Nine Notes from NAACOS16


Post by Scott McLeod


Director of Product Marketing, Caradigm

I was recently at the Spring Conference of the National Association of ACOs (NAACOS) in Baltimore, and attended nearly a dozen sessions. Given the continued challenges many accountable care organizations (ACOs) have had in achieving shared savings, the biannual NAACOS events are excellent opportunities to hear from leading ACOs from around the country. In listening to the speakers as well as conversing with other attendees, I came away with nine key observations.

1) Difficulty: ACOs in general, are working hard to be successful, but that success is hard to come by. Comments I heard confirmed the statistic that only about a quarter of ACOs achieved shared savings. Due to this difficulty, there appears to be an increased appetite for tools that can increase the likelihood of success.

2) Uncertainty: There remains a great deal of uncertainty about value-based care—even among the winners. I spoke with a physician from one of the most successful Medicare Shared Savings Program (MSSP) ACOs, but he admitted that to some degree, they “didn’t know how they did it.”  This uncertainty affects decisions to continue in programs or engage in new ones, and also affects IT investment decisions. Providers must weigh the size of any IT investment against the possible return.

3) Benchmarking: As any shared savings are based on the comparison of actual utilization against the Centers for Medicare and Medicaid Services (CMS) established benchmark, there is strong interest in the methodologies CMS uses to establish the benchmark, e.g. historical v. regional fees, and the process for “rebasing” those benchmarks over time.  There is also interest in analytics solutions that can help (1) determine whether or not to participate in a specific program based on the benchmark, and (2) help manage their network of providers against the benchmarks for programs in which they participate.

4) What’s Next:  Organizations are considering participation in CMS’ Next-Generation ACO (NGACO) program.  While it provides some advantages for home health, telemedicine and skilled-nursing facility (SNF) waivers, it also comes with two-sided risk (i.e. greater potential upside but the addition of downside risk). Given the difficulty and uncertainty noted above, organizations are proceeding very cautiously and trying to garner as much information as possible before deciding.

5) Bundled Antipathy:  There is a level of antipathy among ACOs for awardees in BPCI (Bundled Payment for Care Improvement).  This antipathy results from the fact that CMS does not want to double-count (and double-credit) savings realized. Any savings realized for beneficiaries that qualify for bundled-payment services are credited to the BPCI entity and deducted from the potential shared savings of the ACO.  This is true even if the beneficiary is a member of the ACO. There is some feeling of unfairness as the ACO is responsible for a beneficiary’s utilization over the entire year while the BPCI entity only has to manage utilization during the length of the episode of care.

6) Variability of PAC: Whether for bundled payments or MSSP, several presenters called out the wide range of costs in post-acute care, and cited it as a big opportunity for cost management. This recent Wall Street Journal article also discusses the same issue of variability of costs.

7) Survival of the Fittest: While providing quality care to patients is always central to a provider’s mission, competing within their market is also on their minds. Strategies and initiatives adopted are business decisions that include the goal of capturing market share from competitors.

8) Diversification: The advice to the audience from a panel of large, mostly successful ACOs was to nurture other sources of revenue until the hoped-for shared savings were realized. This includes continuation of fee-for-service (FFS) business, participation in the episode-based BPCI, etc.  There was evidence of one-off agreements with large employers for a specific bundle or set of services.  As the industry makes its shift to value-based reimbursement, I expect we’ll see lots of different activities (though headed in the same direction) rather than a unified strategy.

9) Patient Care vs. Population Health:  Although ACOs are participating in a variety of value-based initiatives, the language of presenters and participants tended to focus on the quality care of patients more than managing the health of populations.  This may be a reflection that many of the speakers were physicians, but it seems that there remains a mindset around individuals rather than populations.

As fast as healthcare has been evolving recently, I look forward to tracking these and other trends over the course of the year. I hope to circle back to them during the Fall 2016 NAACOS event to see if they have changed.

Population Health and “The Wire”


Post by David Lee


Product Marketing Manager, Caradigm

NPR recently published this in-depth article about the challenges of healthcare for Baltimore’s lower income residents. After reading it, it’s hard for me not to think of The Wire, the HBO series that received acclaim for its authentic portrayal of Baltimore’s deep rooted social challenges. I think healthcare is another issue that David Simon, the show’s creator, could have explored as the core premise of the series is the interconnected nature of the city’s struggles – poverty, crime, policing, race relations, politics and the education system. There is a quote from a character on the show that has become emblematic of this theme that also applies to how healthcare has been recently shifting to population health:

“All the pieces matter.” — Detective Lester Freamon to Detective Roland Pryzbylewski, The Wire

