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Crossing the Atlantic—and Embracing this Global Moment in Healthcare

December 15, 2016
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Attending the World of Health IT Conference in Barcelona last month provided reminders of the universality of many health system challenges

There is absolutely question that U.S. healthcare is in a state of great ferment these days. The shift from volume-based payment systems to value-based ones is well underway, with accountable care organization (ACO) programs, both federal and private ACOs growing by the day in number and scope, and with population health management and enhanced primary care initiatives moving ahead by leaps and bounds. Meanwhile, with healthcare costs continuing to rise, and with public and employer healthcare expenditures growing by the day, hospitals, physicians, and other providers in the U.S. are inevitably facing a variety of combinations of pay cuts and an ongoing, accelerating shift towards value-based reimbursement, going forward.

What’s more, the foundational dynamics underlying these changes are only accelerating: an aging population, an explosion in chronic illnesses of all kinds, but especially those related to obesity and poor lifestyles, and exploding costs related to advances in medical technologies and pharmaceuticals. Taken together, they portend a kind of “perfect storm” facing United States society. As I’ve referenced in a number of articles and blogs this year, the Medicare actuaries estimated back in July that total U.S. healthcare expenditures had reached $3.3013 trillion in 2014 and 17.5 percent of gross domestic product, but further, will grow to $5.631 trillion and 20.1 percent of GDP in 2025. In other words, a 70 percent increase in a decade. And as everyone knows, we as a country are struggling to pay for the healthcare system we have now, let alone one costing 70 percent more (and with fewer younger taxpayers to support the increasingly expensive system over time).

All of this is concerning—even alarming—of course. And really, anyone who is awake and alert should be concerned about all of this. But the reality is that this set of challenges extends far beyond the United States. Indeed, virtually all of the western European nations, as well as such advanced, industrialized nations as South Korea, Japan, and Taiwan, and, increasingly, nations like China and India, which have growing middle classes (whose members are also eating more and more processed and fatty western foods), and which are beginning to see their populations move into the age curve as well, are facing these challenges. As some demographers and sociologists have noted, as industrialized societies advance, their fertility rates decrease, creating a growing “upside-down pyramid” problem that has policy experts in many countries worried. Interestingly, it is Italy, historically and stereotypically perceived as a society of large families, now has the lowest replacement factor of all the western European countries, at 8.4 per 1,000 people, as this Telegraph of London report notes. At that rate, people in Italy who are dying are not being replaced by newborns, meaning that Italian society is headed towards a crisis of social services, as people become older and require more healthcare and other services, and the burden for supporting that country’s social welfare system, including its healthcare system, falls on fewer younger, healthier people.

That’s why it was particularly fascinating to participate in the World of Health IT (WoHIT) Conference in Barcelona in November, sponsored by the Berlin-based HIMSS Europe, a division of the Chicago-based HIMSS (Healthcare Information and Management Systems Society). Not that anyone should derive satisfaction from the fact, but it was strangely heartening to learn that virtually all of the western European societies are struggling with the same core problems facing us in the United States.

True, the governmental systems and national healthcare systems of western Europe are different from those of the United States, in very significant ways. And the same goes for many of their societies. For example, the Nordic countries—the Scandinavian countries of Norway, Sweden, Denmark, and Iceland, plus non-Scandinavian Finland—enjoy broad social and cultural homogeneity with relatively small populations, strong overall sociopolitical consensus around the idea of a progressive and encompassing social welfare state, and single-payer healthcare systems. At the same time, all of those countries are experiencing the aging problem that Italy has; and all have significant levels of chronic illness, as well (though none have the rates of chronic illness that the United States has, and none have levels of adult or child obesity comparable to those in the U.S.).

