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UPMC’s Solano Shares What Works in MD-Driven Population Health (Part I)

October 7, 2016
by Mark Hagland
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Dr. Fran Solano shares his insights on what really works in physician-driven population health management

At a time when issues around taking on risk-based contracts are becoming more complex and challenging for physician groups, some physician organizations are moving ahead to lay the foundations for success in risk-based contracting, all of which require strong health risk assessment processes around broad covered populations, and the creation of care management and population health management strategies for the long haul.

Among the physician organizations that has taken on these challenges and begun to lay strong foundations for risk-based contracting has been Community Medicine, Inc., which is the largest group of employed primary care physicians—330 in all—connected to the vast UPMC health system in Pittsburgh. The president of that group is Francis X. (Fran) Solano, M.D., an internal medicine physician, who is also vice president of the Physician Services Division at the umbrella UPMC system.

While taking on potential downside risk has been years in the making—Dr. Solano is currently working to develop a risk-based contract between Community Medicine, Inc. and the UPMC Health Plan—he has spent 15 years helping to lead a quiet, data-facilitated revolution around improvements in care quality and utilization management.

At the core of that effort has been the program Template for Change, which has laid a firm foundation for the taking on of financial risk in contracting, even as Template for Change has focused on initial shared-savings goals between and among the medical group constellation, the hospital system, and the health plan. The program, which has been applied to medical care delivery across all insurance lines (Medicare, commercial, Medicaid), has been implemented across the 330 primary care physicians in the Community Medicine constellation of groups, as well as 30 PCPs at Renaissance Family Practice based at St. Margaret’s Hospital, and 60 internal medicine physicians in a third group.

The focus, Solano says, has been on providing monthly performance metrics to every physician in the program, at the individual, practice, and specialty level, for the following core statistics: inpatient admissions per 1,000, inpatient days per 1,000, ED visits per 1,000, primary care visits per 1,000, specialty visits per 1,000, diagnostic imaging rates per 1,000, and medical expense ratio. The physicians in the program have also been receiving data on their “HEDIS gaps”—gaps in care conveyed by HEDIS (Health Effectiveness Data and Information Set) data. Solano himself and his team look at a monthly 400-page printout of data, but, he notes, he learned early on that sending out massive amounts of raw data to the physicians in practices only led to mass confusion and frustration. The key has been that providing the doctors with these data points has helped them find “the patients who are high utilizers but are not yet in care management.


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Francis X. Solano, M.D.

What’s more, Solano says, the monthly sharing of clinical performance data, along with coaching sessions for physicians who are struggling, has made a huge difference. Still, “The biggest contribution” to physician behavioral change has been the average $20,000 in physician compensation that has been tied to individual physician performance on the various metrics being measured. Also very big has been the fact that the shared-savings program has involved sharing savings with the hospital system, an important factor, given that intended reductions in inpatient admissions and ED visits inevitably will affect the hospitals’ bottom lines.

Dr. Solano spoke this summer with Healthcare Informatics Editor-in-Chief Mark Hagland, as Hagland prepared the September cover story on physicians and risk. Below are some additional excerpts from their interview. This is part one of a two-part interview.

Tell me a bit about the background and context for what you’ve achieved so far at Community Medicine, Inc. This is quite pioneering work. What is the landscape of managed care like right now in western Pennsylvania?

Actually, there is very little true risk-based contracting going on in western Pennsylvania at this time. Most programs really only have upside potential, and not much in the way of downside potential. The Pioneer ACOs [accountable care organizations] can do either upside risk or two-tailed risk, involving some potential downside. We have a shared-savings program with our health plan, which is mainly based on hitting a medical expense ratio. We started our first year in 2013 with that program. Meanwhile, we over 30,000 Medicare members, 28,000 commercial members, and 30,000 Medicaid patients, or the largest [aggregation of such groups of patients by a medical group] in western Pennsylvania.

