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Predicting Patients’ Next Healthcare Moves: How HIT Stakeholders are Keying in on Advanced Population Health Management

July 28, 2017
by Rajiv Leventhal
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Population health is hardly a new term in health IT circles, but a recent report from Black Book Research has shed some light into how serious stakeholders are about being able to holistically under­stand patients as they move across the care continuum.

The report, which included responses from 140 chief information officers (CIOs), 159 chief financial officers (CFOs) and 448 hospital managers involved in planning and executing population health initiatives at their or­ganizations within the next year, revealed that in an ideal world, next-generation population health management systems will be able to identify a plethora of patient groups and predict where, when and how to best en­gage them. In addition, they should have the ability to coordinate care across the entire healthcare continuum, support care team collaboration and measure the ac­tivities, outcomes and overall performance of providers within the network, according to the report’s authors.

While many IT systems have long been developed with fee-for-service healthcare in mind, a shifting landscape (EHR) vendors to tap into new, non-fee-for-service teth­ered platforms for population health. According to the Black Book report, 90 percent of healthcare leaders said that future population health management systems will essentially be projected to perform as next-generation patient accounting systems. Said Doug Brown, manag­ing partner of Black Book Research in a statement that accompanied the report, “Some EHR systems have handled managed care for years, and those that have deep experience with capitation and managed care will be better able to translate that knowledge into value-based initiatives. Systems like Epic that were developed from the start as a single, longitudinal patient record spanning inpatient, outpatient, post-acute and billing will have the advantage.”

What might these “next-generation” systems look like and how will they be tailored to a value-based care environ­ment? Brown, who was also interviewed for this story, says, “We will have to start working on predicting all the coordi­nates of care where patients might end up and when and where they might engage.” He adds, “We have to support the collaboration from the differ­ent care teams. Did the activity happen? Was it ordered and not performed? What were the outcomes? How was the performance of the provider, be it a physician or an outpatient facility? All that data now has to be mea­sured, not for fee-for-service, but it now becomes all of these other data sources that need to be pulled in. So it becomes a patient accounting system.” Brown notes that Epic, Cerner and Allscripts, either via acquisition or through needs from other clients, “are putting funding into building what this appears to be.”

EMPHASIZING POP HEALTH ACROSS THE U.S.

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In Great Neck, N.Y., Northwell Health (formerly North Shore-LIJ), is the largest integrated healthcare system in New York State with 22 hospitals, 6,675 hospital and long-term care beds, and more than 550 outpatient fa­cilities. Simita Mishra, Ph.D., director/service line lead­er at Northwell, oversees the organization’s strategic population health initiatives from within the office of the CIO. Mishra says her job is to work in partnership with whoever is providing care management operational ser­vices on a day-to-day basis within Northwell.

“We [are] their strategic and advisory partners. We look to understand what would be the best business case so we can provide them with an IT infrastruc­ture that will help them provide evidence-based care management to the population that they are serving,” Mishra says. She adds that it’s not just about technol­ogy; rather, her team sits at the leadership level with clients and has councils where they work with them to better understand their requirements. “At times they don’t even understand their own requirements since they are primarily on the clinical side and don’t have that [business expertise]. So we will help in that re­gard,” she says.

Simita Mishra, Ph.D.

Mishra, who doesn’t have a technology background but has worked in population health and consulting for 14 years, has two core population health groups roll up to her leadership within the office of the CIO: the first is the standard population health management team at Northwell; and the second is the team in charge of the Delivery System Reform Incentive Payment (DSRIP) pro­gram for Medicaid patients. These two groups are kept separate, notes Mishra, since the DSRIP grant from New York State mandates that resources not be co-mingled, but essentially DSRIP is a subset of the broader popula­tion health organization.

One of the biggest focuses of Mishra’s work right now is the development and roll-out of Northwell’s homegrown Care Tool software. The tool is developed by the service line team and then designed to meet the requirements and features that are based on what the user wants, Mishra notes. The Care Tool might ca­ter to multiple programs such as a bundled payment program, the New York State Health Home program, or DSRIP.

An example of the tool being put in use, explains Mishra, would be a Northwell patient navigator who is in charge of patient outreach, reaching out to people in the Home Health population. In this scenario, the Care Tool will show the patients linked to that program, and once the navigator sees that, he or she can then see who the outliers are (the non-compli­ant patients), who might need appointment remind­ers, or who has been discharged within the last seven days. Those patients will then be pursued to see their primary care physician (PCP) if necessary, or a similar action will be taken, Mishra says, adding that a clini­cal snapshot in the EHR also gets sent from the Care Tool to the PCP, who can take a quick look to see if vaccines or immunizations are missing. The real-time alerts and ability to risk stratify in order to identify high-risk patients are all triggered by what’s originally entered into the tool, Mishra notes.

