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At the Health IT Summit-Chicago, a Providence Health Leader Charts His Organization’s Journey Around Population Health

May 12, 2017
by Mark Hagland
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Providence’s Preston Simmons shares insights on his organization’s journey around population health

Leaders at Providence Health & Services, one of the nation’s largest not-for-profit integrated health systems, have been moving forward intensively in areas including population health management, patient and community engagement, and clinical transformation. Founded back in 1856, Providence Health & Systems is an enterprise with $22 billion in annual revenues, 50 hospitals, 829 clinics, and 111,000 employees across seven states, serving patients and communities across seven states: Washington, Oregon, Montana, California, New Mexico, Texas, and Alaska, with 40 percent of its presence in Washington state.

Preston Simmons, CEO of the western Washington region of Providence, delivered the luncheon keynote presentation on Thursday at the Health IT Summit in Chicago, being held May 11 and 12 at the W Hotel-City Center in downtown Chicago. Under the title, “Tackling Population Health—Key Elements of a Comprehensive and Sustainable Strategy,” Simmons shared in some detail his organization’s broad population health management strategy and implementation story to date.


Preston Simmons

After noting Providence Health’s absolute commitment to community benefit—noting that Providence organizations provided $1.6 billion in community benefit last year, including $209.8 million in free and low-cost care, $1 billion in Medicaid shortfalls, $110.5 million in community health services, and $180.9 million in education research—Simmons told his audience that he and his colleagues are committed to population health and patient and community engagement out of a sense of mission and vision—and out of practicality. “Healthcare payment will change rapidly. The way we deliver care to our customers will change—through accountable care organizations, technology,” and other means, he noted.

Change has taken place in phases, Simmons said. “Starting in 2015, we focused on taking healthcare online, similar to other industries.” In 2016, he said, he and his colleagues moved towards facilitating more personalized, “on-demand health,” through online scheduling and telehealth-based services; and this year, convenience is becoming a great focus. In terms of the organization’s digital strategy, he said, “The question is, how do you entice consumers to choose your organization, and then stick with your organization, for care?” Among the innovations been Providence’s “Express Care Clinics,” which are of two types—those wholly owned and operated by Providence; and others, which are co-located in Walgreens drugstores, and operated by Providence clinicians in concert with Walgreens staff.

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The connection between convenience and population health management? Simmons gave an example of how those two concepts intersect. In that example, he cited a theoretical young teenaged mother-to-be. Connecting that individual through electronic means, he said, Providence can provide that pregnant teen “a personalized experience, clinically approved answers to her FAQs, timely and local to-dos,” and “convenient access to relevant resources.” As Simmons put it, one should consider the investment in these tools and capabilities, and imagine the fact using technology-based services to engage a young pregnant mom could benefit both her child, in terms of averting, for example, a neonatal intensive care unit stay, while also ultimately save the healthcare system the tremendous costs of having to resort to such care because of a lack of adequate engagement by that young woman in prenatal and postnatal care.

In terms of the organizational structures around Providence’s population health work, Simmons told his audience that, “Four years ago, we created a population health division, and Dr. Rhonda Meadows, who had a background at CMS [the federal Centers for Medicare and Medicaid Services], came in” as the system director for population health. The broad population health work involved spans numerous care delivery and care management settings, including several health system-owned health plans that cover 2 million lives across three states—Washington, Oregon, and Texas. What’s more, he noted, “In 2015, we created the Providence Institute for Healthy Communities. There are four domains we’re looking at” within that arena.

Shortly after he had concluded his presentation, Simmons sat down with Healthcare Informatics Editor-in-Chief Mark Hagland, to converse in detail about some of the topics he had covered in his presentation. Below are excerpts from that interview.

What are the biggest learnings so far on the journey that you and your colleagues have been leading, into population health?

The most important learning involves starting with the right vision and the “why” of where you’re going. Often you fail because you have a scattered vision and things are scattered. You have to be thoughtful about that. We have a centralized governance model and management for population health, and we’re starting to roll out population health at that regional level. It’s hard, because healthcare on one level happens locally, but you want to learn from each other and standardize, where it makes sense. So only by having those clear governance structures and communication patterns, can you work at scale; and working at scale is tough. We’ve just put together a governance model for population health, led by Rhonda Meadows, M.D., a model that involves six different population health domains.

You had mentioned the fact that you are a health system that runs some health plans. I’m sure that fact has been helpful in this, correct?

