Leveraging Population Health to Meet Value-Based Care Goals. 19 out of 25 Organizations view population health as a high priority today.

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1 Leveraging Population Health to Meet Value-Based Care Goals Value-based reimbursement is no longer a futuristic concept. It s a reality that healthcare organizations need to face today. 19 out of 25 Organizations view population health as a high priority today. Indeed, according to Patrick Conway, MD, chief medical officer and director of clinical standards and quality at the Centers for Medicare and Medicaid Services (CMS), the Affordable Care Act gave CMS many new tools to convert Medicare from a program that paid for decades on automatic pilot into one that deliberately pays to promote better health. 1 And, with CMS and private insurers now embracing this model, healthcare providers are finding that they need to quickly implement effective quality-improvement programs. At this point, the way the legislation is set up it is no longer a pie in the sky concept; it translates to actual dollars, said a CMO/CIO from a California-based healthcare system. As a result, many provider organizations are turning to population health management programs to produce the clinical results that will enable them to financially succeed under value-based reimbursement. These initiatives aim to enhance outcomes for an entire group of individuals, instead of merely looking to improve health on a one-to-one basis. The concept is one that is coming into its own. Leaders at 19 of 25 organizations view population health as an important priority today, while 22 of the 25 said it would bubble to the top of the list by next year, according to HIMSS Analytics 2015 Population Health Trends & Insights, a recent study of large integrated delivery networks, each of which manages between 25,000 and 300,000 at-risk lives (Figure 1). 22 out of 25 said it would be by next year One of the study participants, a CMIO from an integrated delivery network (IDN) in the Carolinas, noted that the strategic aim of his entire health system recently was changed to accommodate population-health initiatives. A CIO from an IDN that currently manages about 25,000 lives pointed out that if his health system does not handle the population properly, the organization will experience some financial hardships. With population health clearly a top priority for provider organizations, healthcare professionals are no longer simply talking about the potential of such programs Produced in partnership with Featuring industry research by

2 Organizations must rethink their financial and clinical strategies to consider how to optimize their reimbursement in the transition to new payment models under population health management. Michael Simpson CEO - Caradigm but instead zeroing in on how to get the job done. To move in this direction, organizations must rethink their financial and clinical strategies to consider how to optimize their reimbursement in the transition to new payment models under population-health management, said Michael Simpson, CEO - Caradigm, a population-health company based in Bellevue, Wash. Fortunately, the HIMSS Analytics research shed additional insight into how organizations can launch and sustain population-health initiatives; the value as well as the limitations of electronic medical records (EMRs) in supporting these programs; and what additional technologies might be needed to ultimately succeed. Diving in now Healthcare organizations are jumping in headfirst, launching a variety of initiatives, all aimed at improving the health of various populations. According to the study participants, providers are supporting population health efforts with: care/case management (37 percent), patient engagement/portals/outreach (29 percent), disease management/registries (14 percent) and analytics/business intelligence (10 percent) (Figure 2). When hitting the population-health waters, however, some are experiencing a sting of discomfort, as the change to this new model is a dramatic one. For years, physicians have been compensated and incentivized based on the more patients they see, the more labs they order, the more radiology tests they order [the more money they make], pointed out one of the healthcare executives. Now, however, providers need to take a different tact and concentrate on keeping patients out of emergency departments and clinics, which means shifting resources and rethinking treatment goals. This focus on keeping populations well is challenging as it is, for the first time, requiring various providers to communicate with one another: In the past, the physician office might not even ask for a patient s discharge summary, and now they are calling [the hospital] asking for the discharge summary or emergency department record from two days ago In this population-health world, the handoffs are so critical. The physician is being incentivized to know what is going on with patients. We are pushing physicians to have so much more information, said a CIO who works at a provider organization that manages more than 45,000 lives. With this new focus, healthcare providers are running up against a variety of challenges including: technology/data exchange/accessibility issues (26 percent); resistance to change (23 percent); money/financial issues (21 percent); understanding the proper pace for change and investment (16 percent); and resource constraints (14 percent) (Figure 3). One of the most frustrating aspects of the transition is the fact that it is difficult to move expediently from fee-for-service to value-based care, according to a CMIO at a large health system in the East. When you are trying to go from here to there, you need money to build the bridge, he pointed out. Unfortunately, however, as

3 14% Figure 2 10% 4% 29% Care/case management/ coordination team 37% reimbursement models change, many organizations are struggling to come up with the funds to build an infrastructure that will support new care delivery models. EMRs: Enough to stay afloat, not swim Simply implementing an electronic medical records (EMR) system that can accommodate an entry into population-health is job no. 1 for many organizations. We need to have a good EMR platform something that is comprehensive, interoperable and talks to exchanges and other healthcare systems, said the health system CMIO. To reach that level of data exchange that allows us to look at the patient as a whole that is a challenge in and of itself. Unfortunately, many healthcare leaders are finding that their EMRs simply are not built to handle these sophisticated functions. Our EMR platform is not set up efficiently to support our population health initiatives, said a CIO from a Coloradobased non-profit health system. Patient portal/engagement/ outreach Disease management/registries Invested in analytics/business intelligence Patient-centered medical home (PCMH) Similarly, a CIO from a not-for-profit regional health system said, The biggest challenge is having the EMRs spit out the data in a meaningful way. Some of them only create a report that is on paper and some of them cannot even create a report that is in a common format that you can import. Another executive more specifically pointed out that his organization s EMR has the data we need for the individual care of the patient but does not provide the data aggregation and analytics needed to actually change performance and behavior. As a result, the organization is looking to use other solutions in addition to the EMR to buoy its population-health programs. The health IT infrastructure needed to support population health management initiatives includes capabilities that go beyond what an EMR was designed to do. Organizations must be able to 1) aggregate various types of data from disparate systems across the community; 2) provide deep insights from the data through analytics; and 3) improve clinician workflows by leveraging those insights to drive better outcomes. Adding sophisticated solutions As such, provider organizations are apt to move beyond EMRs and explore other technologies to manage population-health initiatives. In fact, according to the study, leaders acknowledge that their organizations need to add other solutions to help reach their population-health goals. Consider these findings: 56 percent of organizations are looking to invest in business analytics, 52 percent in patient engagement, 52 percent in care management /coordination and 36 percent in data-aggregation solutions.

