Scottsdale Health Partners’ CMO Explains How His ACO Has Beaten MSSP Expectations | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Scottsdale Health Partners’ CMO Explains How His ACO Has Beaten MSSP Expectations

September 11, 2016
by Mark Hagland
| Reprints
James Whitfill, M.D. shares his perspectives on how his organization has achieved MSSP ACO success

At a time when many accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) for ACOs are struggling to meet the cost-savings and quality-outcomes benchmarks set for them by senior officials at the Centers for Medicare & Medicaid Services (CMS), a minority of the MSSP ACOs are doing very well.

Among these is the organization that until a few weeks ago was known as Scottsdale Health Partners. A large multispecialty physician group based in Phoenix, Scottsdale Health Partners had 700 physicians at the time it joined the MSSP program in January 2014. Last month, Scottsdale Health Partners went through a merger with another local group, and has now taken the name Innovation Care Partners; the group now has over 1,200 physicians in the Phoenix area and in central Arizona.

The group’s new name does not reflect idle boasting: innovation has been a hallmark of the Scottsdale Health Partners group for years. Indeed, SHP was named by Healthcare Informatics’ editors as the second place-winning team in the publication’s Innovator Awards Program earlier this year, for its data-driven, multidisciplinary care team-led initiative to optimize care coordination and reduce avoidable readmissions. HCI Assistant Editor Heather Landi’s Innovator Awards profile of Scottsdale Health Partners can be read here.

Meanwhile, Scottsdale Health Partners was one of a small plurality of MSSP ACOs to be able to post outstanding cost savings and clinical outcomes results, when CMS officials announced results for the nationwide program, on August 25. As Managing Editor Rajiv Leventhal noted in his news report on that date, “Although more than 400 Medicare accountable care organizations (ACOs) generated more than $466 million in total program savings in 2015, nearly seven in 10 of those ACO organizations did not generate enough savings to receive bonuses, according to an Aug. 25 announcement from the Centers for Medicare & Medicaid Services (CMS).” Indeed, as Leventhal reported, “According to the just-released CMS data, 125 of the 404 total federal ACOs qualified for shared savings payments by meeting quality performance standards and their savings threshold. The results show that more ACOs are sharing savings in 2015 compared to 2014 and that ACOs with more experience in the Pioneer ACO Model and the Medicare Shared Savings Program (MSSP) tend to perform better over time. However, similar to last year, many of these ACOs did not produce enough savings to earn bonuses.”

But in a press release issued on Aug. 25, shortly after CMS’s national announcement of results, the leaders of Scottsdale Health Partners were able to state that “Scottsdale Health Partners, LLC is one of the ACOs that shared savings.” The SHP announcement quoted James Whitfill, the organization’s chief medical officer, as saying that “Scottsdale Health Partners has invested in physician engagement, innovative technology, and coordinated care models which has laid the foundation for this exciting news. As the first MSSP in Arizona to ever earn a performance payment from savings,” Dr. Whitfill said last month, “we are humbled that a second year of our positive results confirms our innovations are producing real and durable impact. We are particularly proud of our significant increase in quality scores to 94 [out of a possible 100] in this setting.”

Webinar

Cardiology of the Future: Today’s Realities, Tomorrow’s Possibilities

Cardiovascular care stands to be nothing less than transformed by the potent technologies emerging now and in the near-term future—ushering in changes to not only how readily and effectively we...


James Whitfill, M.D.

Dr. Whitfill spoke last week with HCI Editor-in-Chief Mark Hagland regarding his organization’s accomplishments in the MSSP, and related subjects. Below are excerpts from that interview.

First of all, Dr. Whitfill, congratulations to you and your colleagues on your achievement.

Thank you.

So, let’s look at how you and your colleagues have achieved what you have, in the program. To begin with, when did you join the MSSP?

Scottsdale started out with a Medicare Advantage plan. We started in the MSSP in 2014—that was our first performance year. We were humbled to be the only MSSP based in Arizona that year earn shared savings that year, so for us to repeat that in 2015, and in 2015, we were one of three. In fairness, if you look at the files, there were two ACOs that span multiple states and have some presence in Arizona, that also achieved shared savings.

How much savings did you have to achieve to surpass your benchmark in 2014 and 2015?

In the end, we saved about $9.5 million on a population of 18,000 Medicare beneficiaries in 2015; in 2014, we saved around $3.8 million on a population closer to around 12,000 beneficiaries.

So you received a check each year?

Yes, the way Medicare does it—in this case, we got the results at the end of July for the 2015 performance year, and the information becomes public in August, and we anticipate the check by sometime in October, as that’s when we received it last year.