Yes, that’s correct. We have health plans—we’re licensed in Washington, Oregon, and Texas. We’ve had a health plan for 30 years in Oregon, and a lot of experience, and across everything from commercial to Medicaid. We’ve learned a lot during that time about how to run a health plan, do data analytics, partner with providers. What’s more, we have 4,000 contracts of all kinds—contracts with health plans, and contracts of all kinds.

And the broad areas of activity include the Providence Health Plans; payer contracting; physician services; growth strategy; population informatics; communications; and finance.

How would you articulate your organization’s core population health strategy?

It’s our mission—it’s how we improve the health of the communities we serve. It’s very much aligned in that. With the health plans, we can cover the full premium. So there, we have health plan/delivery system synergy. At the bottom line, it’s how do we improve the health of the community? How do we provide structures and activities around that? Population health is one element. And we don’t have to do everything ourselves: we can partner, facilitate, lead. Even out speaking and talking to others, as today, it’s one aspect. And you do that in your local communities, and on an aggregate national level.

And then you progress to designing processes with other partners. So right now, we’re creating a Medicaid strategy or our system, starting in western Washington. There are a variety of domains under that, around how we improve access, use technology, develop partnerships, and improve access. In the Medicaid realm, we’re focusing especially on women’s and children’s, and mental health services. And you can take a technology that works well in a commercial, fee-for-service population, and testing that in a heavily managed care population.

And then, how do we create unique partnerships, where we can best leverage our expertise? If you think about the Medicaid population, typically, Medicaid may pay 60 cents on every dollar of cost on the inpatient side, and perhaps even lower, 40 percent, on the outpatient side. Meanwhile, the national average for Medicare is somewhere around 89 percent. And historically, higher rates on the commercial side would balance out your Medicaid and Medicare losses; that’s gone now. What providers are getting paid now—health insurance has only gone up 1 or 2 percent in payments the past several years. And pharmaceuticals, supply chains, and labor are all going up. So in the Medicaid world, how do we partner between our primary care and FQHCs [federally qualified health centers. They’re cost-based reimbursed. They have wonderful care. They integrate, often, physical, behavior, and oral health, and they know their populations really well. They have wonderful systems of primary care, but have a hard time getting access to specialists.

And when we look at our community—we’ve been able to join the FQHC leadership meetings. And we’re looking at ways where we can create models where we do the specialty care, and also create greater access for the community. And in Washington state alone, 600,000 people have achieved access to care because of the Medicaid expansion, but we haven’t augmented access, and a lot of times, those individuals are going to emergency departments—the default is the ED. So we’re stepping back and saying, how do we design a better system of care, partnering with the FQHCs, and leveraging g information technology, and bringing new access to specialty care. We bring new access into the system, while partnering with the FQHCs.

I have a meeting in fact next week—we’ll be meeting with the FQHCs. We’ve had our digital innovation team go in and meet with FQHC leaders, and find out their biggest issues to solve, so we can help them with that. One of the biggest issues is navigating the social determinants of health. So if it’s getting nutrition services, other services. So we created a program in Snohomish County, and we’re going to beef that up to create care management modules and dashboards for FQHC patients. So as our state moves towards a capitated plan for Medicaid, which it’s moving towards… Under CMS, you can do a wavier for your Medicaid program. So we signed an 1115 waiver, which frontloads $1.5 billion into our state from the federal government, with the promise that we’ll reduce spending trend by 2 percent within five years. So one of the first things the state has to do—they’ve created nine accountable communities of health. Each has required and elective projects to work on. One of the required ones is to create information systems to improve population health. The idea is that we have these governance models in each of these nine; they have some required and some elected projects. Community organizations are supposed to come together, propose a project, and implement projects. And on the back side, it’s like a super incentive—they can get reimbursed for the economics, only if they hit the metrics.

So we’re going to take some of these projects around this portal, and take it to one of these accountable communities of health, and we know over time that that will drop the cost and improve the metrics. They’re around mental health, opioid use, supportive housing, things like that. It’s a pretty cool process; it’s not often you get to redesign care delivery. And that’s one example of working outside your walls, in a community.

As I said earlier this morning in the policy panel discussion, if you can make Medicaid managed care work, you can make anything work. There’s so much potential here in applying population health management strategies and tactics to Medicaid populations, correct?

Absolutely. We’re starting in western Washington, and we’ve created what we call our Medicaid Playbook, a set of domains, with best practices, around how we reduce ED utilization and improve access, work with special care populations, etc., etc., in different areas. And there’s a financial pillar, too, working with payers and how to redesign.