Dr. Marcia Cort, chief medical officer of the non-profit Total Health Care, states in the article that “Baltimore City is in a health crisis.” The life expectancy of residents in the impoverished Sandtown neighborhood is 69.7 years old, which is the same as in poverty-stricken North Korea. Also according to the article, “residents of the ZIP code including Sandtown accounted for the city’s second-highest per-capita rate of diabetes-related hospital cases in 2011, the second-highest rate of psychiatric cases, the sixth-highest rate of heart and circulatory cases and the second-highest rate of injury and poisoning cases. Asthma, HIV infection and drug use are common.”[1]

Over the years, some residents have developed a mistrust of healthcare due to challenges in access and because of negative outcomes experienced resulting from a lack of coordinated and preventive care. A Baltimore resident, Robert Peace, described how he developed a recurring bone infection after undergoing a surgical procedure. Likely due to receiving minimal follow-up care, the infection grew worse, became extremely painful and resulted in five additional surgeries being required in 18 months. Today, Robert has permanently impaired mobility.

Dr. Jay Perman, pediatric gastroenterologist and president of the University of Maryland, Baltimore stated in the article that clinicians have to accept responsibility for patients outside the walls of the hospital. “As a profession, as an industry, we have not sufficiently appreciated, let alone done something about, the impact of social determinants. Guys like me and gals like me can easily say, ‘I made the correct diagnosis. I wrote a proper prescription. I’m done.’ What I say to my students is, if you think you’re done — if ‘done’ means the patient is going to get better — you’re fooling yourself.” To the credit of health systems in the area, they acknowledge that there have been shortcomings in how care was delivered and are implementing improvements. These efforts include a new focus on preventing readmissions, new investment in care coordinators, primary care and post-discharge management.

Although the social challenges Baltimore faces have been ingrained for many years, healthcare is the one for which there may be the clearest path to lasting improvement – via population health. Population health as an approach recognizes that health systems must care for patients outside the walls of the hospital using a multi-disciplinary team. An expanded care team can include friends, family members and social organizations (e.g. assistance with transportation, meals, paying for prescriptions, etc.). It can involve multiple health systems collaborating in the care of patients even though the health systems are in reality competitors. It also recognizes the need for innovation in technology such as a longitudinal patient record shared across all providers, analytics, and workflow tools that can help care teams manage a high volume of patients efficiently.

I would theorize that more than any other factor, it was the shortcomings of the fee-for-service model that contributed the most to the poor outcomes experienced by Sandtown residents. Population health offers a real strategy for change. More than cost efficiency, which is often the most commonly mentioned driver of population health, improved outcomes is the most compelling reason for population health. I am hopeful that health systems like those in Baltimore will continue to invest more and scale their population health initiatives with a sense of urgency. If they can successfully transform to become more patient-centric and improve the health of the people they serve, they will be able to rebuild the trust of the community. That accomplishment would be truly worthy of a television series.

[1] Hancock, Jay. In Freddie Gray’s Baltimore, The Best Medical Care Is Nearby But Elusive. NPR.org, 2.15.16. originally published at http://www.npr.org/sections/health-shots/2016/02/15/466550095/in-freddie-grays-baltimore-the-best-medical-care-is-nearby-but-elusive

Progressing with Population Health and Big Data


Post by Neal Singh


Chief Executive Officer, Caradigm

Last year, I wrote this blog post about the great potential of big data to drive innovation in healthcare. With the rapid progress organizations are making with their population health strategies, I thought it would be a good time to revisit this topic because of its importance to the industry. To be honest, healthcare organizations are still in the early adoption phases of big data.  Only a few organizations are dealing with petabytes of data, which is typically the threshold people think of when it comes to big data. However, I do see significant progress. Big data is in the process of transitioning from a research-oriented activity to a main stream agenda item that enables multiple population health scenarios. Let’s explore why.

Population health is driving the data explosion

Whether healthcare organizations are ready for big data or not, many are faced with exploding amounts of data at their disposal as they embark on new population health strategies. Within a single health system, it is not unusual to have several hundred IT systems and applications in the portfolio, and to have 50-75 that are actually exchanging data. Population health often requires a better understanding of your patient population, utilization, costs, quality, and chronic conditions across multiple systems and or with many partner organizations. This likely involves extending beyond your EMR to other disparate EMRs and IT systems outside your enterprise. Therefore, one needs to aggregate, normalize and share clinical, operational and financial data from many IT systems across the community—including EMRs, billing systems, payers, pharmacy systems, labs, and HIEs. Also consider that today, most of the data sets in the industry tend to be structured. We are now beginning to see early use of unstructured data (i.e. clinician notes), which can contain highly valuable patient information (e.g. ejection fraction for patients with congestive heart failure). Additionally, I see increasing interest in other new data sets such as consumer, genomic, demographic and social data (e.g. fitness devices, purchasing history, Twitter, Facebook) integrated into scenarios for population health. There is no end in sight for the growth of data in healthcare, which I find incredibly exciting because of the ability to draw new value from it.

