Carilion Clinic Tackles Accountable Care on Multiple Fronts
At the 600-physician Carilion Clinic integrated health system, Stephen Morgan, M.D., senior vice president and CMIO, is helping to lead transformative change along a number of dimensions. To begin with, the Roanoke, Virginia-based Carilion organization joined the Medicare Shared Savings Program (MSSP) for accountable care organizations (ACOs) in January 2013, and that step in itself has helped to spur the development of more coordinated approaches to care delivery and the acceleration of the creation of IT foundations to support the ACO financing and delivery model.
What’s more, the avoidable readmissions reduction mandate embedded in the Affordable Care Act (ACA), as well as implied in sharing risk with the federal Centers for Medicare & Medicaid Services (CMS), has further spurred activity already underway at Carilion Clinic to improve the management of such chronic illnesses as congestive heart failure (CHF), coronary artery disease (CAD), diabetes, and chronic obstructive pulmonary disease (COPD).
Both the challenges and opportunities have been many; and Dr. Morgan will be speaking to both, when he participates as a panelist in a discussion entitled “Insights from Patient Data: Managing the Health of a Population,” and being held during the the Health IT Summit in Atlanta, sponsored by the Institute for Health Technology Transformation (iHT2), being held April 15-16. The Institute became a part of Vendome Group, LLC, Healthcare Informatics’ parent company, in December 2013. Below are excerpts from HCI Editor-in-Chief Mark Hagland’s recent interview with Dr. Morgan.
Tell me a bit about Carilion Clinic’s participation in the Medicare MSSP for ACOs, as well as your private ACO participation?
Certainly. Yes, we were selected for participation in the Medicare MSSP program in January 2013. Like everyone else, we’ve had problems getting usable data from CMS. In the first few months of our participation, we received at least two or three corrupt files from them. It was really August when we got that first round of data; that was an incredibly frustrating process. We have about 45,000 members in that cohort; we also have a commercial ACO with Aetna that involves another 5,000 members; that’s mainly upside with a little downside [with regard to risk], in that contract. And our self-insured employees—we consider that group an ACO, in effect, and really try to operate and run that like ACO, since we own the premium. We have 12,000 employees, and that equates to 17,000 covered lives, with family members.
Stephen Morgan, M.D.
What have been the biggest challenges in all this accountable care-related work so far?
The first has been getting the data. And you need to understand that that may not be the easiest process. It was in fact very frustrating with Medicate. And even with Medicare, in terms of claims data, we were not prepared to bring in that data right away, on our end. So we’ve really learned a lot, and quite honestly, I think we underestimated the amount of time, and the complexity, involved in bringing claims and clinical data together in the enterprise data warehouse, and making that useful information. And we use [the Jersey City, N.J.-based] Verisk to help us with the claims analytics for our MSSP population, because that was another area of challenge—we realized we did not have the internal resources to be able to do the detailed claims analysis necessary. So part of the resolution [of the problem] was around time; part was that we had to develop some skill sets that we did not have internally, as far as bringing in the claims data; so we engaged some consultants.
And then the next challenge was really understanding the information, because it brought forward data—and this was our first foray into any type of relatively sophisticated claims analysis. Because really, we’re having to learn how to interpret that data and then bring it to our clinicians. And we’re just starting to do that. In fact, we spent about a year or two trying to bring education to our providers about PMPMs, utilization, appropriateness, etc.
Taking on risk is like a whole new ballgame as a provider organization, isn’t it?
It is. And physicians have started to understand risk. And in our organization (and I’m a family practitioner by training), it’s both primary care and specialists who need to understand the data. And clinicians are starting to understand what some of the risk means, and what the dollars and cents mean to the organization. So they’re starting to ask good questions. And that requires that physicians trust the data and learn to understand it. And so educating them on what the data means and getting them to the point of trusting the data and not questioning it every single time you’re bringing up metrics, that’s critical. And the transparency of the data is very important, too.
CHF, CAD, diabetes, and COPD—many organizations focus on those chronic illnesses first.
Yes, those are exactly the key four that we’ve started with! When we looked at our internal data at the outset to find out where the high-spend utilization was, just looking at our mortality data, those were the end-stage chronic diseases we were seeing. And of course, we were looking at those, understanding that hypertension and hyperlipidemia often lead to those. And we actually started with COPD, realizing that we had put less emphasis on it in the past. It seemed there had been so much more emphasis on CHF, CAD, and diabetes. And it was bigger than we had thought, that population—nor surprisingly, because in Virginia, there’s still a lot of smoking.
