Download integrating patients within the system of care

REPRINT December 2015
COVER STORY
Daniel J. Marino
William Faber
Meredith Duncan
healthcare financial management association hfma.or
g
patient access innovations
integrating patients within
the system of care
As the nation’s
healthcare system
continues to be reshaped
by the forces of reform,
increased patient
engagement will emerge
as a defining outcome
of this profound
transformation.
Provider coordination is of paramount importance for healthcare organizations preparing for
the industry’s shift in focus from volume to value.
The most ambitious coordination model that has
been developed to date is the clinically integrated
network (CIN)—a contractual collaboration
among hospitals, physicians, and other providers
to manage patients across the entire continuum of
care. A CIN uses population health management
tools, including care management techniques, to
build value through improving patient outcomes
and controlling costs. This innovative model
offers providers access to value-based payment
contracts and an opportunity to improve quality
and reduce costs.
Despite the compelling benefits of clinical
integration, this approach also poses risks.
Value-based payment contracts hold CIN
participants accountable for both clinical and
financial outcomes, although the ability to
influence these outcomes depends largely on
patient choice and patient compliance. Whenever
a patient leaves the CIN, even if the patient
returns to the network for certain services,
network providers lose the opportunity to fully
manage the patient’s care and utilization,
ultimately undercutting their ability to coordinate
the patient’s care and accrue the benefits of
improved clinical outcomes and reduced costs.
This risk makes it critically important for CINs to
keep patients within their organized systems of
care. CINs need to make sure patients can access
the network easily and are motivated to stay
connected, requiring a strategic focus on patient
access and engagement.
AT A GLANCE
Clinically integrated
networks seeking to
ensure in-network access
and strengthen patient
engagement should
adopt five strategic areas
of focus:
>> Extend access beyond
traditional models
>> Manage out-migration
>> Make it easy for
patients to stay in the
network
>> Build patient
engagement into
clinical care models
>> Explore innovative
methods to engage
patients
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COVER STORY
A PATIENT ACCESS AND ENGAGEMENT MODEL FOR CLINICALLY
INTEGRATED NETWORKS
Expand Access:
> Nontraditional
> Convenience
> Leverage
Mid-Level
Practitioners
Clinically
Integrated
Network
Boost Engagement:
> Education
> Technology
> Social Media
Minimize Leakage:
> Care Pathways
> Partnerships
> Narrow Networks
Source: The Camden Group
Based on the experiences of leading CINs,
strategies aimed at improving patient access tend
to be most effective when they are focused on
three primary objectives: expanding entry points
to the network, making access more convenient
and inexpensive, and keeping patients engaged in
the care they receive from network providers. The
following five strategies, in particular, have been
proven effective for ensuring in-network access
and strengthening patient engagement.
Extend Access Beyond Traditional Models
Traditionally, healthcare access has been
understood in terms of the patient-provider
relationship, with patient access usually defined
as a patient’s ability to schedule an appointment
with a physician or other healthcare service
provider. This definition continues to be prevalent because traditional fee-for-service reimbursement covers only face-to-face provider
encounters, and organizations have long seen
strong physician relationships as the key to
acquiring and retaining patients.
Health care also has seen the steady growth of new
access models built around nontraditional care
2 December 2015 healthcare financial management
delivery. Examples include urgent care centers
and, more recently, retail healthcare clinics.
Patients visit retail clinics because they provide
convenient access to services such as vaccinations, sports physicals, basic health screenings,
and simple lab tests. For more pressing medical
problems, urgent care centers provide a fast and
relatively inexpensive alternative to hospital
emergency departments (EDs).
Many CIN leaders see retail and urgent care
centers as a threat because of the potential for
these centers to siphon patients away from a CIN’s
organized system of care. However, this view is
shortsighted. CINs also have the option of adopting
these nontraditional delivery models, thereby
creating new access points to network providers.
Such a strategy provides three important benefits.