The mechanics of big data are being established

In order to realize the full value of their data, organizations have been establishing the mechanics of how that data needs to be aggregated, transformed and stored. It’s important to have the right population health data platform in place that can automate numerous processes, or else big data efforts can struggle to get off the ground. Healthcare organizations leading the way in big data have been adopting data platforms for healthcare that have the following capabilities:

  • Automated data ingestion from any originating source in any format in real-time that has existing pre-defined configurations or parsers for a variety of data formats, e.g. HL7, CCD and CCLF, and unstructured.
  • Automated transformation of data regardless if data is in different terminology code sets or structures that includes semantic mapping for code conversion and pre-built tooling that facilitates normalization and deduping of data from pre-defined and custom sources.
  • Automated modeling of data that uses pre-defined healthcare entities that can accommodate most clinical and claims data as well as custom entities to accommodate customer-specific data.
  • Open data sharing APIs that provide untethered read and write access with source systems and the ability to share data with analytics and self-service reporting solutions.
  • Role-based security with auditing.

Initial population health scenarios are being explored

The scenarios for big data are limitless and I believe that one day they will expand to untapped data sources such as social media, consumer purchasing, and even things like smart clothing. Until that day arrives, big data can still have a significant impact on how you manage a population at an aggregate as well an individual level. Here are a few initial scenarios that organizations are already exploring today:

  • Build and share a true longitudinal patient record to see all relevant patient data (e.g. labs, pharmacy, claims, analytics) that covers the full continuum of care.
  • Employ predictive models (i.e. risk stratification), which are especially effective with large data sets so that you can focus your resources where they will have the greatest impact.
  • Expand the scope of your analytics to new areas such as measuring the quality and financial performance of individual clinicians as well as overall organizational financial and utilization analytics.

It’s fantastic to see that healthcare is innovating through big data and population health. The organizations that have built their infrastructure strategically should be in great position to keep refining what they’re doing today while scaling and building new use cases. If you’d like to discuss how Caradigm can help with your big data strategies, then leave us a note here.

 

HIMSS16 Trends: The Maturation of Population Health


Post by Scott McLeod


Director of Product Marketing, Caradigm

The educational sessions at HIMSS16 serve as a barometer of the progress of population health management as a priority for healthcare organizations.

This year, after three days of attending sessions, I note four key themes—

1) Current economic realities are driving new strategies

The changing market is not just a distant-future consideration. Payment reform from CMS and private payers is already occurring and will accelerate. Local markets—in which healthcare organizations must compete—face shifting roles and demands of employers and consumers. In one local market, a reported 75% of payments are tied to risk contract. Facing the fact that maintaining the status quo is not sustainable in the long term, organizations are setting new strategic directions that balance external forces and internal capabilities to achieve success under commercial and Medicare programs.

2) Collaboration is key

Healthcare organizations must work with others to realize the revenue under value-based reimbursement. This includes building relationships with non-contracted physicians and other (often competing) organizations to form accountable care organizations, clinically integrated networks or performing provider systems to provide the geographic coverage required for an assigned population. In addition, organizations are changing their relationships with employers and payers to seek win-win contractual arrangements that improve the quality of care for patients served and manage the costs for all stakeholders.

For example, Inova Health System and Aetna launched a joint venture to form a new health plan, Innovation Health, working together for improved care, cost and quality. Care coordinators steer members to appropriate programs and provide coaching. High-risk patients are enrolled in care management programs at post-acute facilities, and high-performing skilled nursing facilities (SNFs) are selected for inclusion on the network.

3) Results are starting to show

Population health initiatives seem to be more targeted and organizations are more specific about what they want to measure. The result is that—beyond reports of pilots and early steps—we are beginning to see tangible, positive results from these initiatives. The joint venture cited above has achieved a 17% reduction in the number of unnecessary hospital days after surgery, 15% fewer hospital admissions and 21% fewer hospital readmissions. As another example, Banner Health reported on the successes of its telehealth program: 20% reduction in length of stay, 45% reduction in hospitalizations and a 27% reduction in total cost of care.

