Physician Groups Are Taking on Value-Based Contracts—and Learning Big Lessons

Dr. Solano and his fellow physicians have been collaborating with the affiliated UPMC Health Plan to care-manage 125,000 patients who are UPMC Health Plan members, most of them Medicare Advantage plan members. To begin at the headline level with regard to CMI’s shared-savings program with the UPMC Health Plan, “In the first year, 2013, we achieved about $1.5 million in savings and said, wow, this is really great; in 2017, that figure had risen to $24.67 million,” shared by CMI, the hospitals, and the health plan, Solano reports.

How could Solano and his fellow CMI physicians make such noteworthy progress? “We changed the way we practice,” he says flatly. Among other elements in the group’s success, he reports, “I developed a program called the Template for Change, which looked at your whole practice and how to change it to a value-based practice. It’s things like access: how does your staff answer the phone? Does your automated after-hours message simply direct patients to go directly to the ED? There’s actually very high ED utilization at lunch, because people aren’t answering in the office. At night, too. So we changed all of that. And second, we worked on triage for nurses, so there were only two real circumstances where a patient could go to the ED without the physician looking at the note, and that’s if they were having an obvious heart attack or stroke; otherwise, the nurses had to show the note to the physician for review, and most of the time, we could accommodate them directly in the practices or through urgent care.”

Solano also asked primary care physicians to provide their patients with access to their cell phones, something that initially frightened the doctors; in fact, though, they haven’t been overwhelmed by patient calls to their cell phones, and have averted some ED visits. “I always say the ED is the gateway to the hospital, and between 15 and 40 percent of patients who are seen in the ED get admitted.”

In addition, Solano and his colleagues have developed a value incentive program that uses metrics around utilization and quality in order to determine how to divide the shared savings gleaned from the program with the health plan. As a result, CMI’s physicians have reduced ED visits per 1,000 by 13 percent, and inpatient admissions per 1,000 by 20 percent.

And they’ve spent five years developing and refining clinical performance/population health management dashboards for the group’s practicing physicians, so that, for example, they can immediately see within the electronic health record (EHR) which diabetic patients have poor hemoglobin a1c control. When one combines such advances with the development of care management teams, including, for example, diabetes educators, the results can be striking, Solano says. And, he adds, providing strong transparency has also been a critical success factor, as all physicians can see the performance of all of their peer physicians, and of all the groups within CMI. “Making all of this transparent has absolutely been a key,” he emphasizes.

Fast-Forwarding Progress in Phoenix

Asked what the biggest advances have been so far, Dr. Whitfill says, “That we’ve been able to build a model of engagement with our private practice community that has been able to garner their trust, and quite honestly, their excitement, which is hard to do. And in doing so, we’ve taken what could be doom and gloom that the fee-for-service system is going away, and have been able to recreate the collaboration and sense of shared purpose, that our physicians have gotten out of. So there’s a stronger affiliation between and among the physicians, and with our hospital system. And we’ve done it in a way that’s been transparent and fair. And no one has gotten one hundred percent of what they’ve wanted, but neither has either side felt taken advantage of; I think that’s critical.”

And within that, much progress has been made in both existing Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs)—Scottsdale Health Partners MSSP (created in 2014) and the John Lincoln ACO (founded in 2013). As of January, the two have been combined under the Scottsdale Health Partners name. At Scottsdale Health Partners, Whitfill says, two core process elements have contributed to the ACO’s success in the MSSP program. “The first was putting in a very focused care management program that targets high-risk patients and works to produce more coordinated care for them,” he explains. “Our target patient has multiple providers already, and so the care coordinator really works as a good traffic cop for the providers. And the other is, we’ve used technology. We have about 62 EHRs across our network; so we’ve used Orion’s HIE [health information exchange] solution, TigerText’s secure messaging platform, and Par8O’s electronic referrals platform,” to allow clinicians to communicate with one another both securely and conveniently. As a result, “With the help of the HIE solution, clinicians aren’t unnecessarily reordering tests. And with the secure messaging, a PCP can ask a specialist a curbside question without having to refer the patient. And with the referral management program, we can digitize that transaction, and the communication back and forth.” The bottom line? Care management and communications advances have helped the organization to rack up consistently excellent performance in the MSSP.

