At the Raleigh HIT Summit, Mission Health’s CQO Shares About the Quality Journey | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

At the Raleigh HIT Summit, Mission Health’s CQO Shares About the Quality Journey

October 2, 2018
by Mark Hagland
| Reprints
Mission Health CQO Chris DeRienzo, M.D., shared with HIT Summit attendees his perspectives on the quality journey

On Friday, September 28, Chris DeRienzo, M.D., a practicing neonatologist and the chief quality officer of the six-hospital, 11,000-employee Mission Health, shared a wealth of insights around the Asheville, N.C.-based health system’s experience with continuous quality improvement, in his presentation, “Building a Data-Driven Culture of Continuous Improvement.”

Dr. DeRienzo was speaking on the second day of the Health IT Summit in Raleigh, being held Thursday and Friday of last week. He spoke on the topic, “Building a Data-Driven Culture of Continuous Improvement.” As explained in the agenda’s description of the session, “Creating a data-driven culture of continuous improvement requires more than a string of buzzwords. Mission Health has successfully embedded this culture across both clinical and operational teams, leading to dramatic improvements in patient outcomes and more efficient hospital and clinic operations.  Led by Mission’s Chief Quality Officer, Dr. Chris DeRienzo, this keynote presentation will walk attendees through Mission’s journey to instill continuous improvement through analytics using three tangible and specific case studies:  Driving Clinical Continuous Improvement through Care Process Models, Improving ED Throughput, and Implementing a Machine Learning Model to Reduce Readmissions rates.”

At the outset of his presentation, Dr. DeRienzo, who has spent nearly five years at Mission Health so far, articulated why continuous performance improvement, achieved with the help of Lean management and/or other performance improvement methodologies, is so critical an element in the intended transformation of U.S. healthcare delivery. “Medicare and Medicaid alone are now spending $1.1 trillion a year, with that rate rising at a pace of $1,000 a second,” he noted. And, he asked, “Are we delivering a trillion dollars’ worth of value for a trillion dollars’ worth of spend? We’re among the most expensive healthcare systems in the world for every item” of significant expenditure. “Yet our population health outcomes are among the worst, with regard to life expectancy, obesity, and all the major items” on the list of key healthcare system indicators.” Indeed, he noted, “Industries get disrupted when they reach 20 percent of GDP, and that’s what’s happening to healthcare now.” What’s more, he noted, “Our life expectancy is now getting worse for the first time in generations”—and that development ought to concern healthcare leaders nationwide.

Given the “burning platform” facing the healthcare system overall, leaders at Mission Health began six years ago to build a performance improvement culture, Dr. DeRienzo told his audience. “We brought on quality teams, and started to build a system-wide enterprise data warehouse.

The core recipe, as he noted, included the following: a reliable enterprise data warehouse; a reliable data visualization environment; “more structure in clinical program leadership among physicians, nurses, and administrators”; a cadre of Lean management engineers; and, “trusted advisors.” Fortunately, he noted, “I’ve been able to build a team of 21 quality improvement advisors, ‘QIAs,’” all of whom have been trained in Lean management techniques and strategies.

“What do you do with that recipe?” DeRienzo asked. “This starts in orientation. Every single new employee of our health system is told, you have two jobs. Job number one is to do whatever you were hired to do; job number two is to make it better. So from day one, everyone needs to do what they can to improve the work. We tell them, it’s your job to go fishing, we give them the fishing rod, and we teach them how to fish.” And he presented a slide to his audience that showed a quote by President Theodore Roosevelt: “Real progress is won by people who take the next step, not those who theorizes about the two-hundredth.” As a result of their philosophy, DeRienzo noted, “In all of our QI work, we have found that we reach scale when we ask teams, think about the big vison, but focus your energy and resources on taking the next step: make it better tomorrow. And that’s really powerful.”

Chris DeRienzo, M.D., speaking on Friday at the HIT Summit

Meanwhile, in terms of the leadership requirements involved, DeRienzo noted that “We apply multidisciplinary teams that are committed to a Quadruple Aim victory. And in that, we need to start with a multidisciplinary team committed to a Quadruple Aim victory.” Further, he said, “That team has to be led by an engaged physician or provider practicing in the area where it’s going to be used. I’m a neonatologist. I can’t be leading a neurosurgery team. We need neurosurgeons to work on neurosurgery. The clinician has the ‘clinical gravitas’ of their partners, the respect. In other words, we want each effort in any particular specialty to be led by those who are practicing in that specialty; that leads to 100-percent alignment.”

