Can a clinical standards-based infrastructure that pulls data from all participants finally get at the intersection of cost and quality?
This article first appeared in the January/February 2017 issue of HealthLeaders magazine.
Healthcare has always searched for the holy grail—the disruptive force, construct, or innovation that will make vast and necessary improvements in quality while simultaneously slowing healthcare's rapid cost growth. Yet such a solution has eluded everyone from policymakers to patient advocates to senior healthcare executives.
Big data might be a revolutionary advance in healthcare, but without the right tools and tactics, big data won't provide insights to help improve outcomes and value. It will just be a repository of information that doesn't live up to its potential. Many organizations see big data's possibilities and are betting that the right tools and strategies coupled with an organizational structure that gathers data from disparate parts of the healthcare service universe—otherwise known as clinically integrated networks—will yield big gains in both efficiency and quality.
Organizations certainly don't see big data/CIN arrangements as a panacea. It's a relatively untested strategy to weave together incentivized and symbiotic business relationships without the need for any entity to acquire those assets. So while healthcare's holy grail has not been found and may never be, executives believe CINs hold great promise.
CIN strategy
The intersection of cost and quality might be better called efficiency. And if any industry has ever needed a high dose of efficiency, healthcare is it.
CINs are designed to improve that metric in part by applying standards of care based on a patient's disease state for which clinicians are held accountable. Healthcare organizations are eagerly embracing CINs as a structure that allows efficiency to flourish without the huge cash outlays necessary to acquire healthcare business assets. The strategy is a timely one: Further stratospheric growth in healthcare spending is far from certain, with healthcare expenditures already accounting for 17.5% of U.S. economic activity and growing faster than GDP as a whole. Organizations that can manage efficiency well should be well positioned for slowing growth in the long term.
The CIN mindset is different than the hospital mindset because a CIN requires clinicians to think about the entire care experience, says Katherine Ziegler, a director at healthcare consultancy Navigant Healthcare, in Chicago. She says there are four areas of focus that have the most significant impact on successful CIN development: physician engagement, in-network care coordination, postacute care utilization, and management of pharmacy spending. Overall, Ziegler says organizations can achieve great success if there's agreement around clinical standards and effective incentives or disincentives for following them.
"It becomes a very collaborative effort when you bring clinicians together" around common goals designed around an organization's unique clinical capabilities and strategic goals, as well as the needs of its patient population, she says. Such goals can be as simple as setting up to help patients or their caregivers reconcile medicines or automated reminders for staff to double-check that patients are completing follow-up appointments with their primary care physician or rehab facilities following surgery.
Seth Glickman, MD, is the president and executive medical director at the UNC Health Alliance, a CIN developed by UNC Health Care in Chapel Hill, North Carolina. The UNC Health Alliance debuted in 2015 and now includes approximately 3,000 physicians.
As early as 2013 when Glickman joined UNC Health Care, "we recognized we needed a way to tie together all of the population health efforts across the healthcare system and integrate care among all our providers," he says. The health system soon began planning its CIN in order to integrate among UNC and affiliated community providers and participate in value-based contracts with payers.
"We employ a large number of providers as part of being an academic medical center, but we also work with a number of independent community physicians, so we needed a common approach to delivering care and a mechanism to work in a coordinated fashion with payers who were interested in developing relationships that were based on outcomes and value-based reimbursement," he says.
The process UNC used initially involved a lot of what Glickman calls "work on the ground." That included going to practices, engaging them, and educating them about how healthcare is changing in terms of the transition from fee-for service. Those visits were aimed not only at educating but also at enrolling leaders of those practices, both independent and employed, in the process of being part of the development of the network in a partnership that involved ongoing governance and operations.
To that end, Glickman and his team formed a physician steering committee of 30 individuals, including two hospital executives, from a number of different markets in North Carolina. The committee included equal representation of both employed and independent physicians in both primary care and specialties. Over six months, that group made important strategic decisions about how the CIN would work, ranging from what the governing board should look like, operating agreements, branding, participation agreements, and explicit goals. Currently UNC has about 3,000 physicians who are part of its CIN, of which 2,000 are employed by UNC Health Care, which includes its 1,200-physician faculty as well as the employed UNC Physicians Network made up of mostly primary care clinicians, and 1,000 independent physicians.
