How Convergence Benefits Rising-Risk Patients
By Mark A. Caron, FACHE, CHCIO, Geneia CEO
No matter how you look at it, the toll of diabetes and prediabetes is staggering whether you’re the patient, the primary care physician, the employer or the health plan.
That’s why everyone involved is motivated to better identify, manage, engage and educate not only people already diagnosed with diabetes but also everyone at risk of becoming diabetic.
Patients with a diagnosis of metabolic syndrome – commonly referred to as prediabetes – are one of the cohorts of rising-risk patients everyone wants to identify as early as possible and then engage them in their health to prevent progression to chronic illness. This is quite the challenge given that the overwhelming majority (90%) of prediabetics do not know they have it.
Earlier identification and management of rising-risk patients is one of the primary reasons payers, physicians and employers are increasingly using a shared analytics solution. Predictive analytical models are able to identify which cohorts of people are likely to become sick in the next 12 to 24 months. But perhaps more importantly, it allows those who interact with and care for prediabetic patients to easily collaborate and align around shared goals and purpose, effectively intervening and engaging patients in a way that improves outcomes and quality of life.
Let me show you our vision of how healthcare providers, payers and employers work together to improve the health and quality of life for people with metabolic syndrome.
The convergence of payers, providers and employers means greater alignment, collaboration and personalized, patient-centered care that improves the health, satisfaction and quality of life of patients like Lucy.
Meet Lucy*. She is 42, a mother of two teenagers and a part-time caregiver for her elderly father. Through her employer, Lightning Laser, Lucy has been insured by Allegiant Health Plan for the past three years.
Lucy learned of her prediabetes diagnosis last year during her annual physical. In preparation for her physical, her physician ordered a number of tests, including a fasting blood glucose test.
In the year since her diagnosis, a number of people have been working with her and behind the scenes to help prevent her from progressing to diabetes. All of these people are using a shared analytics and insights platform to enhance their individual and collective effectiveness.
Lucy’s primary care physician is Dr. Todd Becker. For the past 10 years, Dr. Becker has been a part of Granite Physicians. The practice has a value-based contract with Allegiant Health that incents Dr. Becker and his colleagues to complete and improve HEDIS® measures such as measuring BMI, checking blood pressure and ordering fasting blood glucose tests for adult patients.
As a part of the pre-visit planning, Dr. Becker viewed Lucy’s information in a shared analytics platform. He saw she was on Allegiant Health’s list of members at risk for metabolic syndrome and ordered the fasting blood glucose test a year ago that showed Lucy, in fact, has metabolic syndrome. (See section below about the payer HEDIS® director.)
Since Lucy’s diagnosis, Dr. Becker and his team have used the analytics platform to monitor her progress on her care plan, including annual measurement of her BMI and nutritional counseling. Lucy’s referral to Allegiant’s health education program was done within the platform.
Jaime is the HEDIS® director at Allegiant Health Plan. At a population level, Jaime works to cost-effectively improve her plan’s HEDIS® performance by simplifying quality measure tracking for network providers including Lucy’s physician, Dr. Becker. For the past three years, her plan has focused on closing HEDIS® measures related to diabetes, including measuring BMI, testing blood glucose levels and blood pressure screening.
Three years ago, Allegiant licensed an analytics platform to, in part, support Jaime’s work. As a result, Jaime has been able to undertake efforts to identify subpopulations of members with gaps in care, many of whom also are the plan’s rising-risk patients. For example, she reviewed BMI trends to generate lists of members at risk for or with a metabolic syndrome diagnosis, which were then shared with Allegiant’s value-based care practices. Granite Physicians’ list from 15 months ago included Lucy.
Until a year ago, Judy was a disease manager for Lucy’s health plan, Allegiant. Traditionally, her plan’s care management program focused on chronically-ill and catastrophically-ill members. The plan’s increasing emphasis on value-based care and managing the population rather than just the sickest of the sick, means care managers – now called population health clinicians – have an expanded role that includes identifying and engaging rising-risk patients and improving key HEDIS® quality measures in the plan’s value-based contracts.
Judy is Lucy’s population health clinician. Using the analytics platform, Judy is able to monitor Lucy’s progress on her care plan. By viewing Lucy’s record in the platform, Judy knows her health education colleague has already reached out to Lucy and enrolled her in the right program. When Judy contacts Lucy, she affirms her participation and answers her questions about metabolic syndrome treatment and prognosis.
Lucy’s employer is Lightning Laser. The vice of human resources, Chase, has been using the analytics platform for the past three years. At the outset, he focused on out-of-network utilization and preventable emergency department visits. More recently, he has used the platform to identify cohorts of rising-risk employees and learned a sizeable percentage of his employees has diabetes and an even greater percentage has prediabetes or is at-risk for prediabetes.
