 to $1,500—and it’s not just because of the diabetics educator—but we’ve noticed that when we hand a list of diabetic patients to our providers, and they say, hey, you haven’t seen this person in months—they do better, they refer patients to the diabetes educator, etc., and that has a financial benefit as well.

So a lot of this is process?

It’s all process. And sometimes, you can link an outcome or process, sometimes, it’s an article of faith. But either way, if you have patients who are high-risk who aren’t seeing doctors, intuitively, you know it’s a bad situation about to get worse. So, fix it, see the patient. OK!

Tell me a bit about physician participation in governance? You have physicians on your board?

We do. We have a 12-person board, with nine doctors and three hospital administrators. Everyone has one vote. It takes two votes to do anything. So immediately, the doctors realized they had veto power, and they loved it. And the hospital was perfectly willing to try it, because, without it, there was no physician engagement, and no evidence of trust. And we’ve never had a divided vote, never; it’s my job to make sure we don’t. But just knowing that they had the power, was very helpful. Second, we try not to “meeting them” to death. We did at the beginning, we were a little bit naïve. Originally, we had four committees—now, we have just one, which covers care management, quality, and data, and that operations committee meets once a month, and the board meets every other month. The other thing is, with 33 primary care physicians, we can ramp up to something quickly. That’s where small works. If we were in central or northern New Jersey, with 300 primaries, this would not work. And the fact that I and my staff are out in the doctors’ offices a lot, means that we can address misunderstandings before they spread.

In terms of misunderstandings, those can be like the classic phone game or grapevine process that gets out of control, correct?

Yes, that’s right, and by being close, we find things out, and we’ve established a track record, so people will at least bring and issue to us and wait for our response, before they wind up, based on mistaken information.

What has been the hardest thing in all this?

The hardest thing has been getting consistent behavior and messages from the payers that are consistent from moment to moment. They zig, they zag, they drop the ball, they send us crap for data, and then change the formula. So the hardest thing is maintaining trust among all the parties. Because when the payers do that stuff, and they may have very good reasons for doing that—they change computer systems, quality metrics, or whatever—but change is not something that providers are happy with, when they don’t understand the whys, the hows and the wherefores.

And the physicians are not going to sit down long enough to hear a paragraph-long explanation. So that erodes trust between us and the payers, and can then erode trust between the doctors and the administrative arm. We’re suddenly coming in, looking for different information in their EMR; or they could submit a manual code and now they have to submit G-codes; every month, and it makes them crazy.

What’s been most successful, what’s worked best, in all this?

Giving doctors data that is actionable. I’ve made plenty of mistakes handing doctors a list of patients and a stack of claims and saying, here’s what’s going on with your patients. And they say, what the hell is this? So I’ve gotten more focused, and that comes from having a data system that works. And having something like HealthEC that has the data and inferential statistics around what’s going on with the patients.

I’ll give you a couple of examples: one is amazingly simple, but so important. Out of HealthEC, for every patient, we get a risk score, both a retrospective and a prospective risk score. What we want to know is, what’s the risk of something bad happening to that patient? We run the numbers, and we’ll look at the patients with the high risk scores. And we’ll ask who they are. A bunch, 1,500, will be seen for cancer, chronic kidney disease, COPD, whatever—OK, those are being managed by specialists. Then we get to 350 who are patients who are high-risk who have not been seen by their PCPs in more than six months. And we tell the PCPs, it’s probably a good idea to see these patients. And that is an incredibly effective intervention to make.

Another example: we give the primaries those lists, and they see the patients. Another example of how we use the data—one of the things about data is that it can be used as a weapon, and it’s really important that we not do that, because that’s how you destroy trust. So in order for data to be useful, it has to have a point; it has to have the right numerator and the right denominator. So one of the things that’s really, really hard is that when the payers send me data, they organize that data based on whom they paid, like Shore Physicians Group—well, that’s an amalgamation of 20 PCPs and 45 specialists. So when I run data on Shore Physicians Group, it’s all a big ball. What I get from HealthEC is totally different; they break out the data down to the MPI, the individual provider ID, level. So they can take a tax ID and break it up into the 16 different MPIs providing care, and I can say, this MPI is doing great, and that MPI is spending like crazy. Now, you show that data to the doctor, they can use it.

What is most important in terms of managing the data and IT in order to be successful?

There are two pieces, the numerator and the denominator, and they both have to be counted correctly. For example, a patient goes to see a radiologist, and they go to the hospital for the diagnostic imaging study. The hospital generates one bill, the radiologist generates another bill, because of the professional and technical components. You need to make sure when you count that visit, that you count it as one, not two, or all your radiology statistics will be wrong. You have to have a vendor who understands that. You would be amazed by how many vendors don’t understand that a global fee and a technical/professional, are not the same. So that’s why I mean about the numerators—how much stuff got done? Measuring how much stuff got done, and who did it, and is that a leak, or something in network, and how much did it cost? All of that I worry about, yes.

