Sanjay Doddamani, M.D., chief physician executive and chief operating officer at the Dallas-based Southwestern Health Resources (SWHR), says he stumbled into the world of population health by chance. He was a heart failure cardiologist working at Montefiore Medical Center in Bronx, New York almost 20 years ago when he started to recognize how many patients physicians were simply unable to help.
“That stuck with me [throughout] my healthcare journey, and it was about a decade later that I got an opportunity to run a department of cardiology at [Nassau Health Care Corporation]. It was a public organization, and as chief of the department, I worked with our [team] to create a [population health] infrastructure.” Offering “one tiny example” of what Doddamani’s department worked on from a population health perspective, he says there were numerous indigent patients who were no-shows to their scheduled appointments, not only resulting in inefficiencies, but also blocking appointment slots that could have otherwise been given to other people with very long wait times.
Doddamani’s team then took everyone on the no-show list and told them that going forward, no appointment would be needed. “As long as they were on that no-show list and had a diagnosis of a chronic condition, we said that you could come in any time you want, Monday through Friday, completely open access. These practical steps that could really help people took me deeper into the road of value-based care,” he says.
From there, Doddamani went to Geisinger where he served as chief medical officer for the health system’s “Geisinger At Home” Program, as well as its Keystone accountable care organization (ACO). Doddamani then turned to the public sector, working for Adam Boehler as a senior advisor at the Center for Medicare & Medicaid Innovation (CMMI). It was there where Doddamani says he got a good sense of how the shaping of policy, especially around innovation models, could help accelerate the pace of value-based care.
Since February 2020, Doddamani has been at Southwestern Health Resources, a clinically integrated network that was jointly formed in 2016 by Texas Health Resources and UT Southwestern. The SWHR network includes nearly 5,000 physicians and advanced practice providers working together to better manage the population in the Dallas-Fort Worth metroplex and Northern Texas. SWHR also now supports more than 700,000 people through contract arrangements with large payers, including almost 100,000 lives within the Next Generation ACO model, and has generated 14 percent of the total savings for Medicare produced by NextGen ACOs, according to officials.
In regards to the COVID-19 pandemic, SWHR officials note several areas in which having an established value-based infrastructure has aided its practices in their response capabilities. Some of those include:
- Quickly enabling telemedicine across its practices with approximately 8,000 virtual visits per day across the network
- From a billing and reimbursement perspective, advancing part of the quality and incentive payments to community physicians in May when these are usually paid post reconciliation in the third and fourth quarters
- Putting out more than 200,000 targeted communications to patients at risk of heart attacks and strokes, urging them to avoid delaying access to acute care. Using advanced analytics from claims and EHR data, there has been additional outreach to patients and members in high-prevalence zip codes to amplify prevention of COVID 19 infections in the community.
- There are currently 450 actively managed COVID seniors in case management. Many have benefited from SWHR’s delivery of vital care packages that contain necessities for personal care and the close follow-up services that were provided
- Continuing to screen COVID patients for social determinants of health (SDOH) so that they can avail the support of social work and case management resources like meals-on-wheels, ride sharing and other services.
Doddamani’s role at SWHR is to help with the innovation strategy, help oversee operations, put the right teams in place, and make sure they are harmonized and working together. “We are a young organization, and have been patchworked together because we inherited a population health services team, and also bought a practice in the Medicare Advantage space that owned its own health plan, so as we pieced and patched these groups together, we recognized a great need to become a high-reliability organization,” Doddamani says.
He adds, “On our mission to become more integrated, we have kind of coined the term ‘interconnected dependability.’ It became obvious during the pandemic that we needed to accelerate our move into becoming a high-reliability organization through this interconnected dependability,” he says. Doddamani recently spoke with Managing Editor Rajiv Leventhal about many of these efforts. Below are excerpts of that discussion.
How has SWHR’s early transition into value-based care played a role in the organization’s COVID-19 response strategies?
