At the 11-hospital Presence Health, an integrated Catholic health system based in Chicago, Sam Bagchi, M.D. has several titles—and a lot of responsibility. Dr. Bagchi, who practiced internal medicine and hospitalist care for 10 years before moving into healthcare administration (he still practices limited telemedicine), is not only the health system’s chief medical officer and its chief quality officer; he currently is also interim president of Saint Francis Hospital, one of the larger hospitals in the system, while that facility, located in the Chicago suburb of Evanston, looks for a new facility CEO. What’s more, the corporate IT and informatics teams at Presence report to him.
As his current corporate bio notes, Dr. Bagchi “provides the vision and direction for a diverse list of system functions including: system quality/risk, care management, information services, telehealth, hospitalists, emergency medicine and clinical analytics. This broad area of focus has equipped Dr. Bagchi with uncommon insights into the challenges and opportunities facing today’s health systems as they move towards highly-reliable care delivery.”
Dr. Bagchi spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland about Presence Health Care’s journey into value-based and accountable care. Below are excerpts from that interview.
How would you frame your organization’s journey around population health?
It’s very much aligned with our mission, which is very much focused on the health of our communities and the patients we serve. So population health is a very nice fit for us, in terms of how we can take care of people outside the walls of the hospital. And because of our Catholic mission, we’ve focused on communities that potentially were not well-served, and also areas that other providers have abandoned or not focused on—behavioral healthcare, for example. In fact, we’re the largest inpatient behavioral health provider in the state. So from a pure clinical services point of view, we’ve been very interested in the full health and wellness of our communities, so it fits really nicely. In terms of our business, we’re still heavily dependent on fee-for-service revenues.
You’re involved in one of the Medicare ACO [accountable care organization] programs, correct?
Yes, we’re in a Medicare ACO; we’re in Track 1 of the Medicare Shared Savings Program. We’re in the third year of our participation in that program. In addition, we have some value-based contracts with a few commercial payers, with Blue Cross Blue Shield of Illinois, with Humana—small amounts of Medicare Advantage with Humana. And we have a clinically integrated network, Presence Health Partners, for our affiliated physicians, who number about 3,000. Most of the physicians in Presence Health Partners are not employed. About 20 percent of our physicians at the hospital level are employed, and 10 percent at the network level are employed. The Chicago market remains a little bit underdeveloped in terms of physicians, compared to some other major metropolitan areas.
What types of technology are you using in order to perform health risk assessment across your covered populations in your MSSP and commercial risk contracts?
We’re using Healthy Planet, the care management system from Epic [the Verona, Wis.-based Epic Systems Corporation]. We transitioned over from another solution. We were part of the Medicaid ACO—we were one of those providers, but we’ve transitioned those lives to a third-party payer. Pretty much all the provider-based plans in Illinois have done that. But we do take the patients we’ve done the risk assessments for, and are trying to develop the best care management programs for the highest-risk patients. One thing for your readers to think about, in terms of ACOs and value-based contracts, then, outside those contracts, is how to how to manage those patients.
Whether you’re at risk through an ACO contract or value-based contracts or via the DRGs for your physicians, you need to find ways to analyze their health status and act on what you find. In our case, we’ve incorporated a high-risk screening process for all of our patients, called the LACE tool—a pretty traditional inpatient methodology for identifying patients at high risk for readmission. “LACE” stands for length of stay + acuity + comorbidities + ED visits. Using that tool, you take those factors into consideration, and create a score, and can determine which patients—those with higher LACE scores—are at higher risk for admission or readmission. And for those patients who are at a threshold score or above, we do a series of things, including specialized discharge planning, care navigation, home care if appropriate, and post-discharge follow-up appointments for them. In terms of care navigation, we’re looking at a couple of touchpoints—making sure people are getting to their appointments, filling their prescriptions, have transportation to follow-up activities, and we’re really tracking patients more than we ever did.
The fact is that we already have a lot of the information we need. For example, the LACE tool is a pretty basic tool that gives us information we can get easily; and its part of our admission assessment when we admit patients. It can have a real impact on readmissions.
Have you been able to measure any results of interventions yet?