Learning through doing

Dr. DeRienzo made it clear to his audience that none of this work is easy. Indeed, he said, “We’ve made just about every process mistake you could make without actually hurting anybody; we had gestational cycles as along as the gestation of the African elephant. We PDSAed our own PDSA cycles,” he said, referring to the “Plan, Do, Study, Act” principle underlying virtually all of the performance improvement methodologies. “You have to define a best practice, built the workflow around it, and measure the workflow,” he said, and referenced a protocol around COPD (chronic obstructive pulmonary disease) exacerbation, which has been implemented in 22 physician practices.

The key? “It’s folks figuring out how we take a best practice and make it as easy to use as possible, DeRienzo said. “Because when it’s frictionless for me to use a CPM—care process model—like water, I’ll flow in that direction naturally, 90 percent of the time. We build it into the workflow. Is it perfect? No. But is it a heck of a lot better than it was five years ago? Absolutely.”

Among the absolute critical success elements? An integrated and intuitive electronic workflow to implement protocols; and “unimpeachable” real-time data served within a reliable analytics platform that reaches the physician and patient patient level with use and outcomes. “When you put data in front of the doctor, and get past the, ‘my patients are sicker, my population is different, I don’t believe the data’ talk,” he said, “well, nobody got into medical school being a B student. And once you get them engaged, physicians will work to improve their clinical performance.”

Major advances have been made through the use of the Ambulatory CPM Explorer Dashboard, which is bringing near-real-time data to physicians. Among the accomplishments in the past few years:

> A 20-percent increase in full sepsis bundle and a 32-percent reduction in mortality from sepsis
> 12 lung cancer deaths avoided with 37 percent increase in screening
> 9 fewer rib fracture deaths and $350,000 in reduced direct cost
> A 42-percent reduction in in-hospital stroke mortality
> 11,000 more women screened for breast cancer, 6,000 more people screened for colorectal cancer, and a seven-fold increase in depression screening

Enhancing tools around readmission prediction and sepsis decline

Dr. DeRienzo spoke extensively about the Readmissions Predictor initiative, which has dramatically enhanced ambulatory care managers’ ability to efficiently predict which patients might be at the highest risk for readmission, following discharge. After his presentation, he sat down with Healthcare Informatics Editor-in-Chief Mark Hagland to discuss that initiative in detail. Below are excerpts from that interview.

When did this initiative begin?

It began in early 2017.

Did you establish the initiative?

I share the data science team with John Brown, our CIO. And in one of our data science sessions, I said, we need to find examples of where data science can improve clinician workflow. I said, this is an example of where care managers are spending too much time on front-end work. And everyone said, this makes sense as a way to intervene in clinician workflow and improve outcomes and their work.

How long did it take to build the Readmissions Predictor?

It took over a year to build and test and validate. HealthCatalyst is our enterprise data warehouse vendor. We had to build the model and figure out where to site the server. Subject Area Mart (SAM). We’ve got this massive lake of tables, and when we decide to build a dashboard, our data architects build a data mart to speed the dashboard time. So the EDW has 20-some-odd just Cerner tables alone; and we’ve got a pipeline for Lawson and others. And it would take forever to search to reload the dashboards that we used for care management. So the tables get indexed. And the data scientists load tables into subject area marts, as with the sepsis dashboard. By 5 AM every weekday, the SAMs pull from the data mart, to refresh the dashboard.

Who was on the team developing it?

Data scientists, data architects, me, and as we moved along, representatives from the care management team; care management leadership. I was the physician leader.

What were the biggest challenges involved?

There were technical challenges—for example, the data science team having to figure out what the right model was. That was an enormous lift. And it was an enormous lift on the data architect side to figure out how to serve the model, once it was built; and a ton of implementation work, as we shifted the care manager workflow. In retrospect, I would have engaged our VP of care management far earlier in the process. At the outset, I asked, can we do this? In retrospect, I should have engaged Tina at the very beginning. We realized that implementation would take much longer and be harder than expected. I learned from that. Tina Donkervoet, R.N., is the VP of care management. She has been a tremendous partner, and very forgiving of the reality that we’re going to make mistakes and it’s not going to be perfect.

What have been the top-line results?

We now serve predictions consistently with 90-percent delivery by 8 AM. IN the past, they would just get a list of who’s discharged from Mission Hospital. It’s an 800-bed hospital, so we may have 100 discharges a day. And they w ere spending hours figuring that out. Now, we’re going to focus our interventions on folks who have the highest scores in the Predictor Tool. And the Predictor Tool serves predictions for 30 days. Probability scale is 0 to 1, in 0.1 increments. Intent: to serve a rank-order list. And not only that, if the care manager chooses to click into the patient case, they can use their clinical judgement to individualize evaluation.

