Clinically integrated networks (CINs) offer smaller physician groups and health systems the chance to remain independent while also participating in value-based care arrangements. In a recent interview, Anna Basevich, senior vice president of enterprise partnerships and customer enablement at data analytics platform company Arcadia, spoke about the evolution of CINs as well as the company’s work on a population health platform with the State of California to support the Cal-AIM Medicaid transformation effort.
Healthcare Innovation: I understand that at Arcadia you work with a lot of clinically integrated networks. Has the timing of their development aligned with the growth of the pay-for-performance and accountable care movement? Are we seeing more of them being created over time? Is it kind of a hot trend right now?
Basevich: I think it is a hot trend. We started to see this way back in the days of Meaningful Use when we started to realize that larger organizations were able and eager to make these IT investments. I was spending a lot of time working in rural primary care at the time and I talked to tons of physicians who said, ‘Look, I'm going retire before I put an EHR in here. I’m at the tail end of my career. But at the same time, you had a new generation of doctors entering the workforce, who expected to be doing everything on their laptops,. They would have thought that it was equally bizarre to pull a paper chart out of a file drawer.
What we started to see, particularly as the transition to value-based care started to kick in, was a really similar process where if you're a physician at a large health system, that health system is going to put the right infrastructure in place to make you successful. And that means data. It means somebody who's going to be dedicated to picking up the phone and calling patients and telling them why it's important for them to come in. And that's inevitably going to equip you to be more successful vs. if you are an individual provider who is picking up the phone in between patient visits and trying to return calls all on your own. They are not going to be able to make that investment.
Through the mid-2000s, we saw more and more organizations at different scales starting to make that investment — whether it was a 15- to 20- provider FQHC that was bringing on a care coordinator or investing more in other members of the care team in order to supplement the work that providers were doing. Or it was a large accountable care organization or whatever the title would have been at the time, saying, we're going to build out a quality improvement team that's going to coach our providers and we're going to make more IT investments.
We're now at a point where it's a given that payment is going to correspond to performance to some extent, and health systems are taking on greater levels of risk, and taking on responsibility for functions like care management, and in many cases utilization management and really getting into a position where they can win really big if they start to bend the cost curve. They're starting to understand the value of coming together so that they can collaborate to be more effective in group purchasing and negotiating with health plans and so on.
HCI: A lot of independent practices feel pressure to merge with larger health systems, but by banding together, do these clinically integrated networks offer an alternative?
Basevich: A lot of these groups have a strong history and presence in their community, and some don’t have particularly positive histories with the more dominant players in their region. But you see a lot of these small to mid-sized health systems getting pushed to the brink of saying I either have to go ahead and accept somebody else's logo on my door and get onto their EHR or I can start up my own collaborative of like-minded organizations and make the investments that I want to make in order to improve care and keep delivering the good quality of care that I want to deliver.
HCI: Do they generally develop a small centralized administrative and tech team to do coordination, support and the quality reporting?
Basevich: Some of these groups are building out their own patient outreach team centrally, where they will grab a list of patients, they'll make the investments to stratify those patients on everything ranging from how many care gaps they have to the overall complexity of care required. And they will start hitting the phones in a really structured and targeted and centralized manner. You will have plenty of other organizations that will say our role is more to equip the health systems and the practices and let them do their own thing. A lot of times it's a combination. An organization might say, you can do your own quality work if you want, but if we get into the middle of the year, and it starts to seem you're not pulling your weight, we're going to need to step in and help you out to make sure that across the CIN, we are going to be successful.
HCI: Would they also be doing the contract negotiations with payers?
Basevich: Absolutely, because that's one of the places where strength in numbers is so critical. As well as focusing on the technology investments. We have seen folks either making investments in getting everybody onto a centralized EHR system where they can control the workflow and configure the templates, as well as investment in tools like analytics, which are inherently stronger when you've got a larger set of health systems. You're getting more data into them and you have much better visibility into that population.
HCI: Have you seen examples of the importance of governance structures within the CIN itself so that people feel like their voice is heard and this is not just a top-down effort?
Basevich: I think it's especially critical in these situations. These groups are oftentimes banding together because there's a dominant player that they don't want to have to bend the knee to. Those are the spots where it's especially critical to ensure that everybody's getting a seat at the table and that organizations are really able to knowledge-share. For example, if they’ve made an investment in analytics tools and care management tools, there's an opportunity to share how it's going for them, what's working really well for them and what the challenges are. That’s one of the most important pieces for quality improvement— this technology doesn't operationalize itself. It can have a really huge impact if you put the right hands to the keyboard and that's one of the places where it can be incredibly helpful for health systems to learn from organizations like themselves.
