Market Report: Dallas’ Slow but Steady Push Toward a Value-Based Care Future

Nov. 9, 2017
Regional healthcare leaders are alert to the idea that leveraging IT at a high level will be crucial to helping them navigate their journeys into value-based healthcare

Editor’s note: To align with our Dallas Health IT Summit in December, Healthcare Informatics took a deep dive into the Dallas healthcare IT and value-based care markets, providing an update on how the region is progressing in these areas.

Everything is bigger in Texas” is an old saying that Texans like to use to describe their home state, and when it comes to healthcare, this phrase also rings true; various patient care leaders in this region point to the Dallas-Fort Worth area specifically as being one of the fastest growing markets in the U.S.

According to a 2016 “Texas Healthcare Market Review” from Allan Baumgarten, a Minneapolis-based independent analyst and consultant studying trends and organizations in local health markets, hospitals in the state are expanding through acquisitions, partnerships and adding new convenient care sites, and all of the area’s major systems are making large investments in new facilities. Indeed, Baumgarten’s report specifically noted, “Bolstered by strong profitability, Texas hospital systems are pursuing a variety of strategies to gain market share, including acquisitions, partnerships and new facilities. However, inpatient utilization is flat or increasing slowly in much of the state. Texas health insurers have added a million Medicaid and individual members in the past two years, but large losses by a few insurers broke a streak of strongly profitable years.”

One type of partnership that this Texas market report is referring to is payer-provider collaboration, when a health system and an insurance provider link up to work on population health management and value-based care initiatives. Interestingly, Baumgarten said in a prior report on Texas healthcare that in the Houston region, there’s more risk sharing between insurance plans and providers than in the Dallas area. Said Baumgarten, “The bottom line is, in Houston, I do think that because they’ve moved toward a fee-for-value type arrangement to a greater extent, that their revenues and income are more modest than in Dallas/Fort Worth. They’re just moving that way today.”

Leaders at major Texas healthcare systems that were interviewed for this piece do acknowledge that historically, the Dallas-Fort Worth region is not the most advanced when it comes to risk sharing agreements and payer-provider collaboration, but in a broad sense, trends in this area are not too unlike other pockets of the U.S. Luis Saldaña, M.D., chief medical informatics officer (CMIO) at the 29-hospital Texas Health Resources (THR), based in Arlington, Texas, says that the Southern/Texas market in general runs a bit behind the North and the Northeast in terms of the penetration of value-based care. But, Saldaña, who has been in a leadership role at THR for over a decade, does add that C-suite executives at the health system are “certainly shifting their mindsets to the value-based world.” He adds, “We are strengthening our alignments with physicians, which you’re seeing in general, and we’re partnering with independent physicians, as well as with some key local partners for various different arrangements that would facilitate delivering population health.”

Similarly, Pamela McNutt, CIO at the seven-hospital Methodist Health System, based in Dallas, notes that years ago, there was a push in the region for providers to dip their toes into population health-specific products, but the population health initiatives didn’t grow as expected in Dallas-Fort Worth. “If you asked me [about risk sharing] a few years ago, the answer would have been about installing systems, and practicing and preparing for our Medicare Shared Savings [accountable care organization] programs so that this big shift to population health would happen. Pundits were saying that by this time, the payment model was going to totally shift and that population health would primarily be the way we would get paid. But that has not been the case,” admits McNutt.

Pamela McNutt

As Saldaña alluded to, the Dallas-Fort Worth region isn’t alone in its lag when it comes to advancements in taking on risk. Depending on the source, statistics might differ, but 2016 research from Salt Lake City, Utah-based analytics vendor Health Catalyst found that about 62 percent of health systems surveyed have either zero or less than 10 percent of their care tied to the type of risk-based contracts identified by the Center for Medicare & Medicaid Services (CMS) as “value-based,” including Medicare ACOs and bundled payments.

Nevertheless, the year prior, the government announced a plan to tie 30 percent of traditional fee-for-service Medicare payments to quality or value through alternative payment models such as ACOs and bundled payments by 2016, and to tie 50 percent of payments to these models by the end of 2018.

