The Community Health Network (CHN) is an accountable care organization (ACO) that was formed three years ago as a participating ACO in the Medicare Shared Savings Program (MSSP) for ACOs. Community Health Network was created by a partnership of the four-hospital HealthEast Care System (including the HealthEast Clinics), the Entira Family Clinics, and independent medical specialists in Minnesota. It is located in St. Paul, Minnesota, and serves 14,000-15,000 patients through the MSSP program, while serving 300,000 patients and consumers in the greater St. Paul metro area in general. CHN’s leaders have been partnering with the Chicago-based Pharos Innovations, using one of that company’s core population health management solutions, in moving forward in its ACO work in the MSSP program, sponsored by the federal Centers for Medicare & Medicaid Services (CMS).
Tim Hernandez, M.D., CHN’s medical director, is a practicing family physician who practices three-quarters-time, and fulfills his CHN administrative duties as well. He spoke recently with HCI Editor-in-Chief Mark Hagland, regarding CHN’s progress so far. Below are excerpts from that interview.
How long have you been in medical practice, and how long an administrator?
I’ve been in practice for nearly 28 years, and I’ve been doing administrative work about 20 of those years.
When did the Community Health Network (CHN) officially join the MSSP program?
We jointed officially on January 1, 2013.
How many covered lives are involved?
It varies a bit, but it’s approximately 14,000-15,000.
And how many physicians are in Entira?
Around 63 physicians and another 14 mid-level providers.
What led you and your colleagues to choose Pharos Innovations as a vendor partner?
When we started our MSSP ACO, and started to get our data, we began to segment our populations into various segments by cost and claims, and then by medical conditions, and then we overlaid the two. It took a while to get a data dump, and then a while to begin to use analytics in a meaningful way. So the first quarter of 2013. And it became clear to us, and it’s pretty universal based on other conversations I’ve been a part of, that a small percentage of our patients were driving a large percentage of our cost. And so that’s when we stumbled on the ones that CMS is promoting in terms of cost reduction and clinical outcomes improvement: heart failure, diabetes, vascular disease, and COPD. So we said, what sorts of interventions can we do, particularly around patients with high acuity? That’s when we started interviewing various vendors to develop some higher-level stratification, and that’s when we were introduced to Pharos Innovations.
When did you go live with Pharos?
It was during February 2014.
What things have you learned so far on your organization’s journey?
Well, of course, that data is always at least a year behind; and when you get your reconciliation from CMS, it’s something like a year and a half behind. In fact, our first year, we didn’t get ours until August. And so our hospital system at HealthEast and medical staff here, were already doing a lot of work on readmissions. Our first year we saved about $1.4 million, but that wasn’t enough for shared savings. You have to hit a certain threshold of savings. And our threshold was 2.8 percent; we were like at about 2.4 percent, just below it. The second year, 2014, after the intervention, we saved about $5.5 million. We don’t have the 2015 results back yet. Our first year, our reconciliation for 2013 came about August 2014. Last year, it was about July 2015 for 2014. That’s one of the frustrating parts of being an ACO.
The reconciliation is the metrics that are shared with you by CMS, correct?
Yes, you get all the claims adjudicated, and they look at your threshold, your comparative groups, and then the other piece is that you need to hit a certain percentage of your quality metrics.
You obviously did achieve shared savings for the second year?
You’re allowed to share 50 percent, but the 50 percent is then weighted by your quality metrics. Fortunately, we’ve been doing well there. We were in the top 15 of 500 MSSPs from a quality standpoint; we hit 93 of the 33 quality measures, and then they take that and multiply it, and we got a little over $2.2 million in shared savings in the second year.
What were the clinical intervention breakthroughs that helped your organization achieve shared savings in the second year?
The most targeted intervention was using Tel-Assurance software. It’s a program set up to trigger a person, and then there are a number of protocols—Pharos had shared some of theirs with us, and we had some of our own. So once someone was highlighted as a potential admission or readmission. What our data has shown is that, using our own MSSP population as a control group, that patients enrolled in Pharos have significant reductions in admissions, in ED visits, and in readmissions.
To what do you attribute such progress?
