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Market Profile: San Diego’s Leaders Manage Parallel Trajectories When It Comes to Population Health

December 12, 2017
by Mark Hagland
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San Diego provider groups figure out how to move forward with population health management in dual risk-based and FFS-based environments

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.”

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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


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On Staten Island, a Highly Innovative Program That's Redefining What’s Possible Under Medicaid

September 17, 2018
by Mark Hagland
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Healthcare leaders on Staten Island have been achieving exciting success in care management and population health management in their community’s Medicaid and uninsured populations

Even as one hears constant complaints and concerns about the challenges facing healthcare leaders who are attempting to help shift the U.S. healthcare system from volume to value, more and more truly encouraging stories are emerging about pioneering organizations that absolutely are moving the needle, in the present moment. One of those encouraging stories absolutely revolves around the Staten Island Performing Provider System (SI PPS), a unique organization whose leaders describe it as a “Medicaid redesign program implementation enterprise.” Under the leadership of Joseph Conte, Ph.D., CPHQ, its executive director, SIPPS has been forging a path forward around robust population health for Medicaid recipients on Staten Island, the New York City borough that is the by far the smallest in population (479,000, compared to Brooklyn, at 2.6 million in population) yet third-largest in land mass, among the city’s five boroughs.

The Staten Island Performing Provider System has been participating very successfully in the Delivery System Reform Incentive Payment (DSRIP) program under the aegis of the federal government. What is involved in New York State’s DSRIP? As NYSDRIP’s website notes, “DSRIP is the main mechanism by which New York State will implement the Medicaid Redesign Team (MRT) Waiver Amendment. DSRIP´s purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25 percent over five years. Up to $6.42 billion dollars are allocated to this program with payouts based upon achieving predefined results in system transformation, clinical management and population health.” The federal Centers for Medicare and Medicaid Services (CMS) approved New York State’s Medicaid waiver requested in the amount of $8 billion over five years, in April 2014.

And SI PPS manages the care of 130,000 Medicaid recipients on Staten Island, in addition to managing the care of 50,000 uninsured Staten Islanders.

According to SIPPS leaders, “Staten Island Performing Provider System (SI PPS) is an alliance of clinical and social service providers focused on improving the quality of care and overall health for Staten Island’s Medicaid and uninsured populations, which include more than 180,000 Staten Island residents. We are co-led by Staten Island University Hospital and Richmond University Medical Center. Our network of over 70 partners includes skilled nursing facilities, behavioral health providers, home health care agencies and a wide range of community-based hospitals, clinical facilities, treatment centers, social service and community organizations, primary care physicians and medical practices across the island. SI PPS is expected to bring more than $200 million to Staten Island over 5 years if successful in transforming our care delivery system. Our mission is to engage partners and stakeholders in the planning and implementation of DSRIP as we move towards a value-based payment model for Medicaid in New York State.”

Among the goals that SI PPS leaders have set for themselves:

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> Develop an infrastructure that lays the foundation for delivery system reform by transforming the Staten Island community through investment in technology, tools, and human resources that will strengthen the ability of providers to better serve our community

> Improve health literacy and share cultural competency knowledge

> Expand access to the appropriate level of care for all patients, including reducing barriers to care

> Expand outpatient and community services including home care, ambulatory detox, behavioral health/substance abuse, and primary care to reduce avoidable hospital/emergency department use on Staten Island

> Improve coordination of care and develop an integrated network

> Improve care management and disease management for high-risk patients, including patients with chronic conditions and behavioral health diagnosis

> Improve population health by addressing social determinants of health

> Integrate technology to allow for the secure exchange of health information across the PPS

> Reduce the per person cost for providing care

> Engage the uninsured, and underutilizing/low utilizing Medicaid patients and connect them to primary care and social services

> Implement innovative and evidence-based care models throughout the care continuum

> Implement training programs and learning collaborations between PPS partners that allow for the sharing of best practices

SI PPS leaders state that “These goals are being reached by implementing 11 DSRIP Projects, identified by a Community Needs Assessment, to address primary care, mental health, substance abuse, chronic disease, long term care, social determinants of health, and population heath.”

SI PPS leaders add that “We leverage a seamless platform that gathers data from multiple sources -- claims data, core reports, department of health information and the like -- and that data is inserted directly into the electronic data warehouse. With geo-mapping, we can identify areas that are lacking in key services. In creating maps of the population, we can filter in on specific conditions, and if we hover over a specific area within a specific map, we can see three years of claims data. We can figure out utilization trends, including hospitalization, medications, etc. We can also filter by demographics, types of chronic illness, etc.” Among the data sources they are make use of include direct data feeds from partners; lead providers’ clinical data; other partners’ clinical and billing data; data from care management partners; and public data; among other sources.

