Even as purchasers and payers of healthcare are compelling the providers of healthcare forward into value-based payment models, one area has until now been left completely unaddressed: how to care for the needs of individuals with intellectual and developmental disabilities (IDDs). Such individuals present severe chronic health conditions, usually present at birth, that limit the trajectory of their physical, cognitive and emotional development and opportunity to live in most integrated community based settings.
Meanwhile, the Medicare Shared Savings Program (MSSP) for accountable care organizations (ACOs) continues to move forward, with hundreds of provider groups collaborating to work with public and private payers of healthcare to share savings, while taking care of patients across the continuum of care.
And now, for the first time, an MSSP ACO has been formed to manage the care of individuals with IDDs. That organization is the Alliance for Integrated Care of New York, LLC (AICNY), based in New York City, the first and only MSSP ACO of its kind in the U.S., formed in 2014 to oversee the healthcare needs of individuals with IDDs.
Seven outpatient diagnostic and treatment health centers and 25 licensed private practices affiliated with the Queens County Independent Practice Association (QCIPA) have come together to form AICNY, in order to focus on treating this vulnerable and underserved population. These provider organizations represent a significant footprint encompassing most of New York. Approximately 200 physicians and other healthcare professionals care for more than 6,000 dually eligible Medicaid and mostly Medicare beneficiaries, the majority of whom are IDD patients.
Like the leaders of so many emergent ACOs, the leaders of the Alliance have had to work through numerous dimensions of obstacles in the way of seamlessly capturing and sharing relevant IDD-patient data such as routine and follow-up visits, prescription orders and refills, and longitudinal medical records. In their case specifically, the leaders of the Alliance had been finding it difficult to reduce the unnecessary utilization of resources; for example, a common problem was that so many of their patients with multiple chronic conditions were being needlessly sent to emergency departments multiple times per month, to avoid citations by the government agency responsible for conducting on-site quality reviews.
So the AICNY leaders partnered with the Piscataway Township, N.J.-based HealthEC, in order to aggregate and analyze IDD beneficiary claims onto a population health management platform; risk-stratify and identify patients appropriate for targeted care interventions; and meet quality data collection and reporting requirements, for such programs as the MIPS (Merit-based Incentive Payment System) program under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law.
The Alliance also equipped its participating physicians with dashboards to unify data and compare their performance against pre-established quality standards so they can track care improvements. In addition, to the extent that primary care physicians and specialists could share electronically information from their consults, unnecessary follow-up appointments could be averted—a significant consideration for a population for whom doctor visits can be mentally and physically taxing.
What’s more, in order to better serve New York’s IDD population, the Alliance is integrating medical care management by digitizing their entire residential world of health centers, private practices and ultimately long-term care agencies. Its goal is to build electronic information sharing of pre-service summaries populated with the most relevant documentation accessible for every provider’s IDD patient visit. And, with that in mind, the Alliance’s leaders have spent considerable time creating workflows that can optimize the appropriate sharing of clinical information.
Recently, Healthcare Informatics Editor-in-Chief Mark Hagland spoke with Duane Schielke, the Alliance’s executive director, to gain insights on how this broad initiative is moving forward. Below are excerpts from that interview.
Your headquarters is in New York City, correct?
Yes, we’re based in midtown Manhattan.
Tell me a bit about the history of the Alliance?
AICNY was established in 2014, initially to buy a group of IDD agencies, which included Cerebral Palsy Associations of New York State, where I'm the executive vice president for healthcare initiatives. There's a 5,000-person minimum requirement to be an MSSP ACO. What we found is through the process of attribution, which is quite a complex process, the 5,000 patients that we had identified that are dual-eligible turned out to be not 5,000, because of how the attribution works. Which fortunately is changing next year in a very positive way so the patients can actually self-select. So, we formed the ACO with another group in Queens, and currently, we have seven IDD outpatient clinics; they're the core part of the piece that I'm mostly involved in.
So, we reached out and recruited some of our cerebral palsy affiliates that run clinics, to join the ACO, and got ourselves started. Then spent a couple of years learning what does it mean to be an ACO, and what does it mean to use healthcare informatics in a way to manage people's care, which was an entirely new concept for us, and there's actually no data available on the spending cost related to people with IDD on the healthcare side. People with IDDs are typically born with a disability or acquire a disability before age 21, and there's federal definitions: mental retardation, cerebral palsy, epilepsy, autism, other neurological disabilities. It impairs their development, because they received it prior to their learning years and they're eligible for special benefits as a result of that.
When did you officially join the MSSP program?
We joined the program in January of 2014, which means that we're in our second three-year term. MSSPs run in three-year terms, so we're in a term that ends at the end of 2019.
And what, very broadly, what have been the biggest lessons learned strategically, so far, in participating in an MSSP?
Well, as I said, there was no data about what it costs to serve people, and because the health information sharing networks are still just evolving we never had any information about what we call "outside providers," meaning people other than our own clinics. So, we have maybe some documentation from the visits that people collect when they leave, but we didn't know what it cost and we didn't know the frequency because nothing was digitized. And you're looking at... in our case, in our residential program for example, 600 people. Paper records with no ability to do any kind of an analysis without taking on a monster, monster project that would probably not be very effective.
So, tell me a bit about your organization’s digital transformation.
The digital transformation was everything. The [HIT] part of this project is the most phenomenal piece; we couldn't even imagine what it was going to do for us at the time, but now that we get claims data, we're expanding the program, and we've convinced New York state Medicaid to share claims data using the same population health management platform that HealthEC provides to us, and [harmonizes with] the outpatient EHR and long-term care software used in patients’ homes, where they’re tracking rehabilitation services.