Tel-Assurance is a software platform, and depending on what medical condition or conditions, there are different questions. It is patient-initiated, so that when a patient is enrolled in it, they have to call or do it online, but they have to somehow contact Tel-Assurance and answer certain questions. And if they don’t call, or let’s say they’re short of breath, or their blood sugars are very high or low, or they’ve gained weight, those are called variances, and if any variances occur, our RN case managers will call them. So it’s a very sophisticated trigger tool.
So that early intervention averts the worsening of situations, correct?
That’s the heart of it, but there are also some more nuanced elements. Of course, we’re dealing with the elderly, and sometimes, for those patients, simply having contact with people, even if it’s electronic, gives patients the sense that somebody’s there, somebody cares, and someone’s able to answer questions. That’s reassuring, and that probably keeps people out of the ED. Secondly, there are questions built in around frailty and around depression. It turns out that a plurality of patients—perhaps around 20 percent—with chronic illnesses, also have comorbid mental health conditions. So that’s a big part of it. And the third piece of it has to do with the way that hospitals are set up now. These days, most hospitals employ hospitalists, and most outpatient physicians work only in the outpatient arena. And even though we physicians talk with one another, there isn’t that continuity that there used to be when we all went to the hospital [and did daily rounding. And this program has really engaged our ambulatory physicians from both HealthEast and Entira, much more closely with the work being done in the hospital.
Have you pursued any other forms of patient engagement yet, to date?
Both of our primary care groups are certified as healthcare homes in Minnesota, otherwise known as patient-centered medical homes. And we’ve invested a lot of time, energy, and money into patient resources. And their job is education but also motivational techniques and behavioral techniques. And a lot of patients who are the rising-risk patients—there’s a tremendous amount of resources put into interaction with them. And the beauty is that the RNs are excellent communicators and educators, and use a variety of different modalities. We haven’t used telehealth yet, but we will. And medication reconciliation is a huge thing; the amount of confusion that goes on is really big. It’s amazing the medication lists these folks are on: sometimes, 13, 15 drugs, and of course, there are drug-drug interactions. And they’re very disease-specific. So with heart failure, we spend a lot of time explaining the specifics of weight gain, and of sodium consumption, and encouraging them to weigh themselves daily, so that also is very important.
What have been the biggest learnings so far in all this, among you and your colleagues?
I think at a high level, the biggest learnings for physicians, including myself, are that population health tools are different from the tools we’re trained on. And the Tel-Assurance tool is a really good example of that. And it takes a while for people to understand that concept. So for example, heart failure was the first condition we focused on with Tel-Assurance, and a lot of physicians, including internists especially, were concerned that some patients might have too much fluid, called volume overload, versus CHF. And there was a lot of arguing about that, and what helped folks get over that was saying, maybe we shouldn’t be so focused on the specificity of diagnosis, but rather that being short of breath could trigger an ED visit, and by focusing on the risk, in terms of understanding the tool, that was important. Because that was a big hang-up for people.
And secondly, and this was not a big revelation, but the social determinants of health, like frailty, loneliness, and health literacy, are huge factors. And if you don’t figure out how to account for them, you’re not going to be able to improve outcomes and cost with these patients.
What should CIOs and CMIOs be thinking and doing right now, in all this?
I think that there are many, many ways of slicing and dicing data. And you have to be able to do it in a way that makes sense that allows you to develop sort of the proper drivers to help you to meet your goals. That includes incentives but also quality improvement and other factors. And you need to be thinking as you’re getting your data, what intentions do I have? There’s no use getting data on thigs you have no ability to impact. So being thoughtful ahead of time around how impactful you need to be—you need to do that ahead of time.
Is there anything you’d like to add?
You know, one of our benchmarks when we engaged Pharos and Tel-Assurance was, looking at patient satisfaction. And we measure it quarterly, and it’s consistently been at 90 percent or better, for patients in the program.
Do you feel optimistic about the results that you’ll get this summer, when you receive your next reconciliation from CMS?
I think you can get the low-hanging fruit. Our next step is, what is the next initiative? And not everybody signed up for Tel-Assurance. And so we’ve got a group who would benefit but have not agreed to do it. So we’re looking at other strategies to help both the high-acuity patients as well as the rising-risk patients.