Why is it so powerful to use Lean and other methodologies in this work?

The way that we can use analytics to scale Lean improvement is exemplified by my stories. In order to drive PDSA cycles, I need data to drive analysis, and then improvement—to see what’s working. For example, with regard to sepsis, I can look today at our sepsis dashboard, and know how many patients we hit the three-hour bundle yesterday; and which patients we missed on, and which doctors were taking care of those patients. And now my sepsis team leads have actual data to know why we missed. Maybe somebody had stage 4 failure and we had to delay the fluid. But having real-time data means that we can go much, much faster, than in a world where we did retrospective chart review.

Can you explain the three-hour bundle, in your sepsis intervention initiative?

If we can do all these things within a three-hour time period, the patient has much greater chance of survival. Things like fluid resuscitation, trending a lactate, getting antibiotics in within an hour. Those are all evidence-based data points that we know that, if we can make it happen, that patients with septic shock and severe sepsis, have a better chance of survival. This is not a predictor; we built a workflow to make sure things happen within the EMR, and the analytical tool to determine what we have. We have a clinical decline tool we use; we work with PeraHealth, using the Rothman index.

So the bundle tool helps you determine how well you’re performing?

Yes, and where we need to improve. It’s by definition retrospective. It’s like a baseball game, had we allowed bunter 3 to get to base… So the Sepsis Dashboard helps the leaders of the teams know where to intervene next. Tone of the first things in Lean, you do your first Plan Do Study Act, then what? There’s rarely one big-bang solution; it’s usually a combination of at least a few changes or interventions.

We can determine what the rate-limiting step is in a situation. In chemistry, the rate-limiting step of an equation is what slows the whole thing down. So, we determine what our rate-limiting step is. How to make it easy for a clinician to document a reperfusion exam? For one dose of a certain type of antibiotic to be administered? Knowing where to focus our energies next—that’s how analytics can super-charge continuous improvement.

What should CIOs and CMIOs think about, as their organizations move into continuous performance improvement work?

Anytime a CIO or CMIO is beginning to engage with continuous improvement work, the most important thing is to focus on things core to an organization’s mission. By building this analytics infrastructure, and focusing it on continuous improvement, we will improve outcomes and reduce total cost of care in a changing environment. So for IT leaders, make sure you’re relentlessly continuing the why. John [Brown, CIO] can tell you why these improvements are so powerful for clinicians. We’ve decreased mortality for things like rib fractures. And our CPM has meaningfully reduced mortality; connecting what we’re doing in IT to improvements that are changing lives is very powerful.





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


Heritage Medical Systems’ Voyage to Value—and How Physicians are Leading the Way

October 11, 2018
by Rajiv Leventhal, Managing Editor
| Reprints
“If you have no risk at all, how hard you work at something is different than if you have some risk,” says one healthcare leader

As the accountable care train continues to speed up, innovative healthcare leaders are realizing that physicians—the ones who are working side-by-side with patients on a regular basis—will be key to making the transition to value successful. In California, Heritage Medical Systems, which also has providers operating in New York and Arizona, has been at the forefront of the accountable care revolution, and its senior executives point to its physicians as the ones who are leading the change.

Mark Wagar, president of Heritage Physicians Organization, which operates under the broader Heritage Medical Systems umbrella, recently spoke with Healthcare Informatics about his organization’s value-based care journey, its accountable care organization (ACO) progress, and how physician culture can be changed as providers take on more risk for their patients. Below are excerpts of that interview.

Where do things stand regarding Heritage’s value-based care evolution?

Heritage Physicians Organization is part of Heritage Medical Systems, which has lots of medical organizations in several states. I believe we have about 3,700 primary care physicians and 12,000 specialists that are involved in our ACO endeavors. This has been driven off the original and largest piece of our business in California. And it was a policy decision early on, from our founder, Dr. Richard Merkin, to get into [the Center for Medicare & Medicaid Services’] Pioneer ACO model, even though it was not our core business.

We have been involved in value-based care, the full-risk version, for decades, but we wanted to demonstrate that if you can surround private fee-for-service physicians with the kind of capabilities and infrastructure that we give our traditional business, an ACO has potential. So we did that and are continuing to move forward with that program. But we also believe this: the country would benefit if this all moved faster.

