The journey into leveraging data analytics for success in value-based care delivery and payment arrangements is turning out to be a long one, industry experts, and those in the trenches, agree. There are multiple challenges and issues involved, among them, underlying issues around incentives. In developing a feature on the subject for the March/April issue of Healthcare Innovation, Editor-in-Chief Mark Hagland interviewed a variety of industry leaders, including Debbie Zimmerman, M.D., corporate chief medical officer of the St. Louis-based Lumeris consulting firm and CMO of Essence Healthcare, the health plan that Lumeris operates. Below are excerpts from their interview.
Tell me a bit about Lumeris. Lumeris operates a health plan, correct?
Yes—at Lumeris, we actually do two things; we do health plan standups, and today, those are all Medicare Advantage health plan standups. Either we own the license, and they’re marketed under Essence Healthcare. Those standups have been established in Missouri and Illinois so far. We also bring up health plans under the licenses of others, for example, Mutual of Omaha, which has launched Medicare Advantage plans in two states, and we’re their operational partner. Essence Healthcare has about 65,000 members; BayCare has about 5,000 members; BlueKC and BlueLA have between 8,000 and 10,000 members each, respectively. Meanwhile, we also work with health systems to help them improve their performance on all value-based contracts, whether Medicare, Medicaid, commercial, self-insured. In those cases, we’re not the plan.
How far along in this journey of 1,000 miles, is the U.S. healthcare industry?
I think that we are probably further along with the analytics itself than we are in changing the care delivery model. When we think about what we need to do, we need to change the incentives and the business model; we have a business model that supports fee-for-service. For instance, we know that in order to move to value-based healthcare, I need population-level data analytics. How is my performance at the population level, the sub-population level, and the individual-physician level? How is the performance on all those levels? And what is the variation of care like? We have yet to see a population where there isn’t variation of care. So you need that population level, and you need a range of analytics on population, health risk, care management, and so on.
And when I say we’re not very sophisticated at it, the situation is that we have it, and we probably know where the opportunities are; it’s a little clunky. We’re not as sophisticated at identifying trends and opportunities, but we’ve put people and brains on it. When we talk about variation at the individual-patient level, we talk about who needs outreach. And we all know that the social determinants of health are a big indicator. So how do we incorporate that with other data, like claims data, pharmacy, data?” There are vast opportunities at numerous levels, she says, including around embedding key data and analytics into clinician workflow, to uncover gaps in care. Meanwhile, she says, “We’re a little bit better now about combining clinical and claims data. But we’ve got some opportunities in being smarter about the data about itself, and then increasing usage of data by reducing barriers introduced by clunky barriers and the like.”
What should clinical informaticists and non-clinical informaticists be doing right now, on the clinical side, to help support these efforts?
For some, not all, my sense is that, having a maybe a little too much confidence that their electronic health record is going to meet all their needs; so keeping an open mind that there may be other needs, and also pushing to make sure that the EHRs electronic health records are prioritizing interoperability; because it’s really unlikely that one partner is going to give them everything they need, if they’re moving to value-based care. There’s a lot of assertions that the EHRs will move into the pop health area and solving all their problems, but that’s going to take a while. So that’s one priority. The other priority would be to work with the other clinical leaders, who are mentoring practicing physicians, and really partnering on what we need to do, which is essentially to change provider behavior. Because those clinician leaders mentoring clinicians, are on the front lines, and don’t feel they’ve got the tools they need.
What will happen in the next few years, in this whole area?
A couple of things. I think that we are going to see industries outside of healthcare coming in; we’ve already seen it with the Amazon Berkshire Hathaway partnership, and others. We’re going to see people outside healthcare, especially in the data field, coming in from outside an opportunity, because it’s too big an opportunity to pass up. And we’ll see a lot of big data; we’ll see how useful it is. We’ll hear a lot about AI; I don’t know how useful it will be. But I hear different things. We’ll hear a lot about it. And I hope that our workflow challenges of today will go away. I hope we won’t be challenged with integration and interoperability and these sorts of things.
Are physicians changing their care delivery patterns now, as payment systems change?
I’m the mother of two young physicians; one’s 30 and one’s 29. I’d like to tell you that their education was very different; but I can’t say that that’s true. I do think that… in primary care, I’m hoping… I think there’s an openness to this, because PCPs have felt that they haven’t really been valued for their cognitive skills, and the value they bring to the system. I think the specialists are behind that curve; they’re worried about what these changes mean for them. But primary care has been looking for alternatives. Look at the rise of these concierge practices. What we try to do at Lumeris—the kind of care I’ve heard about, has been described as being at a level of highly coordinated care, delivered by a trusted physician and care team. They have every reason to manage your health; and they’re rewarded for that. So when it’s a real opportunity, and this feels real to them, PCPs [primary care physicians] are excited about it, because it gives them a real opportunity to practice the way they want to practice, and they’re valued. And there are some medical schools, like this one in Austin, where they’re trying to create change. There are good examples emerging all around the country.