In addition, the SI PPS leaders have plunged into behavioral healthcare management. They note that they are pursuing “a population-health and community wide effort that aims to build capacity across systems by leveraging and developing partnerships to provide a quality integrated health care system, effective, high quality, person-centered care that supports improved health outcomes and optimal physical and emotional well-being. BHIP priorities focus on increasing and sustaining mental health/SUD provider service capacities, assisting community members to navigate behavioral health services, providing support to individuals and providers through education and technical assistance, addressing co-morbidities and co-occurring disorders, and reducing stigma and raising awareness about behavioral health wellness.” Among the numerous individual programs encompassed by the Behavioral Health Infrastructure Program (BHIP) are programs to expand the capacity of professionally certified peer workers in addiction and mental health, to help tackle the substance abuse program; the engagement of patients in the Emergency Department with substance use issues by clinicians and certified Peers to expedite linkages to behavioral health providers and reduce preventable ED visits; an innovative pre-arraignment diversion program designed to redirect low-level drug offenders to community-based health services instead of jail and prosecution; and numerous other programs.

Recently, Dr. Conte spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding the progress being made at SI PPS, and the implications of his team’s work for transformation across the U.S. healthcare system. Below are excerpts from that interview.

Can you explain the basic funding mechanism or model that is supporting your organization?

The New York State Department of Health negotiated a waiver with CMS, and received $7.2 billion over five years to fund the program. About 50 percent of that was guaranteed for pay-for-reporting and program implementation, and 50 percent was set up as pay for performance, so it is very much a pay for performance program. There are 6 million people on Medicaid, and the state spends $65 billion a year, and the federal government pays for half of that; that’s why it’s very much in their interest to fund population health; it pays dividends to everyone.

To take care of the entire Medicaid population on Staten Island?

It’s interesting. We do not pay claims or intervene on behalf of providers, with managed care companies. Our sole purpose is to create innovation and reach population health milestones with providers in the community. So the hospitals, nursing homes, FQHCs, physicians, continue in their payment systems. We exist solely to create innovation and to incent innovation. It’s very much a pay for performance program.

Tell me about some of the main programs that you and your colleagues have been involved in, around this work?

The main initiatives relate to creating integrative care models where we bring in behavioral health providers to work with medical providers and medical providers who work in behavioral health organizations, so people don’t have to shuttle around to access care. We’ve done a great deal in the prevention of avoidable use of EDs for medical and behavioral care; that’s down over 60 percent in the past three years. And a lot of that has to do with looking at data form multiple sources and identifying where initiatives should be implemented. So we have a very big focus on asthma and a very big focus on diabetes. And a lot of the work involves engaging patients with peer educators who suffer from these conditions themselves.

One of the biggest innovations has been doing this with people who have alcohol and substance abuse disorders. We have peers in the EDs 24/7; and the number of people who have engaged in treatment services has tripled in the past few years. We’ve paid the salaries for these individuals, we’ve paid their training, have paid them to go get certified; and as they’ve become certified, they’ve become hired by the organizations, because their services are actually billable. So it helps the individual, helps the patient care organizations, helps the community. And it all comes out of high-level data analytics, doing hot-spotting, geo-mapping, bringing in social determinant of health factors, looking at housing, crime statistics, poverty, graduation lists, things like that. So we’ve done things very fundamental to services, to healthcare services, but in a very smart way. The workforce transformation is also very important; we spend a lot of time and training preparing people for new roles.

What have your biggest lessons been learned so far?

I would say it is that the kind of collaboration that it takes to create transformation is something that people really want to do; but they need organizations like ours that can bring these high-level analytics and resources together. And that includes training to give people new education; as well as providing to organizations high-level opportunities to identify patients most in need. You know, you can hunt for ducks with a shotgun, but it’s not a good idea when you’re trying to conserve ammunition, right? So we’ve helped people put a fine aim on things that need to be worked on, and the community coalitions are very powerful; you can’t go it alone, so working with local governmental units is very important. Also, bringing in information form as many sources of information as possible essential. We bring in ambulance data, social determinants of health data, school data, community data; all are essential.

Have you done geo-mapping or hot-spotting? How did you figure out how to obtain those various types of data?

When we started up, we were a complete start-up; so we didn’t have any legacy systems. So we hired very bright IT people and analysts, and brought the right tools to bear so that we could really be focused on how the resources were applied; that was our core investment.

What advice would you offer the senior healthcare IT leaders in patient care organizations, including the CIOs, CMIOs, CQOs, chief data officers, etc., in terms of what they should think about around all of this?

I would tell them that turning data into business intelligence is critical, and that’s true with respect to everybody. For the medical people, it’s medical business intelligence; for the finance people, it’s financial business intelligence. Don’t get overwhelmed with data; use it to create good information for clinical and business practices, and that will allow you allow you to be successful.