And what did you receive from CMS each year?

We got about a $1.8 million check in performance year 2014; for performance year 2015, we’ll receive a check for about $4.5 million. And not only did our financial savings go up considerably, our quality scores went up considerably as well, and we ended up with a score of 94 out of 100.

Could you mention a few areas in which you improved the most?

Some of the areas we improved most on—we’ve been very efficient in the use of post-acute care. And we’ve been able to implement a very structured form of care coordination, and have seen dramatic improves in people’s depression scores and in their functionality, and in cost savings.

What have you done to improve outcomes and increase savings?

Your publication’s profile of us that earned our place in the Innovator Awards Program covers a lot of it, which was related to leveraging IT to perform enhanced care coordination and care management; the technology we’ve leveraged has encompassed what we’ve done with our HIE [health information exchange] and our secure messaging platform, from Orion and from TigerText. And we’ve developed APIs and integration between them. We have over 47 different EMRs represented in our 200-plus physician practices. Those technologies have helped us create a bridge to improve care coordination. And the physician engagement: 90 percent of our governance positions are filled by physicians, and we’re physician-led. So it’s a true partnership between hospital-based and ambulatory-based physicians. We really have a big tent across those spaces, and a high level of engagement. When physicians get involved and own it, it really drives tremendous changes.

Is Phoenix a pretty advanced managed care market? Because you’ve obviously been involved in advanced healthcare market-related activities.

Yes, it is. If you look at a map of the U.S. and you look at Medicare spending per capita, and then you overlay where there are a lot of ACOs, in general, you find Medicare ACOs concentrated where the per-capita spends are high, which makes sense. But Phoenix is a big exception to that. We think that, though our per-capita spending is lower for Medicare patients than in other places in the country, we think that California’s innovations have impacted us, as well as the innovations of organizations like Banner. That makes all of us have to step up our game and really work harder on this. So Phoenix is an interesting place because of that level of innovation.

What have been your organization’s biggest challenges in all this so far? And what have been some your team’s biggest learnings so far on the journey?

The challenges are many. Moving an organization from a fee-for-service mindset to a mix of fee-for-value and fee-for-service, that in itself is very hard, particularly when people are still largely reimbursed on a fee-for-service basis. I’m an informatics fellowship-trained guy, and I will say that the informatics is really hard—harder than you’d think. I spent a decade as an internal medicine practitioner. And the informatics involved in all this is very hard, surprisingly so; but you can’t wait for the informatics to get good to begin. So we started an initiative around HIE and secure messaging. But we haven’t waited for that infrastructure to be done, to move our physicians forward on shifting into value and care management, and efficiency. So the challenges are myriad; the data and culture issues are big, but the successes we’ve had have been based on starting these processes early. We think it’s because we’ve had physicians helping us and telling us upfront what they can and want to do; and that’s made a big difference.

Are you still in clinical practice at all?

I’m halftime as CMO for Scottsdale Health Partners, now Innovation Partners. I’m essentially the default CMIO as well. And I still have my own analytics and consulting firm, too, with a number of radiology clients in that space—people needing help with analytics and business intelligence. And I’m trained as an internist, and did my fellowship in informatics. So I round on Wednesdays with our transitional care coordinators, our nurses, and meet the patients. And that’s been great.

There are so many things to do in all this ACO work. How should CIOs and CMIOs think about the IT governance, project management, and other aspects of this? How do they prioritize?

Probably one of the biggest challenges is that, certainly on the vendor side, there are a million people trying to sell their tool that claims to be population health-enabled; that’s the buzz term. And so many folks are just digging their way out of their Epic or Cerner implementations. What’s more, they’re still largely operating in a fee-for-service world. And the reality is that value-based care is largely on the outpatient side, and it’s a whole different ball of wax. So you need to tap into people who have been anchored in the ambulatory space, and let them tell you how to make this journey. This is simply not an inpatient play.

I’m assuming you have dashboards for the physicians, to help them analyze and improve their clinical performance, correct?

Yes, we do. On a quarterly basis, I and Tiffany Nelson, M.D., whom you’ve met, we’re the two physicians from Scottsdale—and we’ll expand the that now after the merger—we meet with each primary care physician quarterly, using a dashboard that encompasses financial elements, utilization, and some clinical measures as well, in terms of risk scoring, quality metric scoring, things of that sort. It’s not elegant, but it’s been a powerful tool to give physicians feedback.

What have been the biggest challenges for the individual physicians, in all this?