Meanwhile, Northwell’s DSRIP work creates broader population health challenges, since the state mandates that every physician practice associated with the pro­gram has to have an EHR by 2018, something that some of the health system’s voluntary practices still lack. Also, the practices have to all be Level 3 PCMH (patient-cen­tered medical home), meaning having the ability to col­lect and use data for population health management, as designated by the NCQA (National Committee for Quality Assurance). Like with the EHR mandate, North­well is also currently short of this requirement. Says Mishra, “We are still working towards DSRIP’s goal of 25 percent reduced [avoidable hospital] readmissions over a period of five years. The grant, which I wrote along with other folks on my team, was [based on] proving to the state that your health system was already invested in doing population health management. So you show them that you would have used the health system’s money to invest in population health,” she says. “It’s a lot of contracting and negotiating. Plenty of work is still ahead of us.”

IT’S NOT JUST ABOUT CLINICAL CARE

Most experts would agree that although efforts to im­prove healthcare in the U.S. have largely been focused on the clinical side, it would be unwise to ignore the many social, economic, and environmental factors that influence a person’s health.

At Humana, the Louisville, Ky.-based health insurer, a “Bold Goal” program was put into place two years ago with an overarching aim to make the communities it serves 20 percent healthier by 2020. For this goal to be achieved, it’s necessary to understand that social deter­minants of health are fundamentally important in terms of how to care for populations, says Roy Beveridge, M.D., chief medical officer at Humana. He notes an ex­ample of a diabetic patient being food insecure; the likelihood that this patient will have a prescribed diet and can control his or her sugar intake is quite small. “In the U.S., we have 5.4 million seniors who are food insecure, and if you don’t address that issue, treating someone’s diabetes—meaning also taking care of blind­ness, diabetic foot ulcers, and kidney disease—becomes very hard. But we do know that by working with grocery stores, hospitals, the local government and others in the community, you can begin to take care of food insecu­rity,” Beveridge says.

However, despite a growing recognition that looking at these social determinants of health is a critical com­ponent of improving one’s care, just four or five years ago, most physicians would have said that it’s a social worker’s problem rather than a clinical issue, says Bev­eridge. “This is why the move from fee-for-service to val­ue-based care has begun to focus in on [the notion] that treatment is more than giving someone a prescription. Fundamentally, how can I influence this person’s health as opposed to giving him or her a medication and then saying the patient is non-compliant?” he asks.

Drilling down deeper, Vipin Gopal, enterprise vice presi­dent, clinical analytics at Hu­mana, notes the importance of integrating the internal Hu­mana data that the payer has on its members with the data it has about its communities, and with the social determi­nant data. “That gives us a broader view about the health of a community that we didn’t have by just looking at primary claims from a payer perspective,” Gopal says. What’s more, he notes, understanding the given population in detail is also critical. “What would lead a person to progress from their diabetes condition into getting ad­ditional complexities, be it congestive heart failure or something else?” he asks. “It helps us move things from a population perspective and enables us to be more personalized in the solutions we offer to our members.”

Vipin Gopal

To this end, one of the biggest challenges in Humana’s senior population is that one-third of them have a fall every year. As such, Humana is using advanced analytics to figure out who’s most likely to fall among that senior population, and then enabling them with the right so­lutions to prevent a fall, or making sure that they are in a program in which they have a device that triggers an alert if there’s a fall. “That makes a big difference in their quality of life,” says Gopal. “It increases mobility and confidence, and these are the fundamentals we are tackling, with analytics as the starting point. You need to identify members and communities first, and then put solutions in place.”

In the end, sources interviewed for this piece are in agreement that healthcare’s traditional fee-for-service mentality in which physicians want to maximize the pa­tients they see—thus maximizing their charges—does not encourage an environment in which it’s important to spend time looking at a patient’s social determinant data. But when that physician is getting paid for qual­ity outcomes, all of a sudden, it makes sense to look at these other health factors.

And that right there is the crux of population health management—using analytics and insight to focus on a group of individuals with similar healthcare needs, and improve those patients’ outcomes. Says Gopal, when asked about putting all of this together for improved care: “It’s a nice sweet spot, the intersection of data and medicine that is coming together and revolutionizing this population health management space.”


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/article/population-health/staten-island-highly-innovative-program-thats-redefining-what-s-possible

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

September 17, 2018
by Mark Hagland, Editor-in-Chief
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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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Related Insights For: Population Health

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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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