4) Health Information Technology (HIT) is necessary for success

As the number of population health initiatives increases, and the number of at-risk lives grows, organizations recognize that HIT solutions are required to achieve the efficiency, effectiveness and scale that the programs demand. Successful organizations employ and rely upon solutions for data aggregation, risk stratification, analytics, interoperability and population health management. Staten Island PPS, for example, reports that each of its 11 DSRIP projects actively underway has unique HIT requirements for success including longitudinal patient records, predictive analytics and utilization management, telehealth and patient registries.

One other theme, that overlays the rest, became apparent during the educational sessions. The journey to population health management will continue, but the routes will change. What works today may or may not work tomorrow as the relationships among the different stakeholders shift.

Caradigm offers population health solutions that offer scalability and adaptability over time. You can have a discussion with a Caradigm representative by leaving a note here.

  1. “Value-Based Models: Two Successful Payer-Provider Approaches.” Clifford T. Fullerton, MD MSc and Mark Stauder. March 1, 2016.
  2. “Volume-based to Value-based Care at a Pioneer ACO.” Julie Reisetter, MS, RN. March 3, 2016.
  3. “Addressing the IT Challenges for a Startup DSRIP Program.” Joseph Conte, PhD(c). March 2, 2016.
  4. “Transformative Payment Models.” Jody White and Brian Sandager. March 1, 2016.

HIMSS16 Day 2: The Emergence of Care Transformation


Post by Vicki Harter


Vice President, Care Transformation

I am so thrilled to be at HIMSS16 this year with my newly formed Care Transformation team that includes fellow clinicians, Natalie Benner and Ruth Light. It was also a pleasure to speak in the Population Health Knowledge Center and converse with a number of the attendees afterwards. Having recently moved from a product strategy role at Caradigm to my new position as the VP of Care Transformation, I am excited to be able to collaborate with providers and customers about their population health strategies even more this year. We all know population health requires more than just new technology solutions. The team of clinicians delivering care and how they deliver that care has to evolve as well. What makes it challenging for providers is that there’s no single “right” way to do it. Caradigm’s Care Transformation team was formed to help organizations find their optimal approach given their goals, strategies and resources. Below are a few questions that can be helpful to think about if you are interested in care transformation.

Who should be added to the care team?

As I alluded to above, there are many different ways to set up your care teams depending on your particular area of focus. Some providers partner closely with primary care physician groups and will share resources such as a social worker, behavioral health counselor or a non-clinical admin that helps clinicians work “top of license”. Others may focus on designing care transition teams that ensure effective handoffs between care settings. Community-based services such as transportation can also be a highly effective addition to care teams that can drive immediate results. Providers have had success reducing unnecessary ambulance and ED utilization for non-emergency situations simply by providing access to a taxi service.

How do we align different workflows?

It’s critical to think about care pathways as an end-to-end process. Ask yourself “How do they connect?” “How can we make processes consistent between them?” “How do we remain patient-centric?” After providers take initial steps in population health, often the next step in their journey is to map and align different workflows and teams. Providers need aligned goals, metrics and protocols across the spectrum. Silos between teams need to be removed to enable an efficient patient-centered approach to care.

Can we support different care settings?

Being able to provide effective care in different settings is also critical because patients often move between them (e.g. acute to post-acute, ambulatory to assisted living). For patients with no regular caregiver support, care may be best delivered in a long-term care or skilled nursing facility for which providers must have a plan. For other patients, a medical home with embedded services such as behavioral health and access to community-based services may be the right fit. Effective handoffs between care settings must be established to avoid gaps and lapses in access to services. Being able to communicate and share a plan of care across an interdisciplinary team is also essential for complex patients.

How do we connect with the patient?

Every clinician that I speak with agrees that patient engagement is vital to improving health outcomes, but also agrees that it is extremely difficult. Even contacting a patient can be challenging because providers often have outdated contact info. In order to scale population health programs, providers need their patients to have “skin in the game” and participate in their own care. Providers might be able to create a registry of the most expensive patients, but it’s just as important to find out why they are the most expensive. For example, are they not taking their medications because they don’t have transportation, can’t afford them or are they confused by the different medications that have been prescribed by multiple specialists? Motivating patients and changing behavior is not easy, but it’s important to think about how it fits into the care team’s responsibilities and workflows.

How can technology help?

Coordinating care across the continuum is difficult because legacy health IT infrastructure was not designed to support risk-based care approaches. When I ask clinicians what do they need technology to help with, I hear a lot of common responses. They wish they had access to real-time lab info because while claims data is great, it is dated. Others tell me they wish they had integrated EMRs. They wish all providers could be connected so that everyone can have a true encounter and care summary even if it was out-of-network. Did a patient get admitted? Did a patient get discharged? Scaling population health according to patient risk-level is also another core challenge where technology can be extremely helpful, which is a topic that I’ll cover more in a future blog post. The truth is technology can help in a lot of areas, but how you sequence and scale that investment will depend on your particular organization.

