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.
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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.
By Opening a Front Door to Care, Telehealth Will Finally (Finally) Take Off
Anyone who has written about telehealth in the last decade has penned a January piece that begins, “This is the year telehealth technology finally takes off.” In keeping with the pattern, a second piece inevitably follows about 11 ½ months later, noting that telehealth didn’t quite take off as expected but, frankly, ought to in the year ahead, often for the same reasons that held back adoption over the course of the year.
Admittedly, I’m guilty as charged. My first “telemedicine will take off” piece appeared in early 2013, only a couple months after my first “telemedicine is changing health IT” headline. (You can tell it was a long time ago because I still called it telemedicine.)
At the risk of sounding naïve, 2018 increasingly looks like The Year. But it’s not necessarily due to mergers and acquisitions, good earnings calls, or legislative progress. Yes, these matter, but they reflect outside forces pushing provider organizations. Such forces can only push heavyweight incumbents so far.
Providers are finally starting to flip the script, turning telehealth from something they compete with to a competitive advantage they exploit.
Rather, the evidence that telehealth is taking off comes from incumbents’ response to those outside forces. As last week’s World Congress Virtual Health Care Summit showed, providers have started to take matters into their own hands. The collective goal: Open a new front door to care that makes it easier for patients to access the services they need.
It’s important to distinguish between the front door to care and more traditional telehealth offerings. (While it feels odd to call any type of telehealth “traditional,” please bear with me.) The latter primarily provide phone, email, and video visits, with messaging and remote monitoring emerging as additional options. Kaiser Permanente notwithstanding, these modalities address one-off interactions, even for complex and high-risk patients. Care continuity takes a backseat to convenience. A door to care is opened, but it leads to a single room with no other doors. You have to go out the way you came in.
The front door to care, meanwhile, provides an access point to a much larger array of healthcare services. The enabling technology is largely the same, but the difference lies in the way that it is used – to provide convenience and care continuity, to lead to many other rooms that are likewise linked, to lead patients to the way out, as it were, that makes the most sense for their current and future care needs.
Admittedly, it takes substantial effort to erect a front door to care (and all the other doors behind it). In particular, speakers at the Virtual Health Care Summit noted the operational needs. The front line of patient care is impacted – and so is billing, legal, call center, licensing, collections, human resources, and so on. In other words, it requires a substantive change to the way a provider does business – and it explains why, until recently, providers have not been able to catch up with telehealth’s maturity.
The front door to care provides an access point to a much larger array of healthcare services. The enabling technology is largely the same, but the difference lies in the way that it is used.
Clearly the front door to care is not tenable in fee-for-service markets. (Think of all the parking, gift shop, and cafeteria revenue lost when patients and physicians opt for virtual care!) Nor is it tenable in states such as Massachusetts, which has yet to pass a law providing reimbursement parity for virtual visits. In the Bay State, providers essentially focus on small-scale bundled payment and ACO models while waiting for parity to open up additional opportunities.
Elsewhere, though, the tide is rising. Providers are finally starting to catch up – and it’s because they have flipped the script, turning telehealth from something they compete with to a competitive advantage they exploit. That’s why, as our upcoming Market Scan Report describes, telehealth increasingly has moved beyond high-acuity inpatient care and low-acuity DTC care to play a greater role “beyond the hospital” in order to provide more coordinated care. And that’s because, as the Virtual Health Care Summit discusses, providers know that the revolving door at the entrance to the ED is no longer the preferred front door to care.
Because if 2018 does, in fact, end up being The Year that telehealth takes off, smart providers want to be sure they don’t get left behind.
Opening New Front Doors to Care: Reflections From Bridge to Pop Health East
For all the promise of patient engagement technology such as chatbots, wearables, self-management apps, and passive sensors, engagement is still a high-touch process. But just because cutting-edge technology isn’t part of the everyday workflow doesn’t mean engagement hasn’t been moving forward.
As our recent Population Health Management Market Trends Report concluded, technology adoption is most advanced in PHM’s early stages (risk stratification) and later stages (performance analysis). Producing generic care plans and determining outcomes and goals is mostly automated, though personalizing plans tends to require human intervention.
Engagement often happens the old-fashioned way – in person – whether in a clinical setting, the patient’s home, or an outpatient facility. This is especially true for high-risk and high-acuity patients with a complex set of social determinants of health (SDoH) that inhibit access to care. When interventions don’t take place in person, they often happen over the phone – the speaking-into-a-receiver part, that is, and not the sending-a-text, using-an-app, or watching-a-video parts.
The Bridge to Pop Health East conference in Boston, with a heavy emphasis on strategies and tactics for healthcare providers, reinforced many of our conclusions about technology adoption in PHM workflows. The most mature case studies focused on the use of analytics for patient identification and program assessment. This is hardly surprising. PHM tends to be closely tied to value-based care initiatives that penalize providers for poor performance, so targeting the patients who are most likely to get better is a sound business decision. Engagement matters – but engagement with the right patients matters more.
Modest progress in using technology to improve patient engagement does not necessarily mean that population health management initiatives continue to approach engagement the same old way.
As a result, the examples of digitized patient engagement that did emerge from the conference were a bit closer to “fax machine” than “Star Trek tricorder” on the innovation continuum – though, to be fair, they did come with measurable outcomes.
Providing more “front doors to care”
That said, modest progress in using technology to improve patient engagement does not necessarily mean that PHM initiatives continue to approach engagement the same old way.
Three years ago, we opined that healthcare is bad at engagement because it is bad at engagement, not because it lacks technology solutions that make patients want to engage. Part of the reason (which we admittedly did not articulate at the time) was that traditional healthcare systems offer only one “front door to care” – a door that, when opened, often leads to a seat in a waiting room seemingly designed to make you forget how long you will have to be there before you actually receive care. (Why else is there a pile of magazines and an HD TV?)
Over the last three years, new front doors to care have opened (or been opened further): Retail health, urgent care, telehealth, kiosks, employer-sponsored clinics, monitoring apps and devices, virtual assistants, and even the occasional drone. This broadens patients’ access to care. It also challenges traditional provider organizations to improve patient engagement – or risk losing market share and revenue.
To extend a metaphor, Bridge to Pop Health East also provided examples of new provider-based care team members knocking at the door of the patient’s home.
Moving further, informal conversations at the conference alluded to a host of non-clinical services: Rideshare, meal delivery, home repair (to address fall risks or ventilation concerns) – even housekeeping and landscaping. This points to the importance of accomplishing tasks and alleviating burdens that prevent patients from doing anything but focus on their health and wellness.
As providers move forward with PHM, they are taking a long, hard look at patient engagement. Much of the movement so far has been high-touch, essentially replicating traditional inpatient workflows in the outpatient or home setting.
The new care team roles don’t come with the same educational and licensure requirements as nurses and doctors, and healthcare continues to add jobs, but this growth will be hard to sustain. To be blunt, healthcare systems will no longer be able to throw people at the problem.
When this tipping point comes, forward-thinking PHM programs – those that open community clinics, allow paramedics to conduct home visits, and recommend a handyman to recent surgery patients – will start to turn to the technology that will further empower patients opening the new front doors to care and staff answering those doors. And then the virtual assistants, sensors, and robots will take their place in patient engagement workflows.