Why Provider Leaders Need to Understand the Significance of PBGH’s Recent Foray into Care Management | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

Why Provider Leaders Need to Understand the Significance of PBGH’s Recent Foray into Care Management

June 8, 2016
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The Pacific Business Group on Health’s care management initiative is one worth taking note of—and reflecting on

It was interesting to view a video released at the end of last year by the San Francisco-based Pacific Business Group on Health (PBGH), one of the most progressive—and assertive—regional purchaser alliances in healthcare. PBGH has for years moved ahead to try to help health plans and providers move into the emerging new world of healthcare.

The video I viewed recently was narrated by Diane Stewart, senior director for care design for PBGH. In the video, Stewart, who described her division’s work by saying, “My team seeks better ways to care for patients, ways that improve quality and lower costs,” described a truly innovative initiative that PBGH has been sponsoring that has won praise—and significant federal funding.

Stewart begins by framing the broader landscape around the initiative. “When we take a look at the total healthcare spend in the United States,” she notes, “we see that only 5 percent of the patients account for 50 percent of that spending. And when we take a closer look at that 5 percent of patients who are using most of our healthcare dollars, we find that many of them have chronic illnesses that they’re living with every day—it could be a combination of kidney disease, heart disease, lung disease, and they’re doing their best to manage those conditions on their own, but even doing as well as they can, they find themselves in and out of the hospital and into the emergency room, they’re going back and forth to specialists appointments, and to hospitals, managing multiple medications, and some of them are able to do that on their own, and some of them are not.”

Importantly, Stewart says, “What we’ve learned is that by having them connect and have a trusting relationship with a care coordinator, who can help them better manage their multiple illnesses, who can help them manage their illnesses and help them problem-solve those challenges that those people have, that it can make a huge difference in the quality of life for these patients, as well as for their total spending in the healthcare system.”

As a result, Stewart says, “The Pacific Business Group on Health tested a model with 23 delivery systems in five states. And by matching 15,000 patients who had a history of hospitalization and emergency use, with trusting care coordinators, we found that we were able to reduce days in the hospital, reduce emergency room visits, and improve care for patients.”

Stewart provides a very illuminating example of how the care coordinator program, that of “an elderly gentleman, 85 years old.” That patient, she notes, has “lung disease, trouble breathing sometimes, but is otherwise able to live on his own. But he’s been hospitalized 24 times in the last 12 months,” she notes. “He had a good relationship with his doctor, got good medical care, but still had a lot of unplanned hospital stays. When the care coordinator first went to his home to meet him, she began to understand that he had lost his wife six months ago, was severely depressed; his oxygen tank his doctor had ordered for him, was empty; his wheelchair was broken; and because of his progression, he had no energy to either fill the oxygen tank or make an effort to get out and about and see other people.”

Continuing on with this case study example, Stewart notes, “So here’s an example where, although he has a medical condition, most of his challenges were not medical. What the care coordinator was able to do was, one, make sure the oxygen tank and the walker got fixed. But that alone wasn’t going to solve his problem. She found a senior center nearby and got him free transportation to the senior center three times a week, so he was with other people again, instead of feeling isolated. She got him connected with a food program, Meals on Wheels, which provided him with meals; he had lost ten pounds. And just by talking to him every day and then every week, and then less often, he was able to take care of himself, and find joy in his life again.”

That case study example illustrates exactly why this PBGH program has been successful, Stewart notes in her video narrative. “Let’s take a look at what are some of those care elements that work for this set of patients, and that we were able to spread across 23 delivery systems,” she says. “Number one, a care coordinator needs to establish a face-to-face relationship with the patient. Number two, it has to be connected to the patient’s doctor. It was the patient’s doctor who had sent the care coordinator to the house. And that care coordinator can be the eyes and ears for the doctor about how that patient is doing. Number three, the care coordinator had to understand the patient’s life from their view, not just the medical condition, but everything that got in the way of taking better care. And fourth, had to have the information so that she could connect him to other services in the community that would allow him an improved quality of life, as well as better healthcare. In fact, this elderly gentleman had no hospitalizations or visits to the emergency department, for six months” following the intervention.

That model, which Stewart originally credits to the Seattle-based Boeing Company, PBGH tested at CalPERS (the California Public Employees’ Retirement System) and at PGE (Pacific Gas & Electric Company). “That innovative model worked equally well, and we proposed to Medicare that we spread the model to Medicare patients as well, and won an award from CMS [the federal Centers for Medicare & Medicaid Services] to test the model for Medicare patients across 23 delivery systems in the western U.S. And now we’re just beginning to work with the state of California to adapt the same model to MediCal” (California’s Medicaid). “And we’re looking to figure out where the model is working, and where it needs to be altered, to improve patient care.”

Time to wake up and smell the new-healthcare coffee

Now, let’s look at the implications of this particular initiative, because there are a few very important ones. First and foremost, look who’s driving the train: a business coalition/purchaser alliance. That fact is no accident. Might that fact surprise some on the provider side of healthcare? Perhaps. But really, it shouldn’t. The reality is that the employer-purchasers of healthcare in the U.S. have become increasingly exasperated in the past three decades, as healthcare costs have exploded, even as outcomes have not significantly improved. In other words, the purchasers’ value for services purchased has simply not been demonstrated by providers, who, from the purchasers’ viewpoint, simply want to keep things running as they have been.

But the status quo is no longer acceptable to employer-purchasers. And while most people’s first thoughts around employer-purchasers in healthcare are around the increasing introduction of high-deductible health plans for their employees, the reality is that employers are becoming more and more directly involved in closely overseeing care and care management in healthcare these days, whether providers like it or not. Not surprisingly, some large corporations are even going back to an older concept, that of industrial medicine.

Second, it’s important to note that the nation’s most progressive purchaser alliances, including the Pacific Business Group on Health, aren’t simply coming into all this with sledgehammers; instead, they are working thoughtfully and carefully to sponsor and cultivate the most innovative care management and population health initiatives, and those with the best chance of success. And they’re doing it using sophisticated techniques, and working with good data.

And third, all of this should clearly indicate to the leaders of patient care organizations and to clinician leaders yet another sign of how quickly things are changing in the currently evolving landscape in U.S. healthcare.

What’s more, as the purchasers and payers learn more and more about the mechanics of healthcare delivery and care management, providers had better step up their game, because as purchaser alliances like PBGH learn more about the detailed mechanics of care delivery, it will become increasingly impossible for provider leaders to stonewall and obfuscate around the imperatives facing them in terms of improving patient outcomes, care quality, delivery efficiency, and cost-effectiveness. It’s a bit like restaurant patrons storming the kitchen and making the stew themselves. Once that’s happened, the mystery of the culinary art is gone.

So what the folks at the Pacific Business Group on Health are doing is significant, and should be noted. Above all, provider leaders should be clear that the era in which they could hide behind clouds of opacity around care delivery is definitively gone now—forever—and need to adjust their perceptions, and expectations, accordingly.




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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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