Even as value-based contracting moves forward in U.S. healthcare, both with public (Medicare and Medicaid) and private payers, a number of critical gap areas continue to plague the leaders of patient care organizations participating in accountable care organizations (ACOs) and in other alternative payment models (APMs).
One of the key gap areas has to do with the broad cycle of activity around patients with chronic diseases. Even if they are being care-managed by primary care medical groups, patients often end up accessing care outside their PCPs’ core networks, with that care not being accurately documented for optimized ongoing care management. Or they fail to fill vital prescriptions, thus not doing the best on their part to improve their health status. Or the primary care medical group is not informed of inpatient admissions or discharges or emergency department (ED) visits. And so much data ends up being scattered and unavailable to primary care physicians and their staffs, at the point of care, that it impacts the ability of physicians and their associates to improve patient outcomes over time, especially of those patients living with chronic illnesses.
Per that, the leaders at the eight-clinic Cary Medical Management (CMM), based in Cary, North Carolina, set out to try to solve some of those problems. They partnered with the Cary-based Infina Connect, whose developers customized their coordinated referral platform for Cary Medical Management’s clinicians. And they created algorithms to help them engage in sophisticated health risk management across their covered patient population. And finally, and critically, CMM’s leaders began working very closely with the leaders at NC HealthConnex, the state-mandated health information exchange in North Carolina. The N.C. Health Information Exchange Authority was crated in statute to administer and over see NC HealthConnext and its mandated connections from providers using state funds.
And the work that CMM’s leaders put into this has yielded impressive results. As they noted in their submission to our annual Innovator Awards, “From its 2019 inception, CMM's mission has been to infuse independent primary care practices with innovative technology, enabling them to deliver optimal care at profitability while ensuring the highest possible savings, a critical success factor in value-based contracting. The technologies targeted three specific operational areas: innovative use of health information exchange, provider productivity to drastically reduce administrative burden and increase the number of patients seen per day, and referral management within high-value networks.”
Cary Medical Management’s leaders noted three key elements in their submission:
• Risk Adjustment and Medication Reconciliation: Our patented software robot identifies and compares interacting chronic conditions from the EHR and HIE the day before patient scheduled visits. It then identifies higher Risk Score diagnoses and inserts the data within the EHR for treatment, accompanied by suggested ICD10 codes and any interacting medications. The solution facilitates proactive decision-making during patient visits, ultimately leading to improved patient outcomes and optimized reimbursement for our providers.
• Productivity and Efficiency: The productivity tool cuts down the time our providers spend on typing patient records, enabling 50+ patients (as compared to the national average of 20.2 patients) to be seen per day without sacrificing quality. Without increasing productivity, the national provider shortage will continue to cause clinics to shut down and drastically increase the cost of care.
• Referral Management: We implemented a high-value specialist network and technology to receive clinical notes after specialist visits, lowering the total cost of care significantly.
And, importantly, they noted, “Per our accountable care organization report, the above technologies enabled our eight clinics with 75,000 active patients to achieve a total medical cost improvement of 32 percent in 2023 compared to the previous 12 months for three national commercial payers. For Medicare patients, we achieved an average of $1,636 a year per capita below the regional benchmark, an 18-percent reduction, whereas for the same year, the latest study indicates the national average of cost reduction for all payers was 5.6 percent. This achievement also received special recognition from the North Carolina Speaker of the House of Representatives for using the HIE’s data to improve care and reduce costs, and was the topic of numerous articles written by the State of North Carolina Department of Information Technology.”
The organization’s progress has been building steadily over time: a press release posted to the medical group’s website on June 22, 2023, noted that “Cary Medical Management (CMM), a pioneer in transforming traditional primary care into high-performing, technology-enabled, value-based care (VBC) clinics, announced today that its flagship primary care clinic, Generations Family Practice, achieved 32-percent below target-spending for its UnitedHealthcare commercially insured population for the last plan year. The clinic’s savings of $1,378 per patient per year is also double the below target-spending it achieved for the same payor before the COVID-19 pandemic. Overall, CMM’s clinics have produced an average 21.75 percent savings across commercial and government payors who shared the data,” the June 2023 press release noted. “That compares to the national average savings for value-based care of 5.6 percent, according to a 2018 report. The company oversees 40,000 patients within commercial and government value-based care contracts across 48 clinics.”
For all those accomplishments, the editors of Healthcare Innovation have named Cary Medical Management the First-Place Winner in our annual Innovator Awards Program.
Siu Tong, Ph.D., Cary Medical Management’s CEO, has been driving forward these advances. He explains in a straightforward way the challenges that he and his colleagues decided to address: “When we have a new patient, we have no record, and the patients themselves can’t remember their prescriptions and other vital information,” he says. “So we go to the HIE, and you can download everything. And we use a patented solution [based on the Infina platform] to look at the schedule to see who’s coming in the next day, and we pull the patient’s record. We then compare it to the diagnosis we have in the EHR [electronic health record] and see what we’re missing. If a diagnosis is more serious than we knew, we put it into the problem list. Also, we have a patent-pending algorithm based on AI [artificial intelligence]—something I learned at MIT years ago, how to language process algorithm to create a risk score; we take that and convert it into the system to process many potential diagnoses, and come up with a score, which might be higher based on interactions. If you have diabetes, kidney failure, and CHF [congestive heart failure], for example—a common enough situation among patients with chronic illnesses—we can rescore. That is very difficult for human beings to do. I tested it with 975 patients, and 68 percent of patients ended up with a higher score, based on our using the HIE information, than without. We did not know how sick the patients were. Often, we have not known all the drugs and drug interactions and disease interactions we weren’t aware of.”
