Monthly Archives: June 2015

Super Clinically Integrated Networks Will Lead the Way to Population Health


Post by Steve Shihadeh


Chief Commercial Officer, Caradigm

One of the most interesting recent trends that I’ve seen is that large integrated delivery networks (IDNs) are expanding their reach by forming more diverse and sophisticated clinically integrated networks (CINs). CINs have been around for a while in a much simpler form, typically coordinating activities between employed and non-employed physicians. Today, CINs are more diverse and can include networks of large independent health systems and or physician groups. This type of “Super CIN” provides a vehicle for independent providers to collaborate to achieve shared goals such as population health management for a specific employer contract or to deliver regional care. The MyHealthFirst Network that includes our customer, Greenville Health System is a prime example of a Super CIN.

How prevalent are CINs as a whole? The Advisory Board estimates that there are 500 CINS in the US today.[1] According to a recent research study that Caradigm conducted, 60 percent of respondents indicated that they are forming or active in a clinically integrated network that includes physicians or hospitals not part of their current system. Five years ago, this almost never happened and even basic collaboration between competitors was uncommon. From the conversations I have had with providers, I believe that the trend towards Super CINs is only going to accelerate as it has become essential to succeed in the new value-based healthcare environment. Let’s explore the drivers of this trend further.

Increased need for ambulatory care

As providers take on financial risk for patient populations, ambulatory care becomes more important in order to deliver lower cost, preventive care, and reduce the need for acute care. The challenge for hospital organizations is that they typically aren’t structured to deliver ambulatory care everywhere a large population needs access. Under the fee-for-service model, the focus was inside the walls of the hospital. Population health management now requires providers to expand their reach across the entire continuum of care, which includes primary care physicians, specialists, skilled nursing facilities, community based organizations, etc. Few organizations will be able to do it completely on their own, which is why Super CINs are an attractive option.

Scaling to manage larger populations

According to the study we just completed, 52 percent of respondents have contracted to manage at least 25,000 lives. 61 percent indicated that they are planning to take on more risk over the next 12 months with 36 percent planning to add at least another 25,000 covered lives. As providers take on more risk, they must also scale their ability to drive quality and lower costs for these larger populations. Compared to opening new facilities or growth through mergers, forming Super CINs gives providers a faster path to scalability while maintaining ownership independence.

Alignment with multiple initiatives

There are many different “flavors” of risk that providers can choose to engage in such as Bundled Payments, Medicare Shared Savings Program ACOs, Commercial ACOs, DSRIP programs, direct contracts with employers, etc. Providers often engage in multiple programs to diversify their risk while they develop new care workflows and best practices. The beauty of Super CINs is that they can support a variety of different risk-based programs. Working together, these providers can more effectively compete for payer and employer contracts because they demonstrate higher quality and greater efficiency in care delivery. Super CINs are a foundational strategy whether a provider is looking to form a broader network of hospitals to meet the needs of a large employer, partner with other organizations as part of a state Medicaid initiative such as DSRIP, or strengthen the primary care an organization can provide for a regional population.

The growth of Super CINs also creates a need for new health IT tools. Information has to be gathered and shared among a broader network of providers that may be using disparate information systems. Analytics have to be applied to that information and then shared throughout the network at the point-of-care where it can have an impact. Workflows have to be streamlined so that providers can efficiently provide care for an increasingly larger population. These are new challenges that electronic medical record systems (EMRs) were not built to meet. Ultimately, Super CINs need IT solutions specifically designed for population health management that can complement their existing infrastructure and help them evolve to value-based care. If you’d like to see the full results of the study referenced above you can send us a note or download this whitepaper to learn more about how to take the next step with Super CINs and population health.

[1]Greene, Jay. “Ascension Health, CHE Trinity form integrated network in Michigan.” Modern Healthcare. May 7, 2014. Published on: http://www.modernhealthcare.com/article/20140507/INFO/305079982/ascension-health-che-trinity-form-integrated-network-in-michigan

The Cultural Shift to Population Health


Post by Brian Drozdowicz


Senior Vice President of Population Health, Caradigm

The cultural shift needed for organizations to transition to value-based care is a key consideration in the journey to population health management. A provider must have strong internal alignment across the organization in order to succeed. Three questions that providers need to come to a consensus around are: 1) Do we need to change? 2) Do we want to change? 3) How do we change?

