In part 1 of this three-part series, we looked at the factors involved in the exceptional environment of collaboration among healthcare stakeholders in San Diego. In this article, we will look at some of the elements around efforts to advance population health management and care management initiatives in the San Diego metro area.
When it comes to managing the health of populations, the San Diego metro market has some advantages and some disadvantages. Not to be discounted is a fundamental advantage: the climate, which is one of the best in the continental United States, with 146 days of sunshine a year, making it the eighth-sunniest major U.S. city by one calculation, and temperatures that hover around 70 degrees year-round, with low humidity—a perfect climate for outdoor activities and personal fitness. Yet that very advantage is also inextricably connected with offsets and disadvantages. For one thing, the near-perfect climate also means that San Diego County has a very large homeless population of more than 9,000 individuals, with many more who teeter on the edge of homelessness. And that large homeless count has made the task of combating its recent and ongoing hepatitis A outbreak that much more difficult, as the disease has been spreading rapidly among its homeless population in downtown San Diego.
Meanwhile, San Diego’s beneficent climate has also attracted seniors from all over, and the county has an over-65 population of more than 11 percent (not among the highest senior populations in the country—some communities in Florida are more than 30-percent senior-age now—but still large). And the size of that senior population has helped to spur innovation in the Medicare Advantage market and to encourage the development of ACOs (accountable care organizations) both under the aegis of the Centers for Medicare and Medicare Services (CMS)/Medicare and that of private health plans.
Care management’s challenges and opportunities in an advanced market
All of this inevitably leads to discussions of population health management and care management. And the challenges are many, says Vicki DeBaca, R.N., vice president of health and provider services, at Sharp Rees-Stealy Medical Centers, the 500-physician employed medical group that is a component of the integrated Sharp health system. Looking at the issues, DeBaca says, those facing the leaders of Sharp Rees-Stealy and San Diego healthcare leaders are essentially the same as those across the U.S. healthcare system. “What I find when I participate in conferences,” she says, “is that the issues are all pretty similar. I don’t know that our market has giant differences in this area. You have the uninsured, you have the complex population, the patients who aren’t really actively engaged in their care. It’s really similar everywhere.”
What is different, DeBaca says, partly because of the geographic separation between the San Diego and Los Angeles metro healthcare markets, is that things have evolved forward somewhat differently in San Diego versus across the Los Angeles basin, with the San Diego market having evolved forward into and through capitated payment on a broader scale, and for a longer time. “We’ve been a highly capitated market for some time, unlike the case in Los Angeles,” she says. “So I think over time, the organizations in San Diego, because they’ve had a bit more flexibility with the dollars, have been able to focus and decide on how best to spend those dollars. So we might fund special diabetes programs, or special end-of-life programs, we have flexibility in terms of how we utilize resources.”
And health information exchange, as facilitated by San Diego Health Connect, has clearly been a part of that equation, DeBaca says. “Many of my staff use it,” she says, referring to the HIE’s capability. “Ad our providers have a link within the EHR [electronic health record], and are able to go right into the EHR to find that information. And members of my staff, who are largely case managers, can access that information as well. It’s been excellent in terms of getting patients connected back to their primary care physicians after ED visits and hospitalizations. And the goal of our care managers is really to support the patients, in whatever they need.” So, she says, the continuous loop of information and data has proven to be very important in advancing case and care management.
And in that, DeBaca says, “The goal of our care managers is really to support the patients, whatever they need. So their effort is to follow up with the patients; if they have a chronic illness—and their participation is voluntary—the care managers work with them. Largely, it’s explanatory, in helping support the patients, reminding them to get their lab checks or respond to questions about diet; referring them to services they might need, or around diet, or social services.”
What are the biggest challenges in that regard? On a basic level, DeBaca says, “Care managers are human, and we periodically have shortages of physicians and nurses; and because you have episodic shortages of clinicians, this can end up being a very labor-intensive program. You need flexibility. And that’s still a forward-looking problem. This is highly resource-intensive, and it’s expensive. So we’ve really been exploring and expanding some of the aspects—biometric devices and programs, getting patients online to avert patients having to come live into classes. So for example, we’ve deployed blood pressure cuffs to patients—we use it as a training device for a couple of months; they take their blood pressure and the statistic is transmitted automatically to a cloud-based database, and the nurse can react to that. And that is allowing us some efficiencies in utilizing some of our staffing resources effectively.”