Armed with this information, Chase has been working with Allegiant Health Plan to offer virtual health education and nutritional counseling programs, one of which included Lucy, and semi-annual onsite biometric screenings of BMI, fasting and non-fasting blood glucose, blood pressure and more. Lucy was able to take advantage of the onsite biometric screening this year. Her biometric information was uploaded to the analytics platform so the professionals monitoring her care plan know she is still on track.
I know firsthand those of us who work in healthcare have always wanted to help Lucy and others like her be one of the 30 percent of prediabetics who do not progress to diabetes. For the first time, all of the people who interact with Lucy and have the opportunity to help her adopt a healthier lifestyle and engage in her health – her physician and his team, the population health clinician and HEDIS® director at her health plan, and her employer – have a tool that simplifies collaboration and coordination in a way that directly benefits Lucy. The convergence of payers, providers and employers means greater alignment, collaboration and personalized, patient-centered care that improves the health, satisfaction and quality of life of patients like Lucy.
*Lucy is fictional and not intended to represent any specific person. This information is provided for illustrative purposes only.
This post was originally written as the third in a series of sponsored guest blog posts on our Convergence conference blog.
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How to Succeed with a Provider-Sponsored Medicare Advantage Plan
By Matt Cox (Chief Marketing Officer, Lumeris) and Nigel Ohrenstein (Senior Vice President and head of Market, Lumeris)
Health system and health plan leaders across the country are asking the same question: how will our organizations survive and thrive in a value-based world? As the shift to lower-cost settings accelerates and the population becomes older and sicker, organizations are seeking new ways to manage costs, generate income and control quality.
For many organizations, launching a Medicare Advantage (MA) plan paves the way for value-based care models that reward delivering better care at lower costs by combining clinical and financial expertise. As enrollment in MA continues to outpace traditional Medicare enrollment – with national MA penetration growing from 30 to 50 percent in the next 10 years – organizations must have a strategy that enables success in the future.
MA is increasingly viewed as a potential growth area for organizations. While launching a plan certainly carries risk, it also offers significant upside for providers and payers to successfully manage the health care needs of members.
With an average annual premium of $10,000 per member according to a Lumeris study, MA enables provider-sponsored plans to manage the risk of a population. Access to comprehensive claims data can be used to identify high-risk patients and areas of high utilization, supporting an organization’s population health efforts and steering patients in-network. With aligned incentives, organizations can innovate and invest in care delivery with tools and workflows that support high-value, appropriate care.
Further, MA’s sophisticated risk adjustment methodology supports premium payments that reflect the expected cost of providing medical care to each member, including those with complex conditions. Proper risk adjustment requires providers to capture diagnoses accurately and completely to support reimbursement.
Finally, with Star ratings, well-managed MA plans that earn 4- to 5-Star ratings can attract more members and revenue through enhanced benefits. Highly-rated plans receive performance bonuses that bring in an extra five percent a year, which are used to provide additional benefits to members.
Consider creating a plan built around a collaborative model: one that aligns incentives, bolsters the provider-payer-member relationship and enables delivery of high-quality, cost-effective care.
Establishing a provider-sponsored MA plan is a significant undertaking. Given the large investment of time and money, organizations considering launching a plan must ensure they have several foundational elements in place. Consider creating a plan built around a collaborative model: one that aligns incentives, bolsters the provider-payer-member relationship and enables delivery of high-quality, cost-effective care.
Before launching a plan, organizations must evaluate their tolerance for risk and ability to capitalize said health plan. A strong brand reputation in the market is obviously crucial, but additive resources and significant infrastructure are also required. Organizations should also consider market dynamics, population growth and reactions from key players – competing systems, provider groups and other payers – and how these factors impact their strategy as a differentiated plan offering in the market.
Considerable infrastructure is required for claims processing, actuarial analysis and utilization management, among other payer functions, which can be leveraged from working with a collaborative payer or operating partner. In MA, expertise in Star ratings, risk adjustment, sales and marketing, compliance and plan design add further complication to successful operations. To build the right foundation, provider-sponsored plans must focus on enabling the provider-payer-member relationship, often requiring innovative processes on everything from data transparency and aligned incentives, to coordinated care management programs and shared governance.
Core to a collaborative model is ensuring organizations are aligned. Managing a health plan requires organizations to focus on improving patient outcomes and monitoring the entire population, not just the patient in front of them. Fostering the right network and governance, aligning incentives to create mindshare, sharing best practices and information, and supporting new workflows and behaviors are all critical to success in value-based care delivery.