John Brennan, MD, executive vice president and chief clinical integration officer at WellStar Health System, is excited about the possibilities of WellStar Clinical Partners, the Atlanta-based health system's CIN, in part because of how it standardizes transitions from one type of care to another, such as from hospital to home or to rehab.
"That's where the most mistakes can occur," he says. For example, during a transition, a needed medication can drop off a patient's prescription list, or one might stay on the list when it isn't needed.
Brennan welcomes the new construct because it makes intuitive sense from a patient perspective. It's also a stark contrast to his medical school experience in the 1980s, where training was focused on subspecialty care, not the big picture.
"At that time, the physician was the captain of the team," he says. "We're now in a place where the physician is an important part of the team, and a leader, but very important information and judgment comes from other people on the team. One of the biggest differences is that the CIN is really patient-centric versus physician-centric."
Savings from high utilizers
CINs are tailored to meet the needs of the broad patient community, and operational standards are developed from that base by clinicians who know the overriding goal is to coordinate effective and efficient care that meets the so-called quadruple aim—Donald Berwick's triple aim of improving the patient experience and the health of populations and reducing the per-capita cost of healthcare, plus improving the experience of providing care. That last element is critical to achieving ever-elusive clinician buy-in, says Brennan.
None of the other elements of the triple aim are achievable without improving the experience of providing care, and part of that involves freeing physicians to spend more time and effort on truly high-risk patients.
"We have to identify and spend resources with a focus on care management on a population in order for CINs to succeed in both the short and long term," says Navigant's Ziegler.
She says this population turns over frequently. In fact, she says, only about 25% of patients who are high cost will continue to be so in the following year, which provides opportunity to improve health if the CIN has the data and tools to identify the so-called pre-high-risk patients in the CIN's population.
"It's a real opportunity if you can get to the pre-high-risk patients, which takes the top off that intensity curve," Ziegler says.
Identifying and acting on that population means fewer patients in the high-risk category, which means less use of resources and less effort to keep people well.
"We start with each CIN by looking at their data," she says. "Just getting data and setting relatively simple goals can make a huge impact."
Glickman agrees that is where the most progress can be made. "We're focusing on the rising risk population and, more generally, earlier stratification of patients where intervention can impact the trajectory of the disease course and the ultimate outcome," he says.
The analytics produced by data collected through the CIN's common EMR allows its clinicians to be more predictive and deploy care management or clinical resources before a patient develops a more severe illness. A good example is UNC Health Alliance's wound care for patients with diabetes. "The earlier you can identify an issue and use effective clinical care, the better outcome that patient will have," says Glickman.
He suggests thinking of the risk pool as a triangle. At the top of the triangle are patients with the most significant, most severe disease. These represent 20% of the CIN's population but 70% of the costs. Just below the tip of the triangle are the rising-risk patients.
Using the diabetes example, patients with the disease but no complications occupy the middle of the triangle. Interventions can keep them from moving up.
"If you're working with patients and monitoring whether their A1C levels stay in a normal range, the rate of people who will experience a stroke significantly decreases, so you've prevented huge cost by preventing them from having that stroke," says WellStar's Brennan.
"To affect this in the long term, you have to take care of the rising risk and prevent them from becoming a high utilizer."
Those leading nascent CINs need to manage the initial engagement of physician practices, educating them about how healthcare is transitioning from fee-for-service to value-based reimbursement, Glickman says. Most important, CIN leadership must enlist these practices in the process of developing the network as a true partnership through governance and operations.
The UNC Health Alliance formed a 30-physician steering committee—two of whom were hospital executives—from a number of different markets in the state. Representation on the steering committee was balanced between employed and independent physicians, and primary care practitioners and specialists.
"Over six months, we made important strategic decisions about how we would form the CIN, from what the board would look like to operating agreements to explicit goals, developing participation agreements and even branding," he says.