Right now, about 100 patients at a time are in that program. Those patients “get their blood pressure under better control, and then the cuffs are shifted to others,” DeBaca explains. “We have the same thing for the CHF [congestive heart failure] patients; they have scales, and monitor their weight and answer questions online. And as those patients become independent, they buy own scales.” The CHF patients are “very fragile,” she notes. “With CHF, very little puts you over the edge, and they’re calling 911 and going to the hospital, versus diabetes. There have been some technological advances, and some new drugs, that have made the management more successful over the past 20 years.” And, she underscores, there has been significant advantage in having some of the care management processes in place long-term, that her organization has implemented.
The challenges under capitation remain significant for risk-bearing provider organizations, DeBaca notes. “I think the limitation is patient understanding. There’s no downside under capitation for the patient; they can go to the ER every day. I think we could still come up with a few better incentives for patients to self-manage better.”
And in all this, IT and analytics are absolutely essential, DeBaca notes. In that regard, she reports, “We have a home-grown plan to identify and manage our patients. And we look periodically—there are vendors that provide population health analytics. We haven’t purchased those per se; we have a very robust data warehouse. And we are capitated, so we have a lot of data. We have hospital and physician data. And over time, we’ve built multiple extractions of reports that will help us understand, say, diabetics who are in trouble, or pregnant diabetics, and that information gets fed into a variety of programs or technologies. So for example, we have some patients who need monthly labs. We’re able to data-mine.” Still, at a more basic level, she says, “A significant advantage is being connected to our physicians. We have to loop them in, connected them; so our staff is in the EHR, and we’re communicating with the physicians as needed. And we do track a lot of outcomes, and compare a lot of populations, for example, compliant versus non-compliant patients.” And analytics will drive a lot of process improvement going forward, she emphasizes.
Health system strategy: managing risk-based and FFS-based contracts at the same time
Inevitably, at the health system level, moving forward on population health management means thinking and operating in parallel universes at the same time, says Dan Gross, executive vice president, hospital operations, for the seven-hospital (four acute-care hospitals, three specialty hospitals), 1,836-bed Sharp HealthCare, one of the largest and most market-moving of the area’s large integrated health systems, and the integrated health system with which Sharp Rees-Stealy Medical Centers is affiliated. “When I look at where we’re at and where we came from, it is that one truly has to have an integrated healthcare delivery model, and a very close affiliation and alignment with physicians, to be able to address risk-based reimbursement and capitated managed care, so that there’s an alignment between physicians and having common beliefs around care coordination, commitment to being a high-quality, low-cost provider with a very keen sense of service orientation, to a population served,” Gross says.
In practice, Gross says, what that means is that “We decided very early on that we would approach both populations in the same way. So for some, that means that as you drive, let’s say, improved performance on readmission rates, for the risk-based population, that’s great. In a non-managed care model, that’s not the case. But you can’t design two different care models. And as you’ll recall, a lot of people jumped into risk-based models in the 1980s and 1990s, and then quickly jumped out. And that often was based on not committing to a risk-based model.”
What’s more, Gross says, “We embraced managed care back in 1985, so we’ve had several decades of understanding and committing to a high-quality, low-cost model of care, and so the mindset of filling beds just to obtain economic gains, is something we moved away from a long time ago. So our focus on the inpatient side has been to grow market share. So the hospital has always been seen as a cost center, an expense structure, in our risk-based model. It still offers revenues, on the non-risk-based side. So that risk-based sensitivity is part of our model and our DNA, and what we believe in.”
Only time will tell where precisely all this development takes provider organizations across the San Diego metro healthcare market. But what is clear is that there is a can-do spirit in the San Diego market whose successes to date point the way to the future of population health management and care management in numerous particulars. And healthcare IT and analytics will clearly be important elements in that future trajectory.
In the next article in this series: A MediCal perspective on San Diego healthcare