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Scottsdale Institute 2017 Population Health Fall Summit: Getting Pop Health Right

February 9, 2018
by Scottsdale Institute
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As healthcare professionals straddle the chasm between traditional FFS models and value-based care, the key question becomes: how do you manage these various risk models at a given time?

Executive Summary

Ten healthcare executives gathered in Chicago on October 25-26 for the inaugural Scottsdale Institute Population Health Summit. These leaders from a variety of organizations came together to discuss the current state of the healthcare industry, including challenges, lessons learned and what’s next. This whitepaper summarizes the challenges, insights and learnings discussed that organizations might consider as they transition from fee-for-service to value-based care.

Population Health Fall Summit Participants: Rob Bates, executive vice president, insurance services and population health, Avera Health; Don Calcagno, president, Advocate Physician Partners; David Classen, M.D., CMIO, Pascal Metrics, professor of medicine, University  Of Utah and SI board member; Darby Dennis, R.N., vice president, clinical systems and informatics, information technology division, Houston Methodist; Luke Hansen, M.D., vice president and chief medical officer, population health, Amita Health; Cindy Kartman, clinical data analyst, population health, Amita Health; Waldo Mikels-Carrasco, Sr. director, regional population health research and policy, Michiana Health Information Network; David Mohr, M.D., vice president, clinical informatics, Sentara Healthcare; Carrie Nelson, M.D., chief clinical officer, Advocate Physician Partners; Lara Terry, M.D., medical director, population health and clinical analytics, Partners Healthcare

Organizer: Scottsdale Institute; Sponsor: Cerner Corporation

Moderator: Cerner Corporation—John Glaser, Ph.D., senior vice president, population health, Cerner Corporation


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During the inaugural Scottsdale Institute Population Health Summit, executives from across a variety of organizations came together to discuss the current state of the healthcare industry, including challenges, lessons learned and what’s next. For many years, experts have projected a complete shift to full capitation. However, today, it’s clear that we will continue to live with at least a partial fee-for-service (FFS) world for a long time. As healthcare professionals straddle the chasm between traditional FFS models and value-based care, the key question becomes: how do you manage these various risk models at a given time? Disruption of payment and care models means organizations will be forced to live in two worlds—reactive and proactive—trying to adapt business operations without a standard, one-size-fits-all strategy. The variance between the percentage of patients tied to FFS, Medicare Advantage, shared savings, patient-centered medical homes, full-risk and others will continually ebb and flow, requiring adaptable people, processes and technologies.

The good news—organizations are up to the challenge. Healthcare professionals have always managed complex business models and operated on thin margins, but require management tools to do so. As the market evolves and organizations find the right mix for their local population, FFS, partial-and full-risk models will all be needed.

Balancing FFS and Population Health Management Payment Streams

Fee-for-service vs. Value-based care

Transformation driven by increasing healthcare deductibles and government policy changes has resulted in varying degrees of risk, from FFS to fully capitated value-based care. The degree of risk and composition of payment programs is unique to each local market and will continue to shift over time. Although this disruption is relatively slow, it’s important to adopt strategies to manage FFS and complex, varied levels of risk, while health systems continue to thrive with their existing revenue streams. “We speak of this as ‘managing the flip.’ It is difficult for clinicians to manage in both worlds. There is no incentive to rethink and re-engineer the way care is delivered until there is sufficient volume under value-based or at-risk models,” said Rob Bates, executive vice president, insurance services and population health, Avera Health.

The importance needs to be felt from the C-suite level down to the clinician level with aligned goals and incentives. “After all, 20 percent of a large number is still important —it’s substantial,” said Don Calcagno, president, Advocate Physician Partners. “Incentives are already in place to begin encouraging executives to better manage their risk; at the end of the day, leadership needs to be deeply engaged and knowledgeable about their risk populations to answer questions such as, ‘What percentage of business is capitated and what conditions are driving inappropriate utilization?’ Leaders in this market know how to manage healthcare operations. These are very skilled operators, managing a complex business, so we need to let them apply their management skills—they just need the right incentive and management tools to make it happen,” said Calcagno.