These are the types of questions that I am so excited to help providers tackle this year. The Care Transformation team is in the Caradigm Booth #5427 this week at HIMSS having discussions with providers. If you miss us at HIMSS, you can reach out to us after by leaving a note here.

Vicki HIMSS16

It was an enjoyable experience presenting in the Population Health Knowledge Center

HIMSS16 Day 1: Seeking Interoperability in Population Health


Post by Neal Singh


Chief Executive Officer, Caradigm

The healthcare world assembled in Las Vegas with the kick-off of the Health Information Management Systems Society (HIMSS) Annual Conference. An issue that I expect to have many conversations about at HIMSS16 is the ongoing challenge of interoperability. Organizations engaging in population health continue to be frustrated by disparate information systems that result in outdated and incomplete patient information. This greatly hinders organizations’ ability to effectively coordinate care between providers in different settings, close gaps in care, and manage overall utilization and financial risk. The demand for interoperability has reached a crescendo as it is now a must-have in order to succeed with population health.

As I noted in this recent blog post about the Fast Healthcare Interoperability Resources (FHIR) standard, while FHIR is part of the discussion around interoperability, it is not a cure-all for all data challenges. An ideal solution starts with the foundation of an enterprise data warehouse (EDW) that can support a multitude of data standards and is designed specifically to model healthcare data and share it with other applications. This piece of the solution aggregates, normalizes and models your data, creating a rich data asset that can be used to drive action in any native or third-party application. True interoperability also requires bi-directional integration with any EMR in your community to enable the exchange of electronic care plans, care summaries, and other clinical data within the community.

There has not been an enterprise data platform like this in our industry, until now. At HIMSS16, Caradigm  announced Open Exchange, which works in conjunction with the Caradigm Intelligence Platform (CIP), an EDW for healthcare. The HIMSS ConCert certified solution is unique in our industry for its ability to enable interoperability of EHRs and other data source systems needed for population health. Caradigm is demonstrating its capabilities this week as part of the HIMSS16 Interoperability Showcase, which is the culmination of our participation in several collaboration events with other health IT solution providers.

We are extremely proud of our team’s efforts with Open Exchange and CIP that underscores Caradigm’s industry leadership in innovating healthcare data exchange. If you are attending HIMMS16, then we invite you to stop by the Caradigm booth #5427 or the Interoperability Showcase to discuss your interoperability needs and learn more about how Caradigm can help. Also, don’t miss my colleague, Vicki Harter, who is speaking tomorrow in the Population Health Knowledge Center about how providers can approach different value-based strategies in a presentation entitled – ACOs and CINs and DSRIP, oh my!

 

Neal Accepting HIMSS Award

I was very proud to accept Caradigm’s award for the HIMSS ConCert Certification of Open Exchange

Lessons Learned from a Medical Trip to Ecuador


Post by Ron Reis


Field Marketing Manager-EMEA, Caradigm

Recently, fellow Caradigm employee, Larry Nicklas, and I travelled to Tena, Ecuador to take part in the volunteer Timmy Global Health medical trip. Several members of the Caradigm team had volunteered in the past, and it was upon hearing about their experiences that I was inspired to volunteer. Timmy’s volunteer ‘brigades’ visit regions where there is very limited or no access to healthcare and set up makeshift clinics in a number of communities.

Most of the volunteers’ journeys involved 15+ hours travel time and several flights. Doctors, nurses, dentists, an ophthalmologist and general-purpose volunteers converged in the Amazon basin from other areas in Ecuador and as far as North America and Europe to volunteer their time and expertise.

A Clinic Under a Tin Roof

Being a Spanish speaker, I had the unique opportunity to rotate through various stations as an interpreter and engage with patients. The stations were small areas often separated by cords and hanging sheets. They included patient history and registration, vitals, consultation rooms and a working area for dentists, an ophthalmologist and in some cases a counsellor was also available. I found working alongside the doctors and nurses eye-opening as I was blown away by the level of care and compassion displayed to each patient despite the sometimes rudimentary conditions.

Even though Timmy Global Health and the local partners did an excellent job of preparing the community for our visit, I can only imagine how unusual it must be to see a bus load of international volunteers descend upon a community and set up a makeshift clinic for the day. For this reason, I made sure to welcome patients like I would a family member. The crux of my role was to engage with the patients so I would take a knee, crouch to eye level and verbally walk them through what the clinician was about to do and why. For example, I would say “we are about to put this around your arm to measure your blood pressure” or “we are going to check your baby’s temperature to see if he or she is running a temperature.” Especially when helping dispense medicine at the pharmacy station, it was extremely gratifying to see when patients had a sense of ownership of their treatment and gained an understanding of what each pill was for and when it was appropriate to take it.