No, we just went live with this tool in December and January, so we haven’t measured it yet, but there are demonstrated results in the literature, so we’re confident it will have been helpful. For us, the basic approach is more pragmatic and less sexy than what other people are doing, but we’re trying to focus our efforts on things that work, rather than getting too involved in preparing for a future state that may not happen. A lot of health systems have built architectures for capabilities they think they may need. That worked well in California with Medicare Advantage, and in Massachusetts with global HMO payments; but in the Chicago market, we don’t have the same levels of payer pressures to manage the entire cost of care. So that’s something that’s been a change here at Presence; a couple of years ago, there was a focus on building capabilities for a future state that may not yet happen.
So, essentially, you’re taking a practical, measured approach to this evolutionary process, then?
Yes. We know that the things that affect our hospital book of business will be helpful in any future state scenario, so we’re focused on things that can drive down the cost profile and improve quality of care and outcomes. In any scenario, when you’re managing costs, the hospital always comes up top of list. And that’s where we’re focusing our efforts, and not getting too caught up with the regulatory landscape that’s changing.
You’re young for a health system CMO, correct?
Yes; I’m 41. I’m on the younger side for a CMO. I think the traditional CMO has been one who’s this champion who’s there to be a liaison. It became clear to me very early on that I was very interested in management; I’m interested in systems and process, and trying to help lead change more broadly. We have about nine CMOs in the different business units and hospitals—to be more operationally integrated, to be true executive leaders, and not just being liaisons, though that is important as well. And I’m passionate about quality, and that’s where I would say that we’re trying to drive the physician culture, with them as key stakeholders in driving outcomes, not just driving volume, but driving excellent results for patients. Generally, physicians can get behind that, and it resonates for them, particularly younger physicians who haven’t become jaded by the FFS model. But physician culture is critical.
Shifting physician culture to match the objectives of value-based care delivery and payment and of population health definitely is critical. What are you and your colleagues doing in that regard?
One of the more unique things we’re doing is around the credentialing process. If you think about all the raw ingredients that go into health outcomes, physicians are key stakeholders in that, along with nurses, with capital, etc.—physicians are top-of-list in my opinion; yet there’s been very little done in the industry to vet physicians from a quality and capability perspective. We’ve brought to bear a technology system to consistently credential physicians across the system; we’ve implemented a monitoring system to instantly know if someone’s board certification status has changed, or anything else. And physician-specific quality outcomes are hard to come by and hard to collect. As much as we get a lot of data, a lot of that data does not give us meaningful information about physician performance.
Have you provided your physicians with clinical performance dashboards yet?
Probably not as much as we’d like to have. We do have a variety of physician-specific data elements. We struggle more with our outpatient-focused physicians, where we have less access to their quality data. With our employed physicians, we’re on the same EMR, so we have capabilities to pull HEDIS measures, and have crated quality improvement projects around hypertension management and diabetes management, and raised those to the system level. Put simply, with our employed physicians, we have a lot more data to work. We are working in those areas with hypertension and diabetes, focusing on those two areas. Initially, we just focused on whether we had a blood pressure measure or a hemoglobin a1c measure for patients at risk. So there’s been some crawl-before-you-walk-type work that’s been done. And for our employed, we’re able to incentivize them, with a percentage of pay tied to care management.
And with our larger integrated network with our affiliated physicians, we’re beginning to explore incentivizing our physicians to focus on various care management elements, but it’s a tougher row to hoe, because of the inability to drive all the payment incentives. I will say, though, that while incentives are good and can be a part of the story, as a CMO, I’m constantly trying to reconnect our physicians at the emotional hook of the story, in terms of their relationships with their patients. Part of the struggle is that they may have meaningful interactions with their patients, and yet I tell them that they may not be getting credit for all of those, if we can’t measure their outcomes. I think that that resonates with physicians if it’s framed for them in a positive way and not used punitively as a weapon. Sometimes, with the HEDIS measures, sometimes if you focus too punitively, you lose your physician audience, and we all forget why we’re trying to do this in the first place. So I try to connect emotionally with them around what’s at stake here.
One challenge is going to be around MIPS/MACRA [the Merit-based Incentive Payment System for physicians under the Medicare Access and CHIP Reauthorization Act of 2015], correct? Many physicians still remain woefully ignorant of what’s involved in MIPS/MACRA.
It’s scary—and especially in Chicago, because we still have a lot of these onesie-twosie practices, and they said they would retire rather than do an EMR, and then rather than be measured, and now they’re saying that they’ll retire over MIPS/MACRA.
In that regard, what plans do you have around engaging MDs around MIPS?