4 Figure 3 16% 14% Technology/data exchange/ accessibility issues Resistance to change Money/financial issues Understanding the proper pace for change and investment Resource constraints 26% 23% 21% A CIO from a Florida-based system said that healthcare organizations need to consider investing in a population health management platform that offers workflows and capabilities that drive care coordination and reminds patients of appointments. In addition, these systems need to be able to look into the patient base and identify who needs to be contacted, such as those who have not been seen in a while. And, finally, these systems should have the the ability to generate reporting and give you the ability to do certain amount of analytics. With such goals in place, many organizations are looking to dive much deeper into advanced solutions such as an enterprise data warehouse, predictive analytics, and care-management solutions that can better support populationhealth programs. Indeed, the chief of quality and patient safety at a large multi-specialty group practice in the Midwest has discovered that population health requires a wide array of technologies. To support a variety of patient-centered initiatives, the group has implemented an IT infrastructure to do claims analytics and clinical analytics to identify high-risk patients while also leveraging diseasemanagement registries and care navigation for the highest risk members in an effort to get utilization management to appropriate levels. By leveraging these more advanced solutions, healthcare organizations will be better able to support the new workflows required to achieve the Institute for Healthcare Improvement (IHI) Triple Aim of: Improving the patient experience of care (including quality and satisfaction) Improving the health of populations Reducing the per capita cost of healthcare And, of course, ultimately with these advanced technologies in place, healthcare organizations will achieve the clinical results that will lead to financial success under value-based models of care. By doing so, healthcare organizations can meet the demands associated with delivering care under a value-based model that truly focuses on maximizing health and wellness for all patients, all the time. References 1. Conway, P. CMS Releases Latest Value-Based Purchasing Program Scorecard. Accessed at: About Caradigm: Caradigm is a leading population health company dedicated to helping organizations improve care, reduce costs and manage risk. Caradigm analytics solutions provide insight into patients, populations and performance, enabling healthcare organizations to understand their clinical and financial risk and identify the actions needed to address it. Caradigm population health solutions enable teams to deliver the appropriate care to patients through effective coordination and patient engagement, helping to improve outcomes and financial results. The key to Caradigm analytics and populations health solutions is a rich set of clinical, operational and financial data delivered to health professionals within their workflows in near-real time. Produced by

5 Quotes from Leaders: Current Population-Health Initiatives We have started a lot of work around readmissions. Because of the way the finances work out, we are focusing on patients who are targeted under the Medicare readmission penalties. Those around hospital readmissions, COPD, coronary artery disease, and hip and knee replacements. We are using the experience in our readmissions program, value-based purchasing program, IPAs, federally qualified health center and experience around the ACO when we first joined it to evolve our population health. CMO & CIO from a West Coast health system As far as systemwide we are still in that sort of infancy of figuring out what system we should have and what is population health is going to look like. We are asking ourselves, how does it fit in the core values? There are still a lot of pieces and moving parts associated with population health. We need to narrow it down. CIO from a large not-for-profit IDN Our population-health strategy is doing several things at the statewide level. We are starting to build out our records and starting to figure out how to manage our own population more effectively, starting with our own employees. CIO from a large IDN in the Midwest We do have online access to patient health records, patient alerts and education through our patient portal. We use a CRM program to send patient information in the method they would like to be reached. We are using multiple tools to reach out to patients in that regard. We also have implemented a Population Health Coordinator, who is more or less a care gaps person who helps us identify the different populations that tend to be overlooked. Vice president of population health at an IDN with seven hospitals Two years ago we made a decision that physician alignment was not the right strategy and we had to do something different. We decided that it had to be around population-health management. CIO from an East Coast IDN

6 Quotes from Leaders: What s Needed to Support Population Health If you start with what you have, the claims data and the clinical data from labs, radiology, other structured data, you want to be able to combine the two to come up with some meaningful information. That is the first thing. Then when you really start doing heavy-duty 2.0 population health, you want to be able to integrate it with social-media data. Stuff like the patient was discharged and they are not taking phone calls on their cell phone, they are not using are they depressed, are they isolated, are they sick? Let us go make a home visit to see what is going on and keep the patient out of the hospital. That is the information you are going to need. CMO & CIO from a West Coast health system We will continue to embellish the tools and define the processes. Right now we are moving into bundled care and other value based purchasing and readmission penalties. CIO and CMIO from a healthcare provider in the Midwest Our higher priority is the care management and data aggregation. Data aggregation is something IT is working on currently. We need to set up an EMR interface and get the data into the HIE in a usable format. That is key Leadership is working on the population we want to target for care management. So the clinical side of the business is busy as well to target appropriate population. Risk stratification and analytics are longer-term solutions. CIO from a large IDN on in the East

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