Working with mothers and young children was especially endearing. One day one of the doctors requested a blood sample from a young girl who was about 5 years old. She could tell straight away what was coming and cried loudly as the nurse pricked her finger. After the blood was collected, we countered the girl’s sobs by clapping and cheering enthusiastically, and she eventually gave the nurse a big hug and smiled. Her mother looked on with a huge smile as well, and I think was reassured that we were there not just to provide healthcare, but to care.

Lasting Impact

Having lived in developing nations before, I was conscious of flying in, doing my part and flying out, having only made a short-term impact. I’m glad to say that Timmy Global Health does an excellent job of balancing short-term medical needs while also referring more complex cases to local medical centres or the capital. Even in such a remote location, it was also clear that basic prevention and patient engagement is essential in order to create a sustainable health system. The teams worked with the locals on prevention programs such as employing fluoride varnish to protect against tooth decay, teaching songs to children about the benefits of brushing their teeth regularly, and giving advice to older patients on how to better cope with arthritis pain. Timmy Global Health are also implementing safe drinking water projects in communities where there is limited access to drinking water and plumbing, which should help decrease some of the most common ailments we saw.

After I returned home to London, I realized that I was much more cognizant of the increasing number of homeless in the city. Thinking back to my time in Tena prompted me to talk with an elderly lady one cold rainy day and provide her with a hot meal. Some would describe volunteering as a selfless act, I tend to regard it as an investment, in me as a person and our collective wellbeing. Volunteering with Timmy Global Health and working at Caradigm, a population health company, have changed me for the better. In both cases, I am proud to be part of something bigger than myself and being able to make what I hope is a valuable contribution to the world we live in.

Larry Ecuador 2015

Larry Nicklas supporting the Pharmacy Station

 

Ron Ecuador 2015      

Me in the “Kids Corner”, where children received preventive treatments

 

Building a Culture of Physician Engagement in Population Health


Post by Sameer Bade, MD


Vice President of Clinical Solutions, Caradigm

In population health management, the role of physicians has evolved because the care of chronically ill patients requires a coordinated effort between members of a multi-disciplinary team. However, a team approach does not diminish the role of primary care or specialist physicians. Rather, it should engage and support physicians directly to address quality, outcomes and cost. As provider organizations seek to scale their population health and value-based care efforts, effective engagement of primary care and specialty physicians is critical.

Today, physicians are under escalating amounts of clinical, administrative, time, financial, and legal pressure to perform while their businesses are facing decreasing fee-for-service reimbursements. In increasing numbers, physicians are giving up the independence of private/small group practices and seeking employment with larger groups and health systems. This loss of autonomy coupled with administrative and regulatory pressures can lead to a decrease in physician satisfaction. We often speak about patient satisfaction but physician satisfaction is rarely addressed in a systematic fashion. Despite these pressures, most physicians rightfully view themselves as hard working, high-quality individual performers who care about patient outcomes. However, as organizations start to add the numerous requirements of value based care programs onto already over-burdened physicians, is it possible to maintain effective engagement?

Some larger physician groups and health systems are further along in their population health journey. These organizations have established patient-centered medical homes, continue to expand their multi-disciplinary care teams (nurse care managers, pharmacists, social workers, community health workers and non-clinical support staff) and are transitioning from basic registries to more sophisticated population health analytic and workflow tools. These investments have been made to both transform the care delivery process and simultaneously engage and support front line physicians and nurses. However, the majority of physician groups and health systems that I speak with are still fairly early on in their participation in value-based programs (e.g. planning to apply or in program year 1 of a Medicare Shared Savings Accountable Care Organization (ACO), grappling with the looming impact of the now mandatory  Comprehensive Care for Joint Replacement (CCJR) bundles, trying to effectively deal with the Readmissions Reduction program, participating in newly formed commercial ACOs or narrow networks, managing their own employees, etc.). In these early adopter settings, it is challenging to deeply invest in FTE’s, clinical programs, and technology.

Both physician and hospital organizations will also need to address the upcoming requirements of the 2015 Medicare and CHIP Reauthorization Act which will require participation in MIPS (Medicare Incentive Based Payment System) or APM’s (Alternative Payment Models). Not participating or performing poorly across these programs could result in a loss of 9% of reimbursement. The successful implementation of these programs is firmly dependent on the participation and performance of physicians.

