Accountable Care Learnings in Middle Tennessee

Nov. 19, 2013
Hal Chertok, D.O., president and chairman of the board of the Cumberland Center for Healthcare Innovation, is leading a Medicare Shared Savings Program ACO that is proving that physicians in very diverse settings can innovate very broadly in the accountable care and patient-centered medical home arenas. His ACO's learnings are illustrative of those of the most advanced medical coalitions in the country.

In the October 2013 Healthcare Informatics cover story, HCI Editor-in-Chief Mark Hagland interviewed a wide variety of physician group leaders and industry experts regarding the journey toward population health management, which encompasses numerous vehicles and organization structures, including ACO development, care management, patient-centered medical home (PCMH) development, and avoidable readmissions reduction work, among other types of initiatives.

For that article, Hagland interviewed Hal Chertok, D.O, president and chairman of the board of the Cookeville, Tenn.-based Cumberland Center for Healthcare Innovation, a Medicare Shared Savings Program (MSSP) ACO formed in February 2012. The Cumberland Center for Healthcare Innovation encompasses 30 physicians in 14 medical groups in middle Tennessee, and bridges IT facilitation and data-driven work across 14 different electronic health records (EHRs), while serving a population of 11,000 Medicare beneficiaries; it represents the largest group of practicing physicians in rural middle Tennessee. Chertok and his colleagues are working very closely with the folks from the Atlanta-based Clinigence, which is providing a common data platform and making it possible to harvest data and share it in participating practices, via a clinical dashboard. Below are excerpts from Hagland’s interview with Dr. Chertok.

What made you and your colleagues decide to participate in the Medicare Shared Savings Program (MSSP) ACO initiative?

We decided to get involved when Medicare offered the shared-savings option. Individual practitioners don’t have the funding to put together a group like this, but we saw the opportunity to start linking our EHRs together and start harvesting the data. We’re in an area where a lot of us are being bought up by the hospitals, and a lot of us saw this as an opportunity to stay separate. We’re also in an area where the 800-pound gorilla Blue Cross gets to tell you what to do. I’m in a two-doctor practice called Cookeville Primary Care Associates. And we’re a patient-centered medical home [PCMH]. We got the level 3 certification from NCQA [the National Committee for Quality Assurance] this summer. We use the McKesson EHR, and were able to leverage that data with Blue Cross Blue Shield of Tennessee, and they prompted us to become a patient-centered medical home.

Hal Chertok, D.O.

What has been most challenging for you in developing both the PCMH and ACO concepts?

Getting physicians to all walk in the same direction. We were able to leverage the HIT for our own purposes; we were able to prove that the higher your quality outcomes, the lower your per-member per-month costs. That’s the concept of the ACO. We were able to convince the docs to get off the hamster wheel of volume-based care, and that we could work smarter instead of harder. And with regard to working smarter, I have a dual perspective on that, because I was a biomedical engineer before I was a doctor, and used to design biomedical systems. I was interested in this kind of thing before the formal concept [of ACOs] existed. So naturally, when Medicare gave us the opportunity, we jumped at it.

What have been the biggest IT-related challenges for your organization as you’ve moved forward into ACO and PCMH development?

The most basic challenge is that we have 14 different EHRs among the physician practices in our ACO. That’s when we partnered with Clinigence, and they’ve basically given us the keys to the kingdom. They’re a tech incubator from Atlanta, outside of Georgia Tech, and they were literally able to harvest our data and collate it, and in our alpha practices that are getting data in real time through a clinical dashboard.

When did the dashboard go live?

About six months now, I’ve been live. Only four of the practices right now, representing about six physicians.

What are you learning, and how is it changing your practice?

This is amazing. Medicare holds their data back from you until you submit your data. We were lucky enough to do 100-percent submittal. Most places don’t have the HIT in place to do it. So since we decided to go the tech route—we got 100 percent. Less than a third of the pioneer and breakout ACOs were able to do that. But because we were able to do that, they’re giving every one of our physicians PQRS certification. But once you submit your 22 quality measures, they ten turn around and give you cost metrics. So Clinigence, the group down in Atlanta, was able to harvest the EMR data and compare it with cost metrics, and we were able to prove years ago that increased quality outcomes leads to decreased costs per member. For a 65-year-old male, is his blood pressure in check, etc.; and among 30 physicians, the higher your markers of quality delivered, by the lower your month-by-month cost per member.

The average patient costs $11,400 a year per member per month in the Upper Cumberland. And I can tell you that the range of cost outcomes is broad. One practice with the lowest quality markers cost just over $14,000 per member per year; the practice with the highest quality markers costs $8,300.

In terms of the 22 variables involved?

Right, the variables that Medicare wants us to track. There’s definitely a cost-versus-quality connection.

And it would seem to be a clear connection, correct?

Of course, but no one had ever paid anyone to do the study, so Medicare is doing that now. And they said, look, bring that $11,400 to $10,800, and we’ll split the money with you, as long as you follow the principles of the Triple Aim. I think we’ll be below that in the first year. The practice with the highest quality markers and lowest cost? That’s my practice.

Obviously, physicians have to buy into the concept?

Absolutely, that’s the hardest thing.

But your ACO’s members are now working with that dashboard, too, right?

Yes, and it doesn’t take the doctor to make every decision. The vast majority of preventive measures don’t need physician involvement at all; they involve standing orders that mid-level practitioners can carry out. If someone hasn’t a pneumonia vaccination, colorectal cancer screening or mammogram, blood sugar control, or whatever, those items can be taken care of. And what we’re finding is that the practices with appropriate standing orders on preventive health have absolutely the lowest cost per member per month. Now the goal is to get all of these 14 EMRs to dump into our HIE-lite. Clinigence provides our offshore IT; we do have one in-house IT person, and I’m the “geek person” here support him in his work. And pneumonia vaccination is actually the lowest-cost, highest-yield intervention you can do.

That would seem obvious, right?

Yes, but the issue is the physician practice “hamster wheel.” These guys are focused on the volume of patient visits, and they don’t find out a patient has a blood sugar problem until he has a vision problem.

What would your advice be for physician and other healthcare leaders, based on your experience so far with your initiative?

I think the number-one thing is to stop doing it the way you’ve always done it. This is the time where you need to embrace change; you need to get off that hamster wheel of acute care and switch into preventive care. And if it doesn’t take the physician to do it, it shouldn’t take the physician to do it. Use your decision support tools and your health information technology tools to their highest level of capability to allow you to perform to the best of your ability; and don’t get complacent. The goal is to continuously improve. While the MSSP is a wonderful thing, it would be shortsighted for that to be the end goal. The goal is to be a large integrated system of physicians that provides the best care for patients.

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