- As healthcare spending continues to spike into the stratosphere, Medicare and its commercial counterparts have an urgent mission on their hands. They must find a way to effectively control costs, stem the tide of chronic disease, and deliver significantly better patient outcomes – all while navigating a rapidly shifting and often problematic landscape of federal mandates and other industry-wide reforms.
With physicians already cracking under the strain of meaningful use, unusable EHRs, shrinking revenues, and extra hours of paperwork long after clocking out, it seems almost ludicrous to demand major quality improvements while requiring providers to use even fewer resources than they do already.
But it is not an impossible task. In fact, for some accountable care organizations (ACOs), the process of generating lean and efficient quality improvements is raising patient satisfaction and streamlining workflows for providers.
With some big data analytics knowhow, a sharp focus on population health management, and the support of a committed payer, two ACOs in Iowa are showing the rest of country just how it’s done.
The Iowa Clinic, a 150-physician multi-specialty group with 1.3 million attributed patients, and Family Health Care of Siouxland (FHC), a rural organization with fewer than 30 physicians, may be on opposite ends of the size spectrum. But both combining health IT tools and data-driven quality improvement strategies with a fresh perspective on patient management to see major success in the accountable care arena.
What separates these two providers from the pack of middling or failed accountable care organizations? How can their successes inform the efforts of their peers? Leaders from each group sat down with HealthITAnalytics.com to discuss five key attributes of a comprehensive population health management plan that can bring financial and clinical benefits to all points of the care continuum.
Starting the conversation with a willing payer
Both ACOs are contracted with Wellmark Blue Cross Blue Shield of Iowa, which entered the uncertain ACO ecosystem in 2012, just as CMS was getting its Pioneer ACO Program off the ground. With more than half of Iowa’s physicians and approximately 40 percent of its patient lives now involved in some sort of value-based arrangement, Wellmark has committed a great deal of time and effort towards making the accountable care organization a mainstream option for forward-thinking providers.
The Iowa Clinic is one of those organizations. “The economics of what we were facing, both on the Medicare and the commercial insurance fronts, was not sustainable,” said Ed Brown, Iowa Clinic’s CEO.
“We had to start thinking about some of the things needed to do in order to become the physician organization of the future. What does customer service mean to patients in this environment? What is going to happen to primary and specialty care in terms of operational efficiencies, coordination, and building relationships with our patients?”
It starts with a strong relationship between provider and payer, says Sheryl Terlouw, Director of Network Innovation at Wellmark – and a commitment to excellence, no matter where the provider is starting off on their journey towards quality improvement.
“The cost and the quality does vary among our ACOs,” Terlouw acknowledged. “And we’ve certainly faced the question of why we would want to enroll a practice with a very low quality score. But the answer is that they want to become an ACO because they want to work on it, right? As a payer, that’s exactly what we have to encourage.”
“We would rather bring folks into a relationship with us where they can understand what their quality and performance outcomes really mean, and give them to the tools to work on it, than have someone who is unable to make progress because they don’t have the motivation or the data.”
The Iowa Clinic and FHC each worked with Wellmark to design contracts that best fit their expectations and their financial needs. For the vast majority of ACOs, the process begins with a one-sided arrangement.
Participating providers become eligible for shared savings or financial bonuses if they meet certain quality targets and hold their spending below agreed-upon levels, but they do not take on the challenge of paying penalties or returning funds to the payer if they fail to meet their goals.
The balance of the financial arrangement can shift over time as the provider develops its accountable care competencies. Both organizations agreed to contracts that will eventually push them into more risky financial positions.
“There is no financial risk for us in the first two years, and then we will start to accept risk in the third year,” explained Shanin McCabe-Harding, CEO of Family Health Care of Siouxland. “So we’ve really tried to focus on looking at our costs so that we’re prepared to accept risk when we do enter that side of the contract.”
“I would say that we spend the majority of our time working on the quality metrics and being able to provide better quality of care for our patients,” she said. “Wellmark has a great analytics program that gives us access to our covered patients and what services they need and what services, what care opportunities that they need.”
The Iowa Clinic took a similar route. “We started out with upside risk only, then we migrated into a contract that assumed more downside risk over time,” Brown said. “As you might expect, we started out with only modest results, but we’ve quickly improved in a number of important areas. Our first threshold had to do with quality, and we had some opportunity to have some shared savings by meeting that. From there, we basically chipped away at those opportunities for cutting costs.”
“We met with Wellmark on a monthly basis to go over how well we were doing, what the opportunities were, and how we could succeed with those,” continued Brown. “It’s important to take a multifaceted approach to the overall care of our population.”
