The seven-hospital Community Health Network, based in Indianapolis, has been moving forward with value-based patient care delivery innovation very actively for several years now, even in a Midwestern market that has been less quick to innovate in general in the way that markets on the East and West Coasts have. But the leaders of this large integrated health system, which encompasses over 200 sites of care and 16,000 employees, including 1,300 employed physicians and advanced practice clinicians, has been moving forward steadily on its value-based care delivery and contracting journey. The organization participated in the Next Generation ACO program sponsored by the Centers for Medicare and Medicaid Services (CMS), and has just joined the Medicare Shared Savings Program (MSSP) for accountable care organizations. Not only does Community Health Network care for 30,000 patients in the MSSP, it also counts another 32,000 patients in other value-based contracts, including Medicare Advantage contracts with Anthem, UnitedHealthcare, Cigna, and Humana, all of which involve two-sided risk. And just last year, the organization launched its own direct Medicare Advantage product, called MyTruAdvantage.
Helping to lead his colleagues on this journey has been Patrick McGill, M.D., who was the organization’s chief analytics officer until last November, and is now its chief transformation officer. Dr. McGill, who still practices clinically at least one day a week as a family physician, has been practicing for over 20 years. He leads a team of nearly 600 IT, informatics, analytics, and business process management professionals, out of the health system’s Indianapolis headquarters.
Dr. McGill spoke recently with Healthcare Innovation Editor-in-Chief Mark Hagland regarding his organization’s ongoing journey into value. He will be speaking about that journey at the Midwest Healthcare Innovation Summit on April 18, at the Westin Cleveland Downtown, in Cleveland. Below are excerpts from their recent interview.
What are some of the main value-based contracts that Community Health Network is involved in right now?
We were a participating organization in the Next Gen ACO for five years, which just sunsetted. So we’ve transitioned to MSSP. We have about 30,000 patients in MSSP. We have another 32,000 across Medicare Advantage contracts, with Anthem, United, Cigna, and Humana, all of which involve two-sided risk. And we have Another 500 patients in MyTruAdvantage, and that just launched in 2021. It’s a brand-new Medicare Advantage product. We’re sponsoring that directly.
Starting at a 40,000-feet-up level, what’s your overall perspective on your organization’s journey into value right now?
We started about six years ago on our value-based care journey. We had a joint venture called Primaria. We were 50-percent owners, and VillageMD were 25-percent owners, and Anthem was the other 25 percent. We started that joint venture to look for new ways to do value-based care. We also had the government MA programs. Over time, it became simpler to do the value-based care with the government contracts. We ventured into the MSSP for one year and then the Next Gen ACO—for four years, and now we’re back to MSSP. So we’ve had a lot more momentum and success with the government-based contracts. Commercial is difficult because of the amount of churn in the population. And I think commercial value-based care is going to get more difficult as a result of the pandemic, as employers shift insurers, and people change jobs.
We’ve really focused a lot on the government payers. And we do not do value-based care with Indiana Medicaid, for a whole host of reasons. Medicaid—organizationally, we’re just not set up to do value-based care delivery with Medicaid. We have a partnership with a few federally qualified health centers, and those FQHCs are better at doing Medicaid, especially VBC, so we’ve partnered with them on that, versus taking that on ourselves. They have all the wraparound services; it’s just a different care model that works for that population of patients.
What have been the biggest challenges on your value-based journey so far, how have you overcome them, and what have been some of the main learnings from them so far?
Along this journey, you have to separate out the pre-pandemic situation and the current situation, in the midst of the pandemic. The biggest challenges before the pandemic were really around utilization management, focusing on readmissions, leveraging virtual care, at-home care, post-acute care. I think the pandemic actually helped some of that, because it accelerated the digitization. And now, during the pandemic, the biggest challenge we have is creating predictable models about utilization. You have no idea of your inpatient census or lengths of stay, because of the pandemic. So the predictability of value-based care is the bigger challenge, at this point. And then the other aspect of that is focus. Right now, we’re focused on the Omicron surge. It’s hard to focus on other aspects, when your short-staffed, because of COVID.
Have you been hard hit around staffing?
Oh, yes, we have. And people are out sick.
It has been widely noted that hospital-based organizations for years tried to avoid spending very large amounts of money on traveling nurses, but that, during the pandemic, it’s been impossible to avoid using traveling nurses to address shortages—and that now, even if one has the funds, they can be difficult to get.