Before launching a collaborative MA plan, organizations must assess capabilities to identify gaps in knowledge, expertise and operations. For most organizations, working with an operating partner is more effective than building internal MA competencies from the ground up. Finding a partner with skill and experience in launching a collaborative plan can enable organizations to gain a competitive advantage more quickly. It can improve the likelihood of success while limiting risk and enable providers to focus on their core strength of delivering high-quality, high-value outcomes.
One example of bringing these necessary capabilities together is the newly announced collaboration between Cerner, a global leader in healthcare technology, and Lumeris, an award-winning health plan and value-based care managed services operator. Under the relationship, the companies will provide a suite of offerings under the name Maestro Advantage™, designed to enable health systems and health plans to drive success in value-based arrangements through population health service organizations or provider-sponsored plans. The offerings combine Cerner technology and Lumeris operational services aiming to streamline redundant processes that burden members, payers and providers, including lengthy claims processing and reimbursement cycles, and obstacles to sharing data and records across any electronic health record in the network.
This post originally appeared on September 19, 2018, as the second in a series of sponsored guest blog posts on our Convergence conference blog.
How Health Systems and Health Plans Are Leveraging Each Other’s Strengths Through Telehealth
Mike Baird, President, Customer Solutions, American Well
There are over 5,000 hospitals in the United States, each caring for the country’s growing population of more than 325 million people. Aside from integrated health systems, many of these organizations are operating independently from health plans or other health systems. This type of siloed care has become the norm in the healthcare industry, and while EHRs have improved care continuity over the years, health organizations are still largely operating on their own.
The same can be said for these organizations’ telehealth programs. More than half of healthcare executives say they have implemented some sort of telemedicine service into their organization. Many health systems and health plans launch with a direct-to-patient urgent care telehealth service, before expanding to other service lines including behavioral health, specialty care, chronic care management, follow-up appointments and more. These telehealth programs leverage the healthcare organizations’ provider expertise, clinical services, technologies and unique ties to their communities. While telehealth is helping these organizations deliver more convenient and affordable care, their programs, too, have been historically siloed. Until now, that is.
Today, some of the top health systems and health plans in the country are utilizing their telemedicine programs to connect and exchange services instantly online. Health systems or hospitals who supply healthcare services are partnering with health insurers who generate consumer demand to leverage each other’s strengths. This sharing of patient demand and provider supply is key in driving telehealth and patient success.
Two of the nation’s top healthcare organizations provide a perfect example of this type of telehealth care convergence. Cleveland Clinic, one of the largest and most well-respected hospitals in the country, offers its telehealth services on Anthem’s telehealth platform, LiveHealth Online. Consumers in Ohio, West Virginia and Pennsylvania who use Anthem’s telemedicine platform can connect with Cleveland Clinic physicians and nurse practitioners through the LiveHealth Online mobile or web platform for live on-demand video consults.
For Anthem, this collaboration offers its members unique access to providers from one of the nation’s leading institutions, and for Cleveland Clinic, it allows the health system to extend its telehealth service visibility to Anthem’s 38.5 million members — ultimately increasing usage and attracting new patients.
New-York Presbyterian offers another innovative example of care collaboration and integration through telehealth. New-York Presbyterian is one of the nation’s most comprehensive, integrated academic healthcare systems. The system has ambitious goals for telehealth and has already integrated virtual care into its emergency rooms to provide effective behavioral health treatment and to triage non-urgent patients to reduce wait times. Through its direct-to-consumer telemedicine program, New-York Presbyterian makes its providers available on the Samsung Health Ask an Expert app, which is preloaded onto Samsung Galaxy smartphones. Through this telemedicine exchange, a consumer with a Samsung phone can have an urgent care video visit with a New-York Presbyterian provider from within the Ask An Expert app. For New-York Presbyterian, partnering with Samsung gives their telehealth program unprecedented exposure to consumers across the country, while Samsung can offer consumers access to New-York Presbyterian’s renowned providers.
New-York Presbyterian, Cleveland Clinic and Anthem are the trailblazers for this type of virtual care collaboration, and more healthcare organizations are following suit as focus shifts from fee-for-service to value-based care. These partnerships help accelerate telehealth adoption through greater platform utilization, increased healthcare specialty choices for patients, and expanded access to care.
Recent regulations have also helped make telemedicine collaboration more appealing for healthcare organizations. The Interstate Medical Licensure Compact allows expediated multistate licenses for physicians, which means health systems wanting to extend their services over state lines can expect expedited, multistate licensure for their physicians.
Health systems and health plans have their own unique strengths; by lifting the virtual barriers of telehealth care delivery, they can leverage these strengths through thoughtful telehealth collaborations. In turn, this is transforming the way care is delivered and received for the benefit of both patients, providers, and health systems.
This post originally appeared on September 5, 2018, as the first in a series of sponsored guest blog posts on our Convergence conference blog.
