Category Archives: Population Health

Quality Reporting Season

Post by Josh Schwartz

Healthcare Analytics Program Manager

As you prepare to submit your organization’s clinical quality data, let us take a look back at the changes the Centers for Medicare and Medicaid (CMS) implemented this year and some strategies for success with quality reporting and ongoing quality improvement efforts.

Consolidation and Simplification of Reporting

The end of calendar year 2017 (CY 17) marked the completion of the first year of the Quality Payment Program (QPP). QPP consolidates the various innovative payment models with the intent to move Medicare physician reimbursement away from fee-for-service and towards a value-based care model. As all Medicare physicians move towards value-based reimbursement, a two-year transitionary period (CY 17 & 18) allows reporting providers to ramp up to the ultimate levels of cost savings and quality improvement goals in 2019 that they will be accountable for moving forward. The chart below breaks down the percentages of reporting categories by weight, with payments being adjusted two years following the calendar year of the reporting period. In CY 17 the quality category made up 60% of the payment calculation and after the transition to more cost accountability it will remain equally important, representing nearly one-third of the total cost calculation.

Calendar Year Payment Year Quality Cost
2017 2019 60% 0%
2018 2020 50% 10%
2019 2021 30% 30%

Already during this transition period, CMS has received a lot of feedback in consolidating and simplifying its payment and reporting programs to use the same reporting options. In CY 17 the CMS Web Interface replaced the Group Practice Reporting Option (GPRO) of the Physician Quality Reporting System (PQRS) as the “self-service” reporting mechanism for group practices. It is in this interface that CMS uploads a list of patients for which clinical data points and quality measures must be reported. On January 8th these lists were uploaded, with the submission window running from January 22nd until 5pm PST on March 16th. Providers need to prepare immediately to ensure that their data is validated and reported in a timely manner.

Best Practices for Reporting and Performance Analysis

Quality reporting is an involved process that requires data documentation, data validation, and audits to capture and populate thousands of clinical data fields. Having a plan in place for a systematic approach to completing the web interface template will go a long way towards a successful reporting effort.

  1. Start early. The window from the time the patient sample is provided to the deadline for reporting is 10 weeks. You may have to perform hundreds if not thousands of chart audits to complete this process, so give yourself some extra time.
  2. Divide and conquer. If you have multiple clinics reporting together, make sure to delegate responsibilities in an effective manner.
  3. Develop a timeline. Establish internal check points, milestones and deadlines to ensure progress is on track.
  4. Review your work. Leave time to complete spot checks and conduct self-auditing before submission.

While these steps will guide an efficient and accurate quality reporting effort, regular analysis of clinical quality data remains a keystone of population health. Evaluating quality measure performance at the provider group, facility, and individual provider level enables you to identify areas that need performance improvement and learn from established best practices that can be replicated across provider networks. Incorporating performance review into regular workflows and quality practices will help avoid scrambling at the end of the year to improve performance and serve as the foundation for improvement year over year.

Caradigm Quality Improvement and CMS Web Interface Extract

To facilitate quality management, we have continued to iterate on our quality improvement application, Caradigm Quality Improvement. Leveraging the power of the application’s Advanced Computation Engine, quality measure performance can be evaluated across your organization at all levels. Empowered with this information and the ability to conduct root cause analysis, you can use the application to conduct quality improvement campaigns. The highly configurable solution integrates with the workflows of quality managers and clinicians.

We take our commitment to quality management a step further with the Web Interface Extract. This feature provides an extract of the clinical variables required by CMS for the reporting of quality measures. We do this by running the patient sample list provided by CMS against the Caradigm Intelligence Platform, and then extract and translate the data into the format required by CMS. This extract is then transmitted back to you to serve as the basis for your organization’s reporting.

While clinical quality is top of mind during the reporting period, it is important to remember that quality is the responsibility of everyone involved in the delivery of healthcare for the sake of patients. Good luck with your submission and happy Quality Reporting Season!


For more information on the content or author, please contact us.

