HIMSS’19: Real Value in Telehealth and Virtual Care

This is the second in a series of blog posts recapping HIMSS’19; you can read all our coverage here.  

My primary purpose at HIMSS’19 was gathering information and ideas for our upcoming report on the front door to care. This report will take a close look at the evolving ways patients first enter the healthcare system. Whether from retail health, telehealth, remote patient monitoring, or remote care apps, HIMSS was full of changing ideas and approaches. The conference had a utilitarian focus, looking less at generic or abstract buzzwords to get people excited, and more at what can be done right now to engage providers, payers, and ultimately patients.

My biggest takeaways:

Telehealth, Remote Monitoring, and Virtual Care can significantly erode established HCO business models, or complement them.

Health systems have invested a lot into controlling referrals and leakage. While the PCP remains the central organizing hub of most healthcare, the growth of retail and remote health could lessen the PCP’s centrality in traditional referrals networks.

Unlike the Teladoc model, which employs contracted providers to provide a turnkey outsourced telehealth service, newer entrants offer operational platforms and back-end systems so HCOs can staff and run their own telehealth programs. This allows them to retain control of the patient experience. It’s an easier model for an HCO to understand and use, but whether they adopt such solutions before their competition is an open question.

Behavioral health might finally get its due through Virtual Care apps.

Between shrinking reimbursements and scarce providers, behavioral and mental health care have been the first service line on the chopping block for a while now. PCPs have become the go-to provider for too many behavioral health needs, occupying increasing amounts of time and stretching their expertise thin.

Several of the telehealth and remote health platforms I saw last week had behavioral health components. There were a few well-executed apps dedicated to mental health and wellness, mainly with a CBT/DBT focus and some with solid clinical results. Helping PCPs manage this care and mitigating the effects of comorbidities on patients is an important part of addressing PCP workload and job satisfaction, as well as patient engagement. These virtual care offerings can help struggling PCPs get their patients the help they need, while still working within tight budgetary and scheduling restrictions.

Telehealth, Remote Monitoring, and Virtual Care can significantly erode established HCO business models, or complement them. The question is whether health care systems will recognize that in time.

Performance improvement services are becoming a core component of analytics products

With my background in healthcare performance analysis and improvement, I wanted to see how analytics is evolving to become more effective and efficient.

The future of analytics platforms looks less like pre-built dashboards or reports and a lot more like what Visiquate offers. Its embedded employees work directly with customer end-users to execute Agile-inspired improvement sprints supported by their analytics and reporting. Vendors are coming to grips with the challenge of operationalizing analytics for value and performance improvement. The value proposition behind both improved reporting software and process improvement is pretty well understood. Figuring out how to fit it all into an annual budget in an era of shrinking margins is the real hard part here.

Leveraging data to produce specific, actionable recommendations remains a challenge.

A fascinating conversation about AI at the Geneia booth on Tuesday afternoon summed up the current state of AI and machine learning in the clinical world. While access to existing and new kinds of data is increasing and the ability to integrate it is getting more sophisticated, AI and ML still aren’t the clinical tools many expected them to be. Only imaging, an area where the datasets are complete and the challenges are well understood, has really begun to heavily leverage AI/ML. Everywhere else, the barriers to gathering appropriate context and rendering predictive clinical recommendations have yet to be overcome.

Stay up to the minute.

Did You Know?

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.

PATIENT

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.

PRIMARY CARE PHYSICIAN

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.

PAYER HEDIS® DIRECTOR

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.

PAYER POPULATION HEALTH CLINICIAN

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.

EMPLOYER

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. 

Convergence Analyst Recap: Exciting Progress, Still Plenty to Be Done

What a whirlwind it has been – three major conferences for Chilmark Research analysts in three consecutive weeks. Sure, the Epic UGM and Cerner CHC are industry leading events, but our own humble, inaugural event, Convergence, was influential in its own right.

Attendees, speakers, and panelists from across the healthcare spectrum came together in Boston for two days of in-depth, strategic discussions on how providers and payers will converge to provide a more streamlined health service for the populations they jointly serve. To better understand what is involved in Convergence, we worked with Involution Studios to create the following graphic (feel free to download a larger version and use yourself):

Our friends at Galen Healthcare and media partner SearchHealthIT.com provide cogent summaries of the event’s insightful presentations about payer-provider convergence strategies. Following our team of analysts offers their own highlights and key takeaways from Convergence.

Brian Eastwood, Engagement:

I enjoyed hearing from the Trenton (N.J.) Health Team and Boston Medical Center. They demonstrated that successful examples of provider-payer convergence can stem from collaborations in socially and economically disadvantaged areas, where stakeholders see common vulnerabilities (such as a lack of coordinated care management) that threaten their long-term financial survival.

I also appreciated the message from employer Iron Mountain’s head of benefits planning, Scott Kirschner, about the need for employers to take value-based care (VBC) seriously. Kirschner noted that 95% of the company’s health plan costs are claims, and 80% of those claims are medical. Like it or not, employers have to find a way to get in between employees and their physicians – and to explore the widespread use of proven technology solutions that can address employees’ health and wellness needs without cutting into their billable hours.

