Q&A: Amanda Furr, M.D., on Scaling Up for Value-Based Care in Pediatrics
Amanda Furr, M.D., leads population health efforts at Pediatric Associates, the nation’s largest privately owned primary care pediatric practice, with more than 1,100 providers and 250 locations across seven states. She recently sat down with Healthcare Innovation to talk about how the scale of her organization allows for investment in the teams and technology that are key to success in value-based care.
Pediatric Associates recently began working with population health company Innovaccer to create unified patient records by integrating data from EHRs, HIEs, and payer data for a 360-degree view of patients. The organization has started using prescriptive analytics to help care teams with customizable dashboards to track and spot opportunities around quality, risk, cost, utilization, and performance.
Furr, senior vice president of population health and senior regional medical director at Pediatric Associates, also has worked at Community Health Network and VillageMD, She said she was interested in working at Pediatric Associates because it was an early adopter of value-based care in pediatrics, and was growing nationally very rapidly.
Healthcare Innovation: What are some of the benefits of having the scale of a much larger organization in terms of population health efforts?
Furr: First of all, we can invest in the teams and technology, and that's the key to value based care. It's teams, technology and data, and they're all equally important. It is really hard as a small, independent practice to be able to afford a robust EMR, which we can provide for them, the analytics tools that can really impact their decisions they make clinically. We can help support them through through teams, and team-based care is the way to be successful in value-based care, and it's just hard to afford when you're a small practice.
HCI: As these practices are acquired and brought in, is there an effort to get them all on the same EHR and health IT infrastructure?
Furr: Yes. It is very hard to do, but it is necessary. We do it at a pace that's tolerable for both the patients and the providers, but we do look to transition everyone to the our same EMR. We use eCW [eClinicalWorks] and with that comes the ability to integrate all the data that flows through there.
HCI: Do you have an enterprise data warehouse that all this data flows into?
Furr: Yes, we do have a data lake that we use, and as you can imagine we're ingesting data from not just the EMR, but all the payers, the HIEs of the states, and that's why we needed to partner with someone like Innovaccer.
HCI: What else do they bring to the table in that kind of setting?
Furr: They bring that unified data around the patient. It's centered on each individual patient, which is hard to do as an organization on your own, to marry the claims data and your EMR and all the HIE to say, yes, this belongs to this one patient, which is so important — not just for quality and performance and value-based care, but for safety and for continuity of care. Innovaccer can also provide us with dashboards so we can understand that data, and the most important thing we were looking for is the overlay they have with eCW, so that our physicians and other clinicians at the point of care can see what that patient's at risk for, what they need, and what actions they can take in the moment with the patient.
HCI: Is part of your work improving performance on things like preventive screenings and immunizations across the organization?
Furr: Yes. I feel passionately that you have to be excellent at quality to truly perform value-based care and population health. We're always talking about making sure we're cost-effective and cost-efficient, but we can't do that at the sacrifice of quality. Bringing the data from all the different sources together can tell us what this child truly needs in the moment.
HCI: When we write about value-based care, we usually cover what CMS is doing in in Medicare, and we don’t really hear about examples of value-based care programs in pediatrics. Are there commercial payers involved?
Furr: Our contracts are largely in the Medicaid world. We're looking to expand that to commercial value-based care contracts.
HCI: Is there an added level of complexity working in multiple states with different Medicaid programs and requirements in each state?
Furr: One challenge of scaling is that every state is different. I definitely learned that the contracts vary when I went from a health system in one state to a national position. But I will say there are some core overlapping metrics that I focus on nationally for my providers, so that we're all focused in the same direction. It's kind of getting back to the basics — make sure you're meeting those core quality metrics and getting those immunizations done, managing specific populations like diabetics and asthma. We try to align all our metrics across our providers, and I would say that we're 80 percent aligned across all states in what our incentives are to reward our clinicians when they're achieving great care. That also helps us be cost-effective in building our process because we're focused on similar things.
HCI: Medicaid programs are starting to pay for addressing health-related social needs. Does that require organizations like yours to do more comprehensive screenings of families for those things?
Furr: Yes. we've been implementing social determinants of health screenings in our practices. We have it in Arizona and Pennsylvania, and we're rolling it out currently in Florida and Texas, and we have partnered with organizations that can provide resources. We've now hired social workers in both the states that can provide resources to the patients. We also try to use some of that information in our predictive analytics, because we know that these are big drivers, and so we also try to use that information to work a little bit ahead.
