How MissionPoint Health is Using Population Health Insights to Achieve ACO Success

How MissionPoint Health is Using Population Health Insights to Achieve ACO Success

Background The United States spends more per capita on healthcare than other country, yet is ranked last among industrialized nations for life expectancy. 1 A 2013 Bloomberg ranking of nations with the most efficient healthcare systems ranks the U.S. 46th among the 48 countries included in the study. 2 Of the $2.5 trillion spent on healthcare, a small number of people are responsible for an inordinately large amount of the cost, with just five percent of the population accounting for 50 percent of healthcare costs. 3 Of the $2.5 trillion spent on healthcare, a small number of people are responsible for an inordinately large amount of the cost, with just five percent of the population accounting for 50 percent of healthcare costs. These alarming statistics are among the drivers that led to the passage of the Affordable Care Act, which contains numerous initiatives focused on improving healthcare quality and slowing the growth of healthcare spending. This includes the formation of Accountable Care Organizations (ACOs), which can be defined as groups of doctors, hospitals and other healthcare providers who work together to provide coordinated, high quality care to their patient populations. The term accountable accurately describes the challenge for ACOs; they are tasked with ensuring that defined populations of patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. They are equally accountable for the costs associated with that care, and benefit financially when savings are achieved. This value-based approach to healthcare services changes the focus for providers, who are now encouraged and incented to look at care as a continuum rather than as isolated incidents. This value-based approach to healthcare services changes the focus for providers, who are now encouraged and incented to look at care as a continuum rather than as isolated incidents. Successfully accomplishing this change in perspective requires technology that can enable a high level of coordinated care which also necessitates almost seamless interoperability among participating providers. 2

With this kind of interoperability, providers within an ACO can begin to concentrate on that five percent of the healthcare population that most needs their guidance and expertise. They can create fully integrated care plans that extend throughout the community of care. Additionally, they can use technology to gain predictive insight into those patients just on the cusp of becoming high utilizers of healthcare services, allowing early intervention to stem the tide of chronic disease and potential problems. As an early adopter of both the ACO concept and interoperable technology, MissionPoint Health Partners in Nashville, Tenn., illustrates how a well-coordinated care network can simultaneously bend the curve on healthcare cost and quality. Success at MissionPoint Health Partners MissionPoint Health Partners was created as a nonprofit ACO by Saint Thomas Health and a group of physicians to improve community health. The organization is a clinically integrated network of providers, facilities and services that is payer agnostic. Network of 1,400+ physicians Represents more than 54 specialties and sub-specialties Facilities include major hospitals and 100+ outpatient locations Formed in 2011, MissionPoint serves 50,000 members in middle Tennessee and surrounding communities. It is focused on four primary goals that align with the definition of an ACO: Improve the health status of the communities it serves Reduce healthcare costs Improve the patient experience Enrich the lives of caregivers Although a relatively new entity, MissionPoint already has achieved strong success. In 2012, the organization reduced an employer s health spend by over 12 percent for its 15,000 members by using a customized approach to healthcare delivery. This included a 30 percent reduction in emergency department (ED) recidivism and a decline of over 50 percent in hospital readmission rates. 3

Achieving Coordinated Care Despite 32 Disparate EHRs One of the greatest challenges facing MissionPoint has been the integration of information from multiple data sets to create a comprehensive patient record and to enable population management. Wendy Wright, Vice President of Clinical Integration, estimates that 90 percent of MissionPoint s network is composed of independent physician practices with 32 different electronic health record (EHR) systems. One of the greatest challenges facing MissionPoint has been the integration of information from multiple data sets to create a comprehensive patient record and to enable population management. As a result, the IT and analytics team at MissionPoint focuses heavily on efforts to bring together this disparate information into a single database that supports predictive analysis and care coordination. By ensuring this kind of interoperability, the organization is able to provide medical management services that include: Access management Navigation Integrated care management Disease management Coaching for modifiable behaviors In addition, the database provides a means of measuring progress toward cost saving and quality-of-care goals. One of the precepts of ACOs is that participating physicians financially benefit when certain goals are met. Being able to regularly review updates on cost and utilization offers MissionPoint physicians real-time feedback and reminds them of shared savings, which might not be distributed for a year or more. Patients enter the MissionPoint system in several ways; they might be referred by a physician or make a self-referral, or come in through an ED visit or hospital discharge. No matter how a patient is introduced to MissionPoint, the organization works closely with physicians to ensure that their care plans and advice are executed. Knowing that somebody is picking up the ball and carrying it over the line for them makes physicians really interested in working with us, Wright says. 4