Heritage has evolved from the Pioneer ACO model, to the MSSP (Medicare Shared Savings Program), now to the Next Generation ACO model. Can you talk about the biggest lessons learned so far?

Generally, it’s a step in the right direction. The ability to get more of the funding earlier enables provider organizations to have the funding, change the system, and change what we do. You don’t have to drive off billable events only. We finally have this exploding recognition suddenly that social determinants and behavioral health are important. But that has been apparent to any physician organization for decades, particularly for us as we have been involved in value-based care and risk arrangements since the 1970s.

It became obvious that depending on the patients and the circumstance—what happens in their home and community, what surrounds them, and what their other issues are—may be more important than the physical interaction with their providers. You have to know that in order to manage their health. Once you move away from the mindset of, “I just need to be excellent when you fall in the door, sick or injured,” and move toward, “I will try to help you not fall in the door sick or injured,” or at least have it take longer for it to happen, or maybe you won’t be as bad when you do fall in the door, that’s when the light bulb goes on. We are happy that it’s becoming a broad part of the equation.

Mark Wagar

What are some of the most important IT and data elements to being successful in this transition?

I think as much real-time data and access as you can get is extremely important—so what care a patient is getting, and where, and what is happening in his or her life. If you work from the traditional basis, we pay claims in partnership with our health plan partners, and we pay the claims on the vast majority of our business. And when we do that, our physicians, nurses, pharmacists, social workers, and everyone else involved in the patient’s care, don’t have to wait every three to six months for a review of the data. We see the data today—this hour.

If someone shows up with a conflicting set of prescriptions, or an event that the primary care physician didn’t know about, you want to find out about that right away, and find out what’s happening and what’s wrong. Looking back at trends is important in terms of a future planning perspective, but in terms of what is happening with the patient right now, especially those who are at risk, you want to have that information right now—today, tonight, this hour—and do something about it.

Dr. Merkin’s next question after he talks with physicians about a patient is, “So you know this information, and what are we doing about that right now?” It’s much different than the traditional fee-for-service system where the data just isn’t available to the provider at the level until much later.

What are your thoughts on the recent policy developments on the ACO front these days? Are the government’s proposals to push providers into risk more aggressive than some would like?

Yes, it’s more aggressive than some would like. But this is not about what all of us would like; it’s about how you get to where things are optimal and most effective faster. If you fully embrace both the access to the resources, and the risk, and you are able to spend the money on the resources—in terms of changing the system, changing the way you do business, and not accepting the status quo—you can make a significant difference.

The one-sided risk models are a very important way for providers who may be uncertain to get started, but we are talking about managing a human being-based system of care. If you have no risk at all, how hard you work at something is different than if you have some risk. Providers always want more dollars to do something with, but you don’t get dollars if you aren’t in a position to do something materially different, and essentially guarantee that at least some of it will happen.

We still have a fee-for-service-based system and much of the value-based payments that health plans have moved to is a positive thing that has stimulated some change, but it’s paying you a year or a year-and-a-half later—maybe a little differently if you happen to administer a result as a bonus—but you are still getting that underlying fee-for-service payment. If you are in a one-sided model, it masks and slows down how quickly you get to what could be done if you had more of the resources.  

How have you and your colleagues been able to change the physician culture, in terms of moving physicians to a new understanding of what’s going on in healthcare?

In Heritage’s markets where the models are most mature, it’s a combination of physician groups where the doctors are employed, as well as significant numbers of independent practices and smaller offices in the community, and we can blend those. But the physicians individually are not at personal material downside risk. There is an organizational structure that manages the money that comes in when we are fully at risk, but regardless of whether they are employed or an independent practice, they are all tied to a payment at the individual physician level.

That’s one of the things that is missed in the whole conversation over providers being put more at risk—an individual practice office with a few thousand patients is not in a position, actuarily, to accept all that risk. You have to be partnered with some kind of system.

In our instance, in our most mature markets, it’s a blend of employed physicians and independent practices, but in some markets all we have are independent practices. So we can do this if we surround them with the infrastructure if you aggregate enough members from the plans that give you an actuarily valid risk base, and then you have the money up front, so you can help them with information and give them information faster. Then, they can do good things for their patients faster.

What advice can you give to others who are just starting out on this journey?

I [wouldn’t] sit and stew about how difficult it is to be in your position and be surrounded by all these regulations and requirements that can become tough to manage. You can talk about that all day, but it’s ultimately the people’s money and they are asking for better quality, better service and access, and more moderated costs. The only people that can ultimately change things on all those fronts, for the better, are provider organizations—predominately those led by physicians.

