How MetroHealth’s Success in Risk-Based Contracting Could Show the Way Forward for the Industry

March 26, 2019
Drs. Nabil Chehade and David Kaelber shared with attendees at the Cleveland HIT Summit their successes with risk-based contracting—and now, the entire industry needs to watch closely

As I reported last week, two senior executives at Cleveland’s MetroHealth integrated health system, Nabil Chehade, M.D., senior vice president, population health, and David Kaelber, M.D., chief medical information officer, gave a joint presentation at the Health IT Summit in Cleveland, for an audience of senior healthcare leaders.

Under the title, “MetroHealth’s Road to Success: The IT Approach for One of 30 Successful National MSSPs,” referencing the Medicare Shared Savings Program (MSSP) in which the integrated system has participated for more than five years now, Drs. Chehade and Kaelber shared some of the advances and learnings that have been taking place at the integrated health system, which is Cuyahoga County’s public health system, and which has a payer mix that is 38 percent Medicaid and 7 percent uninsured, and yet which has been able to attain a 4.1-percent operating margin.

Dr. Chehade recited some statistics at the outset of the presentation, with regard to MetroHealth’s MSSP performance over the past several years. “In the first year, 2014,” he noted, “we overspent by 2.1 percent. In the second year, we came under, by 1.7 percent, still didn’t achieve any savings. 2016, we came under by 8.1 percent. And in 2017, when we moved from one-sided to two-sided risk, we were 10.2 percent below our benchmark. This is actually working against ourselves,” in terms of inpatient hospital revenues, he added. Meanwhile, in one commercial risk-based contract that MetroHealth is involved in, which is actually with Cuyahoga County on behalf of its employees, “We were able to stay at 7.36 percent below the established benchmark in 2017, and shared half of that savings with the county,” Chehade said.

In addition, Chehade told the audience, “We have about 100,000 attributed patients in the Ohio Comprehensive Primary care (CPC) Program,” a Medicaid managed care program. And, in that program, he reported, “We were at $285 per member per month” in member costs when “the official results just came out, and there was only one provider lower than us in cost in the state, and that was a very small physician group.” That program’s measures include service and access, efficiency, clinical quality, and total cost of care.

Achieving such advances has taken a lot of hard work, the executives noted; but it has also taken a lot of smart work. And those gains have been particularly remarkable, given that, as the county’s public health system, Drs. Chehade, Kaelber, and their colleagues are providing care delivery and care management to populations that are underprivileged in every way, including, importantly in the context of the Medicaid and uninsured populations, facing every kind of insecurity—economic, personal security, housing, financial, and often lacking any consistency in their medical care over time.

“Now, 66 percent of all unique patients are in a value-based contract—that was last year,” Chehade noted.  Now we’re at 75 percent. Not all are in two-sided risk; our Medicaid contracting is 100-percent value-based. But it is a journey. And our EHR [electronic health record] and analytics are a foundation for success.”

As Kaelber noted, with regard to the intersection of process change and data and information technology, “Analytics and dashboards are very important. And one of the keys to this is transparency. Everybody on the team and in the system can see all the metrics.” And he shared with the audience examples of a provider-specific dashboard, noting that, through the transparent sharing of such data in dashboards, “Physicians can look at all the important quality parameters in the MSSP, and can also look at anybody else’s statistics as well. That makes everyone competitive,” he emphasized. “So collecting data and sharing data with transparency, are a key” to success. In addition, he noted, “Another thing we do is that all the quality measures in MSSP have some sort of health maintenance quality reminder, and we show those to physicians, and put them in the personal health record, and we mail or text or call” patients to make sure they show up for appointments that help manage their care and support their health status.

It is exactly that level of work, involving people, process, and technology—the classic triad in healthcare delivery—that has been reaping rewards for everyone at MetroHealth. Indeed, risk-stratifying attributed plan members, getting those needing close care management into such programs in a timely way, and working hard and over time with physicians to integrate the use of performance data into their day-to-day practices. That advance, coupled with the development of advanced care management processes, is not only vital when caring for disadvantaged populations—it reaps major results, as MetroHealth’s leaders have proved now year after year.

What particularly strikes me here is how powerful the strategic, appropriate leveraging of data, analytics, and information technology, can be in the pursuit of success under value-based care contracts. MetroHealth is doing better than many organizations that are far, far more richly resourced—including under Medicaid managed care. I’ve long said that if providers can succeed under Medicaid managed care, they can succeed in any payment model; and I’ve also long said that the future of U.S. healthcare is going to be moving more and more into the conceptual territory of Medicaid managed care—meaning that the cost cliff that our entire national healthcare delivery system is moving towards, is rapidly becoming a nationwide burning platform for all of U.S. healthcare.

Indeed, as I noted in a blog written just over a month ago now, the Medicare actuaries announced on February 20 their predictions around U.S. healthcare system costs, including the gobsmacking marquee prediction that, as I put it then, “total U.S. healthcare system expenditures will reach $5.963 trillion by 2027—just eight years from now. Oh, let’s just say $6 trillion. That’s right: six trillion, with a t.” And it’s fully 19.4 percent of gross domestic product—breathtaking.

So we need to continue to follow the advances of organizations like MetroHealth, because they are path-breaking for the rest of the industry. I salute Drs. Chehade and Kaelber and all of their colleagues at MetroHealth: they are literally showing us the path to the future of U.S. healthcare.

The work that Drs. Chehade and Kaelber and their colleagues at MetroHealth have been pursuing has evolved forward over several years; in fact, the physician executives told their audience on Wednesday, it hasn’t all been smooth sailing. But, fortunately, they and their colleagues learned quickly how to succeed in value-based payment arrangements.