So the need to figure out how to reaching population health solutions is great in the Nordic sphere, as it is in the U.S.  And thus, it was excellent to be able to sit down with Jaana Sinipuro, whose title is leading specialist in the Digital Health Hub at SITRA, the Finnish Innovation Fund, a Finnish public organization sponsored by the Finnish parliament that sponsors innovative work in social welfare services, education, and technological development. Sinipuro is helping to lead the architecting of what is known as “Isaacus—the Digital Health Hub.” The Isaacus initiative is preparing to collect health status and health data from across all relevant databases in Finland—not only those from the provider sector of Finnish healthcare, but also from social welfare agencies and other sources—in order to improve the capabilities of researchers to uncover social welfare and health status patterns across Finnish society, and therefore support the development of new policies and programs to address issues such as chronic disease and the social determinants of health in that country. As Sinipuri told me on Nov. 26, the Isaacus initiative is creating a national data protocol (another version of this already exists in neighboring Estonia), which will collect data of all types, from all sources, on the Finnish population, in order to proactive engage in analytics that can help improve the healthcare—and health—of all Finns.

“Why Finland, and why now? We believe that there are several elements that are positioning Finland optimally for this work right now,” Sinipuri told me at WoHIT. “First, we have a relatively small population, of a little over 5 million people nationwide, and it is a population with an isolated gene pool. Second, we already have a biobank law that was passed in Finland in 2012 and went into effect in 2013 [read about that law, the Suomen Biopankit, here]. Third, all Finns already have a national personal ID, which makes data collection easier. And fourth, we already have exceptionally extensive, high-quality data, being collected, and available to researchers, across numerous fields of endeavor, now, in Finland.”

So, for American healthcare leaders who struggle a bit to frame all this for themselves conceptually, it is worth remembering that Finland’s population of a little over 5 million is closer to that one of the larger cities—or smaller states—in the United States. And that makes it easier to understand a national database in Finland, as there are U.S. states that are beginning to approach aspects of what is happening in Finland. So really, given an adequate level of social and political consensus—something all the Nordic societies have in abundance—it would be possible to imagine the Isaacus initiative being replicated in the U.S. And that is heartening.

Meanwhile, it was equally excellent to sit down with Vincent Moncho Mas, the next day, at the Centre des Convencions Internacional in Barcelona, during WoHIT, and to hear about the groundbreaking things he and his colleagues are doing in Valencia, Spain. As Moncho Mas, the CIO the Hospital de Dénia/Marina Salud S.A., in the suburb of Valencia called Dénia, told me on Nov. 27, he and his colleagues are providing care to a defined population in the Valencia region for an annual capitation rate of €720 per person per year, or $763.20 PPPY at the euro-dollar exchange rate on the date I interviewed him—in other words, in U.S. managed care terms, a per-member, per-month (PMPM) cap of $63.60. What’s more, as he shared with me, Hospital de Dénia/Marina Salud’s population includes a fair number of seniors, including “snowbird” British, German, and Dutch citizens who winter in the Valencia area and who, as European Union citizens, have the right to access healthcare anywhere in the EU—with a significant percentage of those northern European part-time residents having the same chronic illnesses that American seniors have, most particularly diabetes.

So Moncho Mas and his colleagues are engaging their covered-population members using some of the same patient engagement strategies as are their U.S. counterparts, including via a patient portal, secure direct messaging, and the Spanish equivalent of OpenNotes. Speaking of the organization’s patient portal, Moncho Mas told me that “The patient portal is the highway; it is the door that we open to our patients for channeling their clinical information. And it’s quite important to have this portal, with some standard functionality, such as access to clinical notes, to records, lab results, radiology, etc.,” he told his audience. “It’s quite important to share this with the patient. Of course, we also need to support mobile apps. We need to give all the information not only on a web platform but also through a mobile platform, because patients always have phones with them, but not laptops.”

It was also my honor to moderate a discussion of the Nordic Community Workshop on the Sunday of the conference—in which health information exchange was a major topic; and to moderate an international discussion of healthcare data and IT security on Monday, which absolutely reminded me of how global that set of challenges is right now.

Does any of this sound familiar? It really should. The reality is that, in spite of differences in their governments and the national healthcare systems, the United States and western Europe have a tremendous amount in common. And we, on both sides of the Atlantic, can learn a great deal from each other. What’s more, there is tremendous diversity within individual European nations, as well as between and among them, just as there is in the U.S. between different local healthcare markets and regions. And sometimes, in that regard, one encounters surprises. For example, Moncho Mas told me that, as much as an educated American might assume that certain types of technology adoption would be more common—and more advanced—in, say, Germany, than in Spain, the reality is that some Spanish patient care organizations and healthcare regional authorities have created broader collaboration, including in terms of clinical IT, between inpatient and outpatient care environments, than is common in Germany, where inpatient and outpatient physicians retain a strong operational separation.