So with readmissions reduction work, then, it’s not so surprising as to what populations need to be managed, but it’s process change, right?
Yes, exactly. And we recognized right away with COPD when we pulled our groups together, that we were missing some basic blocking and tackling when we started to look at the gaps in how we cared for people [with that disease]. We looked at other organizations’ care management strategies, and the care continuum—and in particular, the discharge process. The data that we had gathered and analyzed proved the point that, in order to be successful [in managing COPD patients], you need to put a case manager focused on COPD, in the hospital. It was so basic.
We don’t have robust data yet on the [impact of that change on] readmissions, but anecdotally, we’re finding that after six months, it’s making a difference in the quality of life of patients. The difference is showing itself in the basic blocking and tackling—ensuring a good discharge process with good medication reconciliation and a good discharge plan. And so what we’ve tried to do is to risk-stratify who’s really at risk for readmission, and really hit those people hard [in terms of care management].
That has made a difference already—not as much as we’d like yet—but we can see that, OK, we’ve really got to get to those top 12 patients in a panel before everyone else. Meanwhile, the education part is very important, too. The staff want to do the right thing; but when you do the education piece and focus on the patients and the patient experience, people really start to get it. And they are getting it. That’s just a huge piece of this.
The other thing we had difficulty with was identifying patients when they’re in the hospital—making sure to identify that they’re a CHF patient, for example. That’s not rocket science; but people weren’t using a problem list, or whatever; and now, we’re developing processes to make sure we’re identifying them while they’re inpatients. Attribution was another challenge, getting attribution models set, and getting physicians to understand what to do.
CMIOs are so clearly “bridge people” in all this, aren’t they? Bridging the physicians, the pure informaticists, the clinical informaticists Any thoughts on the challenges involved there?
This is one of the most fulfilling roles I’ve ever had. I enjoyed practice, but I also enjoy helping people. I’m currently not practicing, but getting ready to do go back in and do some practice. And I need to practice, as a CMIO. But this has been a very fulfilling job. The other piece of the puzzle is, not only do I find myself being a liaison between physicians, and IT and informatics; I also find that I and other physician leaders are having to translate and explain ACO concepts and payer concepts to the physicians in practice. And of course, a part of that is helping to interpret data for the doctors; and that’s been a learning curve for me. I knew about the clinical stuff, but now I also need to be able to explain the payer stuff.
And that’s probably been more challenging than when we were implementing an EMR and just starting our quality metrics. And my associate CMIO is doing more of the EMR work, and I’m doing more of the ACO metrics work. Now, we communicate back and forth; but that’s created more of a challenge for me. But I’m blessed to have physicians who don’t all hate me, after four years.
Where are doctors now at Carilion Clinic, and nationally, in terms of understanding, and even embracing, healthcare system change?
At the request of our CEO, we at one point created a physician group to discuss some issues. They were all about my age, and I’m 54—and these docs, who I was in residency with—were threatening to leave our hospital over grievances, a lot of which were over EMR issues. But what was poignant about the conversation was how passionate these guys still were about practicing medicine. They understood the data, but it really was about the frustration of having the technology be between them and the patients. They understood why we and they were doing it; but it still was perceived as a barrier. And I don’t think we have that many tyrannosaurs rexes anymore—those folks have either chosen to leave or retired.
Now, we have people who are very, very engaged, but technology, and accountable care, are still issues for many of them. But overall in our system, with a lot of education, I think we’re ahead of where other health systems are, and that’s especially true for our primary care group. Now, I’ll tell you that we have some compensation that is tied to quality metrics and pay for performance, depending on specialty. And even though it’s a small amount, it’s gotten people’s attention, and they’re understanding what this means to them. It typically is the older folks who are just not getting this, but they’re slowly figuring it out.
Do the majority of the Carilion physicians “get it,” in terms of where healthcare is headed as we go forward into the future?
I would so say, yes, with a lot of work from our CEO, CMO, and our senior leadership team, including our chairs. The clinical chairs have helped people understand the accountability issue; now we need to up our game in terms in terms of giving them the tools to understand it.
