Helping independent practices remain successful Insight Article - November 8, 2018 Population Health Value-Based Operations Sign in to save Jaan Sidorov MD Sanjay Seth MD Over the past six years, many physician-owned practices across the country have reluctantly chosen to be acquired in favor of health system ownership that alleviates administrative burden by providing access to integrated systems, resources and influence. A recent study conducted by Avalere Health for the nonprofit Physician Advocacy Institute illustrated this trend: “… hospitals nabbed 5,000 physician practices and employed 14,000 physicians between July 2015 and July 2016, an 11% uptick … Since 2012, that's a 100% increase in hospital-owned physician practices.” Despite the increased market pressure to be acquired, many physicians, particularly high-performing ones, have felt compelled to remain independent to better serve the health of their communities — and they are maintaining their independence in creative ways. In one example, physician-owned practices throughout central and southeastern Pennsylvania are collaborating to simulate the strength of an integrated delivery network. With the help of the Care Centered Collaborative at the Pennsylvania Medical Society, this group of practices is negotiating value-based contracts with payers through a statewide buying group program that includes population health analytics software, a care management platform and case management services. The Care Centered Collaborative was established in 2016 by the Pennsylvania Medical Society to support independent physician practices. The collaborative backs practices with a support system as it works to succeed under value-based care and deliver value to patients, communities and the larger healthcare ecosystem. The collaborative’s technology and services — not affordable for most small, independent physicians to individually license — give Pennsylvania practices insights that improve performance and patient outcomes. Above and beyond support for their patients, the collaborative’s program also helps independent practices deliver the elements of the Triple Aim within their practices, contributing to the success of the collaborative’s program for independent providers under value-based contracts. Second-generation contracts prioritize quality measures Pennsylvania physicians have witnessed notable interest in first-generation (or off-the-shelf) contracts from providers and payers. Early success has led to what are referred to as second-generation custom contracts. For example, a typical provider currently reports value-based measures across 10 to 15 variables in the first wave of contracting. Second-generation contracts, currently less common, would extend deeper into specific patient outcomes and higher quality results across fewer measures. The journey toward second-generation contracts is advantageous for small, independent practices because it allows them to become informed on measures that deliver a higher likelihood of value-based incentive achievement for their specific expertise and patient populations. Second-generation contracts ensure that the measures selected are those that physicians need to best serve their community and thrive under value-based care. Even with an informative journey, success with second-generation contracts requires a meaningful layer of insight alongside longitudinal patient information. Here is a common scenario that single practitioners are often unable to answer but may need to address under second-generation value-based contracts: Show a list of all patients with Type 2 diabetes who reside within a specific ZIP code Of these patients, identify those who visited the emergency department in the past year For the emergency visits, compile a list of medications the patients are currently taking From the medication list, combined with the data in the longitudinal record, determine which patients need an office visit or case manager follow-up or perhaps a review of their medication as the body mass index or HbA1c has not changed in four months. Deeper insights trigger proactive care Independent physicians are held more accountable under second-generation contracts. This evolution in the value-based journey makes the combination of case management outreach and population health analytics software an essential tool to efficiently identify opportunities and help physicians deliver proactive care in independent practices. For example, population health software provides a list of patients who haven’t had a mammogram, vaccine or annual checkup in the past year based on practice and claims data. This information can inform a nurse, case manager or other health professional to proactively reach out to patients, thereby enabling a new approach to care. Without these insights, nurses would have to access the health record directly per individual while physicians would continue to repeat patient questions to check boxes within the EHR. Patients may have had the necessary test done, but results from years past may be buried in the EHR or other systems. Hurdles to overcome Despite short-term quality improvements, manifesting a value-based care model hasn’t come without challenges. Multiple, disparate physician-practice EHRs presented the biggest challenge faced by the collaborative. A dedicated team of physician leaders works with private, independent practices across the state to navigate data sharing and interoperability issues. As an example, one of the collaborative’s participating groups is a large cluster of independent pediatric practices including neonatology, pediatric neurology, endocrinology and other pediatric specialties. This group of pediatric practices has 23 different EHRs implemented across 160 providers. In addition to disparate EHRs, challenges with measurement, statistical significance and lingering ways of working from a check-the-box, pay-for-service model have been difficult to navigate for the collaborative’s participating members. However, the upsides for participation keep enrollment and physician engagement on the rise. Opportunities outweigh challenges In the past, physicians working outside an integrated delivery network (IDN) risked their financial stability for autonomy. Access to advanced information technology and additional human resources for proactive case management remained beyond their budgetary reach. As part of the collaborative, Pennsylvania’s independent physicians continue practicing with the same level of self-government as before, but with all the population health analytics advantages of an IDN or a clinically integrated network (CIN). Participating physicians don’t necessarily have easier quality reporting under their value-based contracts, but quality reports are more meaningful. The technology helps independent practices: Prioritize quality measures Conduct targeted patient care for value-based programs Improve the health of their patient populations Maximize incentive reimbursement under value-based contracts Aligned but not consolidated, as was the case with the pediatric physician group mentioned above, these 160 providers submitted data — including claims and clinical information across 23 different EHRs over two years — to the collaborative’s population health platform. Data analysis is underway to identify important initial population factors: Patients at highest risk for emergency department visit, readmission or complications Redundant and unnecessary medical care being delivered, such as duplication of tests Targeted areas, ZIP codes or even neighborhoods with high incidence of specific pediatric disease for targeted programs or interventions The next step for the collaborative’s work with these independent pediatric physicians is case management or care coordination support. Effective healthcare is a never-ending cycle that includes treatment, monitoring, healing and improvement, which eventually generate incentivized reimbursement under value-based care. But most private physicians lack the time or human resources to effectively track every patient. The collaborative’s case management services and professional care managers extend the reach of private physicians beyond the 20- or 30-minute visit or the four-day inpatient stay. They ensure ongoing follow-up and care management of every patient, especially those at highest risk. High performance and health outcomes The collaborative’s performance during the first two years demonstrates the ability of comprehensive population health solutions — including analytics combined with case management services — used by independent physician practices to help successfully negotiate and thrive under second-generation contracts. High-performing practices have shown the ability to do well under this model while maintaining high levels of quality care.