What will happen in the next couple of years?

There are about 13 states that have Medicaid redesign waivers in place now; CA and TX have received extensions, and we’re hoping for an extension. We’re also looking for other opportunities to extend our work; we’ve set up an ACO. We’ve set up a form of consultancy as well.

Where do you hope to go in terms of accomplishments in the next few years?

The important thing is for us to do things that are sustainable in the community whether we continue on or not, and that’s a lot of the work we have done—it is to grow capacity in organizations in the community. And that’s why the workforce work is so important. When people have new skills and training and ability to bring change into their organizations, these certainly are sustainability factors that are important.

Is there anything you’d like to add?

I would say one thing that we’re spending much more time on now, is continuing to try to work in the behavioral health space, because especially in the Medicaid population, any number of people have co-occurring conditions—they have medical and behavioral problems. And these are the patients with the most problems and who need the most services. So giving them access to more services is important, but also being able to be more predictive about when they’ll need those services, so we can be smarter about it; that is really important.

 

 

 

 


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In Eastern North Carolina, an MD-Run ACO Shows its Success

September 10, 2018
by Mark Hagland
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Stephen Nuckolls, CEO of the New Bern, North Carolina-based Coastal Carolina Quality Care, shares his perspectives on why some physician-led ACOs are making huge breakthroughs on quality and cost

It’s not just in the well-known advanced managed care markets that the accountable care phenomenon is making progress these days; indeed, there are accountable care organizations (ACOs) whose leaders are pressing ahead, all across the U.S. Some leaders are operating ACOs in collaboration with private health insurers; a significant number are participating with the Centers for Medicare and Medicaid Services (CMS) in one of its several ACO programs.

One organization that has been making exciting strides forward in the Medicare Shared Savings Program (MSSP), the largest of the Medicare ACO programs, is Coastal Carolina Quality Care, an ACO based in New Bern, North Carolina, a community of about 30,000 people located about two hours east of Raleigh, that state’s capital, and an hour west of the Atlantic coast.  Coastal Carolina Quality Care is sponsored by Coastal Carolina Health Care, P.A., a multispecialty group practice located in New Bern, and which provides care to its community at 16 locations, involving 43 physicians and 20 allied healthcare professionals. Coastal Carolina Quality Care was created in April 2012 and chartered as one of the first 27 MSSP ACOs; it currently has 11,500 Medicare enrollees attributed to it.

Recently, Stephen Nuckolls, Coastal Carolina Quality Care’s CEO, spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding his organization’s ongoing journey into and through value-based healthcare delivery and payment. Below are excerpts from that interview.

Your organization has now been participating in the MSSP program for six years, correct?

Yes, that’s correct. We are ending our second contract cycle in December. We will renew, under the new proposed Pathways to Success regulations; there will be a six-month period where we’ll stay in our current track, but starting July 1 of next year, we’re planning to enter their Enhanced Track, the equivalent of their Track 3 under the current regulations. That includes downside risk. We’ve been in Track 1 Plus; we came into that starting January 1 of this year.

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In other words, you’re already taking downside risk?

Correct; it’s a limited form of downside risk based on the revenue standard. Eight percent of our Medicare fee-for-service revenue, is the maximum we’d have to pay back. The maximum gain would be 10 percent of benchmark, which for us would be $12 million.

What’s your sense of how your organization is doing in the program this year?

Well, for 2016, we achieved a little over 4 percent savings, and a little over 6 percent savings for 2017; and through the second quarter of this year, we were a little over 8 percent savings—so far.

That’s really great. What do you see as the secret of your success so far?

It’s hard to pinpoint any one thing. There are several things. Number one, it takes time for some of these strategies, such as population health, to pay off. Another thing that’s going on is that our care management program, I give credit for keeping our costs low and getting things in place. And in addition, we really made a lot of strides in our first contract cycle, specific to our market. All of our annual wellness visits and preventive care, we made our marks there and that positioned us well in our second contract cycle. And it just takes time, when you focus on the quality of care, for… when a greater percentage of your patients have their blood pressure under control, you’ll have fewer adverse events. And when you work to lower a1cs, that will avert events over time. And annual wellness visits, vaccinations, screening services—it costs money for screenings; and once you get things set up, that’s then in place. And care management services—when you go into your second contract cycle, you have some of those costs worked into your contract cycle the second time; so it takes time to achieve shared savings, and to get the staff to focus on the sickest population.

With regard to the electronic health record and data analytics, in the context of population health work, what learnings have you and your colleagues achieved so far?