Flexibility and ongoing communication are two of the most important attributes of a successful ACO team, Terlouw remarked. “The first couple of years of an ACO contract are about giving everybody an opportunity to learn how to speak the same language and understand each other’s viewpoints,” she said.
“As an insurer, there are things we need to learn about physicians and how they operate in the clinic, and providers have to become familiar with a few aspects of what it means to be a payer in this environment.”
Laying the groundwork for transparency, education, and buy-in
The conversation doesn’t stop there. Organizational leaders must be sure that everyone involved in patient care is aware of the changes that take place under an accountable care arrangement, and securing buy-in from physicians, nurses, administrators, and other members of the care team isn’t always the easiest task.
“Education is really the underlying theme here,” said Dr. Christina Taylor, a practicing physician who heads up many of the clinical quality improvement initiatives at the Iowa Clinic.
“We try to inform our providers about the big picture – how healthcare is changing and evolving – but also about what that’s going to mean on a personal level to each practitioner and what he or she will have to do differently.”
“In conjunction with that, we focus on transparency,” she added. “We fully believe in everybody seeing everyone else’s everything, from quality scores to panel management and patient care. Positive peer pressure does work.”
“The third leg of the stool with population health management is operationalizing as much as possible. For instance, if we needed to improve our cancer screenings, then we actually put steps into place to improve our cancer screenings. You can’t just talk about it. You have to make sure it happens.”
Taking a population health management approach to patient care requires “a different way of thinking,” stresses Taylor.
“It’s recognizing that you’re responsible for an entire panel of patients, whether or not those patients are engaged with the healthcare system. That requires a different approach than the one many physicians are used to.”
“Your physicians need to take a proactive stance on population health management, and your leaders have to make sure that the providers are getting the education and support they need to enact these changes.”
Engaging physicians can be a monumental challenge, especially in the face of so many competing reforms, new demands on their time and energy, and a constant stream of carrot-and-stick federal initiatives that often seem to emphasize the punishments instead of the rewards.
Adding financial risk to this mixture can be toxic, unless organizational leaders are able to acknowledge the problem and offer effective support as overwhelmed physicians adjust to a new way of thinking.
“There’s something called ‘change fatigue,’ and it’s happening a lot in healthcare,” said Brown. “Certain physicians feel like they’re hitting the wall. As a leader, you have to help pick them up and say, ‘Look, we can get over it and we’ll get over it together.’ You have to provide support, or you’re never going to get results.”
“Adaptability is very important, especially when you start putting some of your financial health at risk in an ACO contract,” he said. “That can produce some controversy, if you’re stepping into it pretty deeply, but it also sets the tone that accountable care is a priority.”
At FHC, a physician quality committee meets on a monthly basis to review results and identify trouble areas, McCabe-Harding said. A clinical quality improvement team in each practice then disseminates the metrics to members of staff. An important aspect of their job is collecting feedback and input on the numbers, as well.
“We try to be very transparent with quality, from the executive board level all the way down to the front office staff in our clinics, so that they're aware of what we're doing, why we're doing it, and how they can impact that,” she said.
“We've rolled out clinical decision support protocols that have algorithms on when to order x-rays and high-end imaging tests. We're trying to educate our staff on maintaining appropriate ordering procedures so we can utilize our resources most efficiently while providing high quality care.”
Crafting streamlined workflows and coordinating care
Physicians at FHC don’t just browse historical data, McCabe-Harding continued. Over the past eight years of EHR use at the organization, providers have taken an active role in designing workflows and making improvements to the population health management process.
“Many of our physicians helped develop our templates within the EHR, and we try to ensure that the workflow is what they like to see,” she said. “We're able to data mine just about anything that we need out of the EHR, so we can run reports that flag patients who have not had screenings or vaccines, or which diabetic patients are running high with their A1Cs.”
Care coordinators, also known as health coaches, play a vital role in patient management at both the Iowa Clinic and FHC. “They work very closely with our chronic disease patients to make sure they are getting the care they need, keeping their follow-up appointments, and accessing the right education,” said McCabe-Harding.
Patients recently discharged from the hospital have access to health coaches who perform medication reconciliation, help coordinate follow-up appointments, and do everything they can do make sure that patients avoid a preventable 30-day readmission, which can be costly under value-based care arrangements.
“We look at any barriers that they may have from a socioeconomic standpoint, and we help them identify resources in our community that might be appropriate for them. Our health coaches also follow up on our well-child visits and immunizations, and other routine care services.”