It’s this: that they’re absolutely bombarded—they’ve got so many things coming at them every day. And it’s very difficult to make this transition. And for the individual physicians, number one is just even understanding what this is all about. And to be frank about it—I’m a pretty smart person, and it took me six months of working in one of these things, to be able to understand how all these pieces work together. And most physicians get 25 minutes a quarter to have this explained to them, and trying to understand the breadth of all this is hard. It’s a lot of information, it involves a complete model, and learning this takes time.

But seeing comparative data, motivates them towards clinical performance improvement, correct?

Yes, and whenever there are any financial stakes involved, people pay a lot of attention. And physicians—we really do want to do a good job. We’re faced with so many competing elements, and oftentimes, just the Hawthorne effect of giving people feedback, can be very motivating.

Of course, the reality is that there is a bigger context around all of this. We’ve been reporting and commenting on the most recent estimates of overall U.S. healthcare spending coming from the Medicare actuaries, and really, the healthcare system is heading over a cost cliff. Do you think that physicians in practice are starting to see that bigger healthcare system picture more now?

That’s a great question. And I’m giving a talk on Monday at the Arizona chapter of HFMA [the Westchester, Ill.-based Healthcare Financial Management Association], and I’ve had to change my talk because of Slavitt’s announcement. The paradox is that on a macro level, we have unsustainable amounts of GDP, and of the federal budget, going to healthcare. And yet at the micro level, physicians feel resource-constrained. They’re working harder and longer than ever. And the unit reimbursement on the average radiology procedure has fallen 40 percent recently. So people are having to work harder just to stay even. And physicians have a hard time grasping this, because reimbursement to them has been cut so much. But as physicians begin to see how these new models work, I think they have a little bit of hope—they allow for collaboration and interaction, and maybe even improvement of patient health status based on the new models. So I think there’s a glimmer of hope there, while at the same time, the same storm clouds of gloom remain.

 


The Health IT Summits gather 250+ healthcare leaders in cities across the U.S. to present important new insights, collaborate on ideas, and to have a little fun - Find a Summit Near You!


/article/population-health/scottsdale-health-partners-cmo-explains-how-his-aco-has-beaten-mssp
/article/population-health/beverly-hills-hit-summit-apg-s-crane-offers-vision-future-medical-care

At the Beverly Hills HIT Summit, APG’s Crane Offers a Vision of the Future of Medical Care

November 11, 2018
by Mark Hagland, Editor-in-Chief
| Reprints
Don Crane, CEO of APG, a nationwide association of physician groups involved in risk-based contracting, offered Beverly Hills HIT Summit attendees a vision of a coordinated care-based future

The signs are that the policy and payment incentives around value-based healthcare are accelerating now and may soon become much clearer, a nationwide physician leader told attendees at the Beverly Hills Health IT Summit, being held in Los Angeles this week and sponsored by Healthcare Informatics. Don Crane, the president and CEO of the Los Angeles-based APG (America’s Physician Groups), a nationwide association of more than 300 physician groups involved in risk-based contracting in healthcare, though participation in accountable care organizations (ACOs) and in all types of value-based contracting, which his association refers to as coordinated care.

Crane, whose organization counts member physician groups in 43 states, the District of Columbia, and Puerto Rico, told his audience at the Sofitel Hotel Los Angeles at Beverly Hills that he believes that the most senior federal health officials—at the Department of Health and Human Services (HHS), at the Centers for Medicare and Medicaid Services (CMS), and at the Center for Medicare and Medicaid Innovation (CMMI), are planning to move forward rapidly and decisively to push as many physicians and physician organizations as possible into risk-based contracting, through a variety of means. Statements from HHS Secretary Alex Azar, CMS Administrator Seema Verma, and CMMI director Adam Boehler, have made it clear that plans are afoot to accelerate the transition from fee-for-service payment to risk-based and value-based reimbursement, he said.


Don Crane

Speaking of his own organization, Crane said, “What distinguishes us from similar trade organizations is that capitation is the preferred model. Probably half of my members are already there in terms of professional or global risk. And what we’re developing is the antithesis of fee-for-service [healthcare delivery]. We’re very much central to the value movement.” Further, he said, “Capitation is the destination” of the current evolution of the U.S. healthcare system. “Groups everywhere are experimenting with Medicare ACOs, other kinds of programs and projects,” he noted, adding that physician groups are advancing forward organically through a series of phases, “starting with fee-for-service with some sort of bonus-based quality incentives, moving next to some sort of shared savings program, then shared-risk, leading to primary care-based capitation or shared risk, and ultimately to global capitation or full risk.”

Further, speaking of APG’s member organizations, Crane told his audience, “All of us see capitation as the destination; our hair is on fire about it; we’re excited about it. We want to move the system to that model, because it produces higher quality at lower cost. As you all know, we’re at 18 percent of GDP right now, with really poor results, and we want to change that, through coordinated care.”

