The Orange, California-based Alignment Healthcare, which describes itself as “a population health management company focused on improving care delivery, one patient at a time,” is a complex, multi-faceted healthcare organization with very different books of business in different healthcare markets in the three states in which it operates—California, North Carolina and Florida. Not surprisingly, that results in complicated explanations of what it does. But whether it is operating as a health plan or a provider of care management or other services, Alignment Healthcare is making serious progress in some key areas around population health—and that is worth noting.
Altogether, the organization serves more than 50,000 people in California, North Carolina, and Florida—with 32,000 of those individuals in California, 9,000 in North Carolina, and 8,000 in Florida—and is growing at 60 percent per year.
The organization uses a statement that summarizes what its people do, and how they do it: “We lead with a proven, replicable and scalable clinical model that improves quality while decreasing costs. We are a one-stop-shop, able to bring health providers (physicians and hospitals) and payers (health plans) onto one team to improve the health and wellbeing of Medicare beneficiaries at a lower cost,” the statement says.
And, in that regard, Alignment Healthcare executives note the following gains they’ve made in the markets in which they operate. Among them:
> In California, seniors have seen 50 percent fewer hospital admissions in 2015 than before they enrolled in Alignment Healthcare’s home-monitoring program.
> In North Carolina, the 30-day re-admission rate for patients enrolled in the organization’s home-monitoring program for all of 2015 was zero—compared to a national Medicare average readmission rate of about 18 percent. This is especially meaningful because these patients are the sickest of the sick.
> In Florida, Alignment Health has achieved a 43-percent lower hospital inpatient admission rate than the Medicare fee-for-service market average.
> Also in Florida, it has achieved a 54-percent lower hospital readmission rate than the Medicare fee-for-service market average.
> In California, it has lowered the ED visit rate by 38 percent, among plan members enrolled in its home-monitoring program.
> In California, plan members enrolled in the organization’s hypertension management program have seen an 8-percent drop in systolic blood pressure.
> In North Carolina, enrollees in the organization’s diabetes management program have seen a 20-percent drop in hemoglobin a1c values.
As to how Alignment Healthcare operates, in California, it is a health plan that manages the care of more than 32,000 covered lives in California. In North Carolina and Florida, it is a risk-bearing entity that takes financial risk and management responsibilities from health insurers and manages defined populations under contract.
Recently, Arta Bakshandeh, D.O., the senior medical officer, and Kerry Matsumoto, the CIO, of Alignment Healthcare, spoke with Healthcare Informatics Editor-in-Chief Mark Hagland about the progress that they and their colleagues are making in managing defined populations through data analytics-driven care management programs. Below are excerpts from that interview.
Alignment Healthcare is a rather complex organization, isn’t it? Can you summarize how you work in the different markets in which you operate?
Arta Bakshandeh, D.O.: In California, we are a health plan, and we hold a Knox-Keene license with CMS [the federal Centers for Medicare and Medicaid Services] and hold 35,000 covered lives, where we’re the payer. In Florida and North Carolina, we’re the risk-bearing medical services organization, and we take the financial risk and management from a payer.
Is there an easy phrase that encompasses that?
Bakshandeh: Population health describes what we do. We are managing a Medicare population in almost every realm that you would manage Medicare—Medicare Advantage, as a health plan; as a partnership; under fee-for-service; and also as a delegated medical services organization. We also deliver services, when we’re not the risk-bearing entity, and contract with a health plan or health system, and help them or teach them to deliver care in Medicare Advantage, using our analytics, and we get a PMPM [per-member per-month capitated payment] and a gainshare. At the end of the day, our mission is to improve care one patient at a time, whether we’re the plan, the risk-bearing entity, or services organization.
So the term ‘population health management company’ is a term that correctly encompasses what you do?
Bakshandeh: Yes, that’s correct.
You’re in how many metro markets or regions?
Bakshandeh: Alignment Healthcare is the parent company, based in Orange. From there, we operate in three states—California, North Carolina, and Florida. We’re the health plan in California, where we’re called Alignment Health Plan, based in Orange, with more than 32,000 covered lives—in Medicare Advantage. In North Carolina, we’re called Alignment Healthcare of North Carolina, with multiple health plan partners, including Humana and FirstCarolinaCare, in Wake County. And services are in six counties, with a risk model in county. In California, we operate as Alignment Health Plan. In Florida and North Carolina, we partner with insurers and plans, and provide services under the name of Alignment Healthcare. Alignment also partners with hospitals, physician groups, and health systems, and provides services under the name of Alignment Healthcare.
