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Report: What Providers Are Learning About Connecting with their Communities

January 6, 2017
by Mark Hagland
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A recent Advisory Board Company report looks at key building blocks in creating community connections

When it comes to making connections with communities in order to improve the health status of their members, the leaders of patient care organizations are learning that there are several key strategies that must be pursued, including building a business case for community connection with the c-suite and board; prioritizing the initial focus of community connection efforts; strengthening existing community partnerships; and designing seamless screening and referral protocols.

Those are some of the highlights of a new report from The Advisory Board Company, the Washington, D.C.-based consulting organization. Published in December, “Building the Business Case for Community Partnership: Lessons from the BUILD Health Challenge,” looks at some of the major challenges facing patient care organizations as they pursue population health management strategies. Its lead author was Rebecca Tyrell, a senior consultant in the Research Division at The Advisory Board.

As Tyrell and her colleagues note in the report, “Healthcare extends well beyond care settings—into homes, schools, and neighborhoods. Transforming health outcomes requires a coordinated effort to tackle such contributing factors as socioeconomic conditions, transportation, housing, environmental issues, and access to healthy food. Partnerships among health systems, public health bodies, and community organizations are the most effective ways to address community health. However, most organizations are traveling on separate but parallel paths toward building healthier communities, and as a result, valuable data, information, and resources are often siloed. Increased collaboration among key stakeholders, the researchers note, “will unlock tremendous power and drive better health outcomes. This research highlights innovative partnerships across the country to transform community health. Specifically, there are four critical steps to build the business case for community partnership.”

Those four, the report’s authors note, include engaging in leadership: “build[ing] a compelling business case to garner executive buy-in and needed resources”; prioritizing initial focus—“determin[ing] what services or programs to start with, recognizing process will be iterative”; strengthening partnerships through “leverag[ing the] unique strengths of community organizations to extend care team reach; and designing seamless screening and referral protocols, through “clearly link[ing] these two steps to ensure timely follow-through and improved patient and provider satisfaction.”

These conclusions are connected to research that Advisory Board leaders have reached, based on experience with efforts by providers to create community connections, including, though not limited to, BUILD Health Challenge communities. As its website explains, “The BUILD Health Challenge encourages communities to build meaningful partnerships among hospitals and health systems, community-based organizations, their local health department and other organizations to improve the overall health of local residents.” The initiative is supported by The Advisory Board and by broad range of foundations and initiatives, including the Robert Wood Johnson Foundation, the Blue Cross and Blue Shield of North Carolina Foundation, the Telligen Community Initiative, and several other foundations and initiatives.


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As Tyrell and her colleagues note in their report, “The first challenge is narrowing down the list of potential focus areas. The wide range of social determinants of health—economic stability, physical environment, education, food, social context—lead to either decision paralysis or an overwhelming number of initiatives that stretch resources too thinly, resulting in limited impact. Instead, leaders in this space work with their community and use their own data to prioritize a subset of initiatives. Across BUILD participants, food and nutrition emerged as the most common area of partnership. Forty-one percent of BUILD communities are designing innovative programs that link residents to food pharmacies, fruit and vegetable prescription programs, cooking demonstrations, nutrition education courses, and an expanded network of food suppliers to expand access to healthy options.” They go one to note that, “To prioritize efforts in your own community, BUILD leaders recommend organizations: “utilize a mix of qualitative and quantitative data; be transparent about how decisions will be made, especially when priorities may differ across stakeholders; define terms to avoid assumptions and misunderstandings; [and] prevent [the] perfect from being the enemy of [the] good.”

According to Tyrell, round 1 of BUILD projects put their emphasis on the following areas of activity: food and nutrition (41 percent); neighborhood and build environment (35 percent); housing (18 percent); and crime and violence (18 percent), as factors influencing the health of communities.

Rebecca Tyrell

Shortly after publication of the report, Rebecca Tyrell spoke with Healthcare Informatics Editor-in-Chief Mark Hagland to discuss what patient care leaders are learning in this important area. Below are excerpts from that interview.

Can you tell me about the core objectives of the BUILD Health Challenge?

The BUILD Health Challenge is really designed to bring hospitals and health systems with public health bodies and community health organizations, to go more upstream to look at social and economic factors that influence health. All the results really come from phase one of this project. And there’s a new application round. But fundamentally, we want to address these social determinants.

What has been the timeline for the forward evolution of the BUILD Challenge?

It has come together within the last year.

How many of each type of organization are involved in the BUILD Challenge?

Each of the 18 projects requires at least one of each of [different types of organizations]—a hospital, a public health body, and a non-profit. And the average number of partners per project was about eight.

What did you find, overall, based on the experiences of the leaders of these initiatives?

A lot of health systems know that they should be addressing the issue of the social determinants of health, but don’t necessarily have the time, resources, or expertise. And in some cases, it’s not for them alone—regardless of where you are, community health resources will be essential under value-based payment models. So we’ve distilled four steps. It’s about formalizing the business case. To date, we’ve seen these activities be one-off projects. But we need to embed this into the fabric of our organizations.

And what were the most important elements involved?

Engaging leadership was one. Prioritizing your initial focus was the second (there are a lot of issues you can address in any one community, but you can dilute your efforts, so get good at one thing first). The third: build and strengthen your partner relationships. How do you bring these stakeholder groups together? And the fourth is, how you actually design the screening and referral protocols? Because you can set up a program, but if you don’t’ identify who needs the service, and identify those folks, you won’t have the ROI that you’re looking for.

Where do hospital-based organizations most stumble, with regard to those four important elements that came out of your research?

