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.
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.
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.