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At Memorial Hermann ACO, Making Strides Forward under Accountable Care

December 12, 2016
by Mark Hagland
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Three Memorial Hermann ACO leaders share their perspectives on ACO work and health system change

At a time when leaders of patient care organizations across the U.S. are looking for pathways forward into accountable care and population health management, a cadre of innovative integrated health systems is showing the way forward on a number of fronts. Among those is the Memorial Hermann Accountable Care Organization (MHACO), created and operated by leaders of the Memorial Hermann Health System, a 16-hospital integrated health system based in Houston, Texas.

According to a spokesperson for the Memorial Hermann Accountable Care Organization, the MHACO has been the country’s number-one Centers for Medicare & Medicaid Services Shared Savings Program (MSSP) ACO in the country for three years running, generating nearly $200 million in savings across three years of participation in the program. The MHACO, which cares for 50,000 lives (up from 22,000 when it started operations three years ago), encompasses a clinically integrated network of 2,500 physicians, which includes the University of Texas academic faculty, employed physicians, and independent physicians. That 2,500 total includes 700 academic faculty practice physicians, of them 200 employed, and 1,800 independent physicians.

Recently, Memorial Hermann senior executives—Chris Lloyd, CEO of the Memorial Hermann ACO and of the Memorial Hermann Physician Organization; Nishant "Shaun" Anand, M.D., physician-in-chief of those two organizations; and Shawn Griffin, M.D., CMIO of both organizations—spoke with Healthcare Informatics Editor-in-Chief Mark Hagland, to discuss the advances that their ACO has been making in its three years of operations. Below are excerpts from that interview.

Tell me a bit about the physicians involved with the ACO. How many of them are primary care physicians?

Chris Lloyd: We have about 500 primary care physicians. What we really bring to the table is a clinically integrated network of 2,600 physicians, which includes the University of Texas academic faculty practice, employed physicians, and independent physicians. That distinction is important, because we’ve brought together the physicians in the community, in an employment-agnostic model, and gathered them around the ACO and the care delivery network, around some of these principles associated with total cost of care. Some ACOs have primarily employed or physician organizations; we’re an employment-agnostic physician organization that’s partnered with our health system, and we think that that’s particularly strong.


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Chris Lloyd

Can you share about your ACO’s cost savings and clinical outcomes?

Lloyd: Our most recent savings were approximately $90 million across those lives. And our aggregate quality score was at the 96th percentile, in terms of member outcomes. Shaun?

Nishant (Shaun) Anand, M.D.: I can give you a three-year trend: in terms of cost savings, we’ve documented $58 million, $53 million, and $89 million, in our three years of operation. In terms of clinical outcomes within the Medicare Shard Savings Program, we’ve been at 83 percent, 88 percent, and 96 percent, respectively.

To what do you attribute your success so far?

Anand: The first success factor is that we have a philosophically aligned group of providers who are very talented at providing holistically aligned care for their patients. They’ve been willing to go the extra mile in addressing quality gaps upfront; and have agreed to improve access to care in their clinics, so we can provide that holistic care. The second success factor is that we’ve built a care management structure to take care of patients with multiple chronic conditions—heart failure, those on dialysis, those with COPD [chronic obstructive pulmonary disease], etc. And when they’re admitted to the hospital, they’re able to make sure they’re care-managed in the hospital. The third success factor involves the fact that we’ve built a data reporting analytics capability that allows us to track and trend our data and identify hot spots. So we can look at claims information and the EHR [electronic health record] and lab data, and we combine those to determine the hot spots [in terms of care gaps]. And finally, around our IT infrastructure, we’ve deployed registries and have worked on interoperability, with data flowing through it, with support tools.

Nishant (Shaun) Anand, M.D.

Can you speak to the human infrastructure and to the processes for care management, that are facilitating your success, and the physician culture changes that have occurred?

Anand: Chris and my team, before I arrived, were already building a culture focusing on partnering and clinical integration. That culture is really there. There’s also a willingness to partner as care teams; that’s a culture change, that healthcare now is a team sport. It’s something where physicians are often the quarterbacks, but you have to rely on your care management teams, and on your hospital teams as well.