It’s in understanding the unique strengths that each party brings to the table. So there’s a flowing pace—identifying relationship needs, where to start; it needs to come from the ground up—what does the community want, and what do the hospital and the public health agency and the community-based organization bring to the table? In a lot of cases, the hospital brings the data. But the challenge is in managing the change management aspects of the project.

Do communities ask for the same thing, or different things?

That’s a great question. About 41 percent of the BUILD Health communities chose to focus on food and nutrition issues; that food/nutrition is closely linked to obesity and chronic conditions, and that seems more closely connected to traditional medical care, and folks are more comfortable starting there. More broadly, we see a lot of organizations focusing also on housing and transportation as the other top two issues; but violence and safety are also an issue.

How are the hospital-based organizations finding success?

It comes down to the fact that no provider has the time or resources to manage these issues, even though they strongly impact total cost of care. So it’s about integrating this data into systems, and connect to the community. So the hospital’s role is screening people and providing liaisons into the community. And that’s why the BUILD Health Challenge, by providing the funding and technical support to foster this collaboration, has enabled these organizations to create those links to help follow patients through the new continuum.

Could you provide a couple of examples of how this is playing out?

There are two different types of grants involved here. Some are planning grants, some are implementation grants. And we’ve also in the report showcased some examples from our Advisory Board consulting division. The BUILD Project has only been running for about a year, but we’ve already seen a lot of progress in a variety of areas. West Oakland in the San Francisco Bay Area. There, as in other places, the existence of food deserts represents a huge obstacle to health, putting the health of its residents at risk. Without access to healthy, affordable food, individuals are more likely to experience chronic stress, malnutrition, obesity, and related diseases. San Pablo Area Revitalization Collaborative’s efforts to address the West Oakland food desert led to the creation of the area’s first full-service grocery store in more than a decade.

Another example in California is what’s going on with the Youth Driven Healthy South Los Angeles initiative. In that instance, ten local youth were trained as Community Health Liaisons to help identify and craft upstream solutions for health issues plaguing Historic South Central Los Angeles. The youth have conducted key informant interviews, presented their findings at a series of town hall meetings, and received stakeholder buy-in to solutions for improving their community’s high prevalence of diet-related diseases.

In Cleveland, leaders of a program called Engaging the Community in New Approaches to Healthy Housing, continue to advance their campaign to rid the city of toxic lead paint, which can lead to developmental challenges and lifelong health issues. Their efforts have benefited from the attention and support of Sen. Sherrod Brown, who has drafted federal legislation to better protect Ohio families and called for increased funding from the U.S. Department of Housing and Urban Development (HUD).

And in Seattle’s Chinatown, International District BUILD Health partners coordinated a series of community meetings to better understand barriers to health and wellbeing in the neighborhood. Safety and crime were identified as major sources of chronic stress and sedentary behaviors, especially after last year’s murder of a community leader. The BUILD Health partners spearheaded a survey to inform the development of recommendations to the City for improved neighborhood safety, making direct links between safety and community health. Those are among numerous examples of the kinds of work being taken on in the BUILD communities right now.

What should the CIOs and CMIOs of patient care organizations be thinking about right now, as they and their colleagues consider participating in such community-oriented initiatives?

You bring up an excellent point. The community health needs assessment gives you an excellent direction, in terms of, say, nutritional support. Then you need to identify patients. So we’re seeing a lot of interest in collecting those non-clinical data points during patient interaction. Can clinical leaders support those in standard risk assessments and intake forms, for more individualized information, to refer folks to those community resources or customize their care plan, so we can address those care needs?

What types of functional roles are involved in collecting the data in patient care organizations? Health coaches, nutritionists, etc.?

Anyone who is engaging heavily in risk-based contracting has these potential capabilities. There tends to be a dividing point between the earlier-phase organizations focused only on high-risk patients, and others that are more progressive and who are approaching the rising-risk patients. They’re starting to get more progressive in terms of roles. It can be community health workers, sometimes social workers, dieticians. So it requires proper resource allocation, and it depends on how they organize and deploy those resources. And medical assistants can do it, too, I would underscore that.

How well are the handoffs going to those people?

In physician practices, the handoffs are being conducted quite nicely. Sometimes, it’s a “warm” handoff, meaning that you’re literally walking someone down the hallway. Others have created pop-ups and alerts in the workflow to stimulate handoffs. And there’s a new and emerging role around the community resource specialist. That’s a final link the chain. What’s needed is a high school-educated person, deeply embedded in the community, and connects patients directly to community-based organizations. These individuals are paid by the health system, they’re part of the multidisciplinary team that includes doctors, nurses, Mas, medical directors. Mass General is the organization we’ve profiled.

What will happen in the next couple of years, in all this?

I think that the role of community partnerships will be even more critical than ever, because of the role that social determinants play in total cost and quality outcomes. So if we have to trickle down to reach those social determinants, partnerships are the only way to accomplish that.

Do you have any explicit advice, particularly for our audience?

I would say, recognizing that fundamentally, people don’t want to be patients. So if we want to get into their sphere of activities and be a partner in their health, especially at financial risk, it’s critical to integrate into their daily lives. And we don’t have to reinvent the wheel; there’s a group of organizations set up to do that. We just have to connect the dots; and that’s a key role that a hospital can play.

Is there anything else you’d like to add?

I would just say that the report is really valuable because it pulls together some practices that jumped out as commonalities or lessons learned, so that regardless of who you are or where you’re at, there should be practices that you can implement now. And our best advices is to be proactive and serious about implementing those now, or you’ll be left behind as we move towards more value-based payment models.



2018 Raleigh Health IT Summit

Renowned leaders in U.S. and North American healthcare gather throughout the year to present important information and share insights at the Healthcare Informatics Health IT Summits.

September 27 - 28, 2018 | Raleigh


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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