Organizations need to more closely align with partners and use the variety of data sources and expertise they can provide to improve population- and person-level knowledge. “As risk increases, we’re getting closer to the data, so we’re learning, and in some cases, we’re learning more of what not to do,” stated Carrie Nelson, M.D., chief clinical officer, Advocate Physician Partners. Resources are another critical factor to consider when managing the broad scope of risk. Plans have different benefit packages and assigning care-management resources to every patient is not an option. “We’re at approximately 20 to 25 percent risk, but when you look at the patients we’re actually taking care of, we suspect that 40 to 60 percent are in somebody’s risk arrangement,” shared Lara Terry, M.D., medical director, population health and clinical analytics, Partners Healthcare.

“There are incentive areas that align with the hospital goals, like readmissions. The oversized influence this has had on hospital operations relative to the absolute scale of the penalties is remarkable. You would think it was a lot of money, but it wasn’t—especially initially when it was only three conditions. Readmission reduction has become its own service line. Another area is ED [emergency department] care. Especially for overcrowded emergency departments, it’s important to make the case for SDOH [social determinants of health] and a more comprehensive view of wellness to decompress the ED and get people to use the right site of care. With that approach, patients still use your services; they just use the appropriate setting. It’s a win, win for everyone,” said Luke Hansen, M.D., vice president and CMO, population health, AMITA Health.

Models for Managing Care

Unfortunately, a perfect solution to solve healthcare challenges around the world is nonexistent. European models are starting to fail; the United States is encouraging innovation through alternative payment models as leaders continue to see the goal posts change. The only alternative to managing the various payment plans is dependent upon how fast your organization can become fully capitated. Is it best to begin managing your business like you’re already capitated? The consensus from the attendees: not yet.

Managed Care Organizations

As of March 2017, there were 275 Medicaid managed care organizations (MCO), supporting a little over 48 million enrollments throughout the United States. Managed Medicaid requirements are subject to varying budget and administration conditions, making market entry difficult for some health systems. For example, low reimbursement levels pressure net contribution margins and challenge Illinois providers to manage and care (or pay) for Medicaid patients. In some cases, accounts receivables are more than a year old, placing more risk on providers.

Innovation Models

Data is a concern for accountable care organizations (ACO), Medicaid Shared Savings Programs (MSSP) and patient-centered medical homes (PCMH), especially around value-based care. Timely, clinical and claims data is needed, although hospitals and payers lack coordination and collaboration to share information and work together to improve patient care. Claims data is comprehensive, but it’s retrospective. “For patients attributed to you, you really want to know about all of those encounters that live outside your system. You’re not going to know about it until the claim comes in, but you may have missed several opportunities to intervene. That’s the cost bubble. So, I always ask, ‘How much do you plan to spend on this person and how much do they cost?’” said Waldo Mikels-Carrasco, senior director, regional population health research and policy, Michiana Health Information Network. These questions are what health systems try to solve every day. Some, but not all Managed Medicaid programs have been able to move the needle for utilization, reduce bad debt while also improving quality of care.

Full or Partial Capitation

Providers managing global capitation often have a very different perspective on business operations and how to manage them. “The benefit of managing clinical services under full capitation and payment based on a per-member-per-month rate is that the provider has a holistic message to deliver to patients. However, communicating a care plan that allows different patients to have different amounts of care management, for example, can be disconcerting,” stated Hansen. “The varying care-plan options leave providers with the feeling of delivering different levels of care based on the benefits package the patient paid for, or not. It’s tough to get the right language, and it doesn’t feel good for the clinician, but we have to figure it out because the reality is providers will need to adapt to having these conversations as risk and payer models shift. It’s about how you frame it—it’s not about giving different clinical care to a patient, it’s the benefits that plan offers that wraparound the clinical care,” said Nelson. In lieu of these conversations, providers would need to treat every patient as if they’re payer-agnostic. However, “if we’re payer-agnostic, then we’re not actually providing people with the services they bought,” said Nelson. For example, if you send a patient to an out-of-network provider they will be forced to pay out-of-pocket rates or a delay in care will exist—so there are negative consequences to being payer-agnostic.

Health Plans

Health systems that consider sponsoring their own health plan must balance opportunities to retain more dollars with the challenge of learning a new competency. Owning a health plan means owning 100 percent of spend that's going toward health-plan expenses and not feeding the competition. “The future is not going to be survivable for health systems if they’re giving up the health-plan dollar to the health plan,” said David Classen, M.D., CMIO, Pascal Metrics, professor of medicine, University of Utah and SI Board Member. The blurring of boundaries—payers going into the provider space and the providers going into the payer space—results in tension from contradictory initiatives.

