Making Major Inroads in the Care Management of High-Needs Populations, at L.A. Care Health Plan | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Making Major Inroads in the Care Management of High-Needs Populations, at L.A. Care Health Plan

July 4, 2017
by Mark Hagland
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Katrina Miller, M.D. describes some of the gains being made in care management optimization at her health plan

L.A. Care Health Plan, a health plan with 2.1 million members, 1.9 million of whom are MediCal (the California Medicaid program) recipients, is based in downtown Los Angeles. Founded 20 years ago in 1997, L.A. Care Health Plan has been moving forward to optimize care management for its MediCal members, particularly those with complex needs and challenging living circumstances. The plan’s chief medical information executive, Katrina Miller, M.D., has been with the organization for two years. Dr. Miller is boarded in both family medicine and in clinical informatics, and continues to practice occasionally, in free-clinic settings.

On May 2, at the World Health Care Congress, held at the Marriott Wardman Park Hotel in Washington, D.C., Dr. Miller and Frances Martini, R.N., director of integrated population health at BlueCare, the Medicaid division of the Chattanooga-based Blue Cross Blue Shield of Tennessee, presented a session entitled, “Consumer-Centric Care: Member Engagement and Retention Strategies for Complex Populations,” as part of the Medicaid & Health Policy Summit and Behavioral Health Summit tracks, at the Congress. Healthcare Informatics Editor-in-Chief Mark Hagland caught up with Ms. Martini last month; and below are excerpts from his recent interview with Dr. Miller.

The kinds of progress that you and your colleagues have been making at L.A. Care Health Plan really speak to the general direction in which the U.S. healthcare system is beginning to move more generally, around data-facilitated population health management and care management, don’t you think?

Yes. What we need to do for the future of any sort of efficient healthcare delivery to be able to exist, we need to care for the entire population. And in terms of the health plan and care coordination side, we need to be the most efficient and effective stewards of the public money. We also need to be running at the most optimized levels, including through technology, that we can, based on our understanding of the need to use resources most efficiently. And you were mentioning the high-cost, high-needs population. And we have to understand really what that population needs as a whole, and the unique categories within that population, so we can be most efficient in getting them the care and services that they need. And it comes down to people, processes, and technology.

We have to use the technology and data to identify those folks and present them to the care coordination staff, and make sure they have an efficient process, with good handoffs, good documentation, and make sure we have the right number of people to provide the services needed. At L.A. Care, we’re trying for a high-tech, high-touch model. So we have to understand who needs what kind of direct care—medical, social worker, dietician, etc., and identify that as precisely as possible to make sure they’re interacted in the way they need to be interacted with. For instance, we have behavioral health members who yell at us and say to get away, when they really need shoes. And we need to understand where they need the help, not what we think their needs are.


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And, once you’ve used data and analytics processes to identify members in need of immediate and near-term intervention, there is actually an element of “shoe-leather” work, in terms of making direct in-person connections with those members in need, correct?

Yes, we first have to identify the whole population, to address the lower-needs populations, to make sure they have access to preventive and primary care, so that we can then also focus on the higher-needs populations. So we stratify into a complex case management program, and a behavioral health program, a social work program, and a disease management program; we have a variety of programs in order to place the right members into the right programs. And we have to prioritize to make sure they’re in the right first program. So if they have complex needs, we put them into the complex care program rather than the disease management program, because they’re covered. And we need to connect them with their PCP [primary care physician], and with our internal people. And we do that through our interdisciplinary care team; we do calls to make sure we’re on the same page. And we’re working with the County on a program called Whole Person Care—it was granted last year, and the actual program hasn’t gone live yet, it should start in July, next month, for the first enrollees. That’s going to be about social services connections with community health workers. It goes beyond L.A. Care, it’s going to be the community—L.A. Care, with our competitor plan, HealthNet, and the County Department of Health Services, and then the jail program, so when folks are getting out of jail, and the Department of Mental Health Services, etc.; it involves ten sub-programs in four areas, addressing the social-services needs in the county.

What has been most challenging and surprising in drilling down to these levels of care?

That’s a big question. I’ve been at L.A. Care for two years now. And I completely respect the folks here who understand my role as a clinician with a good understanding of informatics. And the fact that I’ve just been here two years means that I’ve seen the fact that the organization still has a long way to go in terms of optimizing some things. But the great thing is that in the last couple of years, we really have started to coordinated well, in order to achieve impact. And probably the most surprising thing to me has been that culture change challenge. And a lot of work has gone on here to encourage and support the folks who have been here for more than ten years, to say, you are still needed here, we need your expertise, especially in terms of connecting directly with members, but we do need to change some processes; and guide then through that transition. As you know, culture will eat everything for breakfast. And it really is a challenge, and takes a long time, and even with our leadership, we’ve needed to work on culture change. But things are really moving forward.

What should your fellow CMIOs know about their roles in all of this work?

Actually, when I sit with other CMIOs, I sit there and listen like a sponge to learn from them. I feel like I’m very far behind so many other enterprises; that being said, I would reiterate the importance of an aligned culture supported by leadership. That’s especially true around expensive technological changes that take a lot of time and effort to implement, you’ve got to have senior leadership support. And that leads to a CMIO focusing strongly on what the leadership is focusing on; if the leadership leaves something to the side, you might as well leave that on the side, too. And the communication—internal and external communication, about what the plan is, what the strategy is, the goals, how we’ll reach those goals, and the training. So it’s all of the classic pieces of any type of implementation. And if you skip any of those steps, you’ll have disaster. In so many cases, we cut corners and cut time, and you end up having people come into contention. So really, you need to follow those steps.

Can you speak to some of the data and analytics needs that are being discovered, as you and your colleagues drill down further into this important work?

One thing that we already know is that we’re pretty far behind the eight-ball in some ways, around data and analytics. With L.A. Care being L.A. County, we have a myriad of sources and various ways we’re getting data into the door—ranging from EDI to 847 files, to Excel spreadsheets. And it can be a ridiculous process of data transfer. So we’re obviously starting to try to centralize the data process and make sure we’re using standardized processes whenever we can, and that can be a painful transition; and to make sure we have a more standardized process once we bring data into the door, per semantic layering… enterprise architect, glossary architect; we have a new CTO.

So L.A. Care has seen how important it is to make sure that the data we’re getting in is valid, and that we have an appropriate pathway from initial ingestion all the way through reporting needs. It’s a slow process to make it happen. I’m working more on data metrics and presentation. Obviously, when we end up seeing numbers that don’t make sense to us, we have to go in and investigate.

Can you provide an example of a typical challenge you face in that regard?

Yes, we work with different IPAs [independent practice associations—the most common type of physician organization in California, which has a state law barring direct employment of physicians], and have to represent the performance of those different IPAs. And it’s actually very difficult to identify the providers in those IPAs, and the IPAs within the IPAs—sometimes, you have umbrella IPAs with multiple IPAs within them; and we don’t have that consistently indicated within our system. So when it comes to performance, we have a challenge in correctly representing the performance of a particular group. So any changes, and of the providers working within that group, and making sure we keep that up to date, so that we’re always reflecting the performance of a particular group accurately.

Looking into the future, how do you see things evolving forward in the next two or three years?

I hope that we’ll have a more optimized healthcare delivery process, so the members can say they’re having an excellent member experience, and our staff can say they’re having an excellent work experience, and that interventions that reflect the pre- and post- changes, and are accurately measured, and that we do PDCA [plan-do-check-act] processes to continuously improve what we’re doing.



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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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