Collaboration across entire regions was certainly a major theme of the presentation of Juan Lucas Retamar Gentil, CIO of the Sistema Sanitario Público y de Bienestar Social de Andalucía (Andalusian Health Service), a regional health authority that encompasses one of the largest regions of Spain. Retamar Gentil and his colleagues have been working to improve healthcare delivery, following principles of equity, accessibility, and transparency, across Andalusia, one of the largest regions of Spain. Retamar was one of four senior healthcare CIOs whom I heard speak about their initiatives on the first full day of the conference, the others being Olivier Boussekey, M.D., CIO of the Groupe Hospitalier Paris St. Joseph in Paris, France; Antonio Fumagalli, CIO of ASST Papa Giovanni XXIII in Bergamo, Italy; and Philippe Kolh, M.D., CIO of the Centre Hospitalier Universitaire de Liège (University Hospital of Liege), in Belgium.

Listening to all of these CIOs and other healthcare leaders speak of their challenges and opportunities absolutely brought home to me the universality of many of the core challenges—and opportunities—facing healthcare and healthcare IT leaders on both sides of the Atlantic. I also heard from healthcare leaders from countries outside western Europe, including from leaders from Latin America, who face challenges at least as significant—and in many cases considerably more significant—than those faced by healthcare leaders in the U.S. and Europe. In any case, looking just as the U.S and Europe, it is clear how very much we all have to learn from one another, and also to be reminded once again how many great case studies there are from numerous countries and healthcare systems.

I look forward to learning about and reporting on innovations from around the world, and I know that my fellow editors at Healthcare Informatics do as well. This is such an important moment for healthcare—in the United States, of course, but all over the world, too—and it is a great time to keep our perspectives and our radar screens as broad as humanly possible, because cross-fertilization can be—and I am confident, will be—an important element in global advancements in healthcare policy, delivery, and operations, in the coming years. So, let’s welcome this global moment in healthcare, for everything we can learn from each other, and from it.

 

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On Staten Island, a Highly Innovative Program That's Redefining What’s Possible Under Medicaid

September 17, 2018
by Mark Hagland
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Healthcare leaders on Staten Island have been achieving exciting success in care management and population health management in their community’s Medicaid and uninsured populations

Even as one hears constant complaints and concerns about the challenges facing healthcare leaders who are attempting to help shift the U.S. healthcare system from volume to value, more and more truly encouraging stories are emerging about pioneering organizations that absolutely are moving the needle, in the present moment. One of those encouraging stories absolutely revolves around the Staten Island Performing Provider System (SI PPS), a unique organization whose leaders describe it as a “Medicaid redesign program implementation enterprise.” Under the leadership of Joseph Conte, Ph.D., CPHQ, its executive director, SIPPS has been forging a path forward around robust population health for Medicaid recipients on Staten Island, the New York City borough that is the by far the smallest in population (479,000, compared to Brooklyn, at 2.6 million in population) yet third-largest in land mass, among the city’s five boroughs.

The Staten Island Performing Provider System has been participating very successfully in the Delivery System Reform Incentive Payment (DSRIP) program under the aegis of the federal government. What is involved in New York State’s DSRIP? As NYSDRIP’s website notes, “DSRIP is the main mechanism by which New York State will implement the Medicaid Redesign Team (MRT) Waiver Amendment. DSRIP´s purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25 percent over five years. Up to $6.42 billion dollars are allocated to this program with payouts based upon achieving predefined results in system transformation, clinical management and population health.” The federal Centers for Medicare and Medicaid Services (CMS) approved New York State’s Medicaid waiver requested in the amount of $8 billion over five years, in April 2014.

And SI PPS manages the care of 130,000 Medicaid recipients on Staten Island, in addition to managing the care of 50,000 uninsured Staten Islanders.

