LIVE FROM HIMSS16: The University of Iowa’s Accountable Care Journey

Oct. 4, 2016
Lessons abound in the experience of the University of Iowa Health Care’s journey into accountable care, as Douglas Van Daele, M.D., the health system’s vice dean for clinical affairs, noted on Monday

Moving any health system forward on the path to accountable care organization (AO) development is inevitably a complex venture; but larger numbers of integrated health systems, including academic medical center-anchored ones, are plunging in these days, with meaningful results.

That is certainly the case at the University of Iowa Health Care (UIHC), according to Douglas J. Van Daele, M.D., vice dean for clinical affairs and an associate professor of otolaryngology and head and neck surgery. Dr. Van Daele spoke of the successes and challenges that his organization has faced over the past few years, at the Business of Healthcare Symposium on Feb. 29, at HIMSS16, at the Venetian-Palazzo-Sands Expo Center in Las Vegas.

The University of Iowa Health Care, with 705 beds (soon to expand to 800), 300 clinics, 8,139 staff, 36,000 annual admissions, and 1.2 annual outpatient visits, has been involved both in the Medicare Shared Savings Program for ACOs (MSSP), and also in a private-sector ACO with insurer Wellmark; and in a state Medicaid contract known as the Iowa Wellness Plan.

Dr. Van Daele shared the successes and unresolved challenges to date with the Iowa Health System’s venture into accountable care on Monday, in a presentation entitled “The ROI of ACO,” and noted that data and IT have been core enablers and facilitators of transformation in the venture.

“The biggest benefit that we have seen internally in participating so far in accountable care, Van Daele said, is this: “it really has been access to data. We didn’t have a big primary care network, as an academic medical center. Now, we’re in an ACO with five primary care networks. So we have 75,000 covered lives under Medicare now; and so we’re scaling this. The Wellmark network continues to grow also.” And within the context of those programs, he said, access to claims data, and the ability to combine claims and clinical data, has been transformative.

“We get data from CMS [the federal Centers for Medicare & Medicaid Services], convert it, put it into our warehouse, develop reports, and put the report into our EMR. We load that claims data, about 185 data fields, into our EMR. We’re using CRGs [clinical risk groups] to identify our patients at highest risk, and they are identified and flagged in the EMR. We analyze spend by claim type for top 20 indicators; and we also look at readmits within 30 days.”

Layered on top of the combining of claims and clinical data for analysis is the growing use of predictive modeling at the University of Iowa Health System, Dr. Van Daele said. That predictive modeling, he said, involves the analyzing of spend management, looking at opportunities for care coordination, and continual health risk assessment and stratification of covered lines.

The result the identification of high-risk patients using CRGs is the reaching out to those patients on the part of care managers, through prioritized sets of tasks. Following an inpatient admission, Van Daele said, “An attributed provider is notified of the admission, and then we prioritize our efforts. We reach out primarily via telephone to those at highest risk, and reach out via the patient portal to those at lower risk. If the contact involves partners, we use the referral portal in the EHR to give them information.” Among the tasks performed is the creation of a customized inpatient list to “kick off a care management plan,” with that list including such tasks as falls risk screening, depression screening, chronic disease measures, etc.—“and we’re still contacting them as they discharge from the hospital,” he added.

“We’ve been able to really increase the percentage of patients using that portal. When we started doing this, the administrators said to me, well, that’s all well and good, but Medicare beneficiaries aren’t going to use a patient portal—they don’t have smart phones and won’t log into the web. We have patients in their 90s who communicate with their providers via patient portal. They’re 40 percent of our web portal traffic.”

The OpenNotes Link

One very interesting aspect of this is the role that the OpenNotes movement has played in the evolution of accountable care at the University of Iowa Health System. Van Daele reported to his audience that now, all clinic notes, discharge summaries, and immunization records, are available to patients. Also available to patients in their OpenNotes records are core lab results. “Patients see their lab results when providers do, with the one exception of HIV tests, whose results are provided in four business days.”

In fact, “When we began to roll this out,” Van Daele said, “our providers were really, really worried. We’ve been able to roll out virtually everything. Initially, we didn’t want patients to see their inpatient notes immediately. Now, they can see their progress notes when they get their discharge summary upon discharge. Remember also that a patient who has, for example, been in the ICU, could have a lot of lab results. We release inpatient lab results to patients after four days. In the end,” he noted, “providers’ concerns weren’t borne out.”

What’s more, he noted, data analysis based on patient surveys has found that, contrary to physician concerns, patients are not spending a lot of time scrutinizing specific lines of text in progress notes. “My thoracic surgeons expressed the fear that their patients, given the chance to see operating reports, would pore over them and ask them about very tiny details in their charts. But our surveys have shown that patients mostly look at their labs—lists and results—and messages back and forth with their providers; and upcoming appointments.”

What’s more, the key here is that patients seem to have become more engaged as their notes have been released to them. Indeed he said, “We have 2,000 new users a month, and over 120,000 patients are actually active in their accounts; that represents about 40 percent of active patients at any given time,” Van Daele said.

Struggling Towards Shared Savings

Even with all this good work, Van Daele noted, UIHC has not yet attained shared savings in the Medicare Shared Savings Program. “We’re doing all the right things,” he said, noting that working with high-risk patients using care coordination workflows (identifying patients at high risk, putting data about them into the EHR, establishing care management for those patients), reduced inpatient admissions by 2.27 per 1,000 the first year, and another 2 percent in the past two years. “That may not sound like a lot, but it is a lot. And while medical admits increased by 3.17 percent, a natural consequence of care management, he said, inpatient days per thousand have gone down 10.75 percent, and surgical admissions per 1,000 have gone down by 13.21 percent, with ED visits per 1,000 being reduced by 12.53 percent. An additional positive statistic: days in network continue to rise; so far, they have risen by 10.43 percent.

Why no shared savings? Iowa is already a relatively low-spend state, Dr. Van Daele said, with its average risk-adjusted spend below the national average. What’s more, despite reducing per member per year costs by $56 in 2014 and another $50 in 2015, the fact that “we weren’t paying attention to diagnosis-related coding” has resulted in lower risk scores per patient than should have been the case. All those areas are being addressed now, he noted.

Asked by Healthcare Informatics what CIOs and CMIOs should think about all this, Van Daele said, “First of all, we really do need to be able to help get patients engaged a lot more in their own care, whether through direct care coordination, or using technology to support their engagement, including through our patient portal. That’s the most important.”

In addition, Van Daele said, “Number two is, coding, coding, coding. We talk about it on the inpatient side all the time with DRG aspect. But improving CPT coding is very important, to set the risk of those particular patients, and being able to change the culture to make sure it’s not just about the E&M level, but those diagnoses really need to be down there as well.”