Better cost management. The urgent care and retail
clinic delivery models promote cost management
because they allow the network to address
patients’ low-acuity problems in a low-cost
setting. Patients with flu symptoms, sore throat,
or minor cuts, for example, can receive effective
care without using expensive physician or
hospital resources.
More comprehensive care management. CINs that
incorporate retail and urgent care can better
manage patients’ needs across the continuum of
care. Suppose an older patient goes to a retail
clinic for an infection and gets a prescription for
an antibiotic. If the clinic is linked to a CIN, the
patient’s primary care provider could follow up
directly with the patient to make sure the
prescription is working. The model also could be
used proactively. For example, hypertensive
patients could be directed to conveniently located
CIN retail clinics for their periodic blood
pressure check, promoting compliance while
allowing the network to monitor test results.
COVER STORY
Enhanced marketing opportunities. Greater
convenience and lower costs can be strong selling
points for a CIN. Nontraditional access is
especially important for appealing to patients
with high-deductible health plans, because
nontraditional settings provide certain kinds of
care at lower out-of-pocket expense. Because
patients bear most of these expenses until their
yearly deductibles are met, patients with
high-deductible plans tend to be focused on
costs and convenience.
For most CINs, the best way to leverage nontraditional access is to partner with existing providers.
For example, Providence Health recently announced a partnership with Walgreens to create
retail health clinics in up to 25 stores in Washington and Oregon. The clinics will be staffed by
advanced practice nurses and will be fully
integrated with Providence Health’s electronic
health records.
Retail clinic partnerships can be structured in
several ways. Typically, no money changes hands
between the CIN and the retail clinic organization, because the partnership represents an
opportunity for both parties to benefit from the
arrangement. However, a CIN could offer its retail
partner incentive payments based on performance. For example, the clinic could receive
bonus payments based on meeting patient
wait-time benchmarks.
When pursuing a nontraditional access strategy, a
CIN should take three steps.
First, it should educate patients on the availability
of nontraditional access and how they can benefit
from it. Patients should understand the available
care settings (e.g., retail clinic, urgent care
center, physician office, hospital ED) and how
each setting can help them optimize their health
and minimize their costs.
Second, CINs should establish robust data
sharing among network providers and nontraditional access points, with the objective of helping
primary care providers stay fully informed of the
services their patients have received at these
nontraditional points of care. Such data sharing
not only supports better coordination of care but
also helps primary care providers feel more
comfortable directing patients to retail and
urgent clinics when appropriate.
Third, CINs should pay attention to the attribution
model outlined in payer contracts. Typically,
insurance products that use an attribution model
assign global responsibility for the medical spend
and quality of care to the primary care provider that
the patient sees most often over a period of time.
Contracts often require primary care oversight of
retail or urgent care activities. One way to meet this
requirement is to appoint a CIN physician to act as
medical director for partner clinics. Aligning
clinical practice with the contractual attribution
methodology will ensure payment and help the CIN
manage care, quality, and costs.
Manage Out-Migration
Some level of patient out-migration is unavoidable in any healthcare network. However, a
CIN that is seeing an inordinately high outmigration of its patient population will have
diminished ability to manage care at the population level. Managing out-migration is particularly
important for high-risk and rising-risk patients,
for whom costs of care can be significant, because
the CIN must be able to coordinate care for such
patients exclusively within its network to manage
those costs effectively.
The first step is to determine where out-migrating
patients are accessing care. Claims data, by payer,
can help the CIN identify specific providers and
services that represent the bulk of leakage. With
an understanding of why patients are leaving the
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COVER STORY
network for outside care and where they are
going, a CIN can use three strategies to address
this challenge.
Proactively steer patients to in-network providers.
Effective care management processes can
reinforce patients’ perception of the CIN as the
appropriate setting for addressing their healthcare needs. For example, care management of
patients with high blood pressure should include
appropriate monitoring for kidney disease.
Detecting kidney disease early creates the
opportunity to refer patients to in-network
nephrologists.
Expand the network through new partnerships.