According to SIPPS leaders, “Staten Island Performing Provider System (SI PPS) is an alliance of clinical and social service providers focused on improving the quality of care and overall health for Staten Island’s Medicaid and uninsured populations, which include more than 180,000 Staten Island residents. We are co-led by Staten Island University Hospital and Richmond University Medical Center. Our network of over 70 partners includes skilled nursing facilities, behavioral health providers, home health care agencies and a wide range of community-based hospitals, clinical facilities, treatment centers, social service and community organizations, primary care physicians and medical practices across the island. SI PPS is expected to bring more than $200 million to Staten Island over 5 years if successful in transforming our care delivery system. Our mission is to engage partners and stakeholders in the planning and implementation of DSRIP as we move towards a value-based payment model for Medicaid in New York State.”

Among the goals that SI PPS leaders have set for themselves:

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> Develop an infrastructure that lays the foundation for delivery system reform by transforming the Staten Island community through investment in technology, tools, and human resources that will strengthen the ability of providers to better serve our community

> Improve health literacy and share cultural competency knowledge

> Expand access to the appropriate level of care for all patients, including reducing barriers to care

> Expand outpatient and community services including home care, ambulatory detox, behavioral health/substance abuse, and primary care to reduce avoidable hospital/emergency department use on Staten Island

> Improve coordination of care and develop an integrated network

> Improve care management and disease management for high-risk patients, including patients with chronic conditions and behavioral health diagnosis

> Improve population health by addressing social determinants of health

> Integrate technology to allow for the secure exchange of health information across the PPS

> Reduce the per person cost for providing care

> Engage the uninsured, and underutilizing/low utilizing Medicaid patients and connect them to primary care and social services

> Implement innovative and evidence-based care models throughout the care continuum

> Implement training programs and learning collaborations between PPS partners that allow for the sharing of best practices

SI PPS leaders state that “These goals are being reached by implementing 11 DSRIP Projects, identified by a Community Needs Assessment, to address primary care, mental health, substance abuse, chronic disease, long term care, social determinants of health, and population heath.”

SI PPS leaders add that “We leverage a seamless platform that gathers data from multiple sources -- claims data, core reports, department of health information and the like -- and that data is inserted directly into the electronic data warehouse. With geo-mapping, we can identify areas that are lacking in key services. In creating maps of the population, we can filter in on specific conditions, and if we hover over a specific area within a specific map, we can see three years of claims data. We can figure out utilization trends, including hospitalization, medications, etc. We can also filter by demographics, types of chronic illness, etc.” Among the data sources they are make use of include direct data feeds from partners; lead providers’ clinical data; other partners’ clinical and billing data; data from care management partners; and public data; among other sources.

In addition, the SI PPS leaders have plunged into behavioral healthcare management. They note that they are pursuing “a population-health and community wide effort that aims to build capacity across systems by leveraging and developing partnerships to provide a quality integrated health care system, effective, high quality, person-centered care that supports improved health outcomes and optimal physical and emotional well-being. BHIP priorities focus on increasing and sustaining mental health/SUD provider service capacities, assisting community members to navigate behavioral health services, providing support to individuals and providers through education and technical assistance, addressing co-morbidities and co-occurring disorders, and reducing stigma and raising awareness about behavioral health wellness.” Among the numerous individual programs encompassed by the Behavioral Health Infrastructure Program (BHIP) are programs to expand the capacity of professionally certified peer workers in addiction and mental health, to help tackle the substance abuse program; the engagement of patients in the Emergency Department with substance use issues by clinicians and certified Peers to expedite linkages to behavioral health providers and reduce preventable ED visits; an innovative pre-arraignment diversion program designed to redirect low-level drug offenders to community-based health services instead of jail and prosecution; and numerous other programs.

Recently, Dr. Conte spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding the progress being made at SI PPS, and the implications of his team’s work for transformation across the U.S. healthcare system. Below are excerpts from that interview.

Can you explain the basic funding mechanism or model that is supporting your organization?

The New York State Department of Health negotiated a waiver with CMS, and received $7.2 billion over five years to fund the program. About 50 percent of that was guaranteed for pay-for-reporting and program implementation, and 50 percent was set up as pay for performance, so it is very much a pay for performance program. There are 6 million people on Medicaid, and the state spends $65 billion a year, and the federal government pays for half of that; that’s why it’s very much in their interest to fund population health; it pays dividends to everyone.