Webinar

Cardiology of the Future: Today’s Realities, Tomorrow’s Possibilities

Cardiovascular care stands to be nothing less than transformed by the potent technologies emerging now and in the near-term future—ushering in changes to not only how readily and effectively we...

Speaking of the mid-term legislative elections that had taken place three days earlier, Crane told his audience, “This election on Tuesday means a number of things: for one thing, repeal and replace is dead, yes,” referring to efforts to eliminate the Affordable Care Act over the past two years. “The big takeaway for us in the healthcare industry is the extent to which the ACA has been cemented into our landscape, right there with Medicare and Medicaid,” he said, referring to the legislation, which had been signed into law by President Barack Obama in March 2010. “So with the Democrats controlling the House, there’s nary a chance that it will be repealed or replaced in the next two years. Also, in three states, initiatives were passed that would expand Medicaid.”

Asked by an audience member about the sustainability of the state-based health insurance exchanges, Crane said, “The notion is that, if you don’t get everybody to pay into the risk pool, how can you get everyone covered? The answer is, time will tell. People have worried that the repeal of the mandate would undermine the exchanges; that hasn’t happened. And in fact, premium costs have seen a fairly moderate risk in the past year of about 2 percent.”

Meanwhile, Crane said, moving into the core of his presentation, “Whither and what of the value movement? The value moment got started with the ACA in 2010 with ACOs. More recently, in 2015, MACRA, the Medicare Access and CHIP Reauthorization Act, was passed, and that gave us MIPS [the Merit-based Incentive Performance System] and APMs”—alternative payment models. “So a big tailwind was put behind the whole value movement, where physicians and physician groups would be graded on quality measures, and that so that was brought into the fabric in 2015. And we’re well into the value landscape now.”

Documented evidence of the value of coordinated care

What’s more, Crane told the audience of healthcare leaders, “the announcements that you’re hearing from Alex Azar”—the Secretary of Health and Human Services—“are ones in which he repeatedly says that one of their missions is to accelerate the value movement.” Indeed, he said, referring to the proposal by CMS and referred to as “Pathways to Success,” “We’ve seen a pending rule soon to be made final, that will basically push these 400-plus Medicare ACOs much more rapidly into downside risk. And that’s hard to do unless you’ve got a sophisticated system with rich informatics. Many will be afraid of that, but those who are afraid will be winnowed out, and it will leave a more robust, stalwart cohort.”

And, Crane continued, referring to Adam Boehler of CMMI, “We’ve participated in a number of roundtables with Adam Boehler; in fact, I’m seeing him again next Thursday. We haven’t seen any pending rules yet, but we need to get ready for some bold moves in Medicare, where they accelerate the movement. One thing that’s gotten a lot of attention is delegating large portions of the country to players that want to take risk, and then turn around with physicians and hospitals to deliver care to employers like Google. That would allow for prime contracting that would lead to subcontracting for the delivery of care. Much of it is conjectural, but I think it’s coming. With regard to their request for proposals on direct contracting a few months ago—one can see, coming in from out of the mist, as you read the tea leaves, you can see some profound changes in original Medicare that will accelerate this forward.”

Crane went on to review in some detail the results of a study released on March 1 of this year. As the press release announcing those results noted, “Health care quality and cost for commercially insured Californians varied dramatically in 2015, indicating that where you live affects the care you receive and how much it costs, just one of the new findings from the California Regional Health Care Cost & Quality Atlas. Developed by the nonprofit IHA, in partnership with the California Health Care Foundation (CHCF) and California Health and Human Services (CHHS) Agency, the Atlas is the state’s source of comparable performance information about the quality and cost of care provided to 29 million Californians.”

Further, the March 1 press release noted, “The second edition of the Atlas brings together 2013 and 2015 multi-payer data by geographic region—including commercial insurance, Medicare, and Medi-Cal—on more than 30 standardized measures of health care quality, cost, patient cost sharing and utilization to help purchasers, health plans, and policymakers target performance improvement initiatives. An IHA fact sheet provides more details about the Atlas and measures. In 2015, clinical quality varied across the state’s 19 geographic regions by an average of 25 percentage points and costs ranged from 22 percent below to 29 percent above the statewide average. These differences mean: If care for all commercially insured Californians were provided at the same quality as top-performing regions, nearly 205,000 more people would have been screened for colorectal cancer and 31,000 more women would have been screened for breast cancer in 2015. [And] If care for all commercially insured Californians were provided at the same cost as observed in San Diego―a relatively high-quality, low-cost region―overall cost of care would decrease by an estimated $2.6 billion annually, or about 5 percent of the $55 billion total cost of care for the commercially insured.”

