Population Health in Indiana

Population Health

Clinical Integration Emerging as Groundwork for Value-Based Care

In the shift from a fee-for-service to a fee-for-value health care environment, three Indiana hospitals are leading the charge by creating clinically integrated networks to better serve their patients.

In Columbus and Seymour, adjacent communities hugging Interstate 65 in south central Indiana, leaders of two hospitals and their associated physician groups have formed Inspire Health Partners, a clinically integrated network to change both the structure and mindset of health care. That includes breaking the tradition of doctors being focused on a small number of patients each day. “We’d like that doc to wake up every morning and say, ‘I have 2,500 families that I have to keep healthy,’” says Marc Rothbart, president of Inspire Health Partners.

Meanwhile, in a 20-hospital service area from Kokomo to Evansville, St.Vincent Health in Indianapolis recently organized an integrated network for managing and coordinating care of patients, both within medical facilities and between patient-clinician encounters. “Care coordination is the model in a fee-for-value world,” says Richard Fogel, M.D., CMO for St.Vincent Health.

The term “clinically integrated care” is used by public and commercial payers to describe the health care of the future that creates lower costs and better outcomes, says Rob Schreiner, M.D., managing partner for population health with Huron Healthcare, a Chicago-based consulting firm. In an effort to clarify what constitutes “clinically integrated care,” payers and the government have sought to define in more detail its foundational elements and systemic building blocks.

One of the foundational building blocks are “patient-centered medical homes,” physician-directed groups of clinical, social and educational support for a patient population. Fold in an institutional leadership and governance structure working together for common aims, and add the necessary hospitals and other clinical and social service providers, and you have the makings of a clinically integrated network.

Both the St.Vincent and the Columbus-Seymour undertakings are built around medical home initiatives, but they take significantly different approaches to constructing the overall network.

COLUMBUS-SEYMOUR STAYS LOCAL, PARTNERS WITH COMMUNITY EMPLOYERS

Inspire Health Partners, the network formed through collaboration between Columbus Regional Health in Columbus and Schneck Medical Center in Seymour, is a locally developed organization of physician practices and other providers.

Inspire has 11 medical homes to work with, nine in Columbus and two in Seymour, says Rothbart. Inspire has collected information on the chronically ill and at-risk people in their community and focused on ensuring that they are seen by a doctor. By triaging the patient population and freeing up the practice’s physicians to handle the toughest cases, nurse practitioners and other health care professionals can see a greater number of patients, which in turn, creates better access for everyone.

In addition to triaging the patient population, Inspire has reached out to area employers to play a substantial role in creating its clinically integrated network. For Columbus Regional and Schneck, facilities anchoring two communities that share a lot of employers and some medical services, “a strategic partnership makes complete sense between the two of them,” says Rothbart. “They’re both independent in a world where there aren’t very many independents anymore. And they want to remain independent. They want to be able to say to the big hospital systems or anybody else in the country, ‘We do it better. We have the data to show we do it better.’”

They also want to be able to say to those local employers footing the bill, “we understand that we are disjointed, expensive, volume-driven, and we need to get to value,” Rothbart adds. “We understand that the patient experience needs to be better, and we understand that we need to get on the same risk page as [the employers].”

The governance structure of Inspire goes so far as to include employer representatives on the board. “We want them involved,” Rothbart says. “And we want them to understand that there’s a lot of thought and a lot of effort going into this transformation.”

ST.VINCENT GOES NATIONAL TO BUILD ITS NETWORK

The St. Vincent initiative, by contrast, elected to engage MissionPoint Health Partners—a Nashville-based national network-building organization—to supply staff resources and organizational support across the wide swath of territory the health system covers.

Within the next year, St.Vincent Health will be rolling out eight large medical homes across Indiana, with physicians, nurse practitioners, Medicare wellness nurses, pharmacists, medical assistants and other staff playing specific roles in caring for people. Not every doctor will want to practice this way, and none are being forced into it, says Fogel, but “we believe that a robust, well-conceived, well-executed patient-centered medical home is going to be important for our future.”

The St.Vincent initiative with MissionPoint hinges on an inside-outside structure falling into place to care for people comprehensively, Fogel explains. The medical homes are organizing for thorough and efficient clinical care and wellness endeavors, mainly from within the office or in immediate follow-up to office visits. MissionPoint operates in the time frame between encounters as “a community population health management service. It sees patients in the community.”

Founded in 2011 at St. Thomas Health in Nashville and originally organized to take accountability for 15,000 lives in Middle Tennessee, MissionPoint has since expanded to serve 250,000 people in seven states through formation of clinically integrated networks, says Jordan Asher, M.D., chief medical officer and chief integration officer.

“Yes, health care is regional, but for us, some of the value of what we bring is being able to take that regional approach and make it work in a scalable model across the country, while working with the local entities,” Asher says. “If you’ve created a structure and set it up, you go into a new market and basically create that same structure that’s meeting the same premises.”

Regardless of their different approaches, the ultimate financial goal for both St.Vincent and Inspire Health Partners is to move the medical community toward contracts that take risk for the well-being of the area’s residents. That means changing the incentives away from volume: making sure that services are appropriate and that doctors don’t have to build in services that are not necessary for revenue purposes, says Rothbart. “We want our wealthiest physicians to be the ones that have the best outcomes, not the ones that do the most services.”

Next in the Series: A closer look at how integrated networks are designed and organized