To take care of the entire Medicaid population on Staten Island?

It’s interesting. We do not pay claims or intervene on behalf of providers, with managed care companies. Our sole purpose is to create innovation and reach population health milestones with providers in the community. So the hospitals, nursing homes, FQHCs, physicians, continue in their payment systems. We exist solely to create innovation and to incent innovation. It’s very much a pay for performance program.

Tell me about some of the main programs that you and your colleagues have been involved in, around this work?

The main initiatives relate to creating integrative care models where we bring in behavioral health providers to work with medical providers and medical providers who work in behavioral health organizations, so people don’t have to shuttle around to access care. We’ve done a great deal in the prevention of avoidable use of EDs for medical and behavioral care; that’s down over 60 percent in the past three years. And a lot of that has to do with looking at data form multiple sources and identifying where initiatives should be implemented. So we have a very big focus on asthma and a very big focus on diabetes. And a lot of the work involves engaging patients with peer educators who suffer from these conditions themselves.

One of the biggest innovations has been doing this with people who have alcohol and substance abuse disorders. We have peers in the EDs 24/7; and the number of people who have engaged in treatment services has tripled in the past few years. We’ve paid the salaries for these individuals, we’ve paid their training, have paid them to go get certified; and as they’ve become certified, they’ve become hired by the organizations, because their services are actually billable. So it helps the individual, helps the patient care organizations, helps the community. And it all comes out of high-level data analytics, doing hot-spotting, geo-mapping, bringing in social determinant of health factors, looking at housing, crime statistics, poverty, graduation lists, things like that. So we’ve done things very fundamental to services, to healthcare services, but in a very smart way. The workforce transformation is also very important; we spend a lot of time and training preparing people for new roles.

What have your biggest lessons been learned so far?

I would say it is that the kind of collaboration that it takes to create transformation is something that people really want to do; but they need organizations like ours that can bring these high-level analytics and resources together. And that includes training to give people new education; as well as providing to organizations high-level opportunities to identify patients most in need. You know, you can hunt for ducks with a shotgun, but it’s not a good idea when you’re trying to conserve ammunition, right? So we’ve helped people put a fine aim on things that need to be worked on, and the community coalitions are very powerful; you can’t go it alone, so working with local governmental units is very important. Also, bringing in information form as many sources of information as possible essential. We bring in ambulance data, social determinants of health data, school data, community data; all are essential.

Have you done geo-mapping or hot-spotting? How did you figure out how to obtain those various types of data?

When we started up, we were a complete start-up; so we didn’t have any legacy systems. So we hired very bright IT people and analysts, and brought the right tools to bear so that we could really be focused on how the resources were applied; that was our core investment.

What advice would you offer the senior healthcare IT leaders in patient care organizations, including the CIOs, CMIOs, CQOs, chief data officers, etc., in terms of what they should think about around all of this?

I would tell them that turning data into business intelligence is critical, and that’s true with respect to everybody. For the medical people, it’s medical business intelligence; for the finance people, it’s financial business intelligence. Don’t get overwhelmed with data; use it to create good information for clinical and business practices, and that will allow you allow you to be successful.

What will happen in the next couple of years?

There are about 13 states that have Medicaid redesign waivers in place now; CA and TX have received extensions, and we’re hoping for an extension. We’re also looking for other opportunities to extend our work; we’ve set up an ACO. We’ve set up a form of consultancy as well.

Where do you hope to go in terms of accomplishments in the next few years?

The important thing is for us to do things that are sustainable in the community whether we continue on or not, and that’s a lot of the work we have done—it is to grow capacity in organizations in the community. And that’s why the workforce work is so important. When people have new skills and training and ability to bring change into their organizations, these certainly are sustainability factors that are important.

Is there anything you’d like to add?

I would say one thing that we’re spending much more time on now, is continuing to try to work in the behavioral health space, because especially in the Medicaid population, any number of people have co-occurring conditions—they have medical and behavioral problems. And these are the patients with the most problems and who need the most services. So giving them access to more services is important, but also being able to be more predictive about when they’ll need those services, so we can be smarter about it; that is really important.