The scope of the health plan comes down to a choice. “As a health insurer, we’ve found that we have to provide a variety of products and funding mechanisms. Narrow network or “channeled” health insurance products don’t work for everyone. In South Dakota, where our unemployment rate is about 2%, some employers won’t accept a narrower provider network if they believe it will make it harder for them to attract or retain employees,” said Bates.

Integrating Population Health Management into Clinical Workflows

Patient activation vs. Patient engagement

“In the past, we had patients but never customers, which requires a different mindset,” said John Glaser, Ph.D., Senior Vice President, Population Health, Cerner.

Engaging people in their own health and well-being is the foundation of value-based care strategies. The motivations of a value-based care strategy are very different from the conventional consumer approach, so the challenge for health systems is determining who owns the consumer strategy. Marketing has traditionally taken the lead communicating with consumers using their segmentation and behavioral experience, but the purpose of the relationship needs to shift to align with bidirectional, clinical goals. It’s the difference between creating a patient portal as a channel to increase consumer loyalty versus to support a consumer’s active participation in their healthcare. It’s an important nuance that requires tighter collaboration between marketing and the clinical side of the health system. The shift in payment models is only a portion of the equation. Health systems need to become comfortable communicating with patients in a new, more open and collaborative way.

Meaningful use Stage 2 requirements drove the implementation of patient portals, yet the technology hasn’t been used in its entirety to drive engagement, resulting in very low usage. The challenge is that the purpose of the portal doesn’t encourage two-way interaction and every partner has a different portal with a variety of flavors (portal, gamification, wellness, weight loss, chronic conditions), which is cumbersome for the patient. That’s not patient engagement; it is provider engagement. Without a two-way interaction, “the discussion [with the patient] goes from patient engagement to patient compliance. Patient compliance is telling the patient what to do which is very different from bi-lateral engagement. Some people still confuse the two,” said Mikels-Carrasco.

The general idea is that “patient engagement” is not a one-size-fits-all approach.

In the short-term episode or “patient journey” of pregnancy, a patient often begins with a limited amount of knowledge about their condition, and often takes a very active and engaged role in learning from their provider what they need to do to have a successful outcome (this could also be true for episodes like joint-replacement or other procedure-based episodes). This relationship evolves as the patient learns and changes their short-term behavior and adjusts to the changes occurring and new information necessary for each stage (or trimester), on into and through the perinatal period. While the demands of the changes and challenges are stressful to the patient, the outcome is usually very specific, positive (a new baby, elimination of pain, greater mobility), and time-bound. The provider offers support and motivates the patient to “keep up the good work because we’re almost there.” However, once they have delivered and recovered, they return to or adapt to more self-directed behaviors, and are less reliant on the guidance and need of support of their providers, because they have gotten through the episode successfully, noted Mikels-Carrasco.

This is a different type of patient engagement, he said, than the long-term approach a provider would take with a chronic disease patient where there will again certainly be a good amount of patient education on their newly diagnosed condition at the outset. However, unlike the short-term episode, once the patient begins the ongoing maintenance of her condition, the demands on the patient and the provider are very different. In this scenario, there is no “there” that the patient and provider are going to work together to get to. Rather the goal is to develop a new lifestyle that will permanently replace the patient’s previous behaviors. The provider role now becomes that of continual motivator to help the patient be as successful as possible at realizing and maintaining that lifestyle, said Mikels-Carrasco.

Strategies to communicate with the patient or consumer have typically included two flavors of interaction: patient activation and patient engagement. Although subtle, these two strategies result in very different outcomes.

Patient Activation

Patient knowledge, skills, ability and willingness to manage his or her own health and care

“There is an emerging set of tools to help share knowledge and personal health information, such as electronic dashboards with patient safety information created,” stated Classen. “The patient can see real-time safety concerns via their patient portal with key questions to ask the provider and actions the patient can take to improve the safety concern. Understanding consumer behavior has improved participation by sharing the information in the form of short videos versus text,” he added. Patient activation is needed to ensure behavioral modification is lifelong. The patient portal today is largely transactional and fails to support the personal journey based on an individual’s purpose in life.