So Medicare has several models; it has the ACO model. And a lot of Medicare Advantage programs have developed their own ACOs, and that’s what this is. We’ve been extremely successful, getting this many physicians engaged to care about cost; and we’ve always cared about quality at UPMC. Our first year was interesting in that we were successful. Those programs take three years to become successful usually; but we’ve learned a lot about variability in practice patterns, and also how people approach access to primary care. One of the biggest challenges is to reduce the number of admissions, towards what I call appropriate admissions.

And in western Pennsylvania, where there are a lot of Medicare patients and a lot of Medicaid patients; and our emergency department utilization, urgent care utilization, and inpatient hospitalization, are all off the charts in western Pennsylvania.

Why have those utilization rates all been so high in your region?

I wish I could answer that question. I think some of it is cultural. I know there are patients who feel like they’re bothering me when they call me at night, and don’t want to bother me, so they just go to the ER. And some of it is the default that physicians have on their answering machines or services saying, go to the emergency room. So we’ve changed that to say, always talk to the physician. One example is chest pain. From a primary care office, the admission rate for chest pain is extremely low; from the ER, it’s extremely high, because the ED doctors don’t have an established relationship with the patient and they don’t want to risk legal liability.

So those are some of the big things that we focused on in our program. And our admission rates declined substantially. Most Medicare admission rates are 310-320 admits per 1,000, and we got ours down to 240 within two years. It’s based on changing the way doctors practice. We have a team of nurses who go into the practices and spend a week or two sitting at every staff position in the office, training people to do things differently. It’s called the Template for Change. Program on how to triage patients, how workflow should work, improve gaps in care access, etc. And we’ve expanded access in our offices through walk-in clinics, extended hours at night, even weekend hours. And these walk-in ….

And, in that, you and your colleagues clearly made a calculation that investing strategically in certain positions, such as nurse case and care managers, would pay off in terms of admissions and readmissions, correct?

Yes, there is a real ROI in having people not get readmitted. We didn’t even focus on specialty over-utilization; we focused on more of a concierge format for Medicare patents.

Tell me about the centrality of the pursuit of data analytics in all this?

We have a lot of data coming from our health plan. And one of the challenges in dealing with the federal government versus commercial plans is that it’s really hard to get data from Medicare. In fact, one of the reasons that ACOs are dropping out of the Pioneer ACO program has been the challenges of dealing with the data issues from Medicare. And we have the advantage within This Template for Change applies to Medicare, Medicaid, and commercial, all three. But most of the money is from Medicare. If you’re spending $1,000 PMPM [per member per month] for care delivery under Medicare, and commercial and Medicaid are half of that, you can see where the money is. So we’ve focused most of our efforts on Medicare patients, but there’s a Hawthorne effect on the other patients as well. But the whole program is designed to work across all insurance lines.

And, specifically, what has the role of data analytics been in success to date of the Template for Change program?

We do analytics looking at, say, how successful our practices have been in getting their medical expense ratio down, versus those that haven’t been as successful. Every insurance company has a different medical loss ratio it calculates to break even. Many insurance companies set a MLR of 12 percent; our insurance company is a lot more efficient than that. But when we looked at the practices that seemed to be successful, we looked at their admit and ED rates. Those that are successful in lowering their admissions also tend to have lower ED utilization rates. So we have performance metrics that we share monthly by practice. And we have our doctors grouped into pods by region, so that the data is more powerful.

And you have to have at least 200 patients in a product so that the data is a reliable. So we’re broken down into pods for adequate numbers in each pod. For example, in our Medicare product, we have 1,6000 people in the Bedford pod, close to 6,000 in our central pod around Oakland, Shadyside, and around 7,000 patients in our southern pod, etc. And we’re looking at admissions per 1,000, days, per 1,000, ED visits, per 1,000, primary are visits, specialty visits, per 1,000, diagnostic imaging rates, and medical expense ratio. So when we look at all these metrics, we actually educate our doctors on how to do look at them.