In my travels and meetings with physician groups and health systems around the US, several best practices seem to be emerging around physician engagement:

Education: Frequent education on a variety of topics is critical. Physicians understand clinical care. However, concepts such as ‘benchmark’, HCC (Medicare’s Hierarchical Condition Category coding), minimum savings rate, discounting, two-sided risk, attribution, utilization management, multi-disciplinary care teams, etc. were not taught in medical school or residency. A mix of mediums such as conference calls, webinars, town halls and smaller group meetings are being employed. I’ve seen organizations with staff that travel from clinic to clinic on a rotating basis (much like a pharmaceutical rep) to provide 1:1 or small group education. Physicians need to clearly understand regulatory and industry changes, the organization’s shared goals, and the personal and professional impact of these changes.

Tools: It’s important to engage physicians with informatics tools to help them improve their performance on the metrics being measured. There are a variety of supporting capabilities which include easy to access longitudinal patient records, shared care plans, and gaps in care at the point-of-care. Physicians do not have time to log into multiple systems or read multiple reports while providing patient care. Analytics must be actionable at the point-of-care. Increasingly, physicians have an expectation that this enriched patient centric information should be available while seeing a patient or working in a patient chart. In contrast, the supporting care team may also need a population level view to help with pre-visit or day of visit planning and coordination.

Compensation: The satisfaction of being considered an efficient and high quality provider fosters engagement and can create healthy competition. However, compensation can also be a powerful adjunctive motivation. The most forward thinking organizations are not only rewarding primary care physicians and specialists, but also members of the care team when pay for performance or shared savings are achieved. Organizations are also putting a certain percentage of base and or bonus compensation at risk for actively participating and or achieving quality or targets.

Culture: Ultimately, creating the right organizational culture can accelerate achievement of meaningful physician engagement. Integrating physicians into governance is very effective as most of the top performing ACOs are organized by physician groups. Equally important is for organizations to provide the necessary multi-disciplinary team support and informatics investments. Physicians are competitive by nature, and will push each other to perform if provided a meaningful, mutually agreed upon set of goals and measures.

Measurement: In my next blog post, I will explore the importance and challenges of measuring physician performance further. I will also discuss how new analytics tools can help with measurement and support discussions between clinical leadership and individual physicians.

We have moved past the uncertainty of value based care programs initiated as part of the Affordable Care Act, and are entering the next phase of healthcare transformation anchored by the 2015 MACRA. While our transition from fee- for-service to value-based care is going to be challenging, it provides a real opportunity to decelerate the unsustainable growth in healthcare spending while improving patient outcomes. Physicians have a critical role in this transformation.

As I speak with physicians around the US, they share different and insightful perspectives on their participation in population health and value-based programs and the engagement of their colleagues. If you would like to discuss how Caradigm can help you with physician engagement, then please send a note here.

 

The Paradox of Population Health


Post by Brad Miller


Vice-President of Clinical Solutions, Caradigm

By and large, the healthcare industry talks about Population Health as care across populations of people. While Pop Health has evolved to drive the IHI Triple Aim across those populations, successful Pop Health efforts depend on care given on a patient-by-patient basis. From a clinical care perspective, Pop Health drives care at the Person level – the second “P” in the 3Ps of Pop Health. The paradox in Pop Health lies in that how we deliver care on an individual and personalized basis actually drives population results.

Pop Health is driven on a person-by-person basis. A patient, by definition, is a person receiving care. However, in reality, external and personal factors greatly affect how a person maintains their health and gets their healthcare. This all-encompassing understanding of the person is becoming more important to drive clinical outcomes and Pop Health successes. No longer can providers afford to view people solely as patients – providers who want to drive true global results will have to understand the patient as a person. Ironically, Pop Health has forced us as an industry to get better at data and care on a personal level.

Understanding the Patient as a Person First and foremost, personal factors like financial and family concerns play a large role in how people interact with the healthcare system. The Patient Protection and Affordable Care Act (ACA) has increased the number of covered individuals and also has created more narrow networks, high deductibles and increased healthcare utilization. High deductibles mixed with lower incomes could become a barrier to care, particularly if those individual patients need to obtain services and goods outside the clinical setting (think wheelchair ramps, dietary advice, a divorce or family death and how those factors can affect a person’s ability to get proper care). Even a family dog that a person does not want to leave alone at home during a hospitalization can prevent such a person from getting recommended preventive care. I have personally experienced these as barriers for patients, and I continue to hear those stories as I meet providers and systems across the country. All too often as providers, we are guilty of treating patients, when we really need to be treating the person. Until socio-demographic issues are better understood and addressed, they can hamper the benefits that Pop Health can provide.

