On Tuesday, April 18 at HIMSS23, being held at the McCormick Place Convention Center in Chicago, a senior leader at the Phoenix-based Banner Health shared with the audience at an educational session some of what has been learned so far in Banner’s long, sustained journey into value. Jen Brooks, R.N., is vice president, population health, value-based care and administrative services, at the Phoenix-based Banner Health, which encompasses 33 hospitals, more than 500 physician practices, 25 health plans, three labs, and two health information exchanges and state registries, and which manages about 1.2 million lives in its clinically integrated network. She was joined onstage by Brian Silverstein, M.D., chief population health officer at the San Francisco-based Innovaccer; he and his firm have been partners in supporting Banner Health’s ongoing data analytics journey around population health management under value-based contracts. They spoke on the topic “Accelerating Value-Based Care Transformation With a Unified Data Model.”
After presenting the broad context of population health management and value-based contracting, Brooks and Silverstein discussed the manifold challenges that the Banner organization’s leaders have been working on for well over a decade now, and the lessons that have been learned so far.
With regard to how an organization can succeed under value-based contracts, Silverstein made the point that, “When you think about population health, it really is a different infrastructure than in fee-for-service healthcare. In fee-for-service medicine, it’s all around the visit. When a service is delivered, the payment is essentially the same. Meanwhile, population health really is about thinking about care beyond what happens in a traditional care setting, and the payment is a reinforcing mechanism. And to be successful, you have to have a different infrastructure.”
“One of the main elements in the traditional fee-for-service infrastructure is the RVU model for physician payment,” Books said. “When you start to focus on population health, that RVU model just doesn’t translate. You have to go on a journey to say, hey, we’re going to have to double down on this. And, spoiler alert, it doesn’t happen in a month. So, we need to build the infrastructure.”
“We’re on this journey to value-based care delivery and are nearly two decades in,” Silverstein noted. “But the fee-for-service system is based around transactions, and when you’re organized around transactions, everything’s disconnected. So you have all these different issues in why you can’t see what’s happening comprehensively.”
Challenges with EHR-based data analytics
When speaking of the challenges inherent in patient care organizations’ reliance on data in the electronic health record/electronic medical record, Brooks said, “The reality is that things are happening outside your EMR that you’re not seeing, and that leads to a tougher conversation than you might expect. Doctors saying, it doesn’t exist in the EMR, therefore, it’s not real. So you have to integrate” data and information systems. In our particular market, most people don’t realize that over 70 percent of care is delivered outside of our traditional delivery infrastructure.”
“And that is one of the core problems,” Silverstein said. The lack of connectedness, of integration, “creates frustration and tension. We’re trying to do our best taking care of patients, but the information they’re seeing represents just a fraction of what’s going on. That creates frustration and leads to burnout among physicians and providers, and dissatisfaction among patients.”
In that context, Brooks noted, she and her colleagues came up with the concept of an abstract patient, whom they named “Sophia,” with the goal of attempting to understand what patients want and need. “Starting out on this journey” into population health management, she said, “we found that patients too often are asked to be the deliverer of information. Oftentimes, as the patient or family member, you’re the one communicating between specialists and primary care and doing the coordination. We wanted to take that burden off Sophia.”
“At the end of the day, “Silverstein said, “We’re thinking about how we can actually take better care of patients. Digitizing care is one element, but it can also create problems of its own. There’s a lot of talk about ChatGPT and AI [artificial intelligence], but we need to make sure we are generating and using the right information, and using it correctly. How can you actually make things happen?” he asked.
“Not easily!” Brooks immediately responded. “You need the right partners. We’ve been on this journey for a while. I will openly say we failed a lot, early on, made a lot of mistakes. Understand where your docs are and where your opportunities are. It is not a one-sized model for everyone.”
“When you’re doing something that hasn’t been done before or isn’t easy, there are going to be failures,” Silverstein emphasized. “And when you think about digital health, it really requires so many different systems to be connected, and components put together. We see this in the consumer world, with targeted ads and loyalty programs. However, in healthcare, we haven’t built that infrastructure. You need a layer of engagement and intelligence and infrastructure, all three. We don’t know today all the different components; we don’t have that comprehensive view. Each of these systems have been siloed.”
What the EHR isn’t giving patient care leaders
“I’m a young-enough nurse that I’ve never given a medication without barcodes. And I can take a history with a patient while documenting,” Brooks said. But, she added, “I’m also old enough to know that ever since I started this career, I’ve been trying to solve for what the EHR doesn’t give me. As Brian mentioned earlier, the EHR doesn’t solve our problems. It was designed to capture information, but not to allow people to capture information from it. We’ve made a great amount of progress, but it’s starting from a foundation it wasn’t built to do.” Indeed, she said, “We’ve been trying to solve this [problem] since 2015. And we’ve implemented a couple of systems that have failed. One thing we learned is that if you don’t have that core of a platform that can actually aggregate and normalize, the downstream widgets and bells and whistles are only going to be as good as what can be pulled out. We discovered that none of the information flowing downstream was not accurate. It has to be accurate. And we knew if we could get information there and people could trust it, it would drive our ability to better care for our patients.”