Weathering Change and the Promise of Digital Transformation in Healthcare

Post by Neal Singh

Chief Executive Officer, Caradigm

Providers are among those most impacted by the turbulence in today’s healthcare landscape – whether it be adding facilities, covering more patients, changing leadership, providing additional services, or entering new value-based programs such as MACRA, Bundled Payments, or DSRIP. The “Quadruple Aim” was put forward to address the experience of providers in delivering care that is increasingly tied to cost and quality metrics. The so-called, second wave (post-EHR) of digital technology might be their greatest hope as providers manage this massive transformation to new value-based care and reimbursement models.

With clinicians supporting new populations, managing multiple data sources, and being tasked with additional processes, the burden of administrative tasks should be eased through the availability of resources that drive efficiency and enable a community-oriented, risk-based care approach. Paradoxically, it seems the introduction of new technology and processes can often be an added weight for clinicians to learn and adapt to. As we continue down the path of digital transformation, these tools should evolve to smoothly integrate into workflows and yield quick, measurable benefits for teams.

So how do organizations scale activities and enable their teams to deliver care more efficiently and consistently throughout this period of rapid change?

Weather the Uncertain Regulatory Environment

While lawmakers continue to battle it out we should face one fact: value-based care is here to stay.  Providers should push forward with a “no regrets” strategy. Prioritize efforts to drive more consistent, efficient and coordinated care, integrate your IT systems to support accurately forecasting patient risk, lowering cost structures, and building deeper relationships and loyalty with patients. Providers should not miss out this is an incredible time of innovation in healthcare that I believe is going to accelerate even more as healthcare organizations build off their early successes and learnings. With uncertainty in legislative direction for healthcare (ACA, Value Based Payment Reforms, etc.), providers may feel uncertain about their IT buying decisions. Rather than feel uncertain, I suggest providers should continue moving forward, with a keen focus on flexible and extensible solutions to support any outcome of legislative direction.

Quick Time to Value with an Eye for the End Game

Healthcare organizations need strong capabilities to aggregate data from across the community to connect all clinicians responsible for a targeted population. Providers should demand short implementations to ensure rapid time to value. Beyond this, seeking a flexible and configurable solution “future proofs” the organization to accommodate new programs that may be launched. This “future proofing” will provide organizational agility to rapidly configure to meet continuously evolving payment reforms and legal requirements. Selecting a population health tool should include an evaluation of the vendor’s ability to meet organizations where they are and grow with them across programs, such as Medicare Shared Savings Program, Comprehensive Primary Care Plus, Bundled Payments, etc.

Intelligent Analytics and Sophisticated Tools

Finding tailored software applications that enable clinicians to streamline workflows will drive positive results throughout your organization and help achieve scalability. Tools that facilitate targeted care management activities for prioritized patients will support care team efficiency. Interoperability is especially key in the case of mergers and acquisitions, considering the critical need to bring together data from potentially dozens of systems. Sophisticated risk stratification tools that consider clinical and claims data, financial information, social determinants, behavioral factors, and that employ predictive analytics will further help organizations determine where to focus constrained resources to achieve the highest return and greatest impact on patient outcomes. These are all factors to consider when searching for the right IT solutions to support your organization’s growth and goals, while advancing the health of the population.

Application Integration into Clinical Workflows –  They Can Only Use It if They Can Find It

While many providers recognize the value of using data and analytics to improve the quality of care and lower costs, there are many that have not yet integrated these directly into clinical workflows to realize the greatest impact and efficiency. This integration is especially important for accountable care organizations (ACOs) and clinically integrated networks (CINs). Timely access to data is critical when you are responsible for the health of a population of patients who may be geographically dispersed and receiving care from several hospitals or specialists. IT solutions should be leveraged to surface gaps in care, risk scores, and full medication histories so that a clinician can make educated care decisions while in the presence of the patient.

Value-based care initiatives should be addressed as a series of interconnected activities rather than as distinct, siloed efforts. A successful strategy takes a team-based approach and engages staff across different facilities to focus not only on individual patients with individual diagnoses, but also the health and wellness of the community. IT solutions need to create a unified user experience to support the interconnectedness that plays an integral role in an organization’s evolving strategy. ACOs and CINs should integrate an enterprise solutions portfolio encompassing the capabilities critical to success in value-based care programs, including: data control, healthcare analytics, and care coordination and engagement. Providers should also partner with vendors that have deep industry experience to provide advisory services. The pace of change in our industry continues to accelerate, and no organization should feel they are navigating these waters alone.


