Population Health in Indiana


Clinical Integration, Attention to Access Produce Outcomes for Value-Oriented ACO Era

Building the health care organization of the future requires a keen understanding of what it’s supposed to accomplish through clinical integration. The bumper sticker version speaks of high quality, reduced costs and high satisfaction. The long version involves rethinking care services with that triple aim paramount.

Population health management will have to be part of that rethinking, well-thought-out collaboration among a variety of providers to improve clinical performance and decrease unnecessarily high use of expensive care settings, experts say. “No one entity—whether it’s the hospital, the independent community primary care physician or the acute-care rehab facility—can undertake population health independent of their other partners,” says Graham Brown, vice president and practice leader for population health and clinical integration with GE Healthcare Camden Group.

Clinical integration, of both health care providers and new types of patient-engagement roles, should break entrenched patterns of delivering care in a linear fashion, moving toward providing care in concentric circles around the patient by deploying a range of different services as needed, says Jordan Asher, M.D., chief medical officer and chief integration officer of MissionPoint Health Partners, Nashville, Tenn., which implements and helps to staff clinically integrated networks. “It takes a community to come together and deliver clinically integrated care,” he asserts.

The formula for a clinically integrated network (CIN) that was piloted by St. Thomas Health in Nashville, Tenn., and branded as MissionPoint in 2011, worked so well that Ascension Health took it on the road. Starting with 15,000 self-insured employees and dependents of St. Thomas, the initiative added a Medicare shared savings population in 2012, says Asher, who at the time was the physician network executive at St. Thomas charged with creating and implementing physician alignment strategies. St. Thomas Health is a member organization of Ascension, a national Catholic-sponsored health system.

In its self-insured population, 5 percent of members were driving 65 percent of total health care spending, and health care costs had been increasing an average of 8 percent year over year. The first year of the pilot program netted $6.75 million in savings, driven by an overall 12 percent drop in the cost of claims. Much of that impact came from lower utilization, including a 27 percent reduction in 30-day readmissions to the hospital and a 22.5 percent reduction in emergency department visits.

For the elderly and higher-cost Medicare population, emergency department visits per 1,000 beneficiaries decreased 6.7 percent from 2012 to 2013, while inpatient cost per beneficiary fell 7 percent, and post-acute cost per beneficiary declined 20 percent. Central to the effort was creation of a crew of “health partners” who took responsibility for shepherding patients through the medical continuum of care and keeping track of their health status and life habits once they landed back home, says Asher.

After that auspicious start, Ascension formed a unit to expand the MissionPoint method to its member organizations. St.Vincent Health in central Indiana and St. Mary’s Health System in Evansville launched its local implementations of the national model in January 2015. As the first year of a pilot among St.Vincent’s 21,000-member work force and dependents came to a close, the results were showing “clear trends of decreasing per-member-per-month costs, clear trends in decreasing inpatient admissions per 1,000, clear trends in decreasing emergency department visits per 1,000 and clear trends in decreasing the readmission rate,” says Richard Fogel, M.D., chief medical officer for St.Vincent Health.

Patients who can get in to see providers at the first sign of trouble are more likely to stay away from the emergency department or avoid a precipitous decline at home, and providing access is at the heart of developing a CIN, says Brown. Besides giving people easy ways to gain access to the network, a CIN also has to be the prime mover of efforts to supply access to information on patients wherever they present themselves, he adds.

If a patient with a complex medical history comes to a facility with, say, shortness of breath, and data from many other sites of care are not available, that person “is going to be managed on a very transactional basis” and then sent home, says Brown. Infrastructure and other investments that a CIN can develop by pooling resources and integrating them will offer clinicians access to a much broader field of vision on what others have done for a patient. “That’s when we really get the full picture, and that’s when we can manage their care.”

Fogel sees better access to care as a benefit of organizing patient-centered medical home units, the backbone of clinical integration, throughout central Indiana. By June 30, St.Vincent expects to have seven such units in operation, with plans for significantly more as the model takes hold throughout the network. The purpose of the initiative is to take a comprehensive approach to caring for people from many payer sources and patient populations, he says.

By “maximiz[ing] the strengths of all the caregivers to do what they do best,” physicians can see a bit fewer patients but concentrate on those in need of evaluation and diagnostic skills, while patients in for routine follow up can be seen by a registered nurse or nurse practitioner, Fogel relates. “If there are two physicians, four nurse practitioners, and five other nurses in the practice, we can see a lot more patients at a lot of different times than if there are just two physicians working all day.”

The key to being efficient and effective, and successful at accountable care, is to match appropriate skills to a patient situation.

Full deployment of these comprehensive teams expands the number of caregivers at the ready and increases their ability to offer access at off hours, such as nights and weekends. “If you’re sick, you want to be able to get in and see somebody that day,” Fogel says. “In order to do that, we need to expand the number of open slots that we have in the network.”

Still another dimension of access is around the networkwide distribution of performance data back to participating providers and their practices. Every medical home, says Fogel, will have a panel of people the physician is managing. The network can supply results, such as how many are going to the emergency room, how often they are being admitted and whether they are getting the appropriate screening tests, that may figure into how the physician and network are rewarded or penalized.

“Physicians respond very well to data they believe,” he says, and that advances the cause of the CIN once it is measuring outcomes, such as compliance with medications and screening rates, which are “multiple things that will show a physician how he is doing and how his patient panel is doing.”