Making Major Inroads in the Care Management of High-Needs Populations, at L.A. Care Health Plan

L.A. Care Health Plan, a health plan with 2.1 million members, 1.9 million of whom are MediCal (the California Medicaid program) recipients, is based in downtown Los Angeles. Founded 20 years ago in 1997, L.A. Care Health Plan has been moving forward to optimize care management for its MediCal members, particularly those with complex needs and challenging living circumstances. The plan’s chief medical information executive, Katrina Miller, M.D., has been with the organization for two years. Dr. Miller is boarded in both family medicine and in clinical informatics, and continues to practice occasionally, in free-clinic settings.

On May 2, at the World Health Care Congress, held at the Marriott Wardman Park Hotel in Washington, D.C., Dr. Miller and Frances Martini, R.N., director of integrated population health at BlueCare, the Medicaid division of the Chattanooga-based Blue Cross Blue Shield of Tennessee, presented a session entitled, “Consumer-Centric Care: Member Engagement and Retention Strategies for Complex Populations,” as part of the Medicaid & Health Policy Summit and Behavioral Health Summit tracks, at the Congress. Healthcare Informatics Editor-in-Chief Mark Hagland caught up with Ms. Martini last month; and below are excerpts from his recent interview with Dr. Miller.

The kinds of progress that you and your colleagues have been making at L.A. Care Health Plan really speak to the general direction in which the U.S. healthcare system is beginning to move more generally, around data-facilitated population health management and care management, don’t you think?

Yes. What we need to do for the future of any sort of efficient healthcare delivery to be able to exist, we need to care for the entire population. And in terms of the health plan and care coordination side, we need to be the most efficient and effective stewards of the public money. We also need to be running at the most optimized levels, including through technology, that we can, based on our understanding of the need to use resources most efficiently. And you were mentioning the high-cost, high-needs population. And we have to understand really what that population needs as a whole, and the unique categories within that population, so we can be most efficient in getting them the care and services that they need. And it comes down to people, processes, and technology.

We have to use the technology and data to identify those folks and present them to the care coordination staff, and make sure they have an efficient process, with good handoffs, good documentation, and make sure we have the right number of people to provide the services needed. At L.A. Care, we’re trying for a high-tech, high-touch model. So we have to understand who needs what kind of direct care—medical, social worker, dietician, etc., and identify that as precisely as possible to make sure they’re interacted in the way they need to be interacted with. For instance, we have behavioral health members who yell at us and say to get away, when they really need shoes. And we need to understand where they need the help, not what we think their needs are.

And, once you’ve used data and analytics processes to identify members in need of immediate and near-term intervention, there is actually an element of “shoe-leather” work, in terms of making direct in-person connections with those members in need, correct?

Yes, we first have to identify the whole population, to address the lower-needs populations, to make sure they have access to preventive and primary care, so that we can then also focus on the higher-needs populations. So we stratify into a complex case management program, and a behavioral health program, a social work program, and a disease management program; we have a variety of programs in order to place the right members into the right programs. And we have to prioritize to make sure they’re in the right first program. So if they have complex needs, we put them into the complex care program rather than the disease management program, because they’re covered. And we need to connect them with their PCP [primary care physician], and with our internal people. And we do that through our interdisciplinary care team; we do calls to make sure we’re on the same page. And we’re working with the County on a program called Whole Person Care—it was granted last year, and the actual program hasn’t gone live yet, it should start in July, next month, for the first enrollees. That’s going to be about social services connections with community health workers. It goes beyond L.A. Care, it’s going to be the community—L.A. Care, with our competitor plan, HealthNet, and the County Department of Health Services, and then the jail program, so when folks are getting out of jail, and the Department of Mental Health Services, etc.; it involves ten sub-programs in four areas, addressing the social-services needs in the county.

What has been most challenging and surprising in drilling down to these levels of care?

That’s a big question. I’ve been at L.A. Care for two years now. And I completely respect the folks here who understand my role as a clinician with a good understanding of informatics. And the fact that I’ve just been here two years means that I’ve seen the fact that the organization still has a long way to go in terms of optimizing some things. But the great thing is that in the last couple of years, we really have started to coordinated well, in order to achieve impact. And probably the most surprising thing to me has been that culture change challenge. And a lot of work has gone on here to encourage and support the folks who have been here for more than ten years, to say, you are still needed here, we need your expertise, especially in terms of connecting directly with members, but we do need to change some processes; and guide then through that transition. As you know, culture will eat everything for breakfast. And it really is a challenge, and takes a long time, and even with our leadership, we’ve needed to work on culture change. But things are really moving forward.

What should your fellow CMIOs know about their roles in all of this work?

Actually, when I sit with other CMIOs, I sit there and listen like a sponge to learn from them. I feel like I’m very far behind so many other enterprises; that being said, I would reiterate the importance of an aligned culture supported by leadership. That’s especially true around expensive technological changes that take a lot of time and effort to implement, you’ve got to have senior leadership support. And that leads to a CMIO focusing strongly on what the leadership is focusing on; if the leadership leaves something to the side, you might as well leave that on the side, too. And the communication—internal and external communication, about what the plan is, what the strategy is, the goals, how we’ll reach those goals, and the training. So it’s all of the classic pieces of any type of implementation. And if you skip any of those steps, you’ll have disaster. In so many cases, we cut corners and cut time, and you end up having people come into contention. So really, you need to follow those steps.

Can you speak to some of the data and analytics needs that are being discovered, as you and your colleagues drill down further into this important work?

One thing that we already know is that we’re pretty far behind the eight-ball in some ways, around data and analytics. With L.A. Care being L.A. County, we have a myriad of sources and various ways we’re getting data into the door—ranging from EDI to 847 files, to Excel spreadsheets. And it can be a ridiculous process of data transfer. So we’re obviously starting to try to centralize the data process and make sure we’re using standardized processes whenever we can, and that can be a painful transition; and to make sure we have a more standardized process once we bring data into the door, per semantic layering… enterprise architect, glossary architect; we have a new CTO.

So L.A. Care has seen how important it is to make sure that the data we’re getting in is valid, and that we have an appropriate pathway from initial ingestion all the way through reporting needs. It’s a slow process to make it happen. I’m working more on data metrics and presentation. Obviously, when we end up seeing numbers that don’t make sense to us, we have to go in and investigate.

Can you provide an example of a typical challenge you face in that regard?

Yes, we work with different IPAs [independent practice associations—the most common type of physician organization in California, which has a state law barring direct employment of physicians], and have to represent the performance of those different IPAs. And it’s actually very difficult to identify the providers in those IPAs, and the IPAs within the IPAs—sometimes, you have umbrella IPAs with multiple IPAs within them; and we don’t have that consistently indicated within our system. So when it comes to performance, we have a challenge in correctly representing the performance of a particular group. So any changes, and of the providers working within that group, and making sure we keep that up to date, so that we’re always reflecting the performance of a particular group accurately.

Looking into the future, how do you see things evolving forward in the next two or three years?

I hope that we’ll have a more optimized healthcare delivery process, so the members can say they’re having an excellent member experience, and our staff can say they’re having an excellent work experience, and that interventions that reflect the pre- and post- changes, and are accurately measured, and that we do PDCA [plan-do-check-act] processes to continuously improve what we’re doing.