That study’s press release included a comment by CHHS Secretary Diana Dooley, who noted that “Increasing transparency is essential for improving quality, lowering cost and gaining consumer confidence. Atlas 2 shows where quality and cost are trending in the right direction and where there is room for more improvement.”

As Crane noted at the Summit, “This was a meta-study commissioned by the Secretary of State for California and the California Health Care Foundation. It aggregated the data of 29 million Californians participating with 10 of the major health plans in CA, all the physician groups. The study had two purposes: one, it looked at geographic variation; the other focus was to compare and contrast the two predominant models in California and elsewhere—fragmented, fee-for-service PPO, compared to capitated, integrated HMO. They were looking at products, but that’s how they looked at the delivery and payment models under those products.

There were three domains—familiar HEDIS measures in the quality domain, which was the first domain; hospital utilization measures in the second domain; and then third and finally, and this is where this is such a distinguishing study, total cost of care—not just premium, hospital fees, physician fees, but also the patient’s share of the premium pay and of co-pays and deductibles. So you get quality and spend, so you have what you need to get to the question of where the value is,” when evaluating data from all those domains.

“So you see 19 different contracting regions through CoverCalifornia, the California exchange,” Crane noted, as he shared a slide with visual results from Atlas 2. “The chief thing is that you should look at the little blue pyramids, commercial HMO, and the orange dots, commercial PPO results. The HMO measures show HMOs outperforming PPOs on quality—very important,” he said, referring to the slide, which showed all the blue pyramids rising above the orange dots. “The chief takeaway here is that PPO products are costlier nearly everywhere, with a few small outliers; and we’re not talking about premium here, but about total cost of care. HMOs—representing capitated, integrated delivery models—performed better on cost and quality across the board.”

Importantly, Crane noted, with regard to quality outcomes among Medicare Advantage-enrolled seniors in California over those enrolled in basic Medicare, “Medicare Advantage outcomes were all superior to those in original Medicare.” Indeed, he noted, “Medicare Advantage outperforms fee-for-service Medicare on hospital utilization, on all-cause readmissions, on ED use, on length of inpatient stays. In short, all Medicare Advantage is shown to be of higher quality and lower-cost than original Medicare—and, importantly, our APG members outperformed everyone else on all of these measures.”

Further, Crane said, “Capitated, integrated care delivery was found to be 14 points higher in quality, and 9 percent lower in total cost of care in commercial health insurance products. And there was $4,450 less total cost of care PMPY [per member per year] in Medicare Advantage in California.”

As the Atlas 2 report itself notes, “In 2015, HMO products delivered clinical quality that averaged 14 percentage points higher than PPO products at an 8% lower total cost when member cost sharing is included. PPO members paid, on average, $620 more out of pocket for care in 2015 than HMO members. HMO hospital utilization was generally higher than PPO even though total cost was lower. Given HMO products typically offer networks composed of integrated providers to a greater degree than PPO products, integrated care (HMOs) offered superior value.”

What’s more, Crane said, “Atlas 2 confirmed a total spend of $16,000 a year on average for seniors; that’s 25 percent lower than in original Medicare. Think of the savings that would be achieved if we overlaid this across all the seniors in California or the United States. This is proof positive of a better model, the model of the future, and one on which we will depend on your participation and your leadership.”

APG’s initiatives around advanced payment models

Crane went on to describe initiatives taking place at APG; in particular, he pointed to the Risk Evolution Task Force, and Third Option, two programs that he said show the way to the future for physician groups and for coordinated care. “The Risk Evolution Task Force,” he explained, “is essentially a benchmarking program mostly for our Medicare ACO and Next Gen participants. In the past, twice, I tried to initiate benchmarking programs, in which members had to submit data.” The mechanics of doing so turned out to be difficult to sustain those past initiatives, he conceded. “But moving forward, this data will be freely available in Medicare off 1500 forms.” Meanwhile, he continued, “Third Option is our proposal that we think will see light of day in a month or so. A few months ago,” he said, “CMMI issued an RFI on director-provider contracting. We said, we have the model. Direct contracting with CMS and a sophisticated qualifying medical group. It would have a capitated payment model. The benefit design would be a hybrid of Medicare Advantage—integrated, capitated; but it would be like original Medicare in that enrollees would still have freedom of choice; but the catch is if you went out of network, you’d pay more. It’s very much like a point-of-service model. So it drives patients in network. We think we’ll see a model that bears some resemblance to this model, coming out of CMMI. That will be a red-letter day for us.”