So, we’re digitizing records over on that side, charting blood pressures, menses, bowel movement charts, all of the things that doctors need to know to provide a good clinic visit; those will be all digitized so that we can provide that information to physicians electronically prior to the visit, so that they're prepared for that visit in a way they've never been prepared before. We send them the medication administration record that's actually effective as of that date.
One of the challenges is that when clinicians look at the EHR, they see this continuous flow of medications coming in, but nothing ever stopping, and the physician can never reconcile the patient’s current medications with what the doctor had documented previously in the record, unless we send them the medication administration record from the home. So that has been phenomenal in terms of changing the game, and using digitized records in a way that we were never able to do before.
So now, at the beginning of every month, a patient’s current meds are prefilled out in this form, the staff go in, put electronic signatures in when they administer something, and so on; so now, the physician, whether the primary care physician or the specialist, can clearly see the patient’s current medications. That is truly significant, given that it’s not unusual for our patients to be on nine or ten meds at a time.
What’s more, trying to integrate behavioral health and primary healthcare is a challenge if you don't have current medications data, because that's where most of the work has to be done in terms of reconciling things. You know, one doctor prescribes, another doctor prescribes something else, and then there’s a bad interaction, and it’s not [tracked], and eventually, someone has to start pulling paper to figure out what’s going on—and that’s just so inefficient and ineffective.
Could you drill down on the mechanism involved, the flow of data?
Yes, we’re creating feeds from PrecisionCare, the long-term care solution, into HealthEC’s platform, which sits in the middle, between eClinicalWorks, the clinic EHR, and PrecisionCare. As a result, we can get the digitized records of meds and the charting that occurs by the direct care staff on a day-to-day basis. Then we have a bidirectional channel to eClinicalWorks, so that the HealthEC platform is refreshed daily with any new information from eClinicalWorks, including posted summaries and blood work, radiology or whatever comes into eClinicalWorks, then gets pushed over to HealthEC so that the medical case manager views HealthEC and sees everything in one place. So, they don't have to go back and forth between platforms, which is a nightmare. We found out from the users that, "Don't make me sign into another program." We spent the money and the time to make it electronically interoperable so that they can go to one place, see everything they need, make the decisions, review things, do follow-ups, make another follow-up appointment if necessary; allows the primary care to jump in that loop so we don't repeat follow-ups with outside specialists that are unnecessary, but we can continue forward if we need to.
When did your organization go live with these systems?
We've been using HealthEC for AICNY since 2014, I'm sorry 2016, and eClinicalWorks has been in the clinic since 2012.
So, every night, the eClinicalWorks data is dumped into a server and HealthEC picks up from that server, and you're going to make that a more automated, instantaneous process?
Yes, that’s right.
And how long will it take to go live with the instantaneous, the more fully automated version of that?
Probably about six weeks.
And can you share a bit about the care managers?
There are about 25 care managers in Metro, which is the operation that New York state operates; and if you multiply that number times seven, to 400, that’s roughly the number of care managers across the state, who with about 75 providers, are managing about 25,000 patients in this program.
And those 25,000 patients are all dual-eligibles; does that mean that they are all seniors?
No, not necessarily, as many are younger people with development disabilities who become eligible when their parent becomes eligible for Medicare.
Obviously, you’re working in an environment of constrained budgets. What have been some of the biggest lessons learned so far in terms of innovating on a budget?
Having claims data in a platform that allows us to do analysis shows us who the high users are, because as is typical across populations, there's a select group of people that use the majority of resources. We can sort and stratify to find out what the conditions are that are driving high cost, what are the occurrences that are driving high cost, like high use of an emergency room and inpatient use, use of specialists. We have very, very high use of diagnostics, but that's not a bad thing, that's a good thing. The difference between our group and a typical group is that these folks are challenged in reporting their healthcare issues, either because of communication issues or cognitive issues. The physicians are challenged and do a lot more diagnostics to be able to get to the bottom of what conditions they're treating. So, that's high but that's a good high. Meanwhile, using the emergency room is high, but that's a bad high.
By leveraging health informatics, we can find the “low-hanging fruit,” to be able to focus our care management efforts where it counts. If you just say, "Be intense with everybody," you get nowhere, it's too big of a workload. But if you create reports and you say, "Focus on Johnny, Sally, Susie and Fred," because those are the guys that are going to the emergency room a lot, and you loop that back to the primary care doctor, find out what's causing this high use of emergency room, and then start to do some preventive care so, that you're not just diverting from the ER you're actually solving the problem so you don't have a repeat of these things. The informatics, they're interesting because you see that if someone used the emergency room a lot last year, and you don't do anything about it, they're going to use it a lot this year. The repeat patterns from year to year are quite phenomenal; and they’re logical, once you think about it. But to know who they are, knowing who they are and why they went, because you've [sic] the diagnostic [sic] from the ER, and we find that maybe 60 percent of them are deemed unnecessary, but they needed to be treated, so we can see why they're going in and try to prevent that from happening.
So it’s like so many other initiatives right now, in that you’re trying to drive clinical interventions upstream, correct? And because you have a population of patients who, as you had mentioned, for cognitive and other reasons, find it difficult to articulate what’s going on with them; so using analytics helps you manage care upstream, correct?
Yes, that’s exactly right. Overall, in terms of the big picture, we’re preparing for value-based reimbursement. In fact, New York state has been going through an amazing transformation of converting everything in Medicaid, and that's all of these folks because they're duals, to value-based payments, and at some point, we need to be able to assume upside and downside risk. And in that context, we want to be able to minimize those risk corridors, so that we're managing at a high level, so that we're doing it in an informed way and be able to maximize our effectiveness in a value-based payment methodology. So, that's really the big picture, because we would never have learned how to prepare for that if we weren't doing all of this work.