One of the things that the leaders of many innovative organizations like Providence have described to me is their involvement in what’s sometimes called the “blessed” or “virtuous cycle,” which in this context involves collecting data, analyzing that data, using that data to help guide care delivery  and care management and clinical performance improvement work, and then beginning that cycle all over again with data collection and management.

Yes, and that’s where the money is. And with one of our Medicaid payers, in Snohomish County, we analyzed our Medicaid population there. As you know, typically, roughly 5 percent of your population accounts for 45-50 percent of your costs. In that case, 1 percent of their population 135 individuals, accounted for about 35-40 percent of their total $7 million spend in Snohomish County. And it’s the polychronics. And people go through cycles of high-cost episodes. So the predictive analytics to help you watch a 20 percent who are churning, the rising risk, that’s where your predictive analytics comes in super-important—how do you identify those people and get the intervention in quickly? Care navigation, keeping them out of the hospital, ED, through intensive ambulatory care and home visits, etc. We’re doing a lot of work in that area. And how do you comprehensively case-manage the 5 percent?

On the pharmaceutical side, you need to regularly call them, make sure they have everything they need—that’s why when you’re under capitation, it makes so much sense to invest in those things. It doesn’t have to be high-cost, it can be navigators and case managers. And with telehealth—you have a social worker embedded in a medical home. About 40 percent of all primary care visits, in general, have a psych comorbidity. So if you’re not taking care of behavioral issue, you can’t manage the physical issue. Often, in terms of telepsych [telehealth-delivered psychological care services]—we’ll have a psychiatrist working with a social worker, to manage their medications, and leverage that capability  across geography in rural areas, or even some urban areas.

I was just in Washington, D.C. earlier in the week for the AHA Conference [the policy conference of the American Hospital Association], and was concerned to see what progress might be made around facilitating reimbursement for telehealth-delivered patient care delivery. Last year, we passed legislation to cover telehealth- and telemedicine-delivered care for commercial and Medicaid populations. Medicare is prohibited for the use of telehealth except in rare rural areas, even though 80 percent of Medicare populations are urban. We [healthcare providers] need to provide the CBO [Congressional Budget Office] with studies that prove telehealth’s efficacy. We need Medicare reimbursement for telehealth-delivered services; that will drive a lot more innovation, too. Now, under Medicare Advantage, you’re capitated, so those kinds of things make sense anyway. But we need the federal government to cover this, too, for fee-for-service-based Medicare payment.

What should CIOs and CMIOs be thinking and doing right now, in the context of this discussion?

You have to get the clinical people and the technology people together, to figure out how to add value. It’s like you have CFOs who just sit in their corner offices, versus those CFOs who go out and figure out what’s going on, and can add value. We’ve got to get clinicians and IT people together to innovate. And it takes time. You’ve got to sit down together, especially people who came into healthcare IT from IT in general, and they don’t understand healthcare yet. So how do we incentivize the Medicaid population, what might incentivize them to do certain things, it’s totally different from us. So you might want to give an economic incentive, but for Medicaid patients, they’re often living in the moment, and the ED is convenient and warm. So what’s the incentive to go to an FQHC? So for us to help create innovations to help that population, you really have to understand that population.

And even in the hospital setting, it means understanding what it means to create a service operations center. What are the barriers to flow between care settings, even with the hospital, and then from hospital to skilled nursing or ambulatory care? And there’s so much waste. And a lot of is getting rid of the silos, and creating common knowledge—both internal and external silos. And if we don’t disrupt the disruptors, somebody else is going to come in and do it for us, because we’re too archaic in terms of how we provide care. And it’s not fair to our communities.

Yes, and as I mentioned this morning in the policy panel discussion, every year, the Medicare actuaries publish their projections for total U.S. healthcare expenditures. And as I mentioned, the actuaries are anticipating a 70-percent increase in overall U.S. healthcare spending, with total spending rising from $3.3013 trillion in 2014 to $5.631 trillion in 2025.

Yes, that’s crazy. Yes, it’s unsustainable.

In that context, I believe that healthcare IT leaders and clinical informaticists really can be heroes in all of this.

Oh, I absolutely agree! People feel called to healthcare. So we have the best and brightest and most dedicated people, and if we put the right systems and structures and people together for the Triple or the Quadruple Aim, we’ll create a better healthcare system, and we’ll be able to invest saved dollars back into the social determinants of health, and our IT partners are absolutely essential to that.

 

 


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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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