Southern New Jersey health system Inspira Health operated its own accountable care organization from 2015 to 2020 with inconsistent results, with savings in some years and losses in others. April Venable, the four-hospital health system’s senior vice president for operations, strategy, and transformation, recently spoke with Healthcare Innovation about the challenges her organization has faced transitioning to value-based care and the promising results it has seen since partnering with CVS Accountable Care.
Healthcare Innovation: Could you first describe your role in Inspira’s value-based care evolution?
Venable: I’ve been here for 17 years, and this is my seventh role. My background was in accounting, and I was in our finance department. I was recruited into an internal consulting function we have called the Operations Consulting Group. One of the main projects I did was around Medicare's bundled payments for care improvement. It was Model 1 gain-sharing, which allowed us to share dollars with physicians for hospital-based efficiencies.
I ran that for a few years and that's when payers started to offer these value-based programs where you looked at total cost of care for an attributed population. They said to me, all right, go work on that, and I said, this is not a project; this is a job in a department that we need to form around the whole care team delivery model. So I was able to start that function here. That was about 10 years ago. And along the way, I picked up running our ACO and our clinically integrated network. And then I added service line responsibilities. Last year, I became a senior vice president. Now I have construction and real estate, business development strategy, behavioral health and oncology, but I still have value-based care and it's still one of my best passions.
HCI: I understand that the organization had operated its own ACO from 2015 to 2020, with some inconsistent results. What were some of the early challenges? Was it something about the MSSP program itself?
Venable: I don't think so. I think the strategies that were laid out to help you gain success were very similar to the things we do today. It was really about getting provider buy-in. When you're in all these models that have no downside, you're going to have different levels of engagement. Some people are along for the ride; others are really trying. It wasn't until we aligned with Caravan Health originally, which then became Signify Health, then CVS Accountable Care, that physicians were hearing the same messages that we've been talking about for the last six years but a much stronger infrastructure with a remediation plan if you're not keeping up. There were people who were at risk of being asked to step out, and it just changed the whole level of engagement.
HCI: Does CVS Accountable Care have some other tools or resources that you guys don't have internally?
Venable: They’re experts at gleaning actionable takeaways from the claims data. We take in the claims data and have a system, but it's just not something that is as robust as I would like it to be as we continue in value-based care. The CVS Analytics Platform is really intuitive. You do not have to be a data analyst to go in there and navigate and see where your opportunities are. My current core team didn't have to feed information to 30-some practices. They could go in on their own and pull out their work lists and understand where they were compared to their peers, which was super helpful.
HCI: So since you joined up with CVS in 2021, have the results been much improved?
Venable: For sure. We never had shared savings on our own. We had savings but you have to hit a minimum number and we didn't get there. We earned $1.7 million in 2021, $1.9 million in 2022, and we await results for 2023.
HCI: Have you been in any kind of value-based care program where there is downside risk yet?
Venable: Yes, the track that we are in through MSSP is enhanced, so that does have downside. It's the the most progressive model, so the sharing rate is also the largest.
HCI: You mentioned before that clinicians might have skated along because there was no downside risk. Do people take it more seriously when there is downside risk?
Venable: We have funded the repayment mechanism on behalf of our entire community. So we didn't ask physicians to put any money in the pot. But they knew that we did that on their behalf, so it was even more of an impetus to say if you're falling into those remediation thresholds, we're going to take this seriously.
HCI: You mentioned developing a clinically integrated network. Are most of those physicians employed or independent? And does it make a big difference?
Venable: It does make a difference, and it is a mix. We're about two-thirds affiliated and one-third employee, so it involves a lot of independent practitioners in our communities.
HCI: Is the level of engagement more difficult with the independent physicians than it is with the employees?
Venable: Sometimes the opposite.
HCI: Really?
Venable: Yeah. So what's really important to get providers’ attention is that their compensation plans are aligned with the goals of these programs. The independent providers in the community are running their own businesses. They're not just collecting a salary. So this is additional income for them. In a way that's different, I think, from an employee. We certainly have champions in both parts and we certainly have people we have to bring along, but I think it is an assumption that's often made that your employee providers are more engaged and I would say that's not always the case.
HCI: Do you have 20 electronic health record systems across all those practices, or are they all on the same one?
Venable. It’s more like 20. I think the actual numbers is 13, but payers want you to put all your data together and then feed them one file, and that is not an easy task to accomplish.
HCI: Do you have different payers asking for different quality measures? Would it be beneficial if if there was more alignment among the payers?
Venable: Extremely. I think we have 41 different quality metrics that we have to pay attention to across all eight of the value-based programs we have in place. And mammograms in one is not always the mammogram in the next. You would think with HEDIS having these definitions that it would be easier to standardize, but payers put in their own custom exclusions and inclusions that do make it challenging.
HCI: I understand one of the things you did with CVS was put a real focus on annual wellness visits as one key to success. Can you talk about that a little bit?
Venable: The annual wellness visit, I think, is a win all around. It pays appropriately for the effort required. And if it's done properly, you’re reviewing all the patient’s chronic conditions from a coding perspective, which is very important to their risk score. You're covering a lot of preventive stuff and screenings, immunizations, that they might be due for. You're planning ahead on living wills and things like that. It just it really does check a lot of boxes that you're often rushing to do in a standard office visit.
HCI: Is there anything you'd like to see CMS do differently to make your life easier?
Venable: I really applaud and have been advocating for a long time the new codes that they put out around community health integration. We have community health workers, but their services were not billable. But when you talk about going into the home and seeing some of the environments and the barriers preventing people from health, you have to address them in order to move along with these goals — food insecurity, transportation, social isolation, mental health. Behavioral health integration was introduced as billable as well as navigation. I think that those are welcome additions to what is really needed across a care team to provide holistic services.
I also am excited about and hopeful that there's so much thinking being done about how to engage specialists in value-based care and how to build a story with data that helps us understand who are the high-quality specialists and who might not be because that's a tough one. You can't really look at costs alone. Quality will differ based on procedures and age and complexities. It's not an easy answer, but I think that’s the next phase.
HCI: What about building connections to post-acute care and having more insight into what's going on in skilled nursing facilities and improving care transitions? Is that a key part of what you are working on?
Venable: Yes, we’re really involved in that. Last year, we actually recruited a manager-level individual who had a background in post-acute care, and we’ve started to do regular care conferences and implemented a technology solution so that we know when people go home and can follow them back into the community. Also, we are doing a little bit of nudging on keeping the care progressing. Just because they have 20 days covered through Medicare doesn't mean they need to stay 20 days. Let's start to come up with that plan to discharge when they've met their goals.