How Healthcare Leaders Adapt to the Evolving Front Door to Care
by Brian Eastwood and Paul Nardone
When today’s healthcare consumers have questions about their health, they are no longer limited to phone calls to the doctor’s office or visits to the emergency room. Technology has enabled and supported the creation of numerous new “front doors to care” – including but not limited to telehealth, chatbots, digital therapeutics, retail health, urgent care, and community-based clinics – that threaten to disrupt traditional care delivery models.
We recently interviewed two leaders at organizations leveraging telehealth to meet patients where they are and complement existing clinical workflows:
Excerpts of these interviews appear below. They have been edited for clarity.
Brennan: MedNow is Spectrum Health’s direct to consumer (DTC) telehealth program. It has been in place for four years. It lets patients see a provider on their device for low acuity primary care conditions. Custom-building a mobile app that integrates with the EHR enabled us to enhance the patient experience and complement all of the other digital tools that Spectrum Health offers.
Johnson: We describe Landmark Health as a leading-risk medical group. We contract primarily with payers but can also contract with anyone who takes on risk. We focus exclusively on patients with 6 or more chronic conditions and are available to them 24/7/365 telephonically or in their home. We have physician leaders who take care of patients and are supported by interdisciplinary teams: Case management, behavioral health, pharmacists, dietitians, social worker, and non-clinical healthcare ambassadors who help build relationships with patients in between clinical visits and help them with education.
Brennan: All of the above. The primary driver for us creating a great patient experience is that it is quickly becoming an expectation of patients who want convenient access to care. In addition, as healthcare transitions to value-based care (VBC), cost reduction is paramount.
Johnson: The hospital business model isn’t designed to provide longitudinal care of patients with complex conditions. We designed a model from the group up that could provide care for patients when they need it (24/7) and where they need it – in the comfort of their home. Patients with complex chronic conditions have a generally steady high medical spend year-over-year, so intensive longitudinal models to improve their long-term health work well. There are also psychosocial elements, including depression, dementia as well as addiction. This can be impacted by the interdisciplinary approach – specifically the incorporation social work and behavioral health – of our clinical model.
Hospitals state outwardly that they don’t want inappropriate hospitalizations. We are not taking away their core business treating patients in need of acute care.
Brennan: Throughout development of our program, we were very conscious of cannibalization. Telehealth takes visits out of the emergency department and replaces it with something much less expensive. In preparing our health system for the future, we would rather get ahead of reducing healthcare costs than react to it. We need competencies in virtual care for the future and chose to build it now, rather than trying to catch up later.
Johnson: Hospitals state outwardly that they don’t want inappropriate hospitalizations. If there’s a readmission, they don’t get paid the second time, so we partner with them on discharge planning. Conceptually, they’re aligned. We are not taking away their core business treating patients in need of acute care.
Brennan: We emphasized both clinical and operational benefits. Many health systems focus on one or the other; our strategy was to focus on both. The primary resistance came from physicians who were not convinced this was an appropriate standard of care. Four years into our telehealth journey, some physicians still don’t believe that virtual care is part of the future. We can attribute much of our success to the buy-in and support of executive leadership.
Johnson: We’re something that not a lot of people have seen before. It takes a bit of time to explain who we are and assuage fears that we will be competing for members with primary care physicians. We’re not a PCP, and we encourage strong relationships with a PCP. When we enter a market, PCP visits stay the same, or even increase a little bit. Once PCPs see the effects, they realize it’s really only a small number of their panel – and it’s usually the ones they find the hardest to manage, who have a lot of barriers to care.
When we are measuring the growth of our encounters, we are thinking of it as a convenient front door to the system, so it makes sense to measure how many people come through that door. Other important metrics include new patients to the system, cost savings to payers, avoided ED and Urgent Care visits, and patient miles saved.
Brennan: For us, it’s the number of encounters. With virtual care, the only way to scale is through increasing volume. When we are measuring the growth of our encounters, we are thinking of it as a convenient front door to the system, so it makes sense to measure how many people come through that door. Other important metrics include new patients to the system, cost savings to payers, avoided Emergency Department and Urgent Care visits, and patient miles saved.
Johnson: Our service significantly reduces the medical expense reimbursement for a patient and improves the medical loss ratio for that covered population – from north of 100% to something quite profitable. Health plans can take a segment of members that used to be challenging and bring it in line with the rest of their book of business. This allows our plan partners to keep premiums lows and invest in additional services for their members.
Brennan: First and foremost, it’s access. Our average wait time for a visit is 12 minutes and we are available 24/7. MedNow sees patients regardless of having a relationship with a Spectrum Health provider and we are available to everyone in the state of Michigan. We have created a patient experience that is easy to use so that we can provide care where and when a patient needs it.
