Sunday’s day of Pre-Conference Symposia at HIMSS17 on Feb. 19 in Orlando offered a very wide range of sessions geared towards every constituency group in healthcare and healthcare IT, among them physician leaders, nurse leaders, and those involved in creating the future around population health management, payer-provider collaboration, precision medicine, artificial intelligence, patient engagement, interoperability, medical device management, cybersecurity, and other important topics.
When it comes to successful payer-provider collaboration around care and cost management, the final session in the Population Care Management Symposium offered much for the senior leaders of all stakeholder groups in healthcare—providers, payers, government agencies, and non-governmental, quality-focused organizations—to ponder. “The Path Forward: A State Program that Guides At-Risk Patients to Care,” presented by Cindy Munn, CEO of the Baton Rouge-based Louisiana Health Care Quality Forum, and Ann Kay Cefalu Logarbo, M.D., CMO, UnitedHealthcare Community Plan of Louisiana (based in Metairie, a New Orleans suburb), offered attendees a sense of what it takes to achieve success in efforts to reduce unnecessary emergency department (ED) utilization and improve clinical outcomes, in a Medicaid population.
As Munn—whose organization is a statewide not-for-profit organization that facilitates both quality improvement in hospital- and physician-based organizations across Louisiana, as well as facilitates health information exchange (HIE) and electronic health record (EHR) adoption—noted, what started as a pilot study has now been expanded to all the Medicaid managed care organizations in the state. “The focus of this initiative is around patient-centered care, and moving patients to primary care instead of the ED. We’re also looking at getting data in real time to the health plans and to the providers,” she told the symposium audience, “so that care management activity can occur in a timelier manner.”
The origin of Louisiana’s statewide initiative to reduce unnecessary ED use goes back a few years, Munn said. “What’s the problem? Louisiana is not unique. Non-emergent use of hospital EDs is a critical, complex and costly issue facing Louisiana, and the country. These patients are not getting the care they need, or being care-managed as they should.” She noted that in 2014, Louisiana was the fourth-highest state in the nation in terms of ED utilization, and that in 2013, the state was the third-highest in terms of per capita utilization, with $176 million in excess costs estimated to have come from unnecessary and avoidable ED visits. Analyzing available data, Munn and her colleagues at the Louisiana Health Care Quality Forum found, in fact, that 56 percent of patients could have been better treated in primary care than in the ED setting. In addition, the Louisiana Health Care Quality Forum found that 30 percent of patient visits to EDs in 2015 were followed by at least one more ED visit.
What’s more, Munn told the symposium audience, analysis determined that the most common causes for ED visits have until recently been the following: urinary tract infections; prenatal and post-partum care; abdominal pain; and headaches—with the further finding that pain medication Hydrocodone is both the most commonly prescribed medication in Louisiana EDs—a worrisome finding, given the explosion in opiate abuse being documented in Louisiana and nationwide. Indeed, a significant number of individuals have been identified as “drug-seekers”—people who come into different EDs seeking duplicative prescriptions for opiates.
“We had nearly a $1 billion budget deficit a couple of years ago,” Munn told the audience, speaking of the Louisiana state government’s fiscal crisis. “We have about a $350 million budget deficit now. And so the legislature is really focusing on where the costs are,” she explained. “And they’re turning out to be with the Medicaid population.” As a result, a Senate resolution passed a Senate resolution in 2014 charged directed Louisiana Department of Health with creating a special committee to address use of EDs for primary are.” The committee ended up recommending the following: the establishment of the Louisiana ED Information Exchange (LaEDIE); the development of a communication plan to educate patients; the development and issuance of prescribing recommendations; and the promote of the use of the state’s drug monitoring program.
Since its creation, LaEDIE has gone live, and now, every day by 9 AM, LaEDIE sends every Medicaid managed care organization in the state a report identifying which health plan members went to the ED in the previous 24 hours, with participating health plans following up to make sure that patients, especially those identified as high-risk patients, be seen within a week by their primary care physicians, with the priority being a focus on the highest-risk patients.
Already, Munn noted, “Of Louisiana’s 110 ED-equipped hospitals, 72 percent are participating. 83 percent of participating hospitals are contributing data. All five Medicaid Managed Care Organizations (MCOs) are participating. And there are have been benefits to all healthcare stakeholder groups. “For consumers,” she said, “the benefit is improved health outcomes. For providers, there is the combination of increased efficiency and reduced cost. For payers, it is “improved quality ratings and reduced cost.” And for employers, it is “improved employee health, reduced cost and increased productivity.” The program is now expanding beyond Medicaid health plans to include commercial payers and to self-insured employers, she noted.
Dr. Logarbo, who shared with the audience that she spent over 26 years in private practice as a pediatrician, said she was motivated to join UnitedHealthcare as medical director nearly two years ago, in order to help create change on a broad scale. With regard to the LaEDIE program, she testified, “Before LaEDIE, there was no actionable data for anyone to do anything with that patient”—the patient who was over-utilizing EDs, because of the fragmentation built into the fee-for-service-based healthcare system. Now, she reported, “We take this data from LaEDIE, and feed it into our ACO organizations. We have a unique registry,” she added. “We have about 11 percent of our population in value-based ACOs. This data from LaEDIE is fed into us daily and then fed into the ACOs, where we have nurse case managers working with the plan members identified as needing intervention. We educate the case managers on how to use the data coming in.”
The program has helped UnitedHealthcare leaders advance one of their main strategic goals: to improve patient outcomes and reduce costs through bringing more plan-participating physicians into value-based care contracts. In addition to working with Medicaid managed care members who are attributed members in an ACO—just 11 percent of their Medicaid population—Logarbo noted that “super-utilizers—the 1.5 percent of the population spending the majority of Medicaid dollars, are automatically now enrolled in the Whole Person Care Model”—UnitedHealthcare of Louisiana’s intensive care management program. “That’s the program managing the sickest of the sick, the highest utilizers,” she explained. Those members have nurse case managers assigned to them who receive electronic notifications every morning about their condition and situation, with members of that team managing that population. In addition, she noted, “On February 1, we opened a new ED care follow-up plan. We pull up every member who’s been in the ED twice in 30 days, or who has a diagnosis of diabetes, COPD, CHF, end-stage renal failure, or asthma, and we’ve added pregnancy to that list”—and those Medicaid health plan members are also actively care-managed.
All of this is further tied into UnitedHealthcare of Louisiana’s intensive efforts to bring as many physicians into shared savings arrangements through its ACOs. In that regard, she noted, “We gave out $2.4 million to our practices in ACO shared savings last year. That’s huge in the context of Louisiana. One practice received $300,000 for addressing gaps in care.”
In all this, Logarbo said, “One of the key lessons learned is that, if you’re going to move to a system of paying for value, you’ve got to look at whole populations. And in order to do that, we’re going to have to leverage IT. We’re going to have to expand to all payer groups. We’re going to have to encourage the participation of all ED-equipped hospitals; and you’ve got to persuade the physicians. We’re able to pay for quality incentives by using this data. By feeding the data to doctors,” she said, “we can leverage a major opportunity for shared savings and quality incentive payments. Last year,” she noted, “249 practices earned a bonus for quality/shared savings. What’s more, 63 percent of UHC Community Plan [Medicaid] members access care from value-based physician practices.” In the end, she noted firmly, “the success of a medical practice is no longer merely based on volume, but on quality.”