For more information on the content or author, please contact us.

The CMS and NAACOS results are in… What they are really telling us…

Post by Cindy Friend, RN, BSN, MSN, MBA/HCA

Vice President of Clinical Population Health Solutions & Transformation

Earlier this month, the Centers for Medicare and Medicaid Services (CMS)  released the 2016 shared savings results for the Pioneer and Next Generation (Next Gen) accountable care organizations (ACOs).  In addition, the National Association of ACOs (NAACOS) released the findings of its annual survey.  The results give us hope that this whole “let’s work together to make it better” attitude might just actually work, but we must evaluate the findings a little deeper to better understand correlations between the results and where ACOs need to focus to be successful in value-based risk arrangements.

While CMS did not post the quality results for the Next Gen program participants, it is likely that a few did not have good insight to their financial performance as they must share in losses.  CMS did publish the overall quality score for the Pioneer program participants.  Most notably, a couple of Pioneer ACOs that did not receive shared savings had outperformed many of their counterparts in quality.  As a case in point, Partners Healthcare ranked 3rd with an overall quality score of 94.51% and while it appears that they did not generate losses, they may not have met the minimum savings rate (MSR) required to share in savings.  Michigan Pioneer, on the other hand, had the lowest overall quality score, though still commendable, at 88.93% and achieved a shared savings of almost $7.5M!  These are impressive results and give optimism to others that are on the cusp.  An interesting statement from the introduction of the NAACOS survey:

“Overall, we found that a large number of ACOs are currently considering or have firm plans to participate in future risk-based contracts (47 percent planning for shared savings/shared risk and 38 percent planning for capitation), although care management strategies are largely unchanged. This and the data below suggest that ACOs are slowly becoming willing to accept increased financial risk, but they are largely still learning how to actually manage populations.”

Many organizations spend years focused on building governance, engaging physicians, and talking about what to do – what they fail to or wait too long to focus on are the key items for which they will be measured.  I understand that gaining buy-in and establishing governance are important when you’re first putting an ACO together, but the CMS shared savings results illustrate why ACOs must focus on two additional core tenets to help drive their success – analytics and improved care management strategies.  A few tips to help you advance your analytics and care management efforts are outlined below.

    Successful ACOs have acquired and adopted some sort of analytics technology, but those that are most successful identify IT systems that are able to provide insight across three domains: 1) population risk, 2) quality measure, and 3) cost. ACOs must evaluate their current data analytics capabilities, identify any gaps, and determine the best approach to resolving these gaps.  In some instances, an organization may choose to implement a new enterprise platform; in others, it may be most efficient to integrate a solution to fill the need.  Regardless of the system architecture approach, for a complete view of the population’s health an organization must have the following analytic capabilities:

    • Risk stratification – This type of system will integrate an industry-accepted risk adjustment scoring methodology that will stratify the entire population, while also providing additional data points for analysis. Ideally, the system allows the user to electronically assign these patients to care management for intervention.
    • Clinical quality measures – A clinical quality measures system will provide insight to performance at the quality program level (e.g., HEDIS, CPC+, MIPS, etc.). The system must allow drill down through the measure into the practice, to the provider, and to the patient level.  As patients with gaps in care or measure compliance issues are identified, the system should allow the patient to be electronically transitioned into care management.
    • Financial and utilization insights – These systems provide analytic views of integrated clinical and claims data to reveal, in real time, utilization patterns across populations, care settings, networks, and payers. Systems that can track and trend utilization and cost information, including drill down to the per member per month, is key.  As with the other systems above, the user should be able to electronically forward patients directly  into a care management system.

The capabilities of population health analytics tools have grown significantly over the past several years.  ACOs and other clinically integrated networks, as well, have a tremendous opportunity to position themselves for success by securing the tools and systems that will equip them with the information and insights needed to manage their patient population.  Failure to leverage the power of a complete view (including cost and quality data) analytics platform will have a detrimental impact on an ACO in a risk-based arrangement because they may succeed in quality but not have visibility to their costs and vice versa.