Johnson: The patients we serve often have frequent inpatient stays, or discharges to skilled nursing or post-acute care facilities. It’s often inappropriate and ineffective care; patients leave in worse condition than when they came in. If we can manage or control these patients more effectively prior to an incident, working with their existing PCP and specialists, we may prevent a hospital visit and stabilize longitudinal health.
Brennan: It’s the digital health ecosystem. Similar to Google’s digital ecosystem, it is a suite of products, not just one tool. We will get to a point where the expectation of patients becomes that health systems will meet their needs digitally like other industries, such as banking and commerce.
Johnson: For us, it’s literally the front door. Our mission is to bring healthcare to people when they need it, where they need it. It’s simple but profound. It also allows us to bring family in. A lot of the barriers to care are around families and education and getting people on the same team. We have clinicians who can build great care plans, but also think through the barriers to care and how to ensure the patient can follow that care plan. “How can we implement this? What are the barriers? What is the family alignment that we need?” Being able to do it in the evening, on the weekend, allows us to have better conversations.
A version of this blog first appeared on the Convergence 2018 blog on September 27, 2018.
Humana-Walgreens Partnership: Primary Care Focused on Medicare Advantage
Medicare Advantage (MA) continues to show the most robust growth of any line of business for health insurers. Overall MA growth was 7.8% year over year in July 2018, reaching 21.4 million, while Part D enrollment grew to 25.5 million. To better serve these members, health insurers are considering several strategies – one of which is operating primary care clinics that exclusively focus on Medicare patients.
On June 19, Humana (NYSE: HUM) and Walgreens (NASDAQ: WBA) jointly announced a partnership under which Humana will initially operate two senior-focused primary care clinics inside Walgreens retail stores in the Kansas City, Missouri area. The clinics will open under Humana’s Partners in Primary Care banner; they will join four existing Kansas City area clinics, opened in 2017, which share the same name. The two co-located clinics are slated to open in the fall and occupy ~2,500 square feet (~25% of an average Walgreens store).
These clinics will have their own separate entrance, with an exit into the Walgreen’s pharmacy. While the companies are not sharing details on the nature or economics of the partnerships, Humana did note that it will operate the clinics and staff the doctors and accept a variety of Medicare coverage, including fee-for-service, MA, and Medicare Supplement plans. The clinics will serve seniors exclusively; Humana expects they could take 3-4 years to reach capacity. The companies noted that the collaboration could expand into other markets over time.
This partnership shows how both Humana and Walgreens are focusing more heavily on their longer-term clinical strategy and responding to other competitors “front door to care” strategies.
For Humana, this pilot is a logical extension of the company’s longstanding commitment to an integrated care model that more closely aligns primary care, pharmacy, in-person health plan support, and other services for Humana’s MA and Part D members. It also follows recently acquired minority/joint venture stakes in home health and hospice providers Kindred and Curo.
Humana believes the convenience of the retail pharmacy model should help make primary care more accessible to seniors. In addition to the co-located Partners in Primary Care clinics, Humana representatives will work in select other Walgreens stores to provide general assistance on health-related services to Humana Medicare members and other customers. These in-store “health navigation” services will be available at no cost to members inside the Walgreens pharmacy store (as opposed to the co-located clinic).
The Partners in Primary Care model offers integrated services that “go beyond addressing acute and immediate health issues, and [focus] on developing long-term relationships with patients living with chronic conditions.” In addition to the four wholly owned, standalone clinics that opened in Kansas City in 2017, Humana operates two clinics under the Partners in Primary Care banner in Greenville, SC and another in Gastonia, NC.
All of these providers are risk-bearing for Humana, as will be the locations co-located with Walgreens; the latter may or may not bear risk with other payers, depending on the contracts struck with third parties. Importantly, the collaboration with Walgreens does not preclude Humana from striking any other potential arrangements with other retailers. Humana will also continue to work with Walmart on a partnership that encompasses a value-oriented, co-branded Medicare Part D plan as well as other in-store consultative efforts.
Walgreens has recognized the need to make changes to its store format and is exploring various partnerships that will add new services. This announcement with Humana appears consistent with a strategy of incremental, capital-light partnerships with other healthcare services providers to convert its stores away from retail toward a more comprehensive healthcare offering.
Others within the healthcare continuum have received more attention for their efforts to provide a more convenient location to access healthcare services – namely CVS Health with its acquisition of Aetna. But Walgreens has been actively growing its suite of healthcare services that can be offered both inside and outside the retail pharmacy: Partners in Primary Care with Humana, MedExpress with UnitedHealthcare, LabCorp PSCs, Walgreens Hearing, Walgreens Optical, and its new Find Care Now telehealth service.