Patient engagement

A broader concept that combines patient activation with interventions designed to increase activation and promote positive patient behavior, such as obtaining preventive care or exercising regularly.

Patient engagement incorporates the shared clinical decision-making needed to implement interventions and improve health. Portals are expanded to manage care post-discharge or virtual care to interact with physicians, care managers, pharmacists or others to make a more informed decision.


Telehealth enables providers to access levels of care that are often in short supply in smaller facilities, rural locations or generally across the health system, such as behavioral health, care management or specialist services. Avera Health has created the nation’s largest telehealth program that services over 300 Avera locations in South Dakota, North Dakota, Minnesota, Nebraska and Iowa. Avera Health’s e-Care program connects medical professionals to other hospitals and health systems, long-term care facilities, schools and even correctional facilities. This capability enables smaller rural communities to improve quality and access to care. e-Care provides 24/7 telehealth options for pharmacy, intensive care units (ICU), behavioral health and emergency room care, enabling specialists and pharmacists to reach remote areas, especially when weather adds an extra layer of complexity. For example, many rural populations do not have 24/7 access to a pharmacist on duty or may receive a patient in the ED that requires the care of a specialist. Although the specialist cannot physically get to the location in a timely manner or a local pharmacist cannot be physically available, the telehealth program enables access to a pharmacist or specialist using a video monitor directly within the care suite to triage or treat the patient and fill this gap.

Data analytics framework for population health management

Value-based care relies on quality data to understand attributed patients and the encounters inside and outside a health system. The acute space is such a small portion of health and care data. “It’s not just what happens in your acute care; it’s what happens after leaving your acute care. Coordination of post-acute is so critical,” said Calcagno. “We need to spend more time outside the care facility where innovation happens. However, the data is fragmented and coordination breaks down with limited accountability.” The challenge is asking the right questions and capturing data closer to person. For example: What is the current state of your population? What is the quality of care provided? Are there payer variances? Are you asking the right questions? How do you ask the right questions? What can be done with the insights generated?

Data Sources

Data is only as good as its quality. The sheer volume of trusted data sources can be overwhelming without the right tools to aggregate, normalize and operationalize the output. Technology and skilled analysts/data scientists are needed to support the scale and reporting requirements. Alone, data can provide direction, but expertise is needed to make it valuable. “Ensuring data is meaningful and actionable throughout the organization is crucial. But data alone doesn’t solve for the actions needed; it informs them,” stated Terry. Consolidating clinical and financial data across an organization and all business models provides broader insights of usage, costs and quality versus siloed targets to better align initiatives with areas of improvement.

Data teams spend “a lot of time training the organization about how to get and use data to drive better care,” said Cindy Kartman, clinical data analyst, population health, AMITA Health. The key is to ensure the data is credible and easily digestible. Reporting can be at the patient, provider, practice, population, organization or system level, leaving self-service report meaning and necessary actions open to interpretation. If the report is complex or any piece of data is perceived as wrong, credibility is hindered. Data scientists are comfortable with unstructured data and can perform discovery incorporating third-party data with the clinical data, but the output must be actionable. The data and reports must be interactive using input from physicians, so users can interact with the reports to fit their individual needs, such as monitoring risk population trends as well as the current status. If the information is conveniently accessed and believable, the providers are more apt to use it.

Data sources discussed included: Centers for Medicare & Medicaid Services (CMS); patient-provided information; behavioral health services; home health; health information exchange (HIE); managed care organizations (MCO); electronic health record (EHR) exchange data; Census Bureau and American community survey data; c laims data; CMS certified nursing home assessments


Organizations have reached a tipping point. Formal governance plans are needed to create consistency across organizations and systems. As these programs become commonplace, the reporting structure is not consistent across the industry. Darby Dennis, R.N., vice president, clinical systems and informatics, information technology division, Houston Methodist, shared that its governance team is led by the chief quality officer. “Although the Houston Methodist Hospital is more advanced on the finance side of the business, the governance team still struggles with field definitions,” stated Dennis. Other organizations are undecided or have created new roles, such as the chief clinical officer, to manage governance responsibilities. “One significant challenge across the board, however, is data governance, the definition and use case for each captured term/data element with consensus across the organization,” said David Mohr, M.D., vice president, clinical informatics, Sentara Healthcare.