Data analytics are key with this. We have a dashboard right in our Allscripts EHR. We’ve really used that dashboard, and we’ve used that module to track things; we’ve done things around opioid abuse disorder, and tracking things. Most people don’t associate that crisis with the Medicare population, but there is a good number of people on Medicare for disability. And we’ve really used our EHR to help track prescriptions, and to pinpoint patients to make sure they’re getting the right care and support. And with regard to point-of-care dashboards, we’ve just found those to be incredibly helpful. And focusing on tracking outcomes, at the individual physician level; doctors are competitive, so that helps. And we’ve used Allscripts’ reporting package that allows things to print out well and that works well in meetings, and that helps get the point across about how these numbers relate to the day-to-day practice aspects. That’s what drew us to the program: if you give good care to the patients and it keeps them healthier, it’s good for the practice’s bottom line.

What have been the most difficult challenges in the journey so far?

We’ve had many. One is around physician engagement. We did not achieve savings during our first contact cycle, and that was disappointing, because we felt we were doing a good job. So, maintaining engagement, and making sure we were making good investments in the program. Now, we have reached the point where we’re financially successful, and our projections are looking good for this next contract cycle. Some of it had to do with the vagaries and complexities of establishing this new benchmark. They’ve fixed a lot of those things.

Another challenge is around care management, just getting up to speed on chronic care management, and how to bill for that and set up that program, so it can show itself as a break-even center in a fee-for-service world, cost-justifying that, and training and educating, that was a real hurdle, but I’m proud of that now. It’s a little more than care management, some would call it practice transformation or team-based health. But there’s a lot about how to pay for setting all that up.

Many ACO leaders have commented on what’s popularly known as the “one foot in the boat, one on the shore” problem of having to manage both fee-for-service and value-based payment realities at the same time. Your thoughts?

We’re actually fairly fortunate in that we’re what Medicare considers a low-revenue ACO. Our doctors comprise a low percentage of the overall dollars. When we see patients and are keeping them healthier, we’re at least breaking even.

So you have low overhead, and that keeps you in a good position, in that context?

Correct. We do have our own processes, where we give certain kinds of injections, for example. Now that we’re looking at a 75-percent shared savings track—when you move from 50 percent to 75 percent, you get past what you’d call incremental revenue. You can really start to look at some of the internal costs. If you’re in a 50-percent shared-savings world, and let’s say we get paid $100 for an office visit; if you don’t do that office visit, you increase your shared savings by $50; but you have to look at incremental costs. For example, a shot of Porlea that costs $600. The point is that when you get to 75-percent savings, it makes the math a bit different in terms of your incremental costs of providing a service. You get closer to saying, if I can provide this drug or see the patient, it makes more sense to move to virtual visits or not always bringing the patient in for an in-person visit—when it’s someone we’ve seen three or four times recently and know the patient well—the doctor may handle it over the phone, for example. It changes the calculus as we go forward.

What should CIOs, CMIOs, and other senior healthcare IT leaders be thinking about, based on all of this?

As far as population health management and trying to get the numbers together, make it simple for the physicians to use; make sure they have enough resources at the point of care to use; and make sure you’ve answered the question of what’s in it for them to use it. So a CIO might buy a big, fancy system, and it’s wonderful, but the doctors may not use it unless they know what’s in it for them. Unless there’s an incentive for them to use it, the human behavior is, I’ll just generate as many RVUs as I can, as I’ve always done, and this slows me down. So I’d tell a CIO or CMIO to set up a system that’s simple, that encourages the physicians to use it, and provides incentives to use it. In some cases, we had to hire scribes.

And what has your experience with scribes been like?

It depends. In some practices, we’ve crashed and burned, and then some practices couldn’t live without them. It depends on the number of patients the doctor has, and their comfort level for having someone in the room. Our doctors with larger patient panels and not so particular about how their notes looked, FPs, they’ve done well with scribes; with general internists with smaller panels, they’ve had less success because there’s not so much of a need for it.

What do the next two years look like for you and your group?

I’d like to talk about Pathways For Success and this new rule that comes out: while it doesn’t change our decision-making too much, I think that the forcing of more groups into downside risk earlier, is a mistake, I don’t think it will save the treasury that much. There will be a study released next week by NAACOS [the Washington, D.C.-based National Association of ACOs] that will show significantly greater savings than what Medicare has shown to date. This study uses a methodology that MedPAC and the Innovation Center have used—they look at a matched cohort—and it will show almost twice as much savings in the MSSP than has previously been shown. It also speaks to the policy point—organizations are truly saving the government money, even if it doesn’t immediately show on paper. The evidence doesn’t support the idea that ACOs should be kicked out because they have a bad benchmark. The true savings to the Medicare Trust Fund will then be less. And that’s what they need to focus on, achieving true savings to the government.

And where will this appear?

I think it’s going to come out in Health Affairs. I’m familiar with it through NAACOS, which helped fund it.

 


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