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Getting Practical on Population Health: What Pioneers Are Learning Now

May 9, 2017
by Mark Hagland
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Executing on risk contracts requires tremendous organizational strategy, IT strategy, and flawless execution, pioneers are finding
Mission Hospital in Mission Viejo, California, part of the St. Joseph Health system

No one said population health management would be easy, nor has it been. Indeed, as patient care organization leaders have laid the foundations for serious population health initiatives, they’ve been facing down a welter of challenges, among them strategic, process, practical, and technological. But things are beginning to turn a corner now.

And the truth of that perception is confirmed by the results of a survey published by consulting firm KPMG in January. According to that survey, provider and health plan leaders are making progress in key areas. As stated in the consulting firm’s Jan. 23 press release, “In the survey, 44 percent of respondents at payer and provider organizations found that they have a population health platform in place that is being ‘utilized efficiently and effectively.’ Another 24 percent are in the process of implementing a population health program within the next three years. Only 10 percent said they have no plans to implement a population health platform and another 21 percent of respondents said their organization doesn’t require a population health platform.”

Importantly, KPMG found that “The biggest individual barrier to implementing a population health program is aggregating and standardizing information from multiple sources, 30 percent of respondents said. Stakeholder adoption (10 percent) and integrating with clinical work flows (10 percent) were cited as additional barriers. Another 34 percent cited ‘all of the above,’ which includes those barriers, as well as enabling patient engagement, funding investments, and selecting appropriate vendors as additional challenges.”

Gathering data from diverse sources remains a core challenge

Jess Vamvas, senior product manager, technology, at The Advisory Board Company (Washington, D.C.), is not surprised by such results. “Apart from the overall strategic planning, the analytics is the most complex part of this,” she says, referring to population health management initiatives. “Organizations want to assemble high-performance networks; and along with that comes the various different source information systems and applications the different organizations are already suing. So getting the data from the EMR is really complex; same with combining clinical and claims, even though that’s where everything is moving towards. Even professional billing services data is really, really important in order to aggregate and get a comprehensive view for population health. For instance, registries have long been important, but now, pre-registries—who could become a diabetic, not just who already is.”

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Dennis Weaver, M.D., executive vice president and chief medical officer at The Advisory Board Company, emphasizes that there are several layers to the complexity involved in leveraging data and analytics to support population health. “We can dive down into the clinical examples of the registries and the other things going on,” he says, “but we also need to talk about these multiple stakeholders and the financial aspects of population health management. Too many organizations look at people, process and technology—and they look at these tools that they need to buy for pop health, and then on an economic side of the ledger, they’re looking at accountable payment, whether pay for performance or shared savings, or any number of arrangements. And too many folks just do it based on those payments.”

In other words, Dr. Weaver says, most patient care organization leaders are sabotaging themselves by looking too narrowly at the implications of the population health management framework for their overall operations. And that really speaks to the core strategic challenges of taking on financial risk to begin with. “When we look at population health management,” he says, “we find that focusing on the payment misses two other areas of return beyond accountable payment. As you start to take care of defined populations, the economic return turns out to be 7 to 10 times greater if you can keep that population inside your CIN [clinically integrated network] or your ACO [accountable care organization]. Some people call it reduction of leakage, domestic utilization, or seepage. But the economics here and the quality return that you get if you can keep the patient inside the management system in which you’re doing population health, are very important.”

Dr. Weaver goes on to say that “The third piece of this is an element that people often don’t see as connected to population health; but that is that we’ve got much unwarranted clinical practice variability—and we don’t spend enough time talking about reducing that variability. Because doing that reduces cost and improves quality. There are the clinical components of pop health, but the economic components are so important, too.”

And all that, he says, makes population health “so complicated. And when you talk about the IT components, there’s the clinical, there’s the financial, there’s the patient-facing. But too many folks try to get the ROI just from the payment piece, but not from the network management and clinical variability pieces.”