A sister organization, the UNC Senior Alliance, includes UNC's Medicare ACO and provides similar representation from providers.
"Over six months, we made important strategic decisions about how we would form the CIN, from what the board would look like to operating agreements to explicit goals, developing participation agreements and even branding."
Pick your partners wisely
Organizations learning from others that have been successful with a CIN strategy are taking time to conduct capabilities assessments, says Donna Cameron, Navigant Healthcare's managing director.
For example, creating analytics functions with existing organizational data is important because doing so helps organizations get a head start on targeting where to provide resources. Those analytical constructs frequently point to high-potential ROI in developing preferred postacute partnership networks, Cameron says. Analytics around existing data helps identify postacute providers that are more effective than others in preventing readmissions—for example, pointing organizations to align better with partners that are effective at driving quality, patient engagement, and reducing cost of care.
Such analytical exercises help organizations determine what areas along the care continuum need to be further developed and integrated to build a stronger foundation for the CIN and its performance going forward.
Other analytics that are important, especially at an early stage, are measures of provider engagement, their level of activity on the governing board, and the five core committees that are the "engines that drive the work," says Glickman.
At UNC Health Alliance, those committees are quality, care transformation, information technology, professional standards, and payer contracting. Some 50 physicians staff those committees, and their attendance and involvement in the ongoing work is an important metric at this stage.
"As we move toward defining the specific quality and outcome measures we are setting as standards for the network, our success will be around our ability to meet targets on quality outcomes, utilization, and managing the total cost of care," says Glickman. "We have different ways of doing that across different payers."
Keep it simple
Leaders are cautioned that development of intricate and elaborate scorecards to track metrics is possible, but initially, it's important to keep it relatively simple as clinicians get used to providing care in a different way—that is with the continuum in mind instead of providing care in an uncoordinated and episodic manner.
"Sometimes organizations begin to gain traction with fewer high-impact metrics that align multiple stakeholders, so that as success begins to build, it allows you to build additional momentum," says Cameron.
In postacute care, for example, there is a lot of fragmentation and spending, and myriad metrics to choose to emphasize. However, if a CIN can evaluate providers based on different venues of care, reduced skilled nursing lengths of stay, and reduced readmissions, they can begin to develop criteria for where the most appropriate clinical placement is for one type of patient versus another, that may be enough to start.
"Take the broad view," she says about the process of setting up care pathways based on disease state and demonstrated capabilities of partners. "Route patients to aligned partners and focus on delivering care at the right place at the right time, not just passing the baton."
Innovative technologies can be an important part of this work and should not be ignored—especially in their ability to manage relationships with postacute partners to ensure optimal care for patients and address total cost of care, says Glickman.
"We're early in a lot of our postacute work, but we have done some successful demonstrations and pilots around using innovative technologies to monitor or manage patients who are homebound or in a postacute facility," Glickman says, referencing various telemedicine and/or remote-monitoring capabilities. "We have started to form a narrower network of relationships with high-value postacute providers, where our goals are transparency around quality and outcomes for the members we manage with those facilities."
Some of the most important metrics around postacute evaluation are not surprising: service utilization, average number of bed days, the number of times a patient is readmitted, average length of stay, and costs associated with certain disease conditions or bundles. These metrics are important because by measuring them, "we can understand where opportunities are to work together," Glickman says. "Part of that is developing clear care management pathways and protocols for transitions."
Risk critical mass
At UNC Health Alliance, between 10% and 20% of payment is associated with some type of incentive, and those are usually quality incentives. To really change the underlying behavior of physicians and get the CIN to work in a more integrated way, that number will need to increase to at least 20%–30% and be tied to quality and cost as well, Glickman says.
The alliance anticipates that between the health system's ACO and state Medicaid—thanks to Medicaid reform in the state—value-based incentives will soon make up as much as 50% of reimbursement within the next three years, he says, so critical mass is coming soon.
"We already are experiencing a real shift in our market" toward value-based care, Glickman predicts. "It's a real opportunity for us to align those payments with the types of care models and behaviors we want our providers and patients to exhibit."
Philip Betbeze is the senior leadership editor at HealthLeaders.