 

 

 

 


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In Eastern North Carolina, an MD-Run ACO Shows its Success

September 10, 2018
by Mark Hagland
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Stephen Nuckolls, CEO of the New Bern, North Carolina-based Coastal Carolina Quality Care, shares his perspectives on why some physician-led ACOs are making huge breakthroughs on quality and cost

It’s not just in the well-known advanced managed care markets that the accountable care phenomenon is making progress these days; indeed, there are accountable care organizations (ACOs) whose leaders are pressing ahead, all across the U.S. Some leaders are operating ACOs in collaboration with private health insurers; a significant number are participating with the Centers for Medicare and Medicaid Services (CMS) in one of its several ACO programs.

One organization that has been making exciting strides forward in the Medicare Shared Savings Program (MSSP), the largest of the Medicare ACO programs, is Coastal Carolina Quality Care, an ACO based in New Bern, North Carolina, a community of about 30,000 people located about two hours east of Raleigh, that state’s capital, and an hour west of the Atlantic coast.  Coastal Carolina Quality Care is sponsored by Coastal Carolina Health Care, P.A., a multispecialty group practice located in New Bern, and which provides care to its community at 16 locations, involving 43 physicians and 20 allied healthcare professionals. Coastal Carolina Quality Care was created in April 2012 and chartered as one of the first 27 MSSP ACOs; it currently has 11,500 Medicare enrollees attributed to it.

Recently, Stephen Nuckolls, Coastal Carolina Quality Care’s CEO, spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding his organization’s ongoing journey into and through value-based healthcare delivery and payment. Below are excerpts from that interview.

Your organization has now been participating in the MSSP program for six years, correct?

Yes, that’s correct. We are ending our second contract cycle in December. We will renew, under the new proposed Pathways to Success regulations; there will be a six-month period where we’ll stay in our current track, but starting July 1 of next year, we’re planning to enter their Enhanced Track, the equivalent of their Track 3 under the current regulations. That includes downside risk. We’ve been in Track 1 Plus; we came into that starting January 1 of this year.

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In other words, you’re already taking downside risk?

Correct; it’s a limited form of downside risk based on the revenue standard. Eight percent of our Medicare fee-for-service revenue, is the maximum we’d have to pay back. The maximum gain would be 10 percent of benchmark, which for us would be $12 million.

What’s your sense of how your organization is doing in the program this year?

Well, for 2016, we achieved a little over 4 percent savings, and a little over 6 percent savings for 2017; and through the second quarter of this year, we were a little over 8 percent savings—so far.

That’s really great. What do you see as the secret of your success so far?

It’s hard to pinpoint any one thing. There are several things. Number one, it takes time for some of these strategies, such as population health, to pay off. Another thing that’s going on is that our care management program, I give credit for keeping our costs low and getting things in place. And in addition, we really made a lot of strides in our first contract cycle, specific to our market. All of our annual wellness visits and preventive care, we made our marks there and that positioned us well in our second contract cycle. And it just takes time, when you focus on the quality of care, for… when a greater percentage of your patients have their blood pressure under control, you’ll have fewer adverse events. And when you work to lower a1cs, that will avert events over time. And annual wellness visits, vaccinations, screening services—it costs money for screenings; and once you get things set up, that’s then in place. And care management services—when you go into your second contract cycle, you have some of those costs worked into your contract cycle the second time; so it takes time to achieve shared savings, and to get the staff to focus on the sickest population.

With regard to the electronic health record and data analytics, in the context of population health work, what learnings have you and your colleagues achieved so far?

Data analytics are key with this. We have a dashboard right in our Allscripts EHR. We’ve really used that dashboard, and we’ve used that module to track things; we’ve done things around opioid abuse disorder, and tracking things. Most people don’t associate that crisis with the Medicare population, but there is a good number of people on Medicare for disability. And we’ve really used our EHR to help track prescriptions, and to pinpoint patients to make sure they’re getting the right care and support. And with regard to point-of-care dashboards, we’ve just found those to be incredibly helpful. And focusing on tracking outcomes, at the individual physician level; doctors are competitive, so that helps. And we’ve used Allscripts’ reporting package that allows things to print out well and that works well in meetings, and that helps get the point across about how these numbers relate to the day-to-day practice aspects. That’s what drew us to the program: if you give good care to the patients and it keeps them healthier, it’s good for the practice’s bottom line.