Do you engage in the use of dashboards?

Yes, we do it by practice. Every practice at a primary care practice sees monthly their dashboard, including their medical loss ratio for their line of products. Every month, we get a 400-pate printout of data for our population. So we can find the unplanned care people who are high utilizers. And the true key has been helping our physicians and their teams to identify the patients who are high utilizers but are not yet in care management. Those patients are typically the ones that I jokingly refer to as our Seagram’s 7&7, because these are the people with seven diagnoses, who are on seven medications, and are seeing seven specialists—and they really need to be identified and care-managed.

And you apply incentives to all this work, too, correct?

Yes, absolutely. It’s a combination of things: we share monthly clinical performance data with them, we engage in coaching sessions with physicians who are struggling, and the biggest contribution to physician behavioral change has been the average $20,000 in physician compensation that we’ve tied to individual physician performance on the various metrics being measured. Also very big has been the fact that the shared-savings program has involved sharing savings with the hospital system, an important factor, given that intended reductions in inpatient admissions and ED visits inevitably will affect the hospitals’ bottom lines.

Sharing savings between the physicians and hospitals helps align the hospitals with us, because the hospitals take the biggest hit when you reduce admissions and readmissions. So when you break down the silos by sharing money across the continuum, that helps. And now the passage of the MACRA [Medicare Access and CHIP Reauthorization Act of 2015] law has everyone aware of where this is going. They had never had cost data until recently, and charge-based data is very hard for physicians to understand. But with actual cost data from our health plan, doctors can use that, and they will start looking at the cost differential between a hospital-based colonoscopy and an ambulatory surgery center-based one, for example. And they are starting to pay attention to which specialists are over-utilizers, in terms of whom they refer their patients to.

In part two of this interview, to be published next week, Dr. Solano will share his broad perspectives on where physician practice and the healthcare delivery system are headed, and what CIOs and CMIOs need to do to move their organizations forward in the emerging risk-based world of contracting.


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NCQA Moves Into the Population Health Sphere With Two New Programs

December 10, 2018
by Mark Hagland, Editor-in-Chief
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The NCQA announced on Monday that it was expanding its reach to encompass the measurement of population health management programs

The NCQA (National Committee for Quality Assurance), the Washington, D.C.-based not-for-profit organization best known for its managed health plan quality measurement work, announced on Dec. 10 that it was expanding its reach to encompass the population health movement, through two new programs. In a press release released on Monday afternoon, the NCQA announced that, “As part of its mission to improve the quality of health care, the National Committee for Quality Assurance (NCQA) is launching two new programs. Population Health Program Accreditation assesses how an organization applies population health concepts to programs for a defined population. Population Health Management Prevalidation reviews health IT solutions to determine their ability to support population health management functions.”

“The Population Health Management Programs suite moves us into greater alignment with the focus on person-centered population health management,” said Margaret E. O’Kane, NCQA’s president, in a statement in the press release. “Not only does it add value to existing quality improvement efforts, it also demonstrates an organization’s highest level of commitment to improving the quality of care that meets people’s needs.”

As the press release noted, “The Population Health Program Accreditation standards provide a framework for organizations to align with evidence-based care, become more efficient and better at managing complex needs. This helps keep individuals healthier by controlling risks and preventing unnecessary costs. The program evaluates organizations in: data integration; population assessment; population segmentation; targeted interventions; practitioner support; measurement and quality improvement.”

Further, the press release notes that organizations that apply for accreditation can “improve person-centered care… improve operational efficiency… support contracting needs… [and] provide added value.”

Meanwhile, “Population Health Management Prevalidation evaluates health IT systems and identifies functionality that supports or meets NCQA standards for population health management. Prevalidation increases a program’s value to NCQA-Accredited organizations and assures current and potential customers that health IT solutions support their goals. The program evaluates solutions on up to four areas: data integration; population assessment; segmentation; case management systems.”