A complex—and sometimes-messy—ongoing evolution

The fact is that none of these issues exist in a vacuum. Instead, as Joe Damore, vice president of population health management at the Charlotte-based Premier Inc. notes, IT and data analytics infrastructures to support population health work have meandered forward at most organizations along with their increasing involvement over time in different types of risk-based contracting. “A large organization may have put in an ACO for their employees, may have several Medicare Advantage contracts, or formed their own Medicare Advantage plan on their own or with a major payer; they may be in the Medicare MSSP or Pioneer or Next Generation program; they might have several ACOs with commercial payers, and also may have several bundles going,” he notes. “And those activities represent those of an advanced organization, where they’ve been creating alignments. Meanwhile, on the delivery side, they would have changed the metrics and compensation models for their physicians to match the metrics of their models.”

In that context, Damore says, “shifting from an RVU model to a hybrid model that includes metrics that match those in their contracts,” naturally will create “alignment around metrics,” and shift the IT and data needs for such an organization would naturally shift as well. And, he says, “Once they develop a clinically integrated network that would allow for single-signature contracting with all the payers, one with hundreds of independent physicians, but they could reward those independent physicians with shared savings based on the metrics on those contracts, then the independent physicians would be working off the same metrics. Also then, they would have in place a care management program that would focus on at least three areas.”

In all this, Damore says, “The first piece of IT you need is a claims analytics tool. You’ll need to take the claims from Medicare or the private payer, and identify the people at risk, especially those with a chronic disease. And then a predictive modeling piece of that to predict which people will rise up—the rising-risk people.” Unfortunately, “I would say that fewer than 10 percent of U.S. patient care organizations” have those elements—both a claims analytics tool, and a predictive modeling capability to predict which covered patients will become higher-risk over time, says Angela Lanning, the ITS (Information Technology Services) COO at Premier. Those patient care organizations that have already logged experience with Medicare Advantage work “are generally a bit more advanced,” she says. Still, Lanning adds, “The EHR [electronic health record] vendors claim they have the core capabilities to do this, but that’s not really the case. And a lot of times, the physicians in these rural areas—they don’t have the infrastructure to support this,” she says. “We see that even with Medicare quality data reporting.”

Executing on strategy in Southern California

Patient care organization leaders who are in the trenches right now on population health are finding themselves working their way forward along multiple dimensions at once, as those industry experts have noted. In Orange County, California, what that looks like is inevitably complicated, says Kevin Manemann, president and CEO of St. Joseph Heritage Healthcare, in the Los Angeles suburb of Anaheim. St. Joseph Heritage Health Care is a statewide physician organization within St. Joseph Health, which encompasses 2,000 physicians, 800 of whom work within a medical group structure, and 1,200 who practice within an IPA (independent practice association) structure. Meanwhile, St. Joseph Hoag Health, the hospital organization, encompasses seven hospitals in Orange County. St. Joseph Hoag Health is a division of the statewide St. Joseph Health system, the umbrella organization for both St. Joseph Heritage Healthcare and St. Joseph Hoag Health. (In addition, St. Joseph Health and the Seattle-based Providence Health recently came together into a combined organization, St. Joseph Providence Health.)

St. Joseph Heritage Healthcare not only is in the Medicare Shared Savings Program (MSSP)—MSSP 1, to be specific—in addition, Manemann says, “We’ve formed a clinically integrated network, and do some work with the PPO in that business. And we’re moving more towards risk contracts.” In that context, he says, “One challenge we face here is that one out of every two Medicare patients in Orange County is in Medicare Advantage. So all of the MSSP 2 and 3 groups are working with a [per member per month] benchmark [payment] that was established based on your part of the country [the East Coast and Midwest]. In our part of the country, it’s pretty low, compared to Houston or Florida, for example. Houston’s monthly is $1,330 PMPM, whereas our starting point was $800. That’s why we decided not to go with Pioneer”—the Medicare Pioneer ACO program. Instead, St. Joseph Heritage Health joined the regular MSSP in 2016, and has taken on risk for 50,000 lives, while it has commercial risk for 200,000 commercial lives, through United HealthGroup, Anthem, Blue Shield, Cigna, and Aetna.