But while CMS has said that these targets are on track, others disagree. Notes William Paiva, executive director at the Stillwater, Okla.-based Center for Health Systems Innovation at Oklahoma State University, when asked about the value-based care progress seen across the country, “Maybe about 10 percent of healthcare billings are running through some form of a value-based system and then the rest are still going through fee-for-service models. So we have been talking about it forever, but 90 percent of the market is still dominated by fee-for-service.”

Dallas-Area Healthcare Organizations Make Advances

Last May, THR and Aetna announced the creation of a jointly owned health plan company in which ownership and accountability would be shared equally between the provider and the insurer. The partnership was the first of its kind in North Texas to fully align the incentives and capabilities of a national insurer and major health system, according to officials at the time. The joint venture, called Texas Health Aetna, will primarily be focused on value and quality, notes Saldaña.

Indeed, as reported by D Healthcare Daily, in a meeting this summer among Texas Health Aetna senior leaders, Aetna’s vice president of consumer health and services, Gary Loveman, noted that the new venture focuses on improving population health and pushing value-based care. He added, according to the report, “For the first time, we have a unified set of initiatives [across different health organizations] that are based around improving health.” The new company’s CEO, Jeff Cook, also stated that his job is to be a liaison between the provider and the insurer and “to be more transparent about quality and cost of care.”

THR also recently teamed up with University of Texas Southwestern Medical Center in Dallas to form Southwestern Health Resources, a clinically integrated healthcare network that officials at the time said would not be a merger in its traditional sense, but rather a commitment to combine electronic record keeping and coordinate patient care across a team that includes 3,000 physicians and 27 hospitals throughout North Texas.

Both of these commitments from THR point to one overarching goal, says Saldaña: to ensure that the system serves the needs of the Dallas-Fort Worth healthcare market, which he says is one of the fastest growing markets in the country, adding that Texas has the highest uninsured rate of any U.S. state. “There is continued growth here. And the first thing is a need for foundational growth in our IT infrastructure to support the growing market,” he says. And regarding Southwestern Health Resources, Saldaña says since there is now data from UT Southwestern physicians who are also interfacing with THR systems, “We now have to look outside [our organization] to see where information flows happen and be sure that we facilitate that to support the work we’re doing to improve the health of this market.”

Honing in on Data

In his report, Baumgarten, who stated that “inpatient utilization is flat,” noted that providers face challenges in this area, such as being penalized for having too many patients be readmitted to the hospital. To combat this challenge, and many others that patient care organizations are currently facing as they shift to a value-based care environment, leveraging data and analytics has become a critical endeavor.

THR’s Reliable Care Blueprinting initiative is centered on “hardwiring” evidence-based best practices into the processes at all of its hospitals. The idea is to improve on how to deliver the best care for patients with sepsis, or how to avoid hospital-acquired conditions, for instance. As explained by Healthcare Informatics’ Senior Contributing Editor David Raths in a story this past February, the Reliable Care Blueprinting process first involves a design phase. The design teams are multidisciplinary and include physicians, front-line nursing staff, and pharmacists—everybody in the process is represented on the design team. After the deployment, there is a sustainment phase. “We have learned that once you have deployed something, often you have to go back and make adjustments. For sepsis, we might have new guidelines come out,” Joni Padden, nursing informatics specialist at THR, told Raths.

THR leaders then use tiered dashboards to track progress on metrics. “We have process measures to make sure the process is working as intended,” Padden explained to Raths, noting, “but we also have outcome measures that we are looking at. You have to make sure those are lining up.”

Padden said THR learned early on that it had to have an informaticist on the design teams. “With the EHR [electronic health record], we want to make sure we support the clinical practice these teams are designing and that we will be able to provide the different metrics they are looking at,” she added. So the design is done in tandem with the IT analyst work. Padden said to Raths that THR is already seeing impressive gains in some outcome measures. When its clinicians use the sepsis module and order set, THR is seeing a 4 percent reduction in sepsis mortality. When its clinicians use the catheter-associated urinary tract infection (CAUTI) workflow, it is seeing a greater than 15 percent reduction in CAUTI rates.