Importantly, Crane said, “We see a model like this as offering the antidote to single-payer proposals,” including proposals that governor-elect Gavin Newsom indicated interest in, during the gubernatorial campaign that he won on Tuesday. “We’ve been dialoguing with Gavin Newsom,” he reported, “and we’ve said, look, look, if you were to take the capitated, integrated model and spread it across all of California, the savings would be more than the savings needed to generated universal coverage. All we would need would be subsidies and other support.”

In response to a question from the audience about physicians’ reactions to practicing under capitation, Crane said, “The overarching reaction has been extremely good. Physician burnout nationwide is driven by the fee-for-service model. The fee-for-service physician is a hamster on a wheel, continuing to try to see more and more patients, as Medicare payments go down. Contrast that to where you can focus on the patients with highest needs. Take WellMed in Texas,” Crane said, referring to one APG member group, WellMed Medical Group, based in the Dallas area. “Their PCPs are seeing 15 patients a day, and they want to drive that down to 13, using a multidisciplinary team of clinicians and others to drive down the levels of work” to allied health professionals, in order to relieve some of the burdens physicians are facing in their work lives. “And so one of the byproducts is higher levels of physician satisfaction. So just as this model produces results around the Triple Aim, a byproduct is improved physician satisfaction.”

Finally, in closing his address, Crane addressed the healthcare IT leadership audience directly, saying, “You guys are so central to the management of a population. Informatics has been important in the FFS world to a certain extent. But to a physician group being paid through capitated, needs to know who’s’ diabetic, who’s being admitted to hospitals, who will become sicker in the next year, all of that depends on informatics. So I see our fates as inextricably linked.”

 

 


More From Healthcare Informatics

/article/population-health/key-clinical-and-financial-success-atrius-health-president-gives-out-his

The Key to Clinical and Financial Success? Atrius Health President Gives Out His Recipe

November 8, 2018
by Rajiv Leventhal, Managing Editor
| Reprints
“We have a different history, based on our DNA,” says the organization’s president and CEO

Atrius Health, the Newton, Mass.-based health system that has long been a pioneer in the value-based care movement, recently reported a strong financial performance for 2017, as it finished the year with a $24.4 million operating surplus—representing a turnaround of approximately $56 million from 2016.

Officials noted that a critical success factor for the health system, inclusive of more than 30 clinical locations in the state, was innovating in an array of different ways, including: increasing the use of predictive analytics to support population health management, moving care to lower acuity sites (ambulatory, home, and virtual), and working to improve access to care for high-risk behavioral health patients.

The patient care organization’s president and CEO, Steven Strongwater, M.D., recently discussed with Healthcare Informatics some of these initiatives, as well as other factors that have led to Atrius Health’s strong clinical and financial performances of late. Below are excerpts from that interview.

Webinar

Cardiology of the Future: Today’s Realities, Tomorrow’s Possibilities

Cardiovascular care stands to be nothing less than transformed by the potent technologies emerging now and in the near-term future—ushering in changes to not only how readily and effectively we...

Looking at the revenue success Atrius has been able to achieve recently, what are some of the primary factors you would give credit to?

We have managed our expenses pretty aggressively, and there are three [sub]-areas within that: in the first category we have managed our operational costs aggressively; in the second bucket, we have managed our medical expense trends aggressively; and then targeted growth is the third bucket. And the underpinning of managing our expenses has been in the analytics space.

For example, we historically might review every one of our patients [via] a case manager. We [now] can develop analytical algorithms that would mainly identify our sickest patients, so rather than have to review everyone, we could review the top 1 percent, or 5 percent, of our sickest patients. And then we have interventions and plans, which helps us with medical expense management. We could then re-engineer the case management department, because we wouldn’t need as many nurse case managers since we would be doing less work. So the management of the medical expenses and our operating costs have to a large extent been built on the back of using analytics. 

The transition to value-based care has been difficult for all health systems, but Atrius has certainly been at the forefront of some key initiatives, such as your ACO (accountable care organization) models. What have been the core experiences and takeaways for you, in this shift to value?

We have a little bit of a different history [than most], based on our DNA. We started as a staff model HMO, so we have been doing population health before it was described as population health. We have organized all of our care and systems around individual patients, and then populations of patients, meaning we have developed disease registries, and identified those people who sit in the high-risk categories—either the top 1 percent, 5 percent, or the rising risk categories. Then have planned tailored interventions, including trying to manage and prevent [disease] for the general population. We have built most of this work around our Epic EHR [electronic health record], so there are a series of tools—be it order sets or reminders—that complements the analytics. And we have built the analytics into the EHR so it’s now analytics that are much more actionable.