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At the D.C. Department of Health Care Finance, Digging into Data Issues to Collaborate Across Healthcare

November 22, 2018
by Mark Hagland, Editor-in-Chief
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The D.C. Department of Health Care of Finance’s Kerda DeHaan shares her perspectives on data management for healthcare collaboration

Collaboration is taking place more and more across different types of healthcare entities these days—not only between hospitals and health insurers, for example, but also very much between local government entities on the one hand, and both providers (hospitals and physicians) and managed Medicaid plans, as well.

Among those government agencies moving forward to engage more fully with providers and provider organizations is the District of Columbia Department of Health Care Finance (DHCF), which is working across numerous lines in order to improve both the care management and cost profiles of care delivery for Medicaid recipients in Washington, D.C.

The work that Kerda DeHaan, a management analyst with the D.C. Department of Health Care, is helping to lead with colleagues in her area is ongoing, and involves multiple elements, including data management, project management, and health information exchange. DeHaan spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding this ongoing work. Below are excerpts from that interview.

You’re involved in a number of data management-related types of work right now, correct?

Yes. Among other things, we’re in the midst of building our Medicaid data warehouse; we’ve been going through the independent validation and verification (IVV) process with CMS [the federal Centers for Medicare and Medicaid Services]. We’ve been working with HealthEC, incorporating all of our Medicaid claims data into their platform. So we are creating endless reports.


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We track utilization, cost, we track on the managed health plan side the capitation payments we pay them versus MLR [medical loss ratio data]; our fraud and abuse team has been making great use of it. They’ve identified $8 million in costs from beneficiaries no longer in the District of Columbia, but who’ve remained on our rolls. And for the reconciliation of our payments, we can use the data warehouse for our payments. Previously, we’d have to get a report from the MMIS [Medicaid management information system] vendor, in order to [match and verify data]. With HealthEC, we’ve got a 3D analytics platform that we’re using, and we’ve saved money in identifying the beneficiaries who should not be on the rolls, and improved the time it takes for us to process payments, and we can now more closely track MCO [managed care organization] payments—the capitation payments.

That involves a very high volume of healthcare payments, correct?

Yes. For every beneficiary, we pay the managed care organizations a certain amount of money every month to handle the care for that beneficiary. We’ve got 190,000 people covered. And the MCOs report to us what the provider payments were, on a monthly basis. Now we can track better what the MCOs are spending to pay the providers. The dashboard makes it much easier to track those payments. It’s improved our overall functioning.

We have over 250,000 between managed care and FFS. Managed care 190,000, FFS, around 60,000. We also manage the Alliance population—that’s another program that the district has for individuals who are legal non-citizen residents.

What are the underlying functional challenges in this area of data management?

Before we’d implemented the data warehouse, we had to rely on our data analysis and research division to run all the reports for us. We’d have to put in a data request and hope for results within a week. This allows anyone in the agency to run their own reports and get access to data. And they’re really backed up: they do both internal and external data reports. And so you could be waiting for a while, especially during the time of the year when we have budget questions; and anything the director might want would be their top priority.

So now, the concern is, having everyone understand what they’re seeing, and looking at the data in the same way, and standardizing what they’re meaning; before, we couldn’t even get access.

Has budget been an issue?

So far, budget has not been an issue; I know the warehouse cost more than originally anticipated; but we haven’t had any constraints so far.

What are the lessons learned so far in going through a process like this?

One big lesson was that, in the beginning, we didn’t really understand the scope of what really needed to happen. So it was underfunded initially just because there wasn’t a clear understanding of how to accomplish this project. So the first lesson would be, to do more analysis upfront, to really understand the requirements. But in a lot of cases, we feel the pressure to move ahead.

Second, you really need strong project management from the outset. There was a time when we didn’t have the appropriate resources applied to this. And, just as when you’re building a house, one thing needs to happen before another, we were trying to do too many things simultaneously at the time.