HCI: We talked about the the issue of these CINS having multiple EHRs. Is that where solutions like Arcadia come in — wrangling that EHR data and then surfacing the actionable insights back to the clinical care teams?
Basevich: It's absolutely the case. Even when you look at organizations that are able to get everybody onto a single EHR, that's not your full data source anymore. When we look at the data that these organizations need to manage their populations, we’re looking at health plan data. A CIN based in New England might have patients spending time in Florida during the winter. They also get ADT data, which is just ringing the alarm bell to say, hey, the patient is in this hospital. This comes in lightning fast so you're able to respond a lot more quickly and engage that patient.
HCI: There’s a lot of talk about helping clinicians understand health-related social needs. Are we still in the very early stages of providing them access to that kind of data for use at the point of care?
Basevich: There have been a ton of really meaningful advances that a lot of organizations have made here. I think part of that is setting up appropriate templates like PRAPARE in their EHRs in order to capture this information in a structured manner. During COVID, one of the things that we saw and supported was organizations doing outreach to their patients. They would send a quick message from the primary care physician's office, saying we want to understand how we can best support you if you've had trouble affording food, housing or medication in the past 90 days, and you'd be willing to talk to one of our care navigators about it to see if that's something that we may be able to help you with. That information is so critical in so many ways. If you’re a provider who's working with a patient to develop a care plan, your team needs to know about transportation barriers and need to support them in getting to the appointment.
HCI: I recently interviewed Bob Sarkar who's with the Arkansas Health Network, who was telling me that they were the first clinically integrated network to achieve dual URAC accreditation for clinical integration and employer-based population health. What is the value of accreditation for clinical integration?
Basevich: I think that it's really interesting to see standards start to come out around clinical integration, because it's been the wild wild west, in part because there have been so many challenges to getting true interoperability rules off the ground and getting EHR vendors to make those a priority. I think that the standards are going to continue to evolve. And that's great because that positions health systems that are starting to make these really critical investments in understanding what they're actually getting, particularly as health systems are asked to take on a greater level of risk and consider patient care to a broader degree. You know, I'd love to be at a point where an EHR system doesn't count, so to speak until it's more interoperable, it's pulling in that broader set of data, and it’s equipping providers with some of that social determinants of health information.
HCI: I read in your bio that you're also leading the expansion of Arcadia’s footprint in the public sector, including working on Cal-AIM, the Medicaid transformation project in California. What are you working on in the Medicaid space and with Cal-AIM?
Basevich: We’ve operated in the Medicaid space for about as long as I can remember. One of one of my first engagements here was getting these tools out and adopted at Federally Qualified Health Centers. We work with Medicaid managed care plans extensively as well, in large part because Medicaid is an area where data aggregation is particularly critical because a lot of folks don't have continuous Medicaid coverage. We're seeing 10 million people come off coverage in the last couple of months due to re-determinations.
As you wind up in a place where patients are forced to get fragmented care, that data aggregation is critical to the latest person working with them.
One of the things that's incredibly exciting to me about Cal-AIM is that it's a program that's very focused on supporting the most vulnerable populations and equipping everybody around them to engage with them effectively. Data is a huge part of that. One of the things that Cal-AIM does is it looks beyond the last visit, the last lab result, and says: what does it mean for a patient to have diabetes and live in a food desert? And is that an opportunity to be talking about nutritional support? What does it mean for a patient to be recently incarcerated? And when you think about the transition that individual was going through. There are tremendous barriers to care there, and it shouldn't be incumbent on them to figure out how to get Medicaid coverage and do a lot of paperwork and then get themselves to a primary care physician's office. That's a spot where the system should be engaging them really directly.
That’s the work that we're doing with Cal-AIM. We are building out the data infrastructure behind that and helping pull together this broad set of not just traditional healthcare data, but also social determinants of health data and we’re also engaged in third-party agencies, community agencies, all the organizations that work with these patients, so that there's a really broad set of data about them, but also so that you're not relying on one care manager at the managed care plan to engage them.
HCI: Is Arcadia working with individual Medicaid managed care organizations or with the state itself?
Basevich: We're actually working directly with the state Department of Health Care Services as they are building out a population health platform that can inform the state in understanding population health and offer tools to manage care plans, to health systems, and even offer tools to engage members in order to help them navigate healthcare. We're partnering with a number of other organizations there as well, in order to pull together the next generation of tools. It's a very innovative program, and it's one that we're really excited about.