One example is something we have built for an adult population, a model called CRISPI, our clinical risk predictor, which is based on about 60 variables [to predict a patient’s risk of hospitalization]. If you are a CRISPI patient and you call in, there is a purple flag across the top of the record, and anyone who sees the purple flag is told to [tell the patient to come right in], or if you are over 65-years-old, we send someone to your home if you feel that you can’t come in.

That action has helped us reduce our ED utilization to the lowest in the state. We have built a comparable CRISPI model for pediatrics, called “CRISPI Junior,” and that has allowed us to deploy a pediatric care facilitator to help us manage down our costs and improve patient outcomes.

The lessons learned are that you need: an EHR; a data repository that you can use to do analytics on; and the algorithms to layer in that will then feather back into the workflow, so at the point of care you can manage patients, and/or you can triage the work to case managers, population health managers, and healthcare facilitators.

We also have a large visiting nurse association, called VNA Care, and we coordinate with them. We register our sickest patients, our CRISPI patients, in something called the Care in Place program—a nursing outreach program, so in the event someone gets sick, we deploy a nurse or nurse practitioner to his or her home. That has helped tremendously in reducing ED visits. So we identify those CRISPI patients, get them registered in these programs, and then try to manage down total medical expenses by changing the way we provide care and also the location of care.

We have set up a hospitalization-at-home program as well, called Medically Home, in which we have essentially set up a hospital by virtue of putting a patch on a patient capable of doing the biometrics, and then [installing] an iPad and a phone with direct access to mission control. The idea here is to basically manage patients in their homes, with our VNA Care [providers] caring for these patients.

From an innovation standpoint, what other health IT products or services have been most important and beneficial for your organization?

Working with Johns Hopkins, we have identified indicators of frailty from free-text clinical notes. So this is for people at risk for falls, isolation, and things of that sort. We have also been using NLP [natural language processing] to find and then close care gaps, so if you have an underlying clinical condition such as heart failure, it is best practice to do a certain number of things and be on certain medications. We have used NLP to identify patients who are not getting those medications or treatments, and then we can intervene.

We have also been working with IBM Watson to develop a new product, which allows for reduced foraging in the medical record. It works by compiling a lot of clinical content for a given condition into a single screen, and then it allows you to compare to a similar cohort of patients, like your patient, to then enable you to pick the best treatment option—principally, which medications work best and the like.

NLP is exceedingly important and will be going forward. We have been using NLP to try to reduce unnecessary messages in the inbox, as we are looking to reduce physician burnout. A lot of burnout is due to piling on work through the EHR, so we have focused on the inbox in particular to reduce those unnecessary messages.

Another thing in pilot mode is that we are working with healthfinch to do automated medication refills. To a large extent, that will use a bot inside the EHR to do the things that would otherwise be done manually—checking for labs, for drug interactions, for the occurrence of your last visits, and making sure your dosages are correct, for example—and then making it possible in one review to click “refill” once the patient gives you the pharmacy to send it to. And that will reduce inbox messages by about 15 percent when we are at scale.

Reducing physician burnout is a major theme in healthcare these days. How can addressing this issue help change the organizational culture?

Reducing burnout, or what we call returning meaning and joy to the practice of medicine, is one of our top strategic priorities. And it’s a top priority because unless you have a happy and activated workforce, your patient care suffers. There is a reasonable amount of literature that suggests if your doctors are burnt out, the quality of care suffers and the risk of an adverse event goes up. There is a cost to burnout, in early retirements and turnover, which is quite significant.

We have created a whole department to focus on this; we have a three-part plan, following the framework of the Stanford University professional fulfillment model, which addresses the practice’s efficiency, the organization’s commitment to wellness, and then personal resilience. We have a body of work going on in all those buckets, with the biggest emphasis on improving practice efficiency.

There has been a re-training of our staff to have them work at the top of their license so the physician doesn’t have to do everything. The EHR has changed the workflow, so everything goes directly to the doctor now, as opposed to it going to many team members, which it did historically. We are trying to get back to team-based care and have the record triage messages so that only the work that needs to get to the physician gets there.  

It’s a complicated manner and it has to do with staff training, technology, and workflow. Getting to “joy perfection” is a long road. We have been on this path for three years, and I think we have done more than most, but we have not solved the problem. We have probably reduced 60 million clicks, but it’s still not enough. There is too much of an administrative need currently, and we are trying to work with regulators to reduce that demand, but it’s a heavy lift.

What are a few core pieces of advice you can offer CIOs, CMIOs and other clinical informatics leaders as they continue to forge ahead into this new world?