Progressing with Information Exchange

Beyond data analytics, regional health IT leaders are well aware that exchanging patient data with other health systems in the area is also necessary to improve the quality of care. In Texas, there are various HIEs that are functioning, with the Healthcare Access San Antonio (HASA) HIE announcing two years ago that it would be expanding to the Dallas-Fort Worth region.

Last September, THR went live on HASA, which connects the regions of North, South and West Texas. But Saldaña notes that THR actually has its own, self-developed HIE as well, but the challenge has been embedding it into the EHR workflow. “It has to be in that workflow for physicians to use it effectively. They can’t go outside the EHR workflow; they won’t do it,” he says.

Luis Saldaña, M.D.

Saldaña adds that THR has found that using Epic’s Care Everywhere platform, designed for interoperability, has actually been easiest for data exchange compared to any HIE. “We do feed into the state HIE, but we have found that using Care Everywhere and the work Epic has done with [Carequality] to tie in all of the data has been [efficient] for us,” he says, adding that it’s easier to work on this platform with local partners than it is to bring in national Veterans Affairs (VA) data, for instance. Saldaña’s colleague, Mary Beth Mitchell, R.N., chief nursing informatics officer at THR, agrees that sharing patient information, particularly around pediatrics, is made easier since the Dallas-Fort Worth area is largely on Epic. “We have two large pediatric organizations in the Dallas-Fort Worth area, Children’s on the Dallas side and Cook’s on the Fort Worth side, so being able to share those records is really helpful as patients move from one organization to another,” says Mitchell.

Meanwhile, Methodist’s McNutt points out that the HIE in the Dallas-Fort Worth region “stood up” back when there were incentives, as it was not sustainable. So at the moment, Methodist is not connected right now to any of the Texas HIEs. “We were an early connector in the one that started in the Dallas-Fort Worth region, but just two organizations actually ever joined it before it became unviable. The whole [process] is very expensive. However, in this market, because almost all of us are on Epic, and also because of direct messaging, and now  EpicCare Link (Epic’s web-based service that provides access to patient EHR data), we are exchanging thousands of records every day. This exchange is happening with non-Epic providers, too,” she says.

What Other Tech is Booming?

There are other ways in which regional leaders are leveraging health IT for better care, too. Many might correlate Texas with telehealth, but not because providers are so advanced with it; rather, the ability of telehealth companies to do business in the state has long been complicated. But lately, more hurdles are starting to be cleared, with Texas earlier this year becoming the 50th and final state to enable physicians to utilize telemedicine services with patients they haven’t met in person.

McNutt says that now rules and restrictions around telehealth “have become more relaxed,” providers are moving further forward in their advancements. “Many people [in this region] have a pocket of telehealth, such as tele-neurology in your ED, and what we are doing [at Methodist] is urgent care-type telehealth. But we’re just starting at a basic level,” says McNutt. Adds Saldaña, “You are seeing more applications for telehealth, and we know that is something that’s continuing to grow. Our ED group is doing work with patients that have been seen in the emergency room and trying to prevent bounce-backs by doing telehealth visits post-ED discharge, so we can identify if there are issues that can easily be fixed or addressed. We are seeing lots of innovation in telehealth,” he says.

Saldaña also feels that health innovation trends in the region will likely mirror consumer trends, pointing to voice interfaces as one example, something he believes will be a “satisfier for physicians” while also seeing them becoming usable in the EHR, and in supporting the patient experience. He does note there is “nothing magic in the Dallas-Fort Worth market,” but that “there are lots of startups in the area, and THR is always on the lookout for such partnerships.” He opines, “[Partnerships] help manage the risk that comes with your innovation. And they help leverage different parties’ strengths. So you may have a startup that doesn’t have the scale, so how can we support that?”

In the end, Saldaña and others interviewed for this story are in agreement that as much as anything, they need to be focused on process innovation internally so that they’re more efficient and effective—something that has become imperative organization-wide as they move into value-based care healthcare models.