In terms of working with the physicians involved in risk contracting with the organization, Manemann says that “The strategies are pretty straightforward; a lot of it is around data analytics. We’re using the delegated model, the TPA [third-party administrator] model, more or less, for the risk business. So we’re able to do a lot of risk stratification and predictive modeling. And you have to get your arms around the high-risk patients. So we have analytics that help us identify them, and then we have a program called CareConnect—it involves an R.N., social worker, and pharmacist team that helps manage those patients. That helps keep them out of the hospital and ED.”

Already, 2,500 Medicare patients have been enrolled in CareConnect, or 8-10 percent of the organization’s total at-risk population, including also Medicare fee-for-service. “The high-risk patients represent about 5 percent of our MSSP covered lives, and about 5 percent of our fee-for-service Medicare patients,” Manemann explains. And, the reality, he says, is that “We’ve reached the point where it’s less about analytics and more about use. The bulk of the effort is really about knowing how to lead change and drive change throughout your organization. The bulk of the work now is really around behavior change. There are physicians who will argue the data. And we can pull the data out, and if you have a couple of outliers in a panel of a couple of thousand patients, the direction will be right overall.” Still, with regard to presenting physicians with their data, lags in data availability have a major impact on the dialogue, he says. “The lag can run 60 to 90 days with the lagging indicators, including bed days per 1,000, admissions per 1,000, and ED visits per 1,000; and you can’t manage patients using those lagging indicators. Instead,” he says, “you have to get into your leading indicators—authorizations, referrals, and ED visits—and get those types of data to the clinicians in real time,” to make the care management difference between success and failure in ACO and population health work.

What healthcare IT leaders need to do next

So, what do healthcare IT leaders need to do right now to move forward in this very complex area? What must be done next is “highly variable,” depending on where an individual organization already is, Premier’s Lanning emphasizes. “First,” she says, “you have to understand what data you have now in your systems, to figure out which systems to implement. Even if they have an EHR or a physician practice system, the data required for the measures may be too sophisticated for them. One of the big issues is that in many cases, decisions have been made by [patient care organization leaders] without [their] understanding their data. They’ve really got to step back and understand what data they do have, what they’re missing, and what they need to capture. The problem is that in some cases, the data fields [within different information systems] are empty, or they have to upgrade their EHRs, and that becomes expensive and time-consuming. It’s very expensive, and highly variable. We still have practices that manually abstract data to get the information you need to calculate measures. And that still happens with HEDIS measures. So there’s still a lot of wasteful effort.”

As for what might happen in the next couple of years, Lanning says, “I think we’ll evolve” as a healthcare system. “If you’ll recall, when value-based purchasing started, we had to extract data manually on the hospital side; that’s still true in some cases. The hospitals will continue to buy physician practices. That will accelerate things. I don’t think things will drastically change in two years; maybe in five to 10.”

“I agree,” Damore says. “I think it’s going to be a real challenge for a while. I don’t think we really have the perfect systems today, but we’ve come a long way. In 2001 and 2002, I was using manual chart abstraction to pay incentives to physicians based on HEDIS measures. We pulled samplings of charts, because we couldn’t afford to do all the charts. So the EHR was a major step forward. And we don’t have interoperability yet.”

Still, in the end, Damore says, things are being forced forward on a broad policy level, by the purchasers and payers of healthcare in the U.S. “One factor influencing physicians is that the dollars are going to be more significant,” he notes. “In 2022, someone could earn a 9-percent reduction up to an 18-percent bonus—that’s a 27-percennt swing. The measurement for that would be 2020. So you’ve got two-and-a-half years to get ready for a much higher-risk payment swing under MIPS”—the Merit-based Incentive Payment Program under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law. Inevitably, that will mean an intensification of activity to better leverage data analytics to participate in all types of value-based purchasing contracts. In other words, stay tuned: the saga will be morphing forward.

 


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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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