Strong patterns of out-migration to certain
specialties or providers may indicate the need for
the CIN to expand its offerings. For instance, if
a significant number of patients are using outof-network urologists, the CIN might want to
consider bringing new urology providers into its
network.
If a partnership with the out-of-network provider
preferred by the CIN’s patients is not feasible,
the CIN should at least pursue a data-sharing
agreement. For example, if patients with cancer
are leaving a network to receive treatment at an
academic medical center (AMC), an effective
strategy for the CIN might be to negotiate an
agreement with the AMC to exchange medical
records for these shared patients. This approach
may not help the CIN control the direct cost of
cancer services, but it will help the CIN’s providers deliver more coordinated care overall.
Negotiate narrow network contracts. Direct contracting with employers is emerging as a strong
option for CINs. Under narrow network contracts,
employees pay reduced fees for receiving care
from CIN providers. These contracts are another
means to influence costs and quality by steering
4 December 2015 healthcare financial management
patients to high-value providers within the
network.
Make It Easy for Patients
to Stay in the Network
Even with the rise of nontraditional access points,
physicians remain an important entry point for
patients who receive care from CINs. To make
accessing a physician appointment as simple as
possible for patients, CINs should focus on
optimizing the scheduling process, expanding
accessibility, and increasing capacity by using
mid-level providers.
Optimize the scheduling process. Top physician
organizations have developed convenient,
user-friendly scheduling systems that allow
patients to schedule appointments easily. These
organizations have well-designed appointment
reminder systems for keeping no-shows to an
absolute minimum, and use care coordinators to
follow up on diagnostic orders, specialist
referrals, and other recommended services. The
entire system is focused on helping patients to
receive the services they need in the appropriate
setting when they need them.
Expand accessibility. For many patients, appointment access is limited by traditional medical
office hours, commonly 9 a.m. to 4 p.m. CINs
should consider requiring providers, especially
primary care practices, to establish “open access”
scheduling and to expand hours that enable
same-day or next-day appointments. Practices
also can schedule some providers to be available
later in the day (for example, from 3 to 8 p.m.) to
accommodate patients’ work and school hours.
Increase capacity by using mid-level providers.
Practices patterned after the patient-centered
medical home (PCMH) model emphasize the use
of mid-level providers to handle routine services,
answer patient questions, provide follow-up
COVER STORY
services, and coordinate patient care. The PCMH
model improves patient access to care while
freeing physicians to focus on more complex
patients. It is important to communicate the
“value proposition” to both patients and physicians: Patients gain faster access to the provider
team; quality is maintained and potentially
increased; and costs are held down for both
patients and the system.
Build Engagement into Clinical Care
One often-overlooked opportunity to improve
patient access is to use clinical processes to foster
greater patient engagement. CINs can realize this
opportunity by developing comprehensive
clinical protocols and care pathways for common
diseases and services. For example, a CIN’s
clinical protocols for osteoporosis should specify
all recommended specialist consultations,
nutritional counseling, and guidelines for
medical treatment. The existence of comprehensive clinical protocols can promote better
outcomes by improving patient compliance and
enabling staff to proactively identify potential
complications and refer patients to the appropriate level of care. As with efforts to steer patients
to in-network providers, a strategy to promote
greater patient engagement can benefit from
comprehensive care management protocols.
Another way engagement can be built into clinical
care is to emphasize education early in the care
encounter. Typically, when a patient is hospitalized for an acute condition, staff provides
education and instructions immediately before
discharge. At this point, however, patients will
tend to be focused on getting out of the hospital
and heading home, and may not be fully alert to
the details in the instructions. Patients and
caregivers are more likely to absorb and act on
follow-up instructions if they are initially
provided during treatment and then reinforced at
discharge. Staff should talk with patients and
family members early in the hospitalization about
post-discharge care, potential medications, and
best sites for follow-up care. This approach
results in better compliance, which leads to
improved outcomes.
Explore Innovative Methods
to Engage Patients
Many leading CINs are working to develop patient
engagement strategies that involve the use of
emerging technologies. These organizations are
exploring how to use social media to build
stronger links with patients, among the following
approaches.