This is one important way in which the MissionPoint ACO represents a switch from traditional physician visits, where a doctor might advise patients to lose weight and stop smoking but then leave them to figure out on their own how to execute on the advice once they get home. Instead, thanks to integrated databases, MissionPoint providers know which patients they need to work with to develop weight loss and smoking cessation plans. The information comes full circle when details of the interventions are then sent back to the physicians for their review and follow-up. Solutions: Transitional Ambulatory Integrated care Hospital discharge ED Psychosocial needs Long-term dare Disease management Life resources Skilled Care Wellness Family resources Home visits Combining High Tech and High Touch MissionPoint s proactive approach to population health management may be at an individual patient level or for an entire group. The ability to create integrated data from multiple systems facilitates population health management, yet it also enables one-to-one personal outreach to identify root causes of illnesses and provide effective follow-up. The ability to create integrated data from multiple systems facilitates population health management, yet it also enables one-to-one personal outreach to identify root causes of illnesses and provide effective follow-up. Aggregated data can yield insights that otherwise might not seem significant when viewed individually. For example, MissionPoint discovered that people who are disabled have a very high rate of depression a factor that increased the cost of care by three times. Knowing this, the organization deployed its integrated care team, which includes counselors, to work with this specific population. The MissionPoint team receives daily discharge information from hospitals and can track those patients most in need of follow-up based on patient stratification and risk management tools. The information received by MissionPoint consists of the most recent medical encounters, as well as past ED visits and other medical records. Based upon this discharge information, protocols that are embedded in provider workflows generate reminders to call patients at certain periods and also provide a 5

list of applicable questions. When the information from a call is captured and entered into the system, it creates a comprehensive record that tracks success and pinpoints problems. I like to say that what we do is hand-to-hand combat. We identify the people in need through really sophisticated IT and analytics, but from there it s hand-to-hand combat calling people up and helping them out that s responsible for our success. Wendy Wright, Vice President of Clinical Integration MissionPoint Health Partners The high touch element occurs once the MissionPoint team receives the data. They will call patients, go to their hospital rooms and make home visits when needed. According to Wright, I like to say that what we do is hand-to-hand combat. We identify the people in need through really sophisticated IT and analytics, but from there it s hand-to-hand combat calling people up and helping them out that s responsible for our success. Clipping the Wings of ED Frequent Flyers Coordinating care across a wide range of providers also can help identify those frequent flier patients who visit multiple EDs for their health problems. As reported in a series of studies in 2012 for the Annals of Emergency Medicine, frequent fliers at hospital EDs sought emergency care at least four times a year and sometimes as often as 21+. That means individual patients can account for anywhere from one to two dozen visits, sometimes more. In 2010, the Department of Emergency Medicine at Mount Sinai School of Medicine in New York reported that frequent users comprised 4.5 percent to 8 percent of ED patients, but accounted for 21 percent to 25 percent of all hospital visits. A 2010 Rand Corp. study reported healthcare spending of $4.4 billion on people using the ED for routine, non-urgent care. 4 Wright recalls a female patient who had visited the ED at least six times in a fourmonth period. Despite having gone to different EDs, the patient was flagged in MissionPoint s risk management system. As a result of this shared data, MissionPoint care coordinators reached out to the patient, ensured she saw the right doctors, and assisted with her medication management. Since that time, the patient hasn t returned to the hospital. Not only did this improve the patient s quality of care, it also reduced costs for the ACO and member health systems. The ability to have comprehensive information available regardless of where patients present within an ACO helps to support better quality of care, reduce costs and increase patient satisfaction. Patients are relieved, for example, that they don t have 6