But the other part is the denominator. Over how many people? Just because there were 40 hospital admissions, that doesn’t mean anything. It’s over how many people? 40 in a month might equate to 90 per thousand, and we’ve budged 20. Uh-oh. So the problem is, you have to make sure you’re counting the number of members correctly each month; so if a member terminates and loses their coverage in May, and now it’s December, is that member in your membership? The partial year should count. You ought to have four member months in your denominator while you had exposure to that member. So all of that matters, when you compare your experience to your target, or compare it to last year. Things change. Last year, hips and knees were done inpatient in hospitals, and now they’re being done outpatient in the community? Holy cow, that’s a whole different situation. So, understanding the nooks and crannies of the data, is important, and it’s really hard, if you’re just trying to learn that from scratch, and worse, if your system is just learning it from scratch, because your systems will mislead you.

What would you say to CIOs and CMIOs, as they prepare to develop clinically integrated networks, and participate in ACOs and population health management?

I’ll answer it this way: managers and executives go from the general to the specific, because they get to pick the level of detail they want to get involved with. That’s not how physicians think; they go from the specific to the general. If you’re going from the general to the specific, you’re asking physicians to trust you from the beginning, which they won’t. Starting from the specific, painful as it is, is worth the investment.

What will happen in the next couple of years, for your organization, and for the industry?

I’ll start with us. We will gradually continue to get better. It won’t be in huge leaps, but rather,  inch by inch. Achieving shared savings will get harder and harder. Even if you only periodically re-base, you’ll eventually get to the point where there’s no more savings to get. But it gets harder and harder after the low-hanging fruit is gone. In a broader sense, there is a collision coming between those groups that do well in shared savings and managing care, and payers who do not want to let go of the risk because they don’t want to let go of the reward. And there are many groups out there in Next Gen ACO and other arrangements that would love to step up and do a Medicare Advantage deal, but can’t get payers to step up and work with them. So many providers will convert to risk plans, because payers won’t let go for the risk. Fifty percent, when someone else is setting the benchmarks, is not enough of an incentive.

 

 

 


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NorthShore to Lead “Largest Primary Care-Based Genomics Program in U.S.”

January 14, 2019
by Rajiv Leventhal, Managing Editor
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The Chicago-based NorthShore University HealthSystem and genomics technology company Color are partnering on a new initiative that will aim to deliver the power of genomics to routine primary care at population scale.

Known as "DNA10K," the initiative will engage more than 10,000 patients and will be the largest known primary care-based genomics program in the U.S., according to officials who made an announcement last week.

The approach will build on NorthShore's years of experience in genomics and actionable electronic medical records (EMR) information, while providing access to Color's clinical-grade genetic testing and whole genome sequencing to inform patients about their risk for certain hereditary conditions, according to company executives.

“The knowledge will help patients learn about their genetic makeup, including risk factors for certain disease types such as common hereditary cancers and heart diseases. This insight will help NorthShore personalize care for each patient to support improved outcomes, prevention and overall health,” officials noted.

The announcement comes on the heels of a recent pilot between NorthShore and Color that looked to unlock the benefits of genetic information in routine care.

As officials explained, in less than two months, more than 1,000 patients signed up for the Color population health program as a part of their primary care visit, an adoption rate of more than 40 percent of those eligible and significantly beating expectations of the pilot program. “This is a strong indicator of patients' interest in understanding genetic factors that can influence health and the opportunity to work with NorthShore care providers to make more informed treatment or prevention decisions,” they attested.

Overall, the DNA10K initiative supports NorthShore's efforts to improve patients' health outcomes at a population level, with genomics as a foundation for informing individualized healthcare.

Patients who take advantage of the "DNA10K" offering will provide a blood sample, which is then analyzed in Color's CLIA-certified, CAP-accredited lab, and results are returned to healthcare providers and their patients. In addition to their NorthShore primary care provider, patients will also have access to board-certified genetic counselors and clinical pharmacists from Color and NorthShore, officials explained.

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New Analysis in the New England Journal Finds the Leveraging of IT for Population Health To Be Inadequate

January 14, 2019
by Mark Hagland, Editor-in-Chief
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A new analysis published in The New England Journal of Medicine, and looking at the policy and IT elements around population health development, concludes that healthcare leaders need to up their game around all those elements
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A new analysis published in The New England Journal of Medicine, and looking at the policy, payment, and information technology elements around population health program development, concludes that healthcare leaders need to considerably up their game around all those elements, if they are to make population health management successful at scale.