In addition, Walgreens is piloting a set of differentiated service offerings in the Gainesville, FL market. These include Walgreens Plus (a subscription-based, in-store savings program with an option for free same-day prescription delivery) as well as an in-store partnership with Sprint for phone purchase and activation.
It appears that any new store concept is very much a work in progress, and Walgreens expects to update investors on its store strategy in about a year. We expect Walgreens to test the “Partners in Primary Care” concept in these two test stores before making a decision to roll it out more broadly, as with its other pilots.
We see four key questions about the Humana-Walgreens partnership.
Humana has stated that it could take 3 to 4 years for the two new clinics to reach capacity. Humana did not provide details on how it will advertise these new clinics to new or existing Humana MA beneficiaries, what types of MA beneficiaries are likely to enroll in these clinics, and how it might convince MA beneficiaries to switch from the long-term relationships they have with their PCPs. These clinics might be a good fit for certain Humana MA beneficiaries (e.g. patients within walking distance of a Walgreens or patients without a regular PCP) – but it would not be surprising to see these clinics struggle to reach capacity unless they hire an existing PCP or two who can bring a large patient panel of MA beneficiaries.
Assuming a patient panel of 500 to 700 MA patients per physician at these new clinics, they are likely to only serve 1,500 to 2,000 Medicare patients in addition to the four existing Partners in Care clinics in the Kansas City area. Humana currently supports more than 65,000 MA and Part D prescription drug members in the Kansas City area. Will those few thousand beneficiaries regularly seeking care at Walgreens be enough to decrease hospital admissions and ultimately the medical loss ratio?
While Humana has acknowledged that retail could be a powerful distributor of provider capabilities for its MA members, its view that model as still unproven. Humana expects to experiment with smaller, more targeted retail initiatives vs. broader ones, at least in the near term. Walgreens as well appears to be in no rush to rapidly expand this concept either, with its pilot starting at two sites and expected to last at least 12 to 18 months.
It has not been disclosed if Partners in Primary Care is using a commercially available EHR or choosing to build its own product. Some primary care clinics focused on the MA population, such as One Medical, use a commercially-available EHR (eClinicalWorks). Others such as ChenMed and Iora Health have chosen to build much, if not almost all, of their own IT offerings, including a proprietary EHR. The startups that have built proprietary solutions felt that commercially available EHRs were not well-suited for their patient populations for several reasons (such as insufficient HCC coding and documentation support); as long as they only served the Medicare population, they found they were better off building and maintaining their own EHR.
We expect this type of coordinated care services model for MA beneficiaries to expand to other geographies over time. While this partnership is immaterial to either Walgreens’ or Humana’s financials over the next few years, it shows how both companies are focusing more heavily on their longer-term clinical strategy and responding to other competitors “front door to care” strategy for MA – especially CVS-Aetna and UnitedHealthcare-WellMed.
Da Vinci Project: FHIR Meets Value-based Payments
While healthcare frets and obsesses about the state of exchange between providers, payers have been relatively slow to embrace modern ideas about data movement. On the federal level, Blue Button 2.0 lets Medicare beneficiaries download or authorize the download of their own health data. This federal program has generated a lot of interest, signing up roughly 500 organizations and 700 developers at last count. Claims data on 53 million beneficiaries spanning 4.5 years is available for authorized developers and applications. Commercial payers have yet to emulate such an approach. However, there are indications that they are beginning to take notice and act.
The Da Vinci Project is a new private sector initiative to address the technical requirements for FHIR-based data exchange among participants in value-based care (VBC) programs. Its general goal is to help payers and providers with techniques and ideas for information exchange that contribute to improved clinical, quality, and cost outcomes. More specifically, it wants to facilitate the creation of use case-specific reference implementations of FHIR-oriented solutions to information exchange challenges in value-based care.
The Da Vinci Project is a relatively new project in from Health Level 7. Its founders represent organizations with experience across a range of VBC business challenges and the FHIR standard. Currently, it has the support of 27 organizations, including 11 payers, 10 health IT vendors (including 3 EHR vendors), and 6 providers.
Making coverage information REST-accessible and granular could vastly improve on the flurry of phone calls, faxes, and EDI-based document exchange that bedevil hospitals and physician offices.
Da Vinci aims to deliver implementation guides (IG) and reference software implementations for data exchange and workflows needed to support providers and payers entering and managing value-based contracts and relationships. FHIR implementation guides are roughly analogous to an IHE profile in that they define actors and actions in a defined use case. In this instance, the idea is to help providers and payers operationalize their complementary processes in value-based contracts.
Da Vinci at one time contemplated creating nine use cases. It eventually narrowed this focus to developing IGs for two that have particular VBC relevance:
Medication reconciliation is a time-consuming part of patient encounters anywhere on the care continuum. Post-discharge, this capability can reduce the incidence of adverse drug events and head off re-hospitalizations. The objective of this project is to create a simple workflow that allows providers to attest that a medication reconciliation is complete.