    Organizations that are thinking ahead will select an analytics system that enables users to electronically send patients identified for care management during the analytics process directly to a care management system. ACOs must have the proper tools to support care management activities to effectively manage and measure performance and drive patient outcomes.  ACOs need to carefully evaluate and select a system that can support workflows and processes across the care management paradigm including:

    • Care management – The system must provide the clinician with a holistic view of the patient’s health information including, though not limited to: past medical history, problems, medications, allergies, vitals, personalized goals, etc. The system needs to allow the care team to efficiently document care management activities such as conducting assessments, performing medication reviews, developing care plans, etc.
    • Care coordination – The care management system should allow the clinician to track tasks and follow-ups (e.g., consult notes, patient call, etc.). The system should permit the care team to coordinate care amongst themselves, as well, such as assigning a task like a nutrition or social work consult, for example.  In addition, the care manager can electronically transmit a summary of care documents to another provider that is involved in the patient’s care.
    • Care transitions – The system should alert to the care manager regarding a change in care setting (i.e., ADT feed), and automatically create a task for the care manager to follow-up and support the patient in receiving the right care, at the right time, in the right location.

Organizations that opt to adopt care management technology tools will feel the effects in operational efficiency, team job satisfaction, and quality results.  It is practically impossible to manage the vast, complex, and diverse healthcare needs of a population without technology.

The NAACOS survey results express that many organizations that have not started any risk arrangements are very uncertain and feel as though it will be an average of three years before they are ready.  This uncertainty is likely spawned from the unknown but just remember while uncertainty is expected, avoidance is not an option – ultimately, it’s the right thing to do to improve quality outcomes and address unsustainable costs.  Those making a move today have it a little better than their predecessors with the advancement of population health technology for analytics and care management.  With these advanced tools, organizations are better equipped to take on the risk because they have a deeper insight to their population with the ability to identify and act on those patients who will benefit most from care management intervention.


On a final note, as a nurse, I couldn’t be more delighted as I read the section in the NAACOS piece about the value that the care manager role brings to improving healthcare.  It’s been years in the waiting as nurses have always held education, prevention, and wellness as core to our practice – and the recognition is heartfelt for all nurses.  While we have probably only begun to scratch the surface on improving our industry, it makes me proud to be a part of the transformation.

 For more information on the content or author, please contact us.


Becker’s Hospital Review.  2017.  How the Pioneer ACOs stacked up on shared savings, quality in 2016

Becker’s Hospital Review.  2017.  How the Next Generation ACOs compared on shared savings in 2016

Health Affairs Blog.  2017.  The 2017 ACO Survey: What Do Current Trends Tell Us About The Future Of Accountable Care?


What a Trump Presidency Could Mean for Population Health

Post by Neal Singh

Chief Executive Officer, Caradigm

Based on President-elect Trump’s campaign promises, the healthcare industry could experience significant changes. His commitment to “repeal and replace” the Affordable Care Act (ACA) is at the center of the conversation, and raises a number of questions. Can it actually be repealed? What is the impact for value-based programs currently underway such as the Medicare Shared Savings Program, bundled payments and MACRA? What should healthcare providers do now? This post will address these questions and my opinion on what it means for the future of population health.

1) A complete repeal of the ACA faces challenges

President-elect Trump has indicated[1] that he supports some parts of the ACA such as forcing insurers to cover people with pre-existing health conditions and allowing parents to cover children on their plans into their mid-20s, so it is hard to determine this early the full extent of the changes to come. In addition, Republicans support some aspects of value-based innovations. There are about 283 million insured lives in the US[2] including about 20 million covered under Obamacare.[3] Even if the ACA was to be fully repealed, there are nearly three hundred million lives for whom the fundamentals of economics and quality of care necessitate the move towards value based care.