As the authors, Aaron McKethan, Ph.D., Seth A. Berkowitz, M.D., M.P.H., and Mandy Cohen, M.D., M.P.H., note, in the article, entitled “Focusing on Population Health at Scale—Joining Policy and Technology to Improve Health,” speaking of such areas as the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the Housing Choice Voucher Program (Section 8), and other social welfare programs, “A growing body of research supports the value of investments outside health care for improving health and fiscal outcomes, and many pilot programs are investigating how to implement such an approach. On a population level, however, much work remains to be done.”

As the authors note, many of the combined policy and technology changes come together in the ongoing evolution of the North Carolina Medicaid program. They write, “A telling example comes from our own state of North Carolina. In 2017, North Carolina Medicaid covered prenatal and delivery services for 58,159 births — nearly half (48.4%) of the total births in the state. Yet 31% of these births were to mothers not enrolled in WIC (see graph), despite similar income eligibility criteria for WIC and Medicaid. Since WIC provides nutritional support from the prenatal period through five years of age and has been shown to improve participants’ health, this mismatch risks undermining the benefits of the prenatal, labor and delivery, and pediatric care that Medicaid supports.”

But, they note, “Moving from establishing pilot programs to addressing these issues at scale presents major challenges. Information technology in both the government and health care sectors lags behind what is needed to support seamless integration of Medicaid and other services and programs. Even new payment models explicitly designed to link reimbursement to health outcomes may not effectively stimulate performance of tasks such as WIC enrollment. Perhaps most important, addressing all the factors that affect health will require new ways of thinking, collaboration, and accountability on the part of both health care and government leaders. We suggest three considerations for advancing broader, sustainable initiatives that improve health and use fiscal resources wisely.”

Among the authors’ recommendations: human services programs need to be “integrated into a systematic population health approach,” one that coordinates workflows “that facilitate identification and enrollment of eligible patients”; “it will be important to promote both policy and information-technology innovations that make program enrollment seamless”; and, the researchers write, “[W]e believe policymakers should explicitly consider the effects of human-services programs on health and total cost of care. This approach will require developing rigorous evidence regarding the combined effects of health care and human-services programs as well as evaluations of new ways to integrate such services.”

They further state that, “As health care payments are increasingly tied to population-level outcomes, the sustainability and effectiveness of human services should be an increasingly important priority for health care leaders. SNAP resulted from a political coalition of rural, conservative advocates for farmers and urban, liberal advocates for alleviating poverty; we envision a similar partnership between health care leaders taking on risk for population health and cost-related outcomes and human services leaders supporting the same populations.”

 

 

 

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Global Genomics Alliance Working to Break Down International Data Silos

January 3, 2019
by David Raths, Contributing Editor
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Seeking innovative solutions to enable federated data analysis

The Global Alliance for Genomics and Health (GA4GH) has published a paper reviewing the diverse approaches being taken around the world to integrate genomics into healthcare and presenting a roadmap for sharing strategies, standards, and data internationally to accelerate implementation.

The paper, released Jan. 3 in the American Journal of Human Genetics, notes that while genomic sequencing has traditionally been a research tool, genomic data in the clinical setting will outpace research genomics within the next five years, with 60 million genomes expected to be sequenced by 2025. By 2030, China hopes to reach its goal of adding another 100 million genomes through the Chinese Precision Medicine Initiative. (Saudi Arabia, Estonia, Finland, Denmark, Japan, and Qatar are all developing their own national strategies.)

“The international genomics community has a responsibility to work together to effectively and efficiently role out clinical-based genomics care for the benefit of all,” said Kathyrn North, director of Australian Genomics and Murdoch Children’s Research Institute and lead author on the paper, in a prepared statement. “If we don’t get this right, patients will be the ones to suffer.”

After summarizing the national genomics strategy in the United States, U.K., France and Australia, the authors stress the importance of “breaking down data silos to accelerate the development of knowledge databases that directly improve patient outcomes cannot be underestimated.” Because national regulatory frameworks are unlikely to allow large-scale data migration, innovative solutions will be required to enable federated data analysis without data movement across geographical borders while maintaining public trust.

GA4GH is working with national genomic medicine programs to promote best practices in data sharing by structuring data access and consent processes, collecting clinical and genomic data in interoperable formats, committing to global data sharing, and informing public debate and policy development. The group recently launched a 5-year strategic plan, GA4GH: Connect, that focuses on the development of standards for responsible sharing of clinical-grade genomic, phenotypic and metadata. Genomics England, Australian Genomics, and All of Us in the United States serve as early “Driver Projects” for GA4GH, to inform the iterative development of tools and policies for data sharing, test them under real conditions and disseminate best practice.

“Without global inter-program dialogue and collaboration, clinical implementation stands to proceed in a haphazard fashion,” said co-author Brad Ozenberger, program official for the Data and Research Center for the All of Us Research Program at the U.S. National Institutes of Health, in a prepared statement. “This could mean inappropriate testing at high cost, inaccurate data interpretation, misdiagnosis, and policy that extends existing healthcare inequalities.”

 

 

 

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