Do we need to change?

The statistics say we do need to change. Too much healthcare is ineffective or redundant as “an estimated 20 to 30 percent of [annual U.S. healthcare] spending – up to $800 billion a year – goes to care that is wasteful, redundant, or inefficient.”[1] I believe that the industry also intuitively recognizes a need to evolve its fee-for-service (FFS) model. If the goal of healthcare is to drive better patient outcomes, it’s in the best interests of patients to become healthier so they need less acute healthcare services. FFS does not incentivize organizations to reduce utilization today. Another key driver for change is that it’s becoming mandatory in order to compete for business. For example, to win contracts from government, commercial and employer payers, providers have to prove they can deliver higher quality care at a lower cost.

Do we want to change?

Even if an organization recognizes the benefits and drivers for change, there can be other cultural impediments to making the shift. For example, some organizations are risk and change adverse, and prefer to take a wait and see approach. Making the shift to value-based care can certainly be intimidating from a financial point of view as there is no guaranteed return on investment for value-based initiatives. Only about 25 percent of Medicare Shared Savings Program (MSSP) ACOs have been able to generate shared savings to date[2]. Providers may also naturally wonder how they will succeed in the long run if they see their patients significantly less than they do now.

Despite these obstacles, more providers are coming to the conclusion that they do want to change because they see value-based care as the future that they need to prepare for now. Organizations pursue population health management when leadership views it as a key initiative that will help the organization achieve its highest priority goals such as improving quality, improving access or differentiating itself in the market. Developing this business case for population health is a critical part of building momentum for an organizational shift.

How do we change?

After a provider has developed their business case for population health, they can then implement specific strategies and address specific challenges in care delivery. In terms of which programs to roll out, I recommend that providers start small and then diversify the types of contracts they engage in. This allows providers to experiment with different risk-based contracts, learn from initial efforts and iterate before expanding. Starting with an employee population is a popular way to begin due to the manageable population size and easy ability to communicate with members.

As providers look to build their capabilities and best practices, they need to be able to answer questions such as how do we bring our data together? Which patients should we focus on first? How do we coordinate care across the continuum when patients are seeing a variety of clinicians? How do we best interact with patients when they aren’t in front of us? It’s not uncommon for providers to get by with manual spreadsheets and basic health IT tools when the size of the population is small, however the desire to scale programs successfully requires a higher class of health IT infrastructure.

Technology as an enabler of culture change

Organizations need transparency and consistency in order to help drive cultural change, which is where health IT can help. I have seen customers successfully move to partially reimbursing physicians on quality measures leveraging technology to provide transparency to those physicians. Without that trust in the accuracy and timeliness of the data, physicians would not allow compensation to be tied to quality measures. This transparency also extends to the patient level so that physicians know exactly where to focus improvement efforts.

Technology can also play a major role in ensuring consistency of care by integrating a provider’s best practices and evidence-based guidelines into workflows such as care management workflows. For example, an application can prompt a care manager to ask the right questions during an assessment, suggest the right interventions based on the responses, and then automatically update the plan of care and assign tasks to the care manager. Therefore, adopting change in care management workflows becomes easier because the workflows are automated.

These are just two examples of the ways technology can help with the cultural change to value-based care. Although the amount of change can be daunting, I have seen population health energize and bring together cross-functional groups within organizations that had not historically collaborated much. As population health is ultimately about delivering better quality care in a more efficient manner, it is a worthy goal that I am excited to help providers achieve.

 

[1] America’s Health Insurance Plans (AHIP). “Rising Health Care Costs.” Published from https://www.ahip.org/Issues/Rising-Health-Care-Costs.aspx

[2] Kocot, S., Mostashari, F., White, R. (2014, February 7) Year One Results from Medicare Shared Savings Program: What it Means Going Forward. Brookings.edu. Retrieved from: http://www.brookings.edu/blogs/up-front/posts/2014/09/22-medicare-aco-results-mcclellan