Indeed, says chief medical officer Yu-Chow “Alex” Tse, M.D., “The key to all of this is that a physician can practice better medicine with the data and data analysis at their fingertips. What’s needed is someone who can control and manage all the clinical data and can get it to you at the point of care and decision-making. For example, I practice in Cary County here in North Carolina; but I might have a patient who has traveled out of town and has experienced a medical emergency. For example, during the COVID-19 pandemic, many patients acquired COVID, but a key symptom, lowered oxygen levels, only occurred over time, and often, patients were in a different place, accessing care in different patient care organizations, so we might not have had the most up-to-date data available to us as we delivered their care.”
And on a very routine basis, Dr. Tse notes, there are many things that happen that impact patient health status, and that can change physicians’ decision-making, if they have the information. One excellent element now is that the state government has designated NC HealthConnex as the mandated HIE for prescription drug information, one of the components involved in improved data available to physicians at the point of care and decision-making.
The HIE “Connex-ion”
Christie Burris, who previously was executive director of the NC HIEA, and is now the state chief data officer for the state of North Carolina, and who sees the entire Data Division of the North Carolina Department of Information Technology, of which the NC HIEA is a part, explains that “We’ve been in operation since late 2016. Over time, we have connected all the hospitals in the state, and thousands of ambulatory clinics and two commercial labs. So when Dr. Tong speaks of the richness of the data, North Carolina has about 14 million unique records in a centralized repository, and continues to grow. The NC Notify ADT notifications, is one of our foundational services. And CMM has providers who are credentialed to the portal and can do query and exchange; but are also receiving NC*Notify Alerts. Over time, our data repository has continued to grow.”
And what’s particularly helpful, Burris explains, is that “The state of North Carolina is a bit unique in that we are a state agency and we require participation if you receive funds from the Division of Health Care Services. We also partner closely with Medicaid. Our challenges have been overcoming challenges to data exchange; so the state of NC took an aggressive approach, removing the barriers, and declaring that the state would pay for the HIE. And so now, eight years into our operations, we offer rich data exchange.”
As NC HealthConnex notes on its website, “As North Carolina moves into data-driven, value-based health care, the N.C. Health Information Exchange Authority is working to modernize the state-designated health information exchange, NC HealthConnex. NC HealthConnex is a tool to link disparate systems and existing HIE networks together to deliver a holistic view of patient records. It allows you to access your patients’ comprehensive records across multiple providers, as well as review labs, diagnostics, history, allergies, medications and more. This results in less duplicative testing, more efficient and accurate diagnoses, recommendations and treatment and improved coordination across all levels of care.”
And making the closed-loop connections with the data has turned out to be a critical element in Cary Medical Management’s success in improving patient outcomes and reducing costs over time. “The ADT data from NC HealthConnex has been extremely helpful,” says Clifford Tse, CMM’s vice president of business development. “We get direct data feeds from the HIE, with notifications to the providers, and we’re able to schedule patients in” very soon after their hospital discharges, with care managers from CMM reaching out to just-discharged patients based on ADT alerts from the HIE.” And with regard to the health risk assessment process, he explains that, “As the data goes into the system, the data is provided and fleshed out in an algorithm. So we’re able to get additional data, and we can confirm with the provider whether something is the case, and we can evaluate with them whether a patient has an increased risk. For us, being in various ACOs, it’s important to get the risk score right, in order to ensure the appropriate level of funding for the care of patients with chronic diseases.”
As Dr. Alex Tse explains, one of the key elements in this is the fact that the HCC (Hierarchical Condition Category) coding score generated by accurate assessment of disease burden, in the ICD-10 coding system, allows physicians’ care management of patients with costs arising from chronic conditions to be accurately predicted and accounted for. And he notes that “The reimbursement system needs to take account of the level of complexity of patients’ illnesses.”
One key element of interest in all this is replicability. Asked about how replicable this set of innovations is, Tong says, “I know that this is replicable. Even though we’ve focused on our own clinics, we’re doing this also for some FQHCs. My experience with this is to say, you really have to work with NC Health Connect and be connected bi-directionally. And begin to look at reaching out to the patient. And train someone; you don’t need an MD, a medical assistant can watch out for the ADT feed and reach out to the patient. The patient will be better taken care of, and save the payer money. The hospitals have their EHR portals, and clinics are receiving ADT feeds from individual hospitals’ portals. But that’s a slower path. And you might not be getting all the ADT data. Potentially, a patient had a heart attack at the beach, and was cared for at a different clinic in a different part of the state. That’s why bidirectional exchange is so important.”
Indeed, he adds, “We were getting the information so quickly” on discharges that “we ended up calling patients even before they went home!” The key, he says, is that “As soon as we receive an ADT notification from NC*Notify”—the NC HealthConnex ADT notification system—"we can grab the discharge summary, and the outreach team can grab that information and reach out to the patient.”
The leaders at Cary Medical Management were gratified to receive special recognition from the North Carolina Speaker of the state’s House of Representatives, for using the state’s HIE to improve care and reduce costs. And they are passionate about continuing to build on the advances they’ve made in improving outcomes for patients over the long term, and lowering the costs of their care. And that, clearly, is where patient care leaders across the U.S. healthcare system would like to be in that ongoing, system-wide search for the keys to improving outcomes and reducing costs under value-based contracting—nationwide.