HCI: What’s your organization’s approach to behavioral health in pediatrics and adolescent care, given that there has been a huge surge in need?
Furr: Behavioral health has become absolutely critical in primary care, in general, and it always has been. But specifically in pediatrics post-pandemic, the need for behavioral health intervention has grown exponentially. We’re seeing rising hospitalizations and ER visits due to behavioral health, and we really want to improve the care so we can bring that down.
The interesting thing about behavioral health and value-based care is that typically you're wanting to manage how much a particular service is utilized. Well, in behavioral health, it's almost always appropriate for anyone to get behavioral health services, right? So it's not a cost that I want to drive down. I want people to get the service. However, we do need to make it accessible and effective and evidence-based, so we have a variety of approaches, and we’re really looking to compare and contrast the two. We have integrated behavioral health services, where we have a behavioral health specialist in our clinic that can provide those immediate interventions, and that's showing great results in Florida, but we're also looking to partner with other organizations to make sure that our patients have ready access to care.
Another challenge is that fragmentation that happens where we don't always know what the diagnosis and treatments are on the behavioral health side, when we could really help manage it in primary care. So we're really looking to pull those together, and that does require a technology solution that brings those medical records in from the beginning so we can manage it.
HCI: What has happened in terms of the use of telehealth during the pandemic, and more recently since the pandemic has ebbed?
Furr: We see telehealth as foundational to our patient access. Of course, the utilization of it spiked during the pandemic, and now we're we're looking to see what is the new normal of that utilization, but it is foundational to the care we provide. What's interesting is that it's not foundational everywhere. So as we bring new patients on to us, we have to do a lot of education about their options and the resources. Otherwise it goes underutilized by those new patients.
HCI: Are telehealth visits handled internally, and does a telehealth solution have to be integrated with the EHR?
Furr: I've worked with a variety of options, and the embedded option is the best, I would say. And ours are employed. They all work within our system, and they’re our own providers. We don't outsource that. I think it does two things: One, it avoids the disconnect of information flow, which is a safety concern. I think it also gets the buy-in of our clinicians. It's really hard as a primary care physician to give the care of your patient over to someone you don't know, whereas if it is internal, it feels like their own partner.
HCI: What about partnerships with like the big pediatric hospitals? Is part of getting costs under control understanding where the patients are going when they're not being seen by your clinicians?
Furr: Yes, absolutely, especially in pediatrics, because there's only so many pediatric specialists, and for the most part, they largely live within children's hospitals or hospital networks, so forming those partnerships becomes really critical for managing the complex patients. I would say that needs rebuilding post-pandemic. You know, we all kind of went to emergency battle stations and we lost that rhythm and that coordination and communication we had before, but it is super important, not just from a data exchange standpoint, but just making sure clinically, we're aligned and that we're doing the best we can for the shared patient.
HCI: If you could make a wish list, is there anything that you would like the state Medicaid programs or the feds to do that would improve value-based care programs in pediatrics?
Furr: What I wish we could do is provide coverage for children longer than one year at a time. In Medicaid, you have to continuously re-enroll and prove that you qualify. In this case, your grown-ups have to continuously reapply, and the kids are dependent on their grown-ups to do that process, which can be hard for some. The reason I want coverage for children longer than one year is the outcomes are starkly different. If you look at a company like Pediatric Associates that does value-based care, kids that are enrolled for a continuous 12 months have significantly better outcomes. They go to the ER less. They get admitted less. They need fewer interventions. Kids who come in and out of coverage have to go to the ER, more, they're admitted more. And to me, that's worse care and more misery for those families and those kids.
HCI: We saw this big Medicaid dis-enrollment after the end of the extended pandemic coverage happened, right?
Furr: Absolutely. So many kids lost their coverage that had it before, and what our data is showing is that it is likely their outcomes are going to be worse now because they don't have coverage. If we could find a way to keep kids enrolled for longer than one year at a time, I think we would finally see improvement.
HCI: Anything else on your wish list?
Furr: I would like for CMS to push their payer partners for timely data. We often get data that is three or four months old. We need to have more of a requirement to provide immediate notification of things and data exchange.