We’ve been educating all the physicians in our clinically integrated network around MACRA and MIPS, and really pretty quickly settled on focusing on MIPS. We saw some of our competitors messaging their physicians early on even before the final rules were in, to join our CIN or ACO because we can help you avoid MIPS and stay in a value-based plan; we purposely did not do that. We said, we can be your value-based partner and educate you. There is a real question now, and this comes back to credentialing—we will soon have the quality data we’ve always wanted, to make a more meaningful credentialing process.
In that context, we’ve linked our hospital-based credentialing process, which physicians use to get privileges in our hospitals (and physicians have to have membership on a medical staff to participate with third-party payers), to help our physicians get third-party payer credentialing. And what we’ve all wanted is physician-specific quality data, in order to make better decisions about whom we allow on our medical staff. And health systems aren’t going to want every physician in their network.
Have you chosen already not to credential individual physicians?
Yes. It’s partly based on the high priority our board has placed on this. We’re taking a strong stance on this because of our focus on quality and safety and not wanting to have physicians who aren’t equally aligned. Unfortunately, we don’t have the strongest elements yet, so it’s still primarily based on licensing, board certification, and malpractice history, things that are less appealing. We don’t have anything yet as rigorous as what we’re going to see with MIPS, in terms of the rigor of the quality data. But as physicians get further down this MIPS pathway, essentially, we’ll have physician-specific fee schedules, based on performance and participation, and it will become quickly evident to physicians who don’t perform well, that they won’t fit as nicely into the programs of the payers here, unless they do better on quality. So it will be a “yes, and”—we need the quality programs, the participation in reporting. So I think you’re right, it’s an unprecedented opportunity to engage physicians around outcomes.
We’ve already been on the hook for value-based purchasing readmissions reduction, and healthcare-acquired conditions penalties, under the ACA, and we’ve had to persuade the physicians to engage with us on this. Going forward, I think it will be harder to advance the ball if you don’t involve credentialing in this. And if you have rubber-stamped, paper-based, routine processes, which many organizations do, you’re going to have a lot harder time navigating this. So even though we’re not all the way down to measuring the physician-specific dashboards that I’d like, yet, we are moving around, around credentialing decisions.
In terms of helping individual physicians with their MIPS measurement work, is that something that you might offer them?
Absolutely. We don’t have it in place yet, but it’s in our plans, particularly with physicians who either are in our employed group or are on Epic with us. And down the road, I think that’s absolutely a service that will resonate with physicians as they decide which multi-hospital system to partner with. But to your point, what we’ve found is a lot of willful unawareness of MIPS awareness, or as I like to put it, some doctors are in a ‘pre-contemplative’ state around this. A lot of physicians aren’t yet as interested in having discussions around this, as they should be. The ones who are most interested are already the most engaged in providing value-based care and the most involved in managed care contracting. Those physicians are ahead of the curve; but that’s probably 20 or 30 percent of physicians, and the lion’s share are either still head-in-the-sand around this, or are overwhelmed by issues in their day-to-day practice, or are saying they’re going to retire. I’ve had a lot say that this is it, that they’ll retire—or they’re saying they may go into concierge practices.
There’s not enough of a market for massive numbers of physicians to go into Medicare-free, concierge practices, though, correct?
True, but in some areas like Dallas, in markets with shortages of doctors, some are stopping seeing Medicare patients. So yes, while commercial payers will eventually get there, some of our physicians are going to try to circumvent even more for a couple of years.
What’s next in the next couple of years at Presence?
The focus will be on the health and wellness of our communities and on being good stewards of resources—really making sure we’re the best possible resource we can be to our communities. That’s where all of our focus is. And for me and for many of us, it’s where we can deliver the best possible quality outcomes. We’re very much dependent on our FFS, hospital-based payments. We are focused on increasing our ambulatory offerings; but if we do that at the expense of operational effectiveness of our hospitals, we really risk our core businesses. So we’re trying to provide our best, highest-quality, lowest-cost care at our hospitals, because that will be critical to how population health unfolds; and those organizations that don’t focus on their highest-cost patients, will potentially lose out in terms of the big picture. Right now, our payer mix is about 40 percent Medicare, 20 percent Medicaid, and the remaining 40 percent commercial.
And we’re trying to partner with others who are interested in the same types of community outcomes we are, whether that’s physicians, multi-specialty groups, or health retailers—we’ve been creative about joint venturing and partnering, where it makes sense, and not competing just for the sake of competing.