Lloyd: We’ve been at this for about 10 years in terms of building a clinically integrated network. When the ACOs came along to stress care management and improved quality outcomes, those elements were already a part of the culture of this organization anyway, so ACOs became an extension of that. And without a culture that invites measurement and focuses on doing the right thing for the patient and absorbing new ways of doing things for the patient—that’s all a part of success.

Can you speak to how you’ve been able to change the physician culture in order to engage physicians around this?

Lloyd: We actually don’t spend a whole lot of time talking about saving money; that’s a nice side benefit, total cost of care reduction. But we really went into this around the management of quality and leveraging new tools and processes, around population. In fact, in our original MSSP application, we shared a diagram for what we would do if we got money back, and didn’t really look back at that until we received a distribution.

Have you received a distribution all three years?

Yes, with regard to the savings that Shaun had referenced earlier [$58 million, $53 million, $89 million], we’ve received roughly 50 percent of those savings amount back from the Medicare program each year.

Anand: There are three things that have been really impactful for changing physician behavior. One is giving our physicians data. Different groups are very competitive, so being able to share the data is really eye-opening in many cases. Two, we’ve been making it easier to do the right thing—eliminating workarounds and putting in enabling technologies. And with our clinical program committee, we’ve been able to invoke the best clinical practices and sharing those through clinical decision support in the EHR. We’re on this journey like many. We have roughly 57 committees across all specialties looking at best practices. But one key aspect is hardwiring good practices through ordering and via alerts. And for radiology and pharmacy, we’re looking at CDS for the future.

Lloyd: The clinical programs councils, we bring the physicians together and talk about clinical guidelines we want to hardwire, and that existed before we joined the MSSP; you have to create a level of understanding and engagement with the physicians.

What are some of the key elements that must be in place, for that to occur?                                                                            

Shawn Griffin, M.D.: I think that, as a CMIO, the EMR in the offices and we’ve had a rollout of a subsidized EHR platform to many of our physicians, so we have a decent base across three main platforms, and that covers about 80 percent of our physicians. And we’ve worked with optimization and standardization across those platforms. And our physicians are incredibly engaged in the technology.

Shawn Griffin, M.D.

What should CIOs and CMIOs know and do, with regard to all this?

Anand: Based on my experience here and previously—I would say, build the foundational elements first and well. Building data visualization tools is key and then layer on an analytics layer. If you don’t have the analytics to guide you, healthcare becomes more expensive, so that’s key. Then the next level ifs EHR connectivity, registry tools, CRM [customer relationship management] tools, etc.

Lloyd: And as we get further down this path, the marriage of information sets is pretty key. So creating a longitudinal view of inpatient and outpatient systems, and marry that between the EMR and the claims data, that is changing. It’s challenging bringing together disparate groups who’ve grown up using disparate systems, as well.

Griffin: And you always need to communicate why you’re doing what you’re doing. Recognizing physician burnout means that, if you’re going to give physicians something more to do, you need to also be taking something off their plates at the same time.

What will happen next two years at Memorial Hermann ACO, and also U.S. healthcare system-wide?

Anand: Regardless of the election outcomes, the journey towards value-based healthcare is well underway. We’re just getting into the details now, but we’ll be accelerating this, building care management programs, integrating across the organization from inpatient to outpatient, and launching both a longitudinal health record and case management record; so we’ll continue to build that out.

Griffin: My comment is that we’re going to be working with our physician partners and our technology partners to mature the tools and workflows to make sure care is delivered more efficiently and effectively across populations.

And how would you frame your experiences as physician leaders, with regard to your leadership in helping to transform the healthcare system?

Griffin: This is a revolutionary time in medicine, both in terms of the tools available to us and how we practice, and supporting physicians in this is incredibly important in building towards the future.

Anand: We’re in the third phase of healthcare--the science of healthcare—where people have to come together to work as teams and to leverage tools across the continuum. Physicians are engaged by this and excited by the prospect, but they’re not in there alone in having to manage complex patients.

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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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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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