From the Payer Perspective—Ongoing Challenges Seen

Meanwhile, payer executives, who have a lot of skin in the game when it comes to collaborating with providers on value-based care delivery and payment, are seeing progress; but also some levels of delay because of business and environmental factors present in the U.S. healthcare system. The way that Mark Caron, vice president, business platforms and solutions, at the Harrisburg, Pa.-based Capital Blue Cross Blue Shield, puts it, is this: “I think if you would say what the maturity level is, overall, on a scale of 1 to 10, we’re probably at the midpoint of 1 to 10, maybe at a 4 or 5. And the reason why I say that is that there’s still so much we’re connecting to, and there’s still so much information that’s latent; it’s not prospective enough, intuitive enough, yet. We’re not giving physicians and care teams enough data to make them proactive. We have tremendous physicians and nurses in this country; we’re still behind in getting them what they need to do their jobs appropriately, and to see the right patients, and in the right place.”

Still, says Caron, who has actively helped to load numerous initiatives with physician groups and hospitals around value-based care delivery and payment, serious progress is being made now. The key breakthrough that he’s seeing in more advanced physician groups? “The amount of information that’s being brought to the point of care. It’s really important for practicing physicians to understand the rising-risk factors, and even though those patients might be in their purview in their delivery system, the longitudinal view they get from claims data gives them a much better picture of that,” he explains. “Also,” he says, speaking of health insurers’ data-driven collaborations with providers, “though we’re still early on in being able to provide social determinants data, doing so is helping the physicians. I believe that many of them expected their EHRs to be able to provide a lot of those capabilities; but they’re realizing that to manage risk and manage in a post-acute transitional world, they need connections with care teams, and caregivers at home, and so on. So they’re realizing it’s a broader continuum than the four walls of the hospital or the hospital system. And our analytics need to be enhanced and improved in order for us to get early warnings for rising-risk individuals.”

And though connecting data points and sharing them, across the continuum of care, remains a challenge, health systems are starting to create those connections, Caron says. But one of the challenges remains the sheer amount of business activity taking place right now in the industry. In fact, he says, “Probably one of the larger delaying factors as far as progress by delivery systems has been because of mergers and acquisitions, which have caused delays because of disparate systems involved. They can’t even get their own systems to work together well, yet.” So that remains an area of challenge.

Collective Efforts Emerge Around Accountable Care

Where the Rubber Meets the Road

Meanwhile, as physician organizations move forward around the country, all those interviewed for this article agree: combining advanced population health management and care management strategies and processes with highly useful data analytics, including individual physician- and practice-level clinical performance dashboards, for continuous clinical performance improvement, will be essential to success going forward. As Solano of CMI/UPMC notes, “Within our EHR, we’ve developed dashboards in population health management. Very few doctors have an idea of their performance within each chronic disease. So about six or seven years ago, we started ranking our doctors on certain quality measures. But now we’ve developed dashboards,” so that individual physicians can look at their registries of patients with diabetes, coronary disease, heart failure, hypertension, atrial fibrillation, asthma, and anticoagulation. And, working closely together with UPMC’s clinical data analytics team, Solano and his fellow physician leaders are helping to lead their practicing physicians forward into value-based care—with success.

All those interviewed for this article agree: the next few years will be decisive, as physician organizations move further into value-based care delivery and payment arrangements. For some, full capitation may be the ultimate destination; for others, more likely, arrangements involving a variety of value-based incentives, some of them risk-based. But the core advancements needed around care management, population health management, data analytics, and continuous clinical performance improvement and clinical transformation, will be a part of the picture U.S. healthcare system-wide.