A Person’s Personal “Big Data” The world of truly personalized medicine will also continue to evolve. On top of sensor data (Fitbits, Apple Watches, Bluetooth Scales, Bluetooth Glucometers), we are also seeing an explosion in genomic and proteomic data. All of this creates a more detailed, intricate and nuanced picture of a person as a patient. Collecting, analyzing and integrating this intelligence into clinical care will be one of the next large challenges healthcare faces. As an industry, healthcare may need to consider this information as a critical part of a person’s foundation that will guide personal care.

High Quality and Value Care at the Personal Level Many providers have contracted via ACNs, ACOs, MSSPs and the like to deliver care for a certain dollar value and to a quality standard. Those quality measures vary from population-by-population and contract-by-contract. Ultimately though, each person receiving care in the health system has a set of quality measures and gaps in care that need to be addressed. Put another way, there is no way for a gap in care to be closed without working at a patient level. This may seem obvious, but all too often providers talk about Pop Health and care metrics and gaps in care at a high level (i.e., how is our quality as a system?) vs. a patient-person level (i.e., how are our patients doing?).

Making it Personal Overall, understanding a person and his or her personal situation is critical to their clinical care and therefore paramount to Pop Health achieving the Triple Aim. The practice of Pop Health has a foundation in technology and data. Traditional systems like EMRs and other hospital-based technologies have not been designed to capture the full picture of a person and oftentimes these systems struggle to create a unified clinical record – a longitudinal patient record (LPR) – for a patient’s clinical information. Health systems, in the future of the risk-based model, will need to not only understand the LPR and the complete socio-demographic situation of a patient in order to drive to the desired results. I will address a vision for that technology in my next post. In the meantime, the paradox of Pop Health – that it truly is all about the individual, the person, remains of utmost importance in the current evolution of Pop Health and healthcare at large.

 

Expanding Your Population Health Data Foundation to Claims and Beyond


Post by Niranjan Sharma


Director of Engineering for Healthcare Analytics Platform & Applications, Caradigm

Healthcare is traditionally thought of as the care of patients by healthcare providers. Clinical data is generated during that care, and payers reimburse providers for the services rendered based on submitted claims. For providers engaging in population health, working solely with clinical data only tells part of the population health story. Most healthcare organizations are striving to derive more value and population insight by including claims and other types of data so that they can better stratify their populations, drive other analytics efforts, and improve care coordination among many activities. 

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Siloed Data Challenges

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The challenge is that it is complicated to ingest, normalize and model different types of healthcare data. Healthcare organizations often have many disparate information systems, and many work with partners who in turn also have many disparate systems. Most providers are still working towards harmonizing all of their data so they can view a single picture of their populations and make the best use of it in a timely manner to meet their clinical and financial goals.

 

Harmonize Data, Analyze & Compute

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One of Caradigm’s hallmarks as an enterprise population health company is that we are experts in healthcare data management infrastructure and processes. We help our customers remove the complexity and manual processes associated with data management through the Caradigm Intelligence Platform (CIP), an enterprise data warehouse designed specifically for healthcare. CIP enables organizations to harmonize their data, and then perform a rich array of analysis (e.g. predictive risk stratification, utilization), as well as computations on data (e.g. quality compliance, gaps in care, display last glucose results, display last PCP visit for a patient, etc.).

 

Modeling Claims Data Using Entities

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Caradigm has a proprietary methodology that structures data as specific healthcare entities. On the outer ring in the diagram above are examples of core payer entities that we can introduce with our customers. Seeing payer data organized in this fashion is often eye opening because it provides a harmonious view of the care delivered to patients. What is even more exciting is when payer data is combined with clinical and other data to show a complete picture that can then feed other integrated applications.

 

Lighting Up Applications With Payer Data

  • Risk Management Analytics
  • Accountable Care Organization compliance
  • Gaps in Care
  • Gaps in Billing
  • Network Utilization Analytics
  • LOS Analytics
  • Post-Acute Care Analytics
  • PMPM Analytics
  • In-Patient Analytics
  • ED Visit Analytics
  • Ambulatory Visit Analytics
  • Drug Utilization Analytics
  • Conditions Analytics
  • Bundled Payments Analytics
  • EMR Only Analytics
  • Claims Only Analytics
  • Harmonized Data Analytics

The beauty of a complete and reusable data asset is that it can light up all kinds of analytics applications. You can forecast clinical and financial risk, identify gaps in care, and analyze utilization or network steerage in order to uncover opportunities for financial improvement.

The amount of data available in our industry is growing exponentially. It is time for healthcare organizations to augment their ability to harness all of that data and realize more value. If you would like to discuss how your organization can harmonize its data and better leverage claims data as part of population health efforts, then please send us a note here.