2) Value-based healthcare will continue because it has bi-partisan support

MACRA passed with overwhelming bi-partisan support in both the House of Representatives (392-37) and the Senate (92-8).[4] Bundled payments[5] and ACOs[6] also have bi-partisan support. The reason for this is that both sides of the aisle recognize the clear need for healthcare payment reform. Amongst all the contentious legislative arguments that exist today, there is no debate around the fact that healthcare costs are on an unsustainable growth trajectory. There is consensus that the government has to continue making providers more accountable for reducing costs, improving quality and increasing patient engagement and satisfaction.

3) Expect some changes to the mechanics of value-based programs

While the top-level themes in healthcare payment reform are unchanged, I do think we can expect changes in the mechanics of some value-based programs. Republicans, including President-elect Trump’s nominee to head Health and Human Services, Rep. Tom Price (R-Ga), have expressed concerns about the power and budget controlled by The Center for Medicare & Medicaid Innovation (CMMI)[7], so CMMI’s role could be impacted. Specific programs like the MSSP ACO program could be structured differently in the future although that would have to take place after current three-year contracts with the government expire. Republicans could push for new Medicare and Medicaid reform, which would impact beneficiaries and could drive more formation of Medicare Advantage plans or lead to Medicaid ACOs. No one today knows exactly how current programs are going to evolve, but the reality is that programs must evolve to address cost and quality concerns.

4) “No regrets” strategies for healthcare

Although healthcare faces uncertainty, there are certain priorities for organizations that will apply. So-called “no regrets” strategies for healthcare include driving more consistent, efficient and coordinated care, integrating IT systems, accurately forecasting patient risk, lowering your cost structure, and building deeper relationships and loyalty with patients. Everyone needs to operationalize these capabilities now so they can manage large scale Medicare and Medicaid populations effectively in the future. These are capabilities that take years to refine, which is why some healthcare organizations view the building of these best practices as market differentiators that will ensure their long-term success against regional competition.

Population health is already making a difference for patients. Our customers are seeing tangible improvements in patient outcomes and cost reduction through lower utilization while developing deeper relationships with their patients. They’re even benefiting financially through the generation of significant shared savings. This is an incredible time of innovation in healthcare that I believe is going to accelerate even more as healthcare organizations build off their early successes and learnings.









Filling The Care Management Tool Box

Post by Vicki Harter, BA, RRT

Vice President, Care Transformation

As I talk to many providers across the country about how to transform to value-based care, the conversation inevitably turns to the need for care coordination and care management. With many Centers for Medicare and Medicaid Services (CMS) initiatives including the recently announced Comprehensive Primary Care Plus program emphasizing the need for better care coordination, many providers have concluded that they need to evolve how they deliver care for high risk or at risk patients. This is both exciting and a little bit scary. The hard part is figuring out the right way to go about it given that there is no single blueprint that works for all providers.

One of the best written articles on care coordination that I’ve seen was this one written by Patti Oliver, RN, BSN and Susan Bacheller, BA.[1] I could not agree more with Oliver and Bacheller when they say there is a growing movement toward greater care coordination, as more health systems realize there are better ways to deliver care:

“From our combined experience, we both know how critically important it is to have good care coordination in any healthcare system or arrangement, including ACOs. Care coordination helps providers to form a complete picture of a patient’s overall heath and it also allows them to be able to better communicate with the patient, their family, and with each other. Care coordination also requires constant prioritization and re-prioritization of patients for effective panel management; it means applying art and science to split attention between patients with immediate needs and those ripe for preventive measures or patients we regard as healthy working adults”

Oliver and Bacheller then explored the essential functionality that care coordination software should deliver naming the following five features:

  1. Care coordination tools should be tailored to your patient population.
  2. Care coordination tools should have a single place the care coordinator can visit to get the full picture at the panel and patient levels.
  3. Care coordination tools must allow for convenient use of clinical pathways and be flexible for the care coordinator.
  4. Care coordination tools need to have strong communication features among providers to facilitate care hand-offs and to involve family/caregivers when appropriate.
  5. Care coordination tools should integrate with other systems—or at least be straightforward about their ability to do so.

These five items are solid foundational features to seek when it comes to care coordination and care management tools. Having worked closely with providers to identify their requirements for success in coordinating care across the continuum, I would also respectfully highlight a few other key areas.