But we cannot afford to take decades to make the next set of changes, unless we want government intervention that breeds mediocrity as a result. Physicians and providers should lead this change, and moving this faster will bring the best things for their patients in the long run. Demand more of the dollar in your control immediately, and in order to do that you have to have the structure around you and the willingness to accept responsibility for that dollar. We are trying to show people out there that you can partner with others, and it’s possible to get net better across these factors if you enable the physicians to manage more of the dollar from a clinical perspective, to the patient’s benefit.

More From Healthcare Informatics


Are Disruptive Forces in U.S. Healthcare Accelerating Now? Notes on the Now-Approved CVS-Aetna Deal

October 10, 2018
| Reprints
The DoJ’s approval of the CVS-Aetna merger signals a new phase in the healthcare business world—and it’s time for patient care executives to rethink the meaning of competition

As Associate Editor Heather Landi noted in her news report Oct. 10, on Wednesday, the Department of Justice (DoJ) approved a proposed $69 billion merger between CVS Health and health insurer Aetna, after Aetna entered into an agreement with the Department to divest its Medicare Part D prescription drug plan business.

“The deal,” Landi wrote, “is the latest in a wave of combinations among healthcare companies, including many pharmacy benefit manager (PBM) and insurer integrations. Last month, the Justice Department approved Cigna’s $67 billion takeover of Express Scripts. CVS Health announced in early December 2017 its intention to acquire Aetna in a $69 billion-dollar merger, marking the largest ever in the health insurance industry. Woonsocket, R.I.-based CVS operates the nation’s largest retail pharmacy chain, owns a large pharmacy benefit manager called Caremark, and is the nation’s second-largest provider of individual prescription drug plans, with approximately 4.8 million members. CVS earned revenues of approximately $185 billion in 2017. Aetna, headquartered in Hartford, Connecticut, is the nation’s third-largest health-insurance company and fourth-largest individual prescription drug plan insurer, with over two million prescription drug plan members. Aetna earned revenues of approximately $60 billion in 2017.”

As Reed Abelson wrote in a report in Wednesday’s New York Times, “The approval marks the close of an era, during which powerful pharmacy benefit managers brokered drug prices among pharmaceutical companies, insurers and employers. But a combined CVS-Aetna may be even more formidable. As the last major free-standing pharmacy manager, CVS Health had revenues of about $185 billion last year, and provided prescription plans to roughly 94 million customers. Aetna, one of the nation’s largest insurers with about $60 billion in revenue last year, covers 22 million people in its health plans.”

And, while executives from the two mega-companies assert that this merger will allow them to better coordinate care for consumers, while also better controlling costs, some consumer advocates believe that the opposite could actually take place—that consumers could lose both choice and reasonable medication costs. “This type of consolidation in a market already dominated by a few, powerful players presents the very real possibility of reduced competition that harms consumer choice and quality,” George Slover, senior policy counsel for Consumers Union, an advocacy group, said in a statement. “The combination of CVS and Aetna creates an enormous market force that we haven’t seen before.” The consumer organization, the Times report noted, had opposed the Aetna-CVS merger, arguing that people enrolled in Aetna health plans could be forced to seek care at CVS retail clinics, and that those who were not insured by Aetna could pay higher prices for drugs than those who were.

Meanwhile, what fascinates me in all this is the potentially accumulative impact of all the various disruptive business combinations that have been emerging in U.S. healthcare—not just CVS/Aetna, but also the Amazon/Berkshire Hathaway/JP Morgan Chase collaboration on healthcare costs and other challenges; Wal-Mart’s interest in potentially acquiring Humana; and the forays into consumer-facing healthcare IT on the part of Google and Microsoft.

All of these business deals, collaborations, and potential connections involve either “interspecies” combinations, or forays into new areas on the part of companies from outside those core business areas. And that should concern traditionalist-thinking leaders in patient care organizations, especially senior executives in tradition-bound hospitals and health systems, who have historically thought about competition as being direct hospital organization to hospital organization competition. With all sorts of non-traditional business combinations emerging, that kind of thinking ends up being not just limiting, but potentially debilitating.

The reality is that every part of the policy, business and operational landscape on which hospital-based organizations is now in motion—at the same time. Physicians are coalescing into ever-larger multispecialty physician groups, some of them affiliated with hospital-based integrated health systems, but many of them totally independent. Health plans are acquiring physician practices, and are, in many markets direct competitors with hospitals in the acquisition of those practices. Health plans are also continuing to consolidate among themselves. Employer-purchasers are eliminating the health plan “middleman,” and setting up direct contracting with some of the largest and best-known nationally branded patient care organizations; and on and on.

