At the Cleveland HIT Summit, MetroHealth Leaders Share the Secrets of their ACO Success

March 22, 2019
Drs. Nabil Chehade and David Kaelber shared with their Cleveland Health IT Summit audience some of the secrets to their organization’s exceptional success in care delivery under value-based contracts

The journey into value-based payment and care delivery is a long one, but, more and more, the leaders of pioneering patient care organizations are sharing their success stories, as they participate in a wide variety of accountable care organization (ACO) and other value-based arrangements. Among those doing so are the leaders at the four-hospital MetroHealth, the Cleveland-based integrated health system that is Cuyahoga County’s public health system, and which has a payer mix that is 38 percent Medicaid and 7 percent uninsured, and yet which has been able to attain a 4.1-percent operating margin.

And, in that regard, two senior MetroHealth leaders shared their success story with healthcare leaders attending the Health IT Summit in Cleveland, on Wednesday, under the title, “MetroHealth’s Road to Success: The IT Approach for One of 30 Successful National MSSPs,” referencing the Medicare Shared Savings Program (MSSP) in which the integrated system has participated for more than five years now.

Nabil Chehade, M.D., senior vice president, population health, and David Kaelber, M.D., chief medical information officer, are among the senior executives who have helped lead their colleagues at MetroHealth forward into ACO and value-based contracting success.

The work that Drs. Chehade and Kaelber and their colleagues at MetroHealth have been pursuing has evolved forward over several years; in fact, the physician executives told their audience on Wednesday, it hasn’t all been smooth sailing. But, fortunately, they and their colleagues learned quickly how to succeed in value-based payment arrangements.

Dr. Chehade recited some statistics at the outset of the presentation, with regard to MetroHealth’s MSSP performance over the past several years. “In the first year, 2014,” he noted, “we overspent by 2.1 percent. In the second year, we came under, by 1.7 percent, still didn’t achieve any savings. 2016, we came under by 8.1 percent. And in 2017, when we moved from one-sided to two-sided risk, we were 10.2 percent below our benchmark. This is actually working against ourselves,” in terms of inpatient hospital revenues, he added. Meanwhile, in one commercial risk-based contract that MetroHealth is involved in, which is actually with Cuyahoga County on behalf of its employees, “We were able to stay at 7.36 percent below the established benchmark in 2017, and shared half of that savings with the county,” Chehade said.

In addition, Chehade told the audience, “We have about 100,000 attributed patients in the Ohio Comprehensive Primary care (CPC) Program,” a Medicaid managed care program. And, in that program, he reported, “We were at $285 per member per month” in member costs when “the official results just came out, and there was only one provider lower than us in cost in the state, and that was a very small physician group.” That program’s measures include service and access, efficiency, clinical quality, and total cost of care.

Looking at the results of both the MSSP and the Medicaid Ohio CPC Program, Chehade said, “We’ve got to be doing something consistent. We’re not just doing things for one patient population,” he underscored. “We’ve put processes in place that we can take from one population to another. We built a robust infrastructure, including a Population health Innovation Institute, focused on results,” and which has about 140 people working in it.

“Our journey to value-based has been a long journey,” Chehade said. “Now, 66 percent of all unique patients are in a value-based contract—that was last year. Now we’re at 75 percent. Not all are in two-sided risk; our Medicaid contracting is 100-percent value-based. But it is a journey. And our EHR and analytics are a foundation for success.”

Speaking of the success that they’ve achieved, Dr. Kaelber told the audience that, in order to succeed in risk-based contracting, “You have to think differently. In value-based contracting, the payer knows how sick the patient is. CMS [the federal Centers for Medicare and Medicaid Services] knows that. That’s how the payer knows how to risk-stratify. And the physicians always say, ‘My patients are sicker than anybody else’s!’ But the only way we know anything like that is by appropriately coding for payers. So we started a disease registry, to make sure that all the patient’s diseases were registered. One weird thing about how this works is that a disease only counts when it’s billed as a code within the same calendar year,” he said, noting that such “small” details can end up being critical to success for the leaders of patient care organizations as they pursue value-based contracting.

With regard to the intersection of process change and data and information technology, Kaelber said, “Analytics and dashboards are very important. And one of the keys to this is transparency. Everybody on the team and in the system can see all the metrics.” And he shared with the audience examples of a provider-specific dashboard, noting that, through the transparent sharing of such data in dashboards, “Physicians can look at all the important quality parameters in the MSSP, and can also look at anybody else’s statistics as well. That makes everyone competitive,” he emphasized. “So collecting data and sharing data with transparency, are a key” to success. In addition, he noted, “Another thing we do is that all the quality measures in MSSP have some sort of health maintenance quality reminder, and we show those to physicians, and put them in the personal health record, and we mail or text or call” patients to make sure they show up for appointments that help manage their care and support their health status.

In terms of continuously moving forward in this journey, Chehade said, “We need to get to visuals and understand who’s doing what. So now we’ve taken it to the next level. This is about integrating your claims data and co-mingling it with your EHR data. We finally came up with the cost and utilization dashboard, which summarizes organizational performance or particular metrics with specific populations of patients,” he noted. That dashboard is “based on Tableau, as delivered and maintained by Epic”—the Epic Systems Corporation EHR, the unified EHR for the system,” and which “allows us to standardize the data. It incorporates received claims data from payers to show full 360-degree utilization (MetroHealth and non-MetroHealth providers). It presents data in industry standard metrics like PMPM costs, 30-day readmission rates, and clinic visits per 1,000 patients,” he added.

Chehade and Kaelber walked the audience through a number of examples of the process, analytics, and performance improvement work that they and their colleagues have been engaging in for the past several years. And, speaking of the IT aspects of the overall venture, Kaelber said that, “From a technology standpoint, we are at a stage in our evolution that we’ve done the standard stuff. We got the data, got our quality processes in place; we’re not perfect by any stretch of the imagination. But we are in the process of reinventing ourselves; we call it population health 2.0; and that means truly moving into the social determinants of health.”

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