Population Health and the Analytics Opportunity
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A decade ago, Adventist started working with InforMed Healthcare Solutions, since acquired by Conifer Health Solutions, to use InforMed's set of data warehouse tools to improve its health plan design and determine where interventions were needed, Robertson says. Adventist and InforMed worked collaboratively to develop those tools and restructure the Adventist workflow to ramp up the effectiveness of the population health program.
As a result of population analytics, as well as other measures such as discouraging tobacco use and encouraging use of generic drugs, the inflation rate of Adventist's employee health plan cost over the past nine years was half the national average, Robertson says.
A key development in the population health initiative came in 2005, when Adventist created personal health nurses as part of a pilot patient-centered medical home to work with the approximately 360 high-risk members of Adventist's 6,600 employee-based covered lives identified by the InforMed data tools, Robertson says.
In a pilot, Adventist selected 27 of 50 high-risk patients (54%) and was able to move them out of the high-risk pool into moderate or low-risk pools, and it achieved a 35% reduction in the cost of care for that population, he says.
According to Adventist, the pilot project that achieved the 35% reduction did reduce health plan costs by $381,000 among the 27 patients who moved from the high-risk pool. The amount expended to achieve this 35% reduction was only $31,000, so every dollar spent returned approximately $12 in savings.
"It was actually so dramatic that it brought the inflation rate on our health plan to zero in that year," Robertson says. "We were pretty pleased with that." Overall, Adventist has saved "tens of millions of dollars" due to employee population health analytics to reshape the program and services for employees, he says.
Adventist then expanded this pilot PCMH to 5% of its employees (roughly 360 people), and continues to see the same kind of positive outcomes, Robertson says. Nurses make up the majority of InforMed users.
Three years ago, Adventist created ACES, which stands for Ambulatory Care EHR Support, an initiative to move its ambulatory physicians to use electronic medical records to expand its capacity to do population-focused care. By the end of 2013, more than 400 physicians will be using the ACES system. "So much of the job is how you integrate care across physicians and across the delivery system," Robertson says. "When you have one person who's seeing 15 physicians, but each physician thinks they're the only one, you end up with different challenges than when you can see everything."
All physicians who are participating providers in the Adventist HealthCare employee health benefit plan have access to the InforMed tools and analytics. Only a limited number directly access the information because the personal health nurses provide most of the ongoing care management, with the physicians serving more as the team captains, Robertson says.
The next step for Adventist IT is to tie analytics with the employee EHR. "What we're morphing toward is linking all of this together with HIE infrastructure so that the information that is in the InforMed platform will be available in your EHR platform and vice versa through the information exchange," Robertson says.
Adventist also created financial incentives that help its physicians spend "all the time it takes" to manage high-risk patients, Robertson says. "With an ACO, you don't really get paid an incentive