Technology is vital to facilitate access to information and scalable insights, however, when too many ideas are incorporated the technology can become bogged down. So, let’s take a step back. First, let’s define the questions we need to ask and then determine the tools needed to answer the questions.

Is the data actionable? Clinicians should have a level of confidence that enables them to act and achieve results. The challenge is determining who should act on the data and when—care coordinators and case managers, and so on.

Are subject-matter experts helping to ensure the tools are meaningful and integrated into the clinician, care manager and provider workflows? For Advocate Physician Partners, that means integrating tools across 3,500 independent physicians with a lot of disparate EHRs and 1,500 employed physicians with two EHRs.

How is patient-centric care measured? Patient-centered care can be hard to measure without first identifying key objectives and where that information will be captured.

How will you shift manual processes to automated intelligent workflows? Incorporate predictive analytics using vendor data and intelligence to improve care, customize plans and reach the patient using the individualized channels and methods most appropriate.

Are you aligned with your organization from leadership to individual contributor? Implement unified information technology decision-making across the health system.

Is your technology prepared to incorporate third-party data? Improve the technology architecture to handle unstructured and structured data with the appropriate storage capacity.

“Those who really adopt technology have started to see long-term benefits in closing gaps  in care and utilization, although usability is more complicated than just the technology,”  stated Calcagno. However, providers are overwhelmed. No one is cutting back on the physician responsibility.

Including the Social/Behavioral Context

Per studies, half of all deaths[2] in the United States involve behavioral causes, highlighting the benefits of using SDOH to improve care and predict future risks. SDOH have been used, with manual processes, for a very long time in the public health space. Using this information to support value-based care is the next logical step for health systems; however, automated processes stand between successful, actionable programs and merely contributing information to a database without insight or action. 

As part of value-based initiatives, health systems are driven to determine the highest-cost individuals, actions to reduce those costs and strategies needed to produce savings. SDOH data need to be captured quickly and consolidated with the clinical and claims information to develop a complete picture of the population, determine what has occurred and understand the purpose of behaviors.

At a high level, there are two primary questions SDOH can help to answer:

1. This part of the community has this issue, so how do we remediate the issue?

2. What’s the care plan (clinical and social) for the individual? What are we doing about it?

Society, attitudes and behaviors change over time, sometimes decades. Today, there are key indeterminate problems, such as obesity, that remain challenging for providers. For many years, fear tactics and intervention programs have been created to solve issues, such as smoking or poor nutrition, without success. The missing element in all those tactics is understanding an individual’s purpose to impact long-term change. Smoking secession was only impacted when policy and environmental changes were effected. In other cases, nutrition and health were impacted by focusing on safety in the inhabited neighborhood, creating community bike trails and providing access to fresh foods.

“There is value in bringing the community together to eliminate the social structural barriers,” said Mikels-Carrasco. “However, the health system doesn’t need to fund or coordinate the programs.” Strategies to bridge SDOH and clinical health to improve outcomes have been developed in pockets across the United States.

Health systems should partner with existing community services to solve individual patient challenges. In nearly every community there are existing organizations that provide essential services to those in need. Identify those groups and collaborate when appropriate. MHIN is piloting a program to determine when risk factors are identified and how to address them through a local community program.

Regardless of wealth, aspects of SDOH impact every person and population. Being able to identify the issue and resolve it is vital to reducing healthcare expenses and unnecessary usage. However, the challenge remains—how does a health system add this level of complexity to an already multifaceted, complicated environment? The consensus among attendees: no one has the answer yet. Years of innovation and trial and error will occur before SDOH are used to their full capacity. 

The perspective gathered from the Scottsdale Institute Population Health Summit attendees confirmed that population health management is not a one-size-fits-all strategy to achieve value-based care initiatives. The mix of payer risk, care models and operational structure is unique to each health system. However, the shared challenges, insights and lessons learned offered overarching knowledge about managing a massive amount of data and individual model programs as organizations continue to transition from FFS to value-based care.



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

Friday, October 12, 2018 | 1:00 p.m. ET, 12:00 p.m. CT

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 can diagnose and treat illness, but also in how accurately we can predict and even stave it off. From measurably more productive workflows to palpably more precise assessments, technology surely has much in store for us. Artificial intelligence, seamless data integration, remote image access, and other advances are, quite simply, game changers in cardiology, with cardiologists, their patients, and the healthcare system standing to benefit.

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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.


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 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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