to enter their health and demographic data repeatedly as they move within the system. Because of interoperable technology, the care teams at MissionPoint have the comprehensive information they need to more effectively treat patients, while eliminating unnecessary duplicate tests and services. Looking to the Future After achieving significant savings with a self-insured population, MissionPoint will be extending its reach to Medicare/Medicaid patients as well as the uninsured. As the organization captures more data and history, MissionPoint expects to be able to analyze specific actions to determine effectiveness. For example, does a home visit improve outcomes? Does it reduce the rate of readmission? Being able to determine the actual value or lack of value for certain activities creates new protocols based upon both improved outcomes and cost efficiency. When combined with its high touch approach, MissionPoint feels it is able to make a substantive difference in the community. The organization recently helped one caregiver identify assisted living options for a parent, for example. Not only do services like this help a family during a trying time, they also lead to better outcomes by keeping patients safe and healthy, and avoiding potential ED visits. Ultimately, these types of activities pay for themselves, generating quality and cost improvement for the ACO. Today, through interoperable technology, healthcare organizations are finally able to develop the kind of accountable care that leads to better outcomes at reduced costs. Studies show that the number of ACOs doubled between June 2012 and July 2013,5 with numerous hospitals and physicians indicating they expect to form or join an ACO in the future. Today, through interoperable technology, healthcare organizations are finally able to develop the kind of accountable care that leads to better outcomes at reduced costs. Successes like those experienced at MissionPoint are helping convince many providers that ACOs offer a viable, valuable and forward-looking alternative to traditional care models. 1 U.S. Health in International Perspective: Shorter Lives, Poorer Health (2013) National Institutes of Health Committee on Population, Board on Population Health and Public Health Practice. 2 Bloomberg Visual Data: Most efficient health care: Countries. Bloomberg. 19 August 2013. 3 Understanding U.S. Health Care Spending, NIHCM Foundation Data Brief, July 2011. 4 Hospitals Crack Down on ED Repeat Users, HealthLeaders Media. April 18, 2013. 5 Growth and Dispersion of ACOs: August 2013 Update. Leavitt Partners. 7

ICA is a leading provider of strategic interoperability and intelligent care coordination solutions for the healthcare market provider organizations, public and private Health Information Exchanges (HIEs), Accountable Care Organizations (ACOs) and health plans; and is one of the few independent HIE vendors. ICA s CareAlign platform leverages existing technologies to connect care teams across healthcare settings. CareAlign delivers a flexible architecture to connect, collect, consume and intelligently distribute patient information through standard data transport protocols and custom methods for use in EHRs, third party applications and ICA s proprietary applications. CareAlign aggregates a wide range of information and supports analytic needs associated with population health management, transitions of care communication, readmissions reduction, meaningful use requirements and PCMH/ACO operations. ICA Impact Meaningful Use Stage 2 - Transitions of Care (Direct HISP services leveraging our National HISP) ICA is helping a large number organizations meet the Meaningful Use Stage 2, Transitions of Care (ToC) requirement, including many that are planning to begin attestation in April or July of this year. One of the ToC requirements is to support the electronic referral of patients to another facility which requires an organization s EMR to send these messages (via a Direct HISP) as well as for another organization to receive them (via a Direct HISP). ICA s Direct HISP services enable sending, receiving or both to help organizations meet this requirement. ICA provides secure, bi-directional Direct messaging through XDR technology which allows the sender/receiver to stay in their EMR or use a portal if their systems are not XDR-capable. ICA is also working with a majority of the large EMRs to provide our HISP services, and we support the full range of Direct standards - XDR in addition to the more traditional SMTP and web service. Event-Based Alerting to Facilitate Proactive Care Coordination SmartAlerts targets avoidable readmissions and other key cost drivers for highrisk patients. This capability enables near real-time, predictive analytics that can integrate seamlessly into clinician workflow by automating the identification and risk categorization necessary to take action and proactively engage high-risk patient populations that drive much of the healthcare cost today. This solution moves interoperability beyond facilitating simple communication by creating useable information that brings intelligence to interoperability. For information contact info@ica-carealign.com or 615-866-1500. 8