Indeed, Silverstein said, “ That’s an absolutely core issue—accurate data elements. What’s interesting also is that every health system is facing the core issue of having the EHR as their core information system. “
There are substrata of issues involved as well. “I am very open to say, as an operator” of clinical information systems, Brooks said, “it is exhausting having to continually fund vendors to talk to each other. And what we really want is, let’s please figure out how to take the cost and burden off the end-users. Your system does me no good if it doesn’t connect to others. How do we do better than that? How do we get to a better state? It’s going to require all of us to work in a different way.”
Architecting and implementing provider-based health plans
Getting into the business of managing care through its own health plans has involved a process of continuous learning, Brooks told the audience, and one that was painful and difficult early on. Indeed, she said, “We had operating losses all the way through 2019. Our original population of Medicare Advantage lives was an extremely well-managed population, all in tightly integrated primary care networks. Going from that to a not-well-controlled population coming on and off Medicaid plans every month—you need a very different infrastructure. We’ve had growing pains through it all, but have learned through it all.”
Steps along the way
Per Banner Health’s ongoing progress in value-based contracting, Brooks noted that “We now run three different MSSP ACOs,” referring to the Medicare Shared Savings Program, “and are Track 3+ in all three. So how do we take what we’ve learned, managing a Medicaid population well, how do you put all of that together and move into that population health stage of the work, which is where we’re at today? When someone comes into our primary care clinic, and they’re a Banner member aligned to our network? Should our providers care for the differently? No. But how do we care for that patient and population in a way that helps us be successful? We’re not perfect at it, but we’re scaling for population health in a meaningful way. The next step is to become a truly integrated system. We’re not a Kaiser, and that’s not our goal. But we want to deliver a consistent Banner experience.”
Indeed, Silverstein noted, “One of the biggest challenges everyone grapples with is that, ideally, everyone is managed or treated the same. However, the reality that exists today is that people have different insurance products, and therefore, they have different network options, different pharmacy options. So if they’re in a Banner product, they’ll have access to certain things; it’s not delivering care differently, it’s more options.”
Per that, Brooks said, the goal is always “more seamless, integrated care for Sophia.” And, she said, “If we can actually manage someone all the way through their life continuum. And we have this goal or idea, why not be a Banner member for life? You could start out in a commercial product and end your journey in an MA [Medicare Advantage] product. We’re excited for that opportunity, but it’s challenging us to think about how we create a product that people love. We’re just in the beginning stages of this journey, brining our payer and provider sides together, developing integrated CRM [customer relationship management]; but that’s the vision, a seamless, integrated journey for Sophia in all stages of her life.”
One element in achieving that goal, Brooks said, was the development of a tool called Patient 350, which she described as “our EMR for population health. Using Patient 350, we can look at all the different components for that particular member: you can see their history, including clinical and claims data, including hospitalization, immunizations, prescribed medications, allergies, vitals, problem list, recent visits, diagnosis, labs, surgical procedures, laboratory, and radiology. And one cool story that I can share is that our own employed medical group was having a hard time understanding why we should adopt this. They said, ‘We already use Cerner! Why should we look at anything else?’ But we were able to show the providers that within two clicks, the provider could see that the patient he had been caring for, for over ten years, was being prescribed a medication by a different provider he didn’t know about. And we was able to quickly discover that some of the patient’s issues related to that medication prescribed by a specialist the primary care physician didn’t know about. That’s why this was a good view and was different from the EHR view, and that’s OK.”
Good news on the analytics journey
And the good news in all this development of analytics, Brooks told the audience, is that, “Because we’ve spent the last three years building that foundation, I can see systematic improvement for every single patient that we manage. We are driving year-over-year quality improvement, consistently, in all our lines of business, are driving down the cost of care, year-over-year, consistently, and are supporting a robust community. And none of that would have been possible had we not laid down that foundation. And now we can start doing the cool stuff, going into the AI space and the predictive space. But you can’t jump there if you don’t lay the foundation first. We’ve learned that in our journey: invest in the infrastructure; build that first.”
Asked by an audience member what the top failures and successes along the way have been so far, Brooks answered, “We spent way too much time and energy trying to get providers to adopt the same metrics. We got lost in the noise for a while. The second lesson is that we held onto our EMR as our ‘solver’ for this space for way too long. I worked for another network for about two years and got recruited to come back to Banner. And they said, make it better or break it. So we broke it,” meaning that they rebuilt that capability. The absolute key in that regard, she told the audience, is, “Just force yourself to make something work or not. We were trying to make the EMR work as the foundation, for seven years, and finally had to ‘break’ it. The biggest success? Stay nimble enough to adjust. We knew we had a plethora of information, but we were struggling to get to it. I wanted a platform that would allow me to be nimble enough.”