Workflow automation – as most organizations are looking to scale their population health initiatives, one of the biggest challenges is how to manage large populations given constrained resources. One of the key components to look for in software is the ability to automate time-consuming manual workflows so that the care team can work more efficiently and also at top-of-license. Care management software should be able to auto-generate care plans and assign tasks based on patient answers to assessments.

Evidence-based guidelines – While flexible clinical pathways are important, so is the need to ensure consistency of care. This is especially true for more complex, co-morbid patients who often require care from a larger care team. Care management solutions should help reduce variation of care by embedding evidenced-based guidelines directly into care workflows to guide action. Tools should also be able to help identify best practices so that they can be shared throughout the care team.

Support for multiple programs – Care management technology requirements vary by program. For example, in the CMS Chronic Care Management program, providers must be able to track and report on time spent per month on core care management processes. For the Bundled Payments For Care Improvement (BPCI) program, providers need to be able to transition and track patients to post-acute care. Look for flexible care management solutions designed to support multiple programs so that you can maximize your return on investment.

As Oliver and Bacheller noted in their article, many new technology solutions for care managers are starting to appear. It can certainly be confusing given the broad range of features and different classes available (i.e. enterprise to basic). Ultimately, identifying the right solution will depend on your organization’s specific goals and the scope of what you are trying to achieve with population health. I look forward to having more conversations with providers this year about how they want to transform care.



[1] Patti Oliver, RN, BSN; and Susan Bacheller, BA. ACOs: What Every Care Coordinator Needs in Their Tool Box. American Journal of Managed Care. 9.24.15.


Time to Value in Population Health

Post by Vicki Harter, BA, RRT

Vice President, Care Transformation

The stakes are high when it comes to population health as improved patient outcomes and long-term financial success are on the table. By now, most providers recognize the need to evolve. They must participate in new value-based programs, collaborate with other providers, and tailor workflows to support the changes. Implementing these changes is not easy! It takes significant amounts of time and resources from across the organization. When it comes to acquiring health IT tools to support population health, it often takes providers 9-12 months to evaluate the myriad of available solutions. I don’t blame providers for wanting immediate results after spending so much time investigating population health tools.

One of the key reasons why Caradigm formed its Care Transformation Team is to help customers achieve fast time to value following the acquisition of solutions. Our team serves as a sounding board for our customers who are making the shift to value-based care. We find that some organizations have been engaging in population health initiatives for years and are more mature in their processes while others can benefit from additional support. We tailor our approach to each customer’s strategic vision because it’s not one size fits all. The uniqueness of each organization has to be respected as we seek to identify common best practices and turn them into consistent processes.

I believe that all organizations should seek quick wins soon after acquiring population health technology. They are critical to building positive momentum for workflow transformation. The following are a few suggestions to consider when trying to achieve fast time to value in population health.

Plan early to achieve early success – establishing metrics and what quick wins look like prior to technology implementation provides a huge leg up in achieving them. Our team often collaborates with providers before contract signing to help clarify goals and expectations, and then align technology to them.

Define top value propositions – in addition to meeting specific metrics, population health tools can also deliver other types of value to end user clinicians. For example, the reduction of inefficiency or frustrating pain points for clinicians brings tremendous value to organizations and can be realized immediately. It’s important to document what the pain points and value propositions are in order to recognize that value.

Consider starting with care management – care management tools offer one of the quickest paths to value in population health because they can help remove numerous workflow inefficiencies that are impeding providers today. These can be items like having to hunt for data from multiple sources, having to manually generate care plans, or even being unaware when a patient is admitted to the ED. Care management solutions also give providers flexibility in where to start as they can begin by improving how they manage patients in a particular program, by disease category, or by focusing on a particular area of care management such as improving transitions of care.

While the road to population health can be long, organizations can achieve significant victories along the way. In fact, achieving those smaller wins should be celebrated as care transformation takes many small steps in the right direction. If you’d like to discuss how Caradigm can help you achieve quick time to value in population health, then please reach out to us here.

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., 2.15.16. originally published at

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.

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.