Care managers at the Iowa Clinic perform similar duties, Taylor added. “In addition to reminding patients about screenings and routine care, they focus on some of our high-risk patients who have a lot of needs or use a lot of resources. It’s important to have that personal touch when it comes to chronic disease management.”
Family Health Care has an additional trick up its sleeve for handing the needs of chronic disease management patients and those who may not have sustained or regular contact with the healthcare system. A clinical reporting specialist joined the FHC team in 2014.
“This is a clinical person who works at our corporate office, and she looks at issues like preventative screenings,” explained McCabe-Harding. “So for example, she will identify all the patients over the age of 50 that have not had a colorectal cancer screening. She contacts them, gets them scheduled, puts reminders on charts, and follows up with letters.”
“She communicates with the health coaches and puts reminders on the electronic chart, so that they physician can remember to have a talk with the patient when they come in about the importance of getting those tests.”
“We're looking at implementing an electronic check-in system, so that we can capture some of that screening information electronically as the patients are checking in. They can actually fill that out electronically,” she said. “They can fill out something like a depression screening form before they get back to the exam room, which helps improve our efficiency.”
A good ACO doesn’t waste any of the resources at its disposal, and that includes the time and training of nurses, physician assistants, and other mid-level providers who can easily tick off items on the population health management checklist and relieve pressure on other members of staff.
“We try to keep things as simple as possible for our physicians, and we also try to utilize the rest of the care team in an effective way,” Taylor said. “Not everything has to be done by the doctor. The nursing staff can check the patient dashboard, see a reminder for a mammogram, and talk to the patient about it. That doesn’t necessarily have to be the physician all the time.”
Enacting meaningful change for patients and providers
In an ACO, one form of success is measurable. Improvements in quality and outcomes are printed in black and white, codified in the data. But sometimes, the personal stories are what send providers home feeling accomplished and energized after a long day.
“A lot of our physicians have success stories,” McCabe-Harding said. “We have patients that have been diagnosed early with colorectal cancer because of our vigilance. Our providers love to share those anecdotes. They can even use those stories to prompt patients who may be reluctant to get their colonoscopies, which can produce some very positive results.”
Taylor agrees that spreading news of these victories can have a positive impact on the organization and the community. The message she wants to send is that persistence pays off, even in the most unlikely cases.
“We’ve had some instances where we reached out to particular patients every week, and instead of them being in the hospital or the ED once a month, we’ve gone six months since their last ED visit,” she recalled.
“We try to share those stories, because your natural reaction to hearing about a patient like that is that there’s nothing you can do to change that person. It’s not medical – it’s a behavior problem that you’re not going to be able to change.”
“But you know what? It turns out that if you can form a real relationship with that person and find out what is important to them and what’s driving them into the ED so often, it may be something completely different than what you think,” she asserted. “It could be a social problem that you can help address. It could be a mental health need. You don’t know unless you ask the patient what the issue is.”
“So if we can attend to our patients’ needs and help them manage their lives and manage their illnesses better, then we can see some pretty drastic results. These stories are great examples to show just how this way of thinking can make a difference with someone, even if the provider didn’t think there was anything they could do about it.”
Translating big data into continuous improvement
At its heart, the accountable care organization is about quality, and the continuous improvement required to keep pushing the bar higher. While Medicare has come under fire recently for its attempts to urge participants towards what many feel are diminishing financial returns, the opportunities to improve outcomes and engage patients are limitless – and not always driven by revenue concerns.
“You have to figure out how you can make these things meaningful,” said Taylor. “It’s a continual process and a continual struggle. There is no sense of having arrived or finished. We’re always striving for more. You can’t rest on your laurels, because then your efforts will decrease. You just have to keep moving forward.”
“Every day is a school day here,” agreed Terlouw. “Every day we learn something new from our data, or we figure out how to present something more effectively. Our physician partners have helped us improve, as well, and we keep learning about how to make these reforms more actionable from their perspective.”
“You also need somebody who's got some analytical skills, so that you can understand what your data is telling you,” she said. “If you want to dig into your performance and really make improvements, you must be able to leverage those analytics skills to be successful.”
A data analyst or reporting specialist who can dedicate his or her time to the intricacies of clinical quality metrics, risk scores, and outcome measures is a critical member of the care team, agreed McCabe-Harding. This person can become an accountable care champion, and disseminate the information that keeps providers keen to maintain high quality and a patient-centered attitude.
“You need to have someone inside your organization that keeps their thumb on this every day of the week: looking at things, talking to staff, educating, keeping it out there in front of everyone, from the physicians down to the front desk staff so that everybody is familiar with these issues,” she said. “Share your success stories. Share the numbers. Get them excited about the work they’re doing, and you’ll be able to see great results.”