Before the pandemic, we might have maybe ten to twenty travelers working in our organization at any given time. Now, we’re up to 200 at any given time, and our labor costs have skyrocketed, not just from travelers, but because of retention issues. And people are not resigning to become a traveler to go across the country as they often would do; they’re resigning to become a traveler at literally the hospital next door to us, at a higher salary. And we’ve focused on process improvement and clinical variation reduction for ten years now; and when you hire a lot of travelers, a lot of that process improvement goes out the window. And we’re being held accountable for quality, around such areas as infection, falls, everything. And quality issues are hard to control during a pandemic like this. And the number-one thing that prevents falls is having family in the room, and now they can’t be in the room. So if this becomes the new normal, we collectively need to focus on what the right quality measures are to measure engage on.
And look at the readmissions situation, for example: you can do all the right things, but because of COVID, your readmissions will be higher. For example, when patients are discharged to nursing homes but come back because of COVID infection, that will impact your total lengths of stay, total cost of care, and everything else.
If some pandemic conditions persist, how might that impact the value movement in healthcare, especially as it becomes endemic. How might such an ongoing situation affect the value movement?
Yes, a lot of epidemiologists believe that after Omicron, we’ll see a shift to an endemic level, where it’ll become more like the flu, where you’ll see some seasonality, as in the wintertime; and my hope is that the financial actual models and predictive models will start to take that into account. And that might take two, three, five years, but the standards by which you’re judged—those factors will be rolled into the model, and you can still focus on VBC. It will become the way we do business. Really, what we’ve seen is that the COVID situation has been more of a black swan type of event, and it will transition into the new normal way of doing business.
What do the next two to five years look like for you, in terms of your ongoing journey into value?
We’ll continue to participate in the government models; direct contractingis one that will have to be worked out. But we’ll continue to focus on the Medicare market. And direct-to-employer is another area we’ll explore. Per the commercial, value-based products—we’re in the Midwest, and we actually don’t have any capitation; but we’ll see what might be a hybrid, some combination of bundling and total cost of care, something along those lines. Per direct-to-employer, we’ll have to see how the disruptors—the Amazons, Googles, Walmarts—will play out. Are they going to continue to try to disrupt primary care? Or focus on centers of excellence for treatment? A larger driver of what happens will be around technology; another driver will be around how the pandemic resolves itself. Those are the factors.
What have been some of your and your colleagues’ key learnings around the systematization of clinical performance improvement?
You can’t discount the need and importance of data and data literacy. We’ve spent the last five years really focusing on our data and analytics capabilities, and on data literacy. So having data readily available related to value-based care, outpatient practice performance, and having a systematic structure in place—all those are important. When it comes to process improvement, it goes back to my first answer around analytics. A lot of people will come to us and say, I need a dashboard to help me improve. So we’ve focused on systematizing dashboards, so that your process improvement can help move you towards continuous progress. We’ve built that out. And the third thing is having willing partners. And we’ve got several great partners, Epic, HealthCatalyst, Coltrix, partners that are helping us along this journey as well.
What would be the core advice that you would give to the leaders of other patient care organizations, as they begin to move forward in their value journeys?
The first thing I would say is, you have to start somewhere. A lot of people get stuck in analysis paralysis. You can’t let that stop you from driving change. Second, you have to understand how VBC works—value, coding, risk acuity, cost of care; you have to have that understanding permeate the organization. Third, you have to engage your physicians—including case management, nursing, pharmacy, administrative leadership. A lot of that starts with the CEO and the transformation officer. And the last thing I would say is that if you have you put process improvement methodologies in place first. We dabbled in Lean, Six Sigma, and other methodologies, into The Community Way: The Way We Lead, the Way We Improve, The Way We Care. And The Way We Improve distilled down the various methodologies. We just broke it down into seven steps and very plain language that people can understand. We’ve now started to map processes end to end, with the support of a repository.
It also seems clear that leadership is a key element in all of this; that the leadership of senior executives in a patient care organization is an absolutely necessary ingredient moving forward.
It takes a certain amount of organizational resolve and resiliency, to be able to do this. You’re going to have years that are better than others. So start small, focus on your capabilities. And you can get there. But you have to have that North Star, you have to have that organizational resolve, to push through. There’s a certain amount of leadership involved. Organizations that can start at the top, can absolutely do this. The other thing that people get hung up on is that they see VBC as the flavor of the month, thinking they can sit on the sidelines and let it pass. But if you look at clinical quality and the patient experience and patient friction, those areas are areas where you’ll success regardless of your types of contracts. And reducing clinical variation and eliminating waste, works under any type of contract. It’s scary to do downside risk; so start with upside-only or shared-savings contracts. The journey of value-based care is a marathon, not a sprint; a lot of times, people are looking for sprint-type results. But the most important thing about a marathon is to be in the race all the way to the end.