How do you see population health right now, in the contexts in which you work?
Bakshandeh: It’s important to understand how complex the population is. We don’t have a stagnant population. We have not only a multicultural population, but one that is also multi-genetic; and understanding where your patients are utilizing, what quality measures are needed [to measure their patient outcomes], and understanding how their needs are changing daily, is very important. So the way we’ve gone about looking at that is two-fold. One, in our command center in Orange, we’re using our data analytics structure, which is home-grown, and lab, pharmacy, EHR [electronic health record], claims, case management, all those forms of data, are coming into our analytics hub and are being redistributed out to the clinical teams, so they can execute care plans and intentions with a population that is changing on a daily basis. And real-time alerts allow us to provide that level of care management, which then leads to decreased utilization and improved health status.
But you can only do that through a model that can be executed on. So the second piece of this is our care management model, with physicians, mid-levels like physician assistants and nurse practitioners, and home care teams that can work with a case manager and social worker, and help lead towards a better outcome.
So you’re working on three levels, with data collection and analysis, followed by real-time alerting of your clinicians, coming from your command center; and then the level of physicians and their care teams in the clinics, followed by care going into patients’ homes, correct?
Bakshandeh: That’s correct.
Please tell me about the information technology infrastructure supporting and facilitating all this.
Kerry Matsumoto: The central nervous system [for our population health and care management work] is our analytics hub, which ingests and analyzes all of our partner and Alignment-generated data to create actionable alerts based on thousands of proprietary algorithms. Think about this as the NASA control center where all information known about the patient is ingested, analyzed, and then shared with clinicians who need to know to take action and improve care. We have centralized the analytics and alerts into this single engine instead of the traditional alert management in each individual ecosystem, which resulted in alert fatigue, alert conflicts between systems, etc. You also need to execute around the core operational elements — you still have claims, eligibility, and all the operational and clinical delivery transaction systems such as utilization management, disease management and case management. We have Alignment Healthcare Centers, where we’re delivering care through employed physicians, nurse practitioners and medical assistants. Then we enable the ecosystems and clinicians with vital information for delivery in the home, in the care center, in our partner provider offices, and in our markets.
So you’re managing all of this through a single nationwide command center, correct?
Matsumoto: Yes, we have a single nationwide command center hosted here in California. At the same time, command center information is decentralized to our markets and market partners —it’s delivered in all of our markets, and delivered to the desktops of clinicians, and we deliver that data to our physician partners. Dr. Bakshandeh does virtual rounds with our clinicians in North Carolina and Dr. Henry Do does the same in Florida, and our senior medical officers and clinical teams in each market are all viewing the same patient information.
So at a very high level, you’re analyzing data from all three states?
Bakshandeh: That’s correct.
Matsumoto: Yes, and because this command center is such a vital element to our technology-enabled care model, we will continue to use it in all of our markets, for all of our delivery models. A key aspect of analytics is acquiring timely, complete, and high-quality data from all of our partners (CMS, health plans, providers, hospitals, consumer sources, etc.), and we place a high degree of focus from my team on getting that data ingested into our EDW [enterprise data warehouse], immediately cleansed and pushed into the command center. We push to get all data that is available daily, or as near real-time as possible because it directly impacts patient care. Our command center will generate a real-time alert that can make a difference in our patients’ health status.
What are the biggest medical management challenges and the IT challenges, in doing this work?
Bakshandeh: From the clinical management standpoint, it’s regional culture change. The landscape is so different across the country in terms of culture, that the shift towards using data or data analytics in your day-to-day medical care is not something widespread yet, and that culture change is something that’s very difficult to implement, and I see a six-month learning curve towards helping physicians to understand the data and use it. When you’re in a more populous area, such as bicoastal, large cities, people are already doing this type of thing, and are more savvy. But as you move out into different parts of the country, the culture of the fee-for-service system remains [and hasn’t yet matured to embrace risk-based care delivery], and so it makes it difficult to penetrate those types of markets, where they’re like what Los Angeles was 20 years ago.
Matsumoto: I think one of the fundamental challenges—data has been around a long time, but acquiring timely, complete, high-quality data, is still problematic. HIEs [health information exchanges] and EHRs were supposed to transform the market, but at the end of the day, there’s still a lot of work to be done. The network path is there now. The challenge is finding a balance between insuring that you’re still maintaining HIPAA privacy, and actually delivering to the nuances of all the different instrumentation that’s needed, is still there.