Coverage requirements discovery enables a provider to request payer coverage requirements in their clinical workflow. In-workflow coverage details can make point-of-care decision making about orders, treatment, procedure, or referrals more efficient. The ability to make both clinical and administrative decision mid-encounter and with a patient minimizes the non-clinical cognitive burden on providers. By reducing denials and delays administrators can be freed for other patient-specific work. As prior authorization becomes more common in value-based payment programs, providers could save time if such information were more readily available to them.
Both IGs will be balloted in HL7’s September Ballot Cycle, and Da Vinci is actively encouraging people to comment. Da Vinci team members will be on hand to help implementers interested in these two initial use cases at HL7’s September Connectathon in Baltimore, MD. It has also begun working on requirements for a third use case, Documentation Templates and Payer Rules.
While the data scope of this effort is not nearly as broad as Blue Button’s, which provides access to a patient’s claims history, it is a reasonable first step. Making coverage information REST-accessible and granular could underpin applications, vastly improving the flurry of phone calls, faxes, and EDI-based document exchange that bedevil hospitals and physician offices. Hopefully, this effort is a leading indicator of better access to commercial payer data to come for patients and providers.
Blockchain in Healthcare: Enthusiasm is growing, but still a long way to go to realize impact
The speculative craze around Bitcoin and the Initial Coin Offering (ICO) market for startups in the digital currency and blockchain space has heightened the interest in blockchain beyond the crypto-community and into the mainstream. The speculation in the ICO market has driven investment in these vehicles to reach nearly $7 billion in 2017 virtually dwarfing venture capital for startups across all sectors including healthcare. Among the hundreds of startups in the blockchain ICO count are over 70 dealing with healthcare according to industry observer Vince Kuraitis. But speculative capital rarely translates into long-term sustainability and the disruptive business models that startup founders espouse. Limitations with scalability, transaction speeds, energy consumption have been some of the dominant concerns. This is particularly true in healthcare and we have reached an important point in the evolution of the blockchain space where it is worth pausing to take stock of how blockchain applications are evolving and what specific pain points in health IT can current blockchain infrastructures realistically address.
Blockchain can be valuable in contexts where there is dependency between transactions and an asset, such as data, passes from one party to another. Furthermore, when verification of the integrity or provenance of the data is valuable the immutability and time stamping features that blockchain provides are very useful.
Chilmark Research is releasing our “Market Scan Report (MSR) on “Blockchain in Healthcare” with this goal in mind. We wanted to explore the first generation of use cases and startups in the blockchain space and provide a strong foundation for understanding the potential applications in areas that speak to the core capabilities of blockchain as they relate to payers and providers: identity management, data sharing/exchange, provider directories, patient indices, claims adjudication, supply chains and revenue cycle management. We can think of blockchain as having a role in addressing pain points in the healthcare system where we see some of the following challenges:
Contexts where there is dependency between transactions and an asset, such as data, passes from one party to another are important areas where blockchain can be valuable. Furthermore, when verification of the integrity or provenance of the data is valuable the immutability and time stamping features that blockchain provides are very useful.
Our research into the current applications in development and most-ready for prime time in the next year include companies working in the following areas of the provider-payer nexus:
We provide brief vendor profiles of consulting firms, large tech providers and startups working in the blockchain space and an analysis of where we see this market going in the coming years. These also include some of the larger consulting and tech firms offering enterprise Blockchain-as-a-Service offerings including IBM, Accenture, Deloitte and T-Systems. The startups profiled include PokitDok, Simply Vital Health, Solve.Care, MedRec, Change Healthcare, Factom. There are also alternatives to blockchain or a growing number of companies that have chosen to develop “blockchain friendly” applications until the blockchain ecosystem reaches a higher level of maturity. Google’s DeepMind Health is using an alternative distributed ledger technology with patient records in the UK’s National Health System after creating an uproar over perceived misuse of patient data without approvals or prior consent. Blockchain offers an auditable way to address this controversy. A supply chain/cybersecurity offering by Cloudface provides an analytics solution for hospital supply chain with plans to create blockchain applications in the near future. There is also growing interest in IOTA’s Tangle for the Internet-of-Things (IoT).