I wrote last year about attending a fascinating session on employer direct contracting that took place at the World Health Care Congress in Washington, D.C. last spring. Employer-purchaser executives talked with great enthusiasm about such contracts. One executive, representing the nationwide Lowes home improvement retail company, shared his enthusiastic response to contracting directly with the Mayo Clinic, to bring patients from places as faraway as Montana and Mississippi, to Cleveland, for total joint replacement surgeries, at scale.

I quoted Bob Ihrie, who had recently retired as senior vice president, compensation and benefits, at the North Wilkesboro, North Carolina-based Lowe’s Companies, about that contracted relationship. “As Ihrie noted, for an extremely far-flung self-insured employer like Lowe’s, with its 1,800-plus home improvement stores spread across the U.S., doing what the Chicago-based Boeing Corporation, with its massive plants in Washington state, California, Missouri, and South Carolina, and its ability to build bricks-and-mortar corporate medical clinics in those locations, the options for Lowe’s are rather different,” I wrote. “Thus, the desire to create systems to improve their patient outcomes for their covered lives, and improve costs.” Indeed, I wrote that Ihrie told that World Health Care Congress audience, that, “The quality results have been so overwhelming that for Lowe’s for 2017, if you elect not to go to a center of excellence, you need a mandatory second opinion, and if it doesn’t approve, you won’t be covered.” He further noted that “Wal-Mart actually mandates travel to a center of excellence.”

In other words, the old thinking among hospital organization senior executives—to think primarily about market competition as being illustrated by the fact that the hospital down the road is building a new facility—is hopelessly outdated at this point. Indeed, it’s time to consider that market competition may now mean a major nationwide retailer with a strong local presence, compelling its employees and their family members to fly across the country to a patient care organization with national branding and presence, rather than to one’s own facility, or to the facility down the street.

In short, it’s time for hospital executives to think very differently about what market competition and market disruption might mean for their organizations. It’s time to start playing three-dimensional chess.

And I haven’t even discussed the role that consumer-facing technologies, many of them spread through online apps and wearable technologies, will begin to play in all this. That adds yet another cross-hatch factor to this entire discussion.

So it’s time for healthcare executives to rethink the very definition of market competition, and to think in unprecedented ways about market disruption; because this DoJ approval of the CVS-Aetna merger should absolutely be taken as a sign of things yet to come.




Related Insights For: Value-Based Care


At the HIT Summit in Raleigh, a Health Plan Executive Points to the Future of Value-Based Care

October 8, 2018
by Mark Hagland, Editor-in-Chief
| Reprints
Speaking at the HIT Summit in Raleigh last month, Humana’s Ben Lunsford offered attendees insights into the future of value-based healthcare, and his health plan’s future intentions

Speaking at the Health IT Summit in Raleigh, held September 27 and 28, and sponsored by Healthcare Informatics, Ben Lunsford, vice president, value-based strategies, at the Louisville-based Humana, offered attendees insights into the future of value-based healthcare and the trajectory of value in the current U.S. healthcare system.

Lunsford spoke on the topic “Humana’s Value-Based Strategy,” on Friday Sep. 28 at the Summit, which was held at the Washington Duke Inn & Golf Club, on the campus of Duke University, in Durham. As of 2014, according to the Wikipedia entry on the company, Humana had over 13 million customers in the U.S., and 41,146 employees as of 2018, and net income of $2.448 billion on revenues of $53.767 billion, in 2017.

Lunsford, who is based in Birmingham, Alabama, and has been at Humana for 14 years, focused on the company’s Medicare Advantage (Medicare managed care) business, which encompasses 3.5 million members; in addition, the health plan counts 1.5 million commercial group members and 9 million military members.

As Lunsford shared in his presentation, “Value-based care is different from the current fee-for-service (FFS) model of care, which simply pays for the number of services a patient receives. These services include physician and hospital visits, procedures and tests. While value-based care pays physicians for these services, it also includes more pay for meeting quality measures, coordinating care, preventing repetitive treatments, controlling overall costs and improving health outcomes.”

Lunsford proceeded to share with his audience the Primary care Value-Based Continuum model that Human has been executing, in its contracting with primary care physicians. It consists of four stages of development, with intensifying contracting features from one to the next. In order from least to most advanced, they are: the “Star Rewards” program, model practice program, medical home program, and full-value program.