Ultimately, where is this going for your organization in the next few years?

What we’re hoping is that this would be incorporated into our health information exchange. We have a separate project for that, utilizing the claims data in our warehouse to share it with providers. We’d like to improve on that, so there’s sharing between what’s in the electronic health record, and claims. So there’s an effort to access the EHR [electronic health record] data, especially from the FQHCs [federally qualified health centers] that we work closely with, and expanding out from there. The data warehouse is quite capable of ingesting that information. Some paperwork has to be worked through, to facilitate that. And then, ultimately, helping providers see their own performance. So as we move towards more value-based arrangements—and we already have P4P with some of the MCOs, FQHCs, and nursing homes—they’ll be able to track their own performance, and see what we’re seeing, all in real time. So that’s the long-term goal.

With regard to pulling EHR information from the FQHCs, have there been some process issues involved?

Yes, absolutely. There have been quite a few process issues in general, and sometimes, it comes down to other organizations requiring us to help them procure whatever systems they might need to connect to us, which we’re not against doing, but those things take time. And then there’s the ownership piece: can we trust the data? But for the most part, especially with the FHQCs and some of our sister agencies, we’re getting to the point where everyone sees it as a win-wing, and there’s enough of a consensus in order to move forward.

What might CIOs and CMIOs think about, around all this, especially around the potential for collaboration with government agencies like yours?

Ideally, we’d like for hospitals to partner with us and our managed care organizations in solving some of these issues in healthcare, including the cost of emergency department care, and so on. That would be the biggest thing. Right now, and this is not a secret, a couple of our hospital systems in the District are hoping to hold out for better contracts with our managed care organizations, and 80 percent of our beneficiaries are served by those MCOs. So we’d like to understand that we’re trying to help folks who need care, and not focus so much on the revenues involved. We’re over 96-percent insured now in the District. So there’s probably enough to go around, so we’d love for them to move forward with us collaboratively. And we have to ponder whether we should encourage the development and participation in ACOs, including among our FQHCs. Things have to be seen as helping our beneficiaries.

What does the future of data management for population health and care management, look like to you, in the next several years?

For us in the District, the future is going to be not only a robust warehouse that includes claims information, vital records information, and EHR data, but also, more connectivity with our community partners, and forming more of a robust referral network, so that if one agency sees someone who has a problem, say, with housing, they can immediately send the referral, seamlessly through the system, to get care. We’re looking at it as very inter-connected. You can develop a pretty good snapshot, based on a variety of sources.

The social determinants of health are clearly a big element in all this; and you’re already focused on those, obviously.

Yes, we are very focused on those; we’re just very limited in terms of our access to that data. We’re working with our human services and public health agencies, to improve access. And I should mention a big initiative within the Department of Health Care Finance: we have two health home programs, one for people with serious mental illness issues, the other with chronic conditions. The Department of Behavioral Health manages the first, and the Department of Health Care Finance, my agency, DC Medicaid, manages the second. You have to have three or more chronic conditions in order to qualify.

We have partnerships with 12 providers, in those, mostly FQHCs, a few community providers, and a couple of hospital systems. We’ve been using another module from HealthEC for those programs. We need to get permission to have external users to come in; but at that point, they’d be able to capture a lot of the social determinants as well. We feel we’re a bit closer to the providers, in that sense, since they work closely with the beneficiaries. And we’ve got a technical assistance grant to help them understand how to incorporate this kind of care management into their practice, to move into a value-based planning mode. That’s a big effort. We’re just now developing our performance measures on that, to see how we’ve been doing. It’s been live for about a year. It’s called MyHealth GPS, Guiding Patients to Services. And we’re using the HealthEC Care Manager Module, which we call the Care Coordination Navigation Program; it’s a case management system. Also, we do plan to expand that to incorporate medication therapy management. We have a pharmacist on board who will be using part of that care management module to manage his side of things.



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