But we also try to put ourselves into the position of the recipients of the data. Providers will say, I work with five different plans with different information systems—can’t you make this unabrasive to me? I think if you find the least-abrasive path that actually works within their ecosystem, that’s the solution, in terms of it being within their workflow.
So instead of sending them too many alerts that they then have to import and extract, we are working on new pathways to allow them to see Alignment data inside their EMR [electronic medical record] system while they are in the patient record, giving them direct access to our command center. We’re not there yet, but because we employ physicians who work with physicians, we’re constantly trying to improve that workflow for PCPs to reduce abrasion
With regard to some of the areas where you’ve made progress [per the statistics in the introductory section of this article], where do you see that you’ve made some of the strongest gains?
Bakshandeh: An area where we’ve made excellence progress has been in original admissions per 1,000, and in readmissions—we’ve dropped those dramatically. Looking at Wake County in North Carolina, that rate had been 240-260 admissions per 1,000—and we finished off the year just under 170. And when you bring in the other chronic disease management outcomes into play, getting high blood pressure from uncontrolled to controlled, and hemoglobin a1c has improved in diabetics.
That goes back to getting the data to the care teams in real time, correct?
Bakshandeh: Right. We’ve extended that data through an app that can be downloaded. I’m still a practicing physician—I’m an internist and hospitalist—and I still use the data daily. A couple of examples: The command center has a 360-degree view of all the information we have on a patient—I can see the patient’s pharmacy data, clinical alerts, a global history of a member for as long as they’ve been a member with us. Example from over the weekend, where I didn’t have to work up a patient as much as I might have had to, which would have led to waste and a burden on the patient, who has dementia. But in 2011, he was treated for leukemia—but when he came into the hospital, his labs weren’t quite as off as they might have been. And because I had that data in front of me, and the patient couldn’t tell me because of his dementia and the family didn’t even know about the previous tests, I was able to do one simple blood test to confirm the recurrence of leukemia, and then produce a clear care plan. It was very powerful that I was able to pull that information right off my iPhone. That’s very powerful.
How do you see all of this work developing further in the next couple of years?
Bakshandeh: Where I see this going is the use of ‘big data,’ and non-healthcare data, like weather patterns, pollen counts, pollution counts, water quality: those types of data points will begin to be used in overall analytics, and will give us a better idea of those members that may be moving towards or prone to certain types of exacerbation in their health, and will leading to teams preventing initial symptoms, or controlling those symptoms before they get worse, and the more data we have and AI we use and the ability to move this data to care teams that understand how to action it, that will help us change the paradigm of healthcare and allow us as a healthcare system to provide better healthcare to the masses.
And what’s important to understand, from the IT leadership standpoint?
Matsumoto: All the things that Dr. Bakshandeh just said are right, and they all need to be technology enabled. The way we’ve architected both the EDW and command center gives us flexibility—it allows us to quickly ingest new data sources like pharmacogenetics, operationalize new analytics, and integrate new technologies. We have been able to quickly flex our data analytics to meet the unique needs of our various lines of business described earlier. But you still have to get the fundamental building blocks right, like your operational and clinical transactional systems, core infrastructure and security, EDW and analytics, service and change management, blended waterfall and agile software development, and data governance and ownership. And they have to be operationally excellent. I’m fortunate to have a strong IT leadership team who connect the dots with our operational leaders, and great business partners who understand our business, understand the connection between operations and technology, are passionate about the delivery to our members and patients, and believe in our mission. This makes IT delivery that much easier.
What should our core audience of CIOs and CMIOs be thinking when they hear about your organization’s story?
Bakshandeh: For me, it relates to something I say every time I explain the command center, and that is that you have to make your member touch count, because it might be the only member touch you make all year. So you have to use it to maximize your member’s health, your regulatory compliance, and your financial operations, and the only way to do that is through really excellent use of data and analytics.
Matsumoto: And you could take two different operators and give them the same data set—at the end of the day, if you give them data daily and it’s comprehensive and timely, but if they don’t do something with it, it won’t matter. One of the reasons that we’re driving to five stars in medication adherence now when we weren’t a year ago, is that our pharmacist executive Ali Farrokhroo and his entire staff do real-time outreach to make sure that patients are med-adherent based on daily pharmacy data.