Kirshner also reflected on the savings – the clear ROI – that Iron Mountain has seen through aggressive moves to optimize benefit design. A key contributor to ROI is the use of High Performance Networks for employees across the country – HPMs are most often based on a converged model between provider and payer. Current insurer Cigna is not expanding its HPMs fast enough for Iron Mountain, which led the company to look elsewhere and ultimately choose Aetna for 2018 due to Aetna’s aggressive moves to drive towards a converged model.

The impact of high-performance network structure and cost savings on employee benefits at Iron Mountain. Courtesy of Scott Kirschner.

Matt Guldin, Care Management:

Convergence is underway in the form of providers becoming their own payers, as well as providers acquiring payers. Geisinger Health, for example, has moved to value-based contracts in 70% of its business and does not intend to go back to volume-based care. However, the trend is still in the early stages, just as the move to VBC is occurring slowly and, amid political turbulence, sometimes erratically.

John Bulger discusses the Geisinger Farmacy concept during his opening keynote.

The healthcare payer-provider alliances that are sprouting across the country, along with employer-provider deals, will require more advanced health IT systems to manage and analyze complex data undergirding value-based care: Big data and analytics, data governance, wellness platforms, and healthcare approaches like remote patient monitoring are key to the transformation.

One major challenge to making both convergence and VBC produce better care and lower costs is the current widespread variability and lack of interoperability of health information. In addition, as healthcare transitions to value-based care, providers will increasingly be responsible for the entire continuum of care, from prevention to rehab.

Ken Kleinberg, Analytics:
First, convergence is not for everyone – yet. The speakers and attendees at the event were those who either realized that something key and important needed to happen, or was happening, or they were making it happen. Out of the many health IT events going on in the fall months, leading vendors, providers, payers, and other stakeholders choose to attend this event – and in so doing, became part of this growing movement to transform our industry.

Second, convergence affects everyone – now. The most powerful moment of the event had key leaders from the health IT community sharing their personal stories of their interaction with a dysfunctional system where each stakeholder, in its efforts to do what it thought was right for its interests, had the unwanted effects of increasing costs, decreasing quality, and increasing the friction of access. It affects the very patients, members, and employees the system is supposed to be helping – that is, all of us, even our leaders.

Third, convergence is coming – there is hope. From payers like Aetna completely rethinking interactions with their members and their goals, to employers like Iron Mountain taking healthcare as a new core competency, to providers like Beth Israel Deaconess Medical Center reaching out to share data with their payers, to vendors like Allscripts, CareEvolution, Cerner, and Epic putting their best people and increased resources on population health management, we see many reasons for not just hope, but action and progress.

Brian Murphy, Interoperability:
The challenges of adequate access to data and the need to build new and improve old applications are deeply intertwined. APIs will be a major part of the solution. As we saw in presentations from Cerner’s Dave McCallie, Boston Children’s Hospital’s Dan Nigrin, and Google’s Aashima Gupta, providers are moving deliberately to adopt APIs on many fronts.

Application programming interfaces (APIs) are being used to extend EHRs. The combination of APIs built on the Fast Healthcare Interoperability Resources (FHIR) standard and SMART today allow clinicians to augment and extend their EHRs with new or different workflows. McCallie noted examples such as better clinical decision support, clinical trial recruiting, and different visualizations. Organizations and independent developers can build such extensions in a fraction of the time it would take for the EHR vendor to spec and build new features into their base products.

The Evolution of Interoperability courtesy of Dr. David McCallie

APIs are being used to empower patients. Gupta used a Google Home device to show how APIs can make it much simpler for a patient to schedule an appointment at a local clinic using just a voice-activated smart home device. Google’s developer portal for healthcare helps engineers build the FHIR APIs needed to support customer-facing apps.

APIs are being used to more effectively coordinate care. They provide a more efficient and easier-to-program way for different organizations and users to contribute data. At Boston Children’s, SMART has enabled an application that tracks patients’ disease symptoms and response to therapy over time. To date, more than 5,000 patients with complex needs have used the application to provide valuable information to clinicians.

While these anecdotes attest to the progress being made, we still have a long way to go before the industry can claim that data is readily available wherever and whenever it is needed. Many eyes are now on the Office of the National Coordinator as it develops new rules stemming from the API provisions of the 21st Century Cures Act. On the one hand, there is some trepidation about how ONC will define data blocking and how fines will or won’t be levied. We know that EHR vendors must make patient data available “without special effort, through the use of APIs.” The specifics of what “special effort” means is still very much up in the air. The addition of a new requirement to provide a bulk API also raises questions.

Let’s Continue the Convergence Conversation

Convergence may be over, but there are still several opportunities for further collaboration and learning:

  • Watch our videos from the conference as we edit them, including full recordings of most sessions.
  • Check out our Meet the Speakers series of in-depth interviews with more than a dozen Convergence presenters.
  • Take our survey and tell us how your organization is progressing toward the transition to VBC.
  • Follow us on Twitter and LinkedIn as we ramp up our research coverage of Payer-Provider Convergence topic, along with our other domains of Analytics, Care Management, Engagement, Interoperability, and Population Health Management.
  • Contact us if you have specific questions or research needs, or if you’d like to become a member of the Chilmark Advisory Services and gain insider access to our analyst team.
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