What have been the most difficult challenges in the journey so far?

We’ve had many. One is around physician engagement. We did not achieve savings during our first contact cycle, and that was disappointing, because we felt we were doing a good job. So, maintaining engagement, and making sure we were making good investments in the program. Now, we have reached the point where we’re financially successful, and our projections are looking good for this next contract cycle. Some of it had to do with the vagaries and complexities of establishing this new benchmark. They’ve fixed a lot of those things.

Another challenge is around care management, just getting up to speed on chronic care management, and how to bill for that and set up that program, so it can show itself as a break-even center in a fee-for-service world, cost-justifying that, and training and educating, that was a real hurdle, but I’m proud of that now. It’s a little more than care management, some would call it practice transformation or team-based health. But there’s a lot about how to pay for setting all that up.

Many ACO leaders have commented on what’s popularly known as the “one foot in the boat, one on the shore” problem of having to manage both fee-for-service and value-based payment realities at the same time. Your thoughts?

We’re actually fairly fortunate in that we’re what Medicare considers a low-revenue ACO. Our doctors comprise a low percentage of the overall dollars. When we see patients and are keeping them healthier, we’re at least breaking even.

So you have low overhead, and that keeps you in a good position, in that context?

Correct. We do have our own processes, where we give certain kinds of injections, for example. Now that we’re looking at a 75-percent shared savings track—when you move from 50 percent to 75 percent, you get past what you’d call incremental revenue. You can really start to look at some of the internal costs. If you’re in a 50-percent shared-savings world, and let’s say we get paid $100 for an office visit; if you don’t do that office visit, you increase your shared savings by $50; but you have to look at incremental costs. For example, a shot of Porlea that costs $600. The point is that when you get to 75-percent savings, it makes the math a bit different in terms of your incremental costs of providing a service. You get closer to saying, if I can provide this drug or see the patient, it makes more sense to move to virtual visits or not always bringing the patient in for an in-person visit—when it’s someone we’ve seen three or four times recently and know the patient well—the doctor may handle it over the phone, for example. It changes the calculus as we go forward.

What should CIOs, CMIOs, and other senior healthcare IT leaders be thinking about, based on all of this?

As far as population health management and trying to get the numbers together, make it simple for the physicians to use; make sure they have enough resources at the point of care to use; and make sure you’ve answered the question of what’s in it for them to use it. So a CIO might buy a big, fancy system, and it’s wonderful, but the doctors may not use it unless they know what’s in it for them. Unless there’s an incentive for them to use it, the human behavior is, I’ll just generate as many RVUs as I can, as I’ve always done, and this slows me down. So I’d tell a CIO or CMIO to set up a system that’s simple, that encourages the physicians to use it, and provides incentives to use it. In some cases, we had to hire scribes.

And what has your experience with scribes been like?

It depends. In some practices, we’ve crashed and burned, and then some practices couldn’t live without them. It depends on the number of patients the doctor has, and their comfort level for having someone in the room. Our doctors with larger patient panels and not so particular about how their notes looked, FPs, they’ve done well with scribes; with general internists with smaller panels, they’ve had less success because there’s not so much of a need for it.

What do the next two years look like for you and your group?

I’d like to talk about Pathways For Success and this new rule that comes out: while it doesn’t change our decision-making too much, I think that the forcing of more groups into downside risk earlier, is a mistake, I don’t think it will save the treasury that much. There will be a study released next week by NAACOS [the Washington, D.C.-based National Association of ACOs] that will show significantly greater savings than what Medicare has shown to date. This study uses a methodology that MedPAC and the Innovation Center have used—they look at a matched cohort—and it will show almost twice as much savings in the MSSP than has previously been shown. It also speaks to the policy point—organizations are truly saving the government money, even if it doesn’t immediately show on paper. The evidence doesn’t support the idea that ACOs should be kicked out because they have a bad benchmark. The true savings to the Medicare Trust Fund will then be less. And that’s what they need to focus on, achieving true savings to the government.

And where will this appear?

I think it’s going to come out in Health Affairs. I’m familiar with it through NAACOS, which helped fund it.

 


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