You need to have a great data repository, and you may need to assess the skillset of the people working in the organization. Data scientists become important and helpful. You need to be able to create disease registries and identify people, so you can plan interventions to improve outcomes and lower costs. It cannot be a “hint-and-hope” strategy; it has to be a structured approach.

A lot of this is built on an important data foundation, so you need to have the infrastructure that is the data repository, the tools to extract the data, and the mechanism to push it out to a group of people who can take action on it.

 


Related Insights For: Population Health

/article/population-health/precision-medicine-alliance-brings-democratization-precision-medicine

Precision Medicine Alliance Brings Democratization of Precision Medicine

October 5, 2018
by Damon Hostin and Robert Weil, M.D., Industry Voices
| Reprints
The goal is for every patient to have access to the best treatment possible, when and where they need it.

Hospitals are built on data. Most often, medical data for research pile up in silos instead of being appropriately shared to develop more innovative ways to treat patients.

At Catholic Health Initiatives and Dignity Health, we have started to think differently about the possibilities that surround the data and expertise our clinicians bring to solving our patients’ care needs.  It’s why we joined forces to create the nation’s largest precision medicine partnership.

Because of that spirit of innovation, investment and the information-sharing agreements we established under the Precision Medicine Alliance, LLC, about 12 million patients in 16 states will have access to more promising treatments based on a genetic understanding of their disease.

The alliance currently is focused on advanced diagnostic tumor profiling. However, we are preparing ourselves to provide more specific diagnostic and personalized therapies for a number of genetic and acquired conditions, including cardiovascular medicine, neonatology and pharmacogenetics.

Before the alliance was formed, access to precision medicine-based care was inconsistent to all populations, making it available primarily to the well-insured and those with the personal wealth needed to pay for the specialized tests.

Webinar

Cardiology of the Future: Today’s Realities, Tomorrow’s Possibilities

Cardiovascular care stands to be nothing less than transformed by the potent technologies emerging now and in the near-term future—ushering in changes to not only how readily and effectively we...

In a sense, the alliance represents the democratization of precision medicine. That’s because, for the first time, we have created a cost-efficient program that allows community-based hospitals, both large and small, to become partners with the alliance and introduce these vital programs locally.

The alliance highly complements national oncological programs at CHI and Dignity Health, which together serve more than 100,000 patients annually. Starting this fall, each oncology patient at active sites will be matched to all biomarker-appropriate therapeutics and will be screened for eligibility to enroll in a clinical trial. This makes Englewood, Colo.-based CHI and Dignity Health, which is headquartered in San Francisco, the first health systems in the nation with their own precision medicine program with reach across a national footprint. Together, the two systems have 139 hospitals and hundreds of other care sites.

The alliance couldn’t have happened soon enough amid the rapid pace of advancement in cancer treatments. Identifying new genetic markers and their effects on cancer occurrence, prognosis, and treatment options occurs at a staggering pace. Even the best-informed physicians may struggle to keep up with new treatment regimens for the most common cancers, let alone rarer forms. 

The alliance is working to accelerate change. It is switching how we view and treat oncology patients throughout our network as well as working on wellness and prevention among our higher risk populations.

By actively screening patients and learning more about how genetic makeup and some environmental factors may influence health and care, we are far better positioned to identify and intervene earlier.

We already have hundreds of thousands of patients under management in the system today—a mega-community of actionable medical information. That community is enabling CHI and Dignity Health caregivers to share—in real time—their insights and outcomes on patients with cancer.

At CHI and Dignity Health, we see our early work as a catalyst for furthering this emerging science, using next generation strategies, technologies and a strong partnership.  Our precision medicine alliance is not centered on discovering the next major genetic marker.  We view our purpose as creating a model that disseminates the benefits of precision medicine to more patients and more caregivers.  Access is equity and it is dictated by our mission.

Through the alliance, CHI and Dignity Health caregivers can more effectively identify the best drug therapies and possible clinical trials for their patients. Besides changing the way we treat some of our patients, we are also creating a repository of data to drive better clinical decision-making and treatment discoveries for generations to come.

We believe our early commitment to precision medicine through the alliance has helped set the stage for even greater and wider use of this promising methodology. With that, every patient can have access to the best treatment possible, when and where they need it.

Damon Hostin is the CEO of the Precision Medicine Alliance of Catholic Health Initiatives and Dignity Health.  Robert Weil, M.D., is senior vice president and chief medical officer of Catholic Health Initiatives and a board member of the Precision Medicine Alliance.


See more on Population Health

betebettipobetngsbahis bahis siteleringsbahis