There are two angles to look at here. One is to keep the doors open and lights on in primary care. We know the value that primary care brings to a community, in [terms of] preventive care and being the captain of the ship for patients’ healthcare journeys. In a fee-for-service model, keeping the lights on is doing transaction after transaction and not getting to the truest form of value-based work.
During this pandemic, we have meaningfully provided resources to primary care physicians. For example, when they were moving into the EHR space and couldn’t afford [certain] platforms, we got them eClinicalWorks’ [EHR platform] to [implement] across the system, meaning thousands of physicians. As a result of that, we were able to take the data insights from the EHR, along with claims [data], and marry them into our population platform that could help provide better insights into our vulnerable risk groups.
The second physician-directed approach is aligning incentives. For example, at CMMI, the innovation models are mostly payment innovation models, so they align financial incentives. For us, the best way of doing that was to move forward the payments we would provide physicians in Q3 and Q4 and get those to them right now while their businesses are under siege. So that helps us work more closely with them to do a lot of the work that could be done outside of physically having patients in the office—through providing telemedicine access, doing some of the preventive work around quality, and then really aligning the priorities—especially gaps in care.
As for the community approach, we know that many minorities are being unduly impacted by COVID-19. There are many essential workers who come from minority backgrounds, and there can also be health literacy challenges. So our chief communications officer has been instrumental in taking the data from all our patients, beneficiaries and members in the community who come from zip codes that we know are our high-prevalent zip codes, and doubling down on our messaging in terms of social distancing, wearing masks, and other prevention-related efforts, and then self-quarantining when infected. We have heard that after [hearing] these patient-friendly instructions in Spanish, patients have come back to us all along saying that they were being told to stay distant and wear masks, but no one was ever explaining to them why we need to wear masks, or why when they wear a mask they have to cover their noses, too. They assumed that it was only about coughing and covering the mouth.
The other thing is recognizing that in many communities, in the early days of the pandemic, many deaths were non-COVID related, and were from heart attacks, strokes and other acute events happening, so people were fearful of going to the hospital. So we took all our diabetic and hypertension patients—some who had prior strokes and heart attacks—and told them not to delay your care. This presented an opportunity to get the message out there, and we’re now noticing the downtick in hospitalizations is not the same as it what it was [earlier] on in the crisis.
And the patient interactions—such as getting vital care packages to COVID-positive patients, especially to seniors who are socially isolated—can only be achieved because of value-based care. The way in which we’re paid allows us to find the resources to have the teams in place that we would have otherwise struggled with.
Can you discuss the intersection of SDOH and COVID-19, and how connecting underserved patients with key resources is a critical response to the crisis?
The top few things when we think of SDOH are medical transportation, health literacy and food insecurities. We have a COViD-19 registry from both UT Southwestern and Texas Health Resources, and we get a daily list of our COVID-positive patients from them. That helps us to drive our outreach teams to do a quick SDOH screening, and make sure that if patients respond positive to any of these screening questions, that we plug in our social workers and case managers. We can then determine what the challenges are, and if those challenges are access to care, we can certainly help solve that.
We helped 400 practices stand up telehealth into their offices, and that’s more than just technology, but also education and getting the waivers in place. We work with partners to get urgent visits to the home, and we also partner with home health agencies in the area, doing pre-acute work for high-need patients. We are even providing Lyft services to our patients; we have had to think out-of-the-box in terms of what those needs are.
Financial challenges have unfortunately hamstrung too many physicians during the pandemic. Reports of revenues lost continue to be bleak. How do you view this landscape?
There were a number of federal loans that some have gotten access to, but others have not. We instituted weekly webinars with physicians, and early on we had 500 to 600 physicians on these webinars, asking us what waivers are in place, or how they do an attestation for telemedicine. About 90 percent of our practices switched over to telemedicine within a week of the public health emergency announcement. More practices are asking the question of what can they do to support patients during the pandemic, and improve outcomes, and it’s really important to have a continuous source of funds so they can keep the lights on.