Use of smartphone apps to support patient selfmanagement and provider communication. Hundreds of apps are now available to help patients
manage their health. The most advanced apps
allow patients to share health information with
their caregivers. For example, an app recently
cleared by the U.S. Food and Drug Administration
(FDA) allows patients with arrhythmia to take
electrocardiogram readings using a smartphone
and an add-on device. A patient can then email
the results to his or her physician. An FDAcleared app for patients with asthma links to a
sensor device that tracks inhaler use. Patients can
share inhaler usage data with their providers, and
providers can monitor data remotely to detect
poor adherence or worsening conditions. These
types of apps can help CINs stay in touch with
patients and respond to potential problems early,
enabling timely interventions to improve
outcomes and control costs.
Use of social media to support connected patient
communities. A CIN in the eastern United States
recently created a Facebook page for patients with
a specific kind of cancer. Patients use the page to
share their experiences, encourage each other,
and ask questions. CIN staff monitor the discussion to answer patient questions and share
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COVER STORY
targeted educational information. Monitoring the
page also enables staff to identify patients who
may be experiencing emerging problems and
complications. CIN leaders report that the
initiative has been well-received by patients.
The strategy keeps patients engaged with their
care and with their network caregivers.
Use of claims data to predict health needs. Many
healthcare organizations have begun to analyze
claims data to identify patients at risk for poor
outcomes or high utilization. For example, claims
data might help identify patients with heart
failure who are at risk for hospitalization. More
specifically, an analytics program could detect a
pattern of patient age, medication consumption,
office visits, ED visits, diagnoses, and prior
hospitalization to predict the likelihood that a
patient with heart failure will be admitted within
the next 30 days if the care team does not
intervene.
The weakness of this approach is that it is
necessarily retrospective. However, leading CINs
are beginning to use “big data” analytics to get a
real-time view of patients’ health status. This
approach focuses on social determinants of
health. For example, a diabetic patient who
experiences a job loss might be less able to
control his or her disease due to stress or diet
changes. Data analytics tools that identify the job
loss event could help the CIN intervene proactively with special counseling and resources.
Such an approach moves beyond risk stratification: The CIN is able to segment patients, much
the same way that consumer goods companies
segment the market.
A Financial Imperative
CINs have compelling financial reasons to
optimize patient access. Cost reduction initiatives
inevitably target redundant utilization. Care
improvement efforts prioritize prevention over
highly reimbursed interventional services. Care
coordination activities add expense to the system
and simultaneously decrease utilization of
services for which systems are paid in a fee-forservice environment, making it incumbent on
CINs to seek and participate in payment methodologies that reward quality and cost effectiveness.
To make up for the loss of revenue from providing
redundant or unnecessary services, a CIN must
adopt a paradigm of expanding its patient base
by providing patient access that emphasizes
expanded entry points, patient convenience, cost
efficiency, and strong patient engagement. By
integrating patients within the organized system
of care, a CIN can influence patient behavior and
manage care and utilization, improving both
patient outcomes and the organization’s
bottom line. About the authors
Daniel J. Marino, MBA, MPH,
is executive vice president, GE
Healthcare Camden Group, Chicago,
and a member of HFMA’s First Illinois
Chapter (dmarino@thecamdengroup.
com).
William K. Faber, MD, MHCM,
is vice president, GE Healthcare
Camden Group, Chicago, and a
member of HFMA’s First Illinois Chapter
([email protected]).
Meredith D. Duncan, MPH,
is vice president, clinical integration and
accountable care, Seton Health Alliance,
Austin, Texas, and a member of HFMA’s
South Texas Chapter (mdduncan@
seton.org).
Reprinted from the December 2015 Early Edition of hfm magazine. Copyright 2015 by Healthcare Financial Management Association,
Three Westbrook Corporate Center, Suite 600, Westchester, IL 60154-5732. For more information, call 800-252-HFMA or visit hfma.org.