One interesting example that emerged at the end of our writing this report was the recently announced Optum-Quest-Humana-MultiPlan blockchain initiative to improve provider directories. This is part of an effort to streamline back-office operations for payers. The initiative was developed to address the problem that arises when claims from providers enter the system and there is a mismatch between the records payers have on providers and the provider identity. Often the payer directories are not up to date and the resulting lack of reconciliation of claims submitted by providers results in delays or non-payment of claims. The initiative will launch a pilot during the summer of 2018. What is important about this initiative is the involvement of multiple stakeholders making it a more salient use-case of blockchain for pain points resulting from lack of coordination and effective sharing of data across multiple companies. We view blockchain as a tool for industry transformation rather than disruption of companies, this is a prime example of how to begin thinking about utilizing blockchain in a transformative manner. Over the next decade, we expect to see fewer discussions of blockchain in isolation and it will be a component alongside the cloud, AI and other technologies used to automate administrative functions and enable more efficient sharing of data.
Over the next decade we expect to see fewer discussions of blockchain in isolation and it will be a component alongside the cloud, AI and other technologies used to automate administrative functions and enable more efficient sharing of data.
The example above also leads us to how Chilmark Research is beginning to think about the future of blockchain in healthcare. Blockchain is an inherently complex new technology that necessarily involves coordination across networks of stakeholders. This means that blockchain ‘disruption’ of healthcare that solves the interoperability challenge or other major pain points with a single technological quick fix is not anywhere even remotely close on the horizon, but we do believe the full impact of the transformative potential of blockchain will play out over the coming decade. 2018 will see a growing number of pilots and experimentation as the hype of 2016-17 spurred considerable interest.
Even government has gotten involved with a Blockchain Caucus in Congress. The ONC’s white paper challenge and recent Trust Exchange Framework bode well for blockchain’s future as well. Blockchain proponents would be well served in the long run by moving beyond a strict techno-centric approach and developing more robust thinking on managing consortia, governance mechanisms, and the broader cryptoeconomics of blockchain in the context of the health economy. Thinking is lagging on these fronts and the froth around easy money via ICOs in 2017 has not helped matters in developing the critical thinking tools towards long-term success for blockchain in the health IT ecosystem.
For those interested in learning more Chilmark Research will be attending the Second Annual Healthcare Blockchain Summit on June 11-12 in Boston where many of the vendors and use cases we analyze in our report will be represented.
Podcast: The Convergence of Providers and Payers
Chilmark’s founder and president John Moore recently took some time to speak with the producer of the Relentless Health Value podcast, Stacey Richter, to discuss current strategies of one of the biggest trends in healthcare right now, provider-payer convergence.
The discussion begins by outlining how convergence is unique compared to the many other changes and initiatives sweeping through American healthcare. Most organizations enter into these partnerships as an answer to high administrative costs, the wave of recent consolidations, and unsuccessful provider-sponsored health plans. Most importantly, a successful convergence partnership requires a deep understanding and commitment to the local market served and trust between the organizations. John also outlines some of the challenges to creating successful partnerships and suggestions to overcome or avoid them entirely. For widespread convergence success, health care organizations (payers and providers) will need to systematize both the business processes and IT infrastructure to support data sharing and actionability.
Listen here and be sure to scroll to the end of this post to see some of the content discussed:
00:00 Convergence and the delivery of health care.
02:20 “How do we deliver greater value?”
03:00 Why establishing health plans within a provider organization is often not the best idea.
04:30 How you can get around needing prior authorization and subsequently cut costs.
05:50 The motivation for a payer and provider to form a partnership.
08:00 Why consolidation doesn’t necessarily drive down costs.
08:50 Payer-provider population health management.
09:20 Understanding where the patient might be going outside of the network to get their health care.
10:00 What does it take to be good at collaboration?
10:30 “What is the opportunity here?”
10:40 “Is there a level of trust between the payer and provider?”
18:00 Advice for payers looking to partner with providers.
18:50 Look for someone wanting to deliver high-value care.
19:30 “Trust, then verify.”
23:00 New and interesting innovations coming out of current convergences.
24:00 Things still being worked out in the market today.
25:25 The innovator’s dilemma.
26:30 “How do you scale quickly?”
27:20 “Is that scalable?”
30:20 The path forward for most markets in the United States.
Throughout the program, John and Stacey touch on several Chilmark publications, available here:
John emphasizes how prior authorization requirements are driving up admistrative costs for both providers and payers. Even outside of a full convergence partnership, both parties can begin to work together to reduce these costs and share the benefits.
As a population health management becomes more essential to healthcare, robust solutions are incresingly important for sharing and analyzing data from several sources, including payers, for sustainable value-based reimbursements.
Stacey mentions how difficult, yet important successful behavioral change can be for improving overall health. This report covers both factors driving adoption plus profiles for leading solutions for a variety of conditions and users.
John talks a little about his predictions for the future of the CVS-Aetna healthcare offerings in the podcast, including how MinuteClinics might become the first point of care. Read more in our blog about MinuteClinics, the implications for Epic Systems’ EHR, and challenges both companies face as they ambitiously attempt to transform how Americans seek healthcare.