In the Star Rewards program, primary care physicians have their outcomes evaluated using HEDIS-based quality metrics, with an annual payout benefit calculated in terms of a percentage of claims opportunity. In the model practice program, both HEDIS-based quality metrics, and clinical measures developed by Humana medical managers, are employed, and the rewards to primary care physicians involve a quarterly shared savings opportunity. The medical home model involves primary care physicians working in medical groups that have received some official form of recognition as patient-centered medical homes; those physicians are eligible for a PMP (per member per month) care coordination opportunity, with increased financial incentives. And finally, the full-value program involves monthly PMPM global capitation.

The Star Rewards Program this year has been using very well-known measures, such as breast cancer and colorectal screening rates, nephropathy screening rates and hemoglobin a1c control measures for diabetics, medication adherence rates for hypertensives, etc. PCPs are asked to meet six of nine NCQA (National Committee for Quality Assurance) HEDIS (Healthcare Effectiveness Data and Information Set) measures; practices that achieve that goal receive a 12-percent bonus paid annually.

Meanwhile, incentives accelerate both in terms of amounts of money, and pay schedules, as PCPs move into more advanced programs. Those in the Model Practice Program who meet quality measure standards (which are more extensive and include a readmission rate measure) receive $8 PMPM quarterly. Then, as they advance to the Medical Home Program, PCPs can participate in shared savings with Humana. And of course, for the PCPs ready to advance to the most advanced model, full capitation, those physicians will be participating in a model that is continuous in payment differentials.

Humana is also developing bundled payments in specific areas of specialty care, beginning with total joint replacements.

Speaking of all these models, Lunsford told his audience, “The patient experience of healthcare can seem fragmented. It can be frustrating for the health consumers. Ultimately, care delivery needs to be integrated rather than episodic, and focused on coordinated care and overall population health. This transition from volume to value is critical in enabling the shift to this integrated healthcare model, which… will allow us to have a sustainable healthcare system.”

It is of course no accident that Lunsford put the main focus of his comments on primary care physicians, who, he said, have the most influence on the health outcomes of patients. “Outside of direct care,” which itself is a huge part of all of this, he noted that PCPs “have an amazing amount of influence on the integrated care model; they’re the ones deciding which specialists to send patients to; providing needed prescriptions; educating patients on wellness. They’re our quarterbacks of care.”

That said, he continued, “Meanwhile, likewise, the patient has an amazing amount of influence on their own care. They’re the decision-makers. They’re deciding to engage in wellness and disease management programs; they’re deciding to be with a payer or a provider, based on the care they get. It’s absolutely critical to making the integrated care model succeed. And lastly, as a health plan, we bring an amazing amount of resources to the table, including a considerable amount of data. With that data, our historical picture of a transactional relationship is changing. We’re developing data to help physicians; we provide care referral and insights to physicians; and we can provide health and disease management programs, and care delivery options for where patients want to receive care, which oftentimes, is in the home. So we all bring something to the model.”

Though most of his time was focused on primary care physicians, and secondly, on plan members/patients, Lunsford did share about Humana’s new program, initiated on January 1, focused on hospitals, its Hospital Incentive Program. As described in his presentation, “The Humana Hospital Incentive Program (HIP) provides hospitals with an opportunity to participate in a value-based program that recognizes hospitals’ continuous patient improvement efforts, via earned annual incentive.”

The program provides annual incentives for hospitals based on performance in the areas of patient experience, patient safety, and patient outcomes. Among the specific measures included are a hospital’s HCAPHS (Hospital Consumer Assessment of Healthcare providers and Systems) scores; healthcare-associated infections; care coordination; palliative care; readmission rates, and average lengths of stay. The various measures are individually weighted, collectively totally 100 percent of the eligible incentive.

“We’re not only experiencing a seismic shift in the approach to integrated care, but also in the way we reimburse for it,” Lunsford told his audience, as he explained Humana’s value-based payment program. Meanwhile, he added, “Brand loyalty is another component of value. We make as consumers a choice around value in every purchase we make.”

Indeed, Lunsford said, “Humana’s primary care value-based continuum is truly the cornerstone” of the company’s strategy. And he noted, it is purposely “structured as a continuum: participants can move into the model. From Star rewards, to model practice, to medical home, to full value. As providers progress down that path. Each program builds upon the previous one. Star rewards just starts with quality; that continues forward into the other stages.” What’s more, he said, “This ability to enable and encourage, but not mandate, progression down that path to full value, is something that we find very valuable.”

Meanwhile, after explaining about the measures being used in the health plan’s programs, Lunsford said, “I often hear, why can’t payers get together and focus on the same set of measures? Wouldn’t that be a perfect world? I agree. But we seek guidance and counsel from many providers. And we also look at things like prevalence? Is a particular condition prevalent? We look at the PCP’s ability to impact the measure. And we look at things like our ability to measure. You’ll notice on the right that some of the measures are relatively binary. Did something occur or not? That is one factor. Also, the priority CMS places on us from the point of health plan scoring, influences us, too.”

Further, he said, “Let’s talk a little bit about how we set payment models. There’s a value placed on the achievement of certain measures. And it’s a delicate ballet between behavioral, actuary, and our clinical leaders, to determine what the best amount is that we can set. Second is the competitive element. If we pay you a dollar for something and Blue Cross or Aetna pays you five dollars, who will you focus on?”

Meanwhile, Lunsford noted of the model practice program, whose participating physicians are delivering care to 37 percent of Humana’s Medicare Advantage population, “Each measure has an incremental dollar amount assigned to it.” What’s more, he noted, elements such as ER utilization, readmission rate, and patient experience, that are being measured. Meanwhile, the measures used in the medical home program, the next step up, match those measured in the model practice program.

When it comes to medical specialists who contract with Humana under Medicare Advantage, they can participate in bundled payments around total joint replacement; and specialists participating in commercial insurance with Humana can participate in a maternity program.

As for the Hospital-Incentive Program that Humana launched in January, Lunsford noted, “We partnered with the Joint Commission on developing this model and a couple of its measures. It centers around the patient experience, patient safety, and patient outcomes, with, as mentioned above, six key measures: HCAHPS score; healthcare-associated infection; care coordination; palliative care; readmission rate; and average length of stay.

“We continually evaluate the care our members are receiving through value-based payment models,” Lunsford told his audience; and Humana executives plan to “aggressively” push value-based payments going forward. Meanwhile, he touted the fact that “Sixty-six percent of our Medicare Advantage members are now in some sort of value-based arrangement.”

Following his presentation, Lunsford spoke with Healthcare Informatics Editor-in-Chief Mark Hagland. Below are excerpts from that interview.

Can you say what percentage of all members are in value-based arrangements?

We don’t publish that number; but we can provide the number of members we have on the commercial side.

Understandably, much of your presentation focused on your arrangements with primary care physicians. Can you speak to your goals around contractual arrangements with hospitals?

The tie for us between a member or patient, the one responsible for care in value-based models, is the primary care physicians. To be sure, that PCP can be employed by or affiliated with a hospital or integrated health system, and we’ll still interact with that physician in the same way.

Can you speak to changes in the physician culture that are making physicians more amenable to entering into value-based contracting arrangements? Do you see progress accelerating?

Yes, I think so. Just by the sheer fact that we have 66 percent of our Medicare Advantage members in those value-based arrangements, shows that this concept of value-based is not going away; and it’s becoming more solid.

Are physicians more hip to what’s going on than a few years ago, in terms of the trajectory of the overall healthcare system?


Can you speak to physicians’ preparedness to participate in measurement programs?

There is a wide array of capabilities in that space. And as a payer, we have to be able to meet those providers where they are in that capability space. Our Carebook team manages that digital interface.

Can you speak to physicians’ success, to date, in working with you in those measurement arrangements?

An early understanding of where their opportunity is, in terms of quality improvement—understanding where those gaps exist, and the tools that exist to address those gaps, early on as possible, is the most important element.

In what direction do you see your programs heading, over time?

We’d love to see an increase in participation, even at 66 percent now. We want all the groups in those programs to be successful. All three of us—the patient, the provider, and the health plan—all win, when they’re succeeding in these programs. So, growth, success, and I would say, expansion; so as we look at other value-based models, that’s a critical focus for these programs.

Can you say a few words about the hospital-based program?

Yes. This is our first program we have focused on improving quality delivered in the inpatient setting. Incentive arrangements are relatively new, and of course, new to Humana. Our number-one goal there aligns with the goals of our primary care programs, and that is being focused on hospitals succeeding in all the measures we’ve stablished in the program.

Can you say how many hospitals are participating so far?

We’ll release that number soon.

Is there anything you’d like to say to the healthcare IT leaders in our audience?

Recognizing the capabilities and influence that we all have in interacting together to help this model succeed, that’s crucial. The cooperation of everyone to help drive success, is critical.




See more on Value-Based Care