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What Can Urban Areas Learn from Rural Hospitals?

June 27, 2017
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My father, who is now retired, chose to spend most of his long career as a certified registered nurse anesthetist working in smaller, rural hospitals because he preferred a small-town quality of life as well as being a part of a close-knit clinical team serving patients at a local community level.

Like many other rural healthcare professionals, he is acutely aware of the challenges—social, economic and cultural—that rural communities face that directly impacts the quality of healthcare and the health outcomes for people in those communities. In fact, at least one small hospital where my father previously worked, a medical center in Wharton, Texas, outside of Houston, closed its doors just last year. That 159-bed facility had, at one time, served as a regional hospital and a healthcare hub for the surrounding community.

Hospital closings are just one challenge that rural communities face even as the disparity in health status between rural and urban Americans continues to grow. Recent data from the Centers for Disease Control and Prevention (CDC) indicates rural Americans are more likely to die from the five leading causes of death—heart disease, cancer, unintentional injuries, chronic lower respiratory disease, and stroke—than residents in urban regions and that a greater percentage of rural deaths may be preventable.

During a recent webinar presented by the Commonwealth Fund, several rural healthcare leaders offered a more hopeful outlook for the future of rural health within the larger picture of the transformation of healthcare to value-based care. Titled “Banding Together for Population Health: New Business Model for Rural Hospitals,” the webinar first focused on the significant challenges facing rural healthcare—a higher percentage of elderly patients, a higher concentration of uninsured patients, as well as a higher poverty rate. Rural populations have less access to care with 39.8 physicians per 100,000 people compared to 53.5 physicians per 100,000 people in urban areas.

Looking at health status and behaviors, there is a higher percentage of smokers in rural areas as well as a higher prevalence of diabetes and coronary heart disease. The suicide rate among young men is also significantly higher in rural communities.

“Rural America presents a unique healthcare delivery environment—we have elderly populations, a sicker population, and a higher concentration with those at lower incomes, yet it seems that we have the fewest options available when it comes to seeking care. It’s a perfect storm,” Brock Slabach, senior vice president, member services at the National Rural Health Association, said during the webinar.

While this paints a dire picture, what was fascinating to me, and what the webinar really zeroed in on, was that despite these challenges, there are a number of rural healthcare systems that have become incubators for health system innovation. The webinar focused on how accountable care contracts and other value-based payment approaches can strengthen rural hospitals and enable them to innovate.

Slabach noted during the webinar, “Despite challenges, rural communities have begun to innovate, adopting the use of alternative payment models, and initiating delivery system reforms that help to address many long-standing issues that have plagued rural America: the workforce shortages, hospital closures, and a daunting reimbursement challenge for services that impact every rural provider of care.” With regard to alternative payment models and population health, he added, “Rural can lead in this effort; we have small, nimble facilities, with communities that are eager to rally behind change, and with the right leadership and technical assistance, we can be the leaders in this movement, showing urban areas how this movement can really make a difference in not only improving the quality of care but improving the population’s health.”

The National Rural Accountable Care Consortium (NRACC) is supporting rural health systems and hospitals in their journey toward accountable care. The first National Rural ACO was formed in 2013, and today the network organizes 6,000 providers in 164 hospitals in 23 Medicare Shared Savings Program (MSSP) ACOs [as part of the Centers for Medicare & Medicaid Services (CMS) MSSP ACO program], according to Lynn Barr, CEO and founder of Caravan Health and chief transformation officer at NRACC, who was also a speaker during the webinar.

“We’re in the process of signing up our 2018 cohort and are going to about double the number of rural hospitals, as we think 17.5 percent of rural hospitals are going to be in ACO programs next year, which I think is tremendous,” Barr said. “It’s been a very exciting process. In 2015, only 6 percent of our Medicare beneficiaries received annual wellness visits. In 2016, 24 percent of our Medicare beneficiaries received annual wellness visits. That’s the kind of change that really makes a difference.”

She added, “We’ve seen that every one of our sites have begun bending the cost curve—two-thirds have lower costs than the prior year, and one-third appear to be prepared for shared savings.”

During the webinar, two CEOs at rural hospitals, including a critical access hospital, shared their organizations' journeys into accountable care contracts and value-based payment approaches to improve care and population health.

Tim Putnam, CEO of Batesville, Ind.-based Margaret Mary Health, a 25-bed critical access hospital, said his hospital was in the original National Rural ACO in 2014 and that opportunity provided a pathway into population health. “Our board of directors and leadership team, in that 2013 time frame, really felt that the volume to value transition was the future of healthcare delivery. There’s no way with things like chronic care management that we cannot continue to go down the volume treadmill and be successful. So how do we move into that? We were very frustrated. We felt that from insurers and CMS, we were left out, because you had to have 5,000 lives to be a part of it,” Putnam said.

One of the valuable aspects of participating in the ACO is having access to Medicare data about beneficiaries served at the hospital, he said. “Before we got the data, we were really guessing, ‘What’s going on with this patients?’ How, with the Medicare data we can look at the patients and see where do we have the ability to improve cost of care and improve their lives.”

Putnam said one key learning from the journey so far is that what improves care is not medical; “it’s things like transportation, social services, behavioral health services, reducing a fall risk.” The hospital has been able to work with community partners to provide those services, he said. He continued, “And this fits to what we do well, and the fact that small communities can have a positive impact on the population. It’s a lot different than a large metropolitan environment, where they talk about population health, but they only have a small fraction of the population. In small communities, we have the population, so I think that has allowed us to be impactful.”

Lee McCall, CEO of Neshoba Hospital and Nursing Home in Philadelphia, Mississippi, discussed the impact of his health system’s 2016 MSSP participation as part of the Magnolia-Evergreen ACO, which consists of seven rural hospitals in Washington and Mississippi. Neshoba Hospital is a rural Prospective Payment System (PPS) hospital servicing a population of 28,000. McCall said by collaborating with other providers in the Magnolia-Evergreen ACO, the hospital was able get to a high level attribution that was needed for the Medicare population for the MSSP ACO program.

“What [participating in the ACO] provided to us was an opportunity to impact the health of our community, learn the new ways to practice in the value-based world to improve performance and remain independent. Without this program, we were looking at other opportunities, and certainly remaining independent was very important to us,” McCall said.

Through the ACO, the hospital has been able to effectively build its care coordination program and focus on population health. “We were able to gain access to data, as close as you can get to real-time data, to start making decisions and to really determine what was going on with the patients we were serving. Where were they going to get their care? What are the determinants of the high cost of care they had received? We could gain access to that information and start talking with them about better coordination of that care.”

What’s more, physician leaders were able to focus on process and clinical quality improvement. “By getting involved in this, it’s allowed that opportunity for us to drive quality and measure that quality and monitor it as we move along.”

McCall also shared projected 2016 financial performance figures for the ACO: for the seven rural hospitals, local hospital revenue went up 7 percent while seeing cost savings of 8.4 percent per Medicare beneficiary. Also, net patient revenue went up $30 million while saving Medicare $11 million, and inpatient revenue increased $13 million while saving Medicare $7 million, he said.

“That has been a great opportunity for us to get involved, to take control of our destiny and not be a passenger in the bus. I think from a rural collaborative approach, we have seen benefits in our community and its given us the ability to take charge and really transform the way we practice and effect the populations that we serve,” he said.

Despite all the challenges rural hospitals face, the strategies these two hospitals have employed to introduce new care models could provide a path forward for other rural healthcare providers, and for urban ones as well.

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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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Kerda DeHaan

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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