Want to Get Real about Change? Look at How FQHCs Are Moving the Needle on Care Access | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

Want to Get Real about Change? Look at How FQHCs Are Moving the Needle on Care Access

November 8, 2016
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North County Health Services physicians have come up with an ingenious solution to an indigent-care problem

It was great recently to interview leaders from North County Health Services (http://www.nchs-health.org/), a 13-clinic federally qualified health center (FQHC) organization based in San Marcos, California, which serves more than 70,000 patients spread across the North County region of San Diego County. I spoke last month with Patrick Tellez, M.D., the organization’s chief medical officer, and Denise Gomez, M.D., its clinical director of adult medicine.

As Drs. Tellez and Gomez shared with me, they and their colleagues have been leveraging information technology to overcome a common but very large and difficult obstacle facing FQHCs and other community-based clinics that serve indigent patients: the intense difficulty getting those patients specialist referrals, and then getting them to those specialists. At North County, as at most FQHCs, most patients are either on Medicaid (which in California goes by the name MediCal), or are uninsured. And not only are most specialists unwilling to see Medicaid and/or uninsured patients; even when specialists accept referrals from primary care physicians (PCPs) to see those patients, the patients often don’t show up, as they are plagued with problems such as lack of transportation, unstable living situations, and other challenges.

Given the difficulty of connecting their patients directly to specialists, Drs. Gomez and Tellez hit upon an ingenious solution: they partnered with the folks at the San Diego-based AristaMD, collaborating with them to test and market a platform that brings primary care physicians and specialists together. Essentially, using that platform NCHS’s primary care physicians can share their clinic notes with specialists participating in the AristaMD, who can remotely provide the NCHS primary care physicians with specialty consults, sharing specialist expertise with them and ensuring that they can better care for their patients.

Listening to Drs. Gomez and Tellez describe the challenges they face, and the path they’ve taken to address those challenges, what is absolutely clear is that, rather than trying to proverbially “boil the ocean,” they instead decided to tackle one discrete yet important issue facing their organization—how to improve care for their patients by regularly accessing specialty consults. They’ve been both idealistic and realistic at the same time: they are getting their patients what they directly need, which is the knowledge of specialists, while recognizing that consistently getting them face-time with specialists would be largely unrealistic.

Patrick Tellez, M.D.

This is an example of where leveraging information technology in a very precise way can really be impactful. “Being that we have a robust service in primary care to serve the underserved, the majority of our patients who have insurance are insured under MediCal, which is Medicaid in California,” Dr. Tellez explained in our interview. “That’s about 74 percent of our patients; that enrollment has grown substantially since the ACA. The challenge that we face is that, in California, reimbursement to private-sector physicians, is the third-lowest in the country. So that limits access to specialty care. And our population is one with a lot of deferred medical issues, even though they’re not very old. And they deserve specialty medical care, so the access issue has been a challenge. So we would make 2,500 or more referrals to specialty care in a given month, and only a small percentage would ever get seen. Access issues—the inconvenience of having to drive 30 miles, and also long wait periods. And people lack transport. And there’s the affordability if there are any out-of-pocket charges.”

And here’s the key element in all this. As Dr. Tellez described it, “I was introduced to AristaMD, and engaged them to produce a pilot. My hypothesis was that many of the referrals might involve a level of care that, with specialty guidance, could be provided in a primary care setting. We wanted to test that hypothesis, and we got funding that NCHS got from HRSA, which oversees all the FQHCs. So we took some funding we got as a reward for our clinical quality, and funneled into a pilot with AristaMD that would seek to define the applicability of electronic consulting, which we define as provider-to-provider consulting on patients, in a secure, asynchronous communication environment, and which allows a primary care provider to document specialty care recommendations as to care that can be provided by primary care, and that can be documented.”

And Dr. Gomez explained this in further depth, when she said in the interview that the portal “will help guide you before even doing a consultation. So if it’s a mid-level, and they’re not sure how to write up a thyroid nodule. So if you have a question about a diagnosis, you can do the electronic consultation with the endocrinologist specialist; so you’re asking a question with concerns, you give a history with notes and labs, and the endocrinologist would send back their recommendations. And those might include, the patient needs a biopsy, needs to see an ENT doctor; or the patient may have a benign nodule, in which case the endocrinologist recommends medication and a follow-up. And if you just have a question, you can just ask the endocrinologist the question.”

Denise Gomez, M.D.

What’s more, she noted, “Working with HMOs, you need authorizations for specialty care. We do 2,500 specialty referrals a month, and there’s a huge amount of work around that—you’re not having to do authorization, having the person contact the patient, and getting the results, that can be the most difficult part. So that whole process is bypassed. And I can tell you, in North County, for a MediCal patient to see a neurologist is five to six months, and at least six to eight weeks for most specialties.”

What I find so refreshing and encouraging here is the smart, sensitive realism of Drs. Tellez and Gomez and their colleagues at North County. Rather than trying to rectify a complex set of practices in the medical world that are implicitly discriminatory towards indigent patients, they came up with a concept, worked with a solutions provider to make it a reality, and implemented it seamlessly into their care delivery processes, with a resulting win for their patients. The harsh reality is that getting specialists to see MediCal and uninsured patients in any numbers, they instead put control of the process into the hands of the primary care physicians in their clinics who are dedicated to their care. What’s more, they are also implicitly broadening the medical knowledge of those PCPs, as they take the online and telephonic specialist consults they are able to obtain, and implement their findings in their direct care of their patients.

This is just one example of how really smart, innovative physicians and other clinicians are leveraging information technology, along with, in this case, the contracted services of specialists, to make a real difference in the lives of their patients. And I believe we’ll see many more examples like this going forward, as the U.S. healthcare system transforms itself over the next several years. Because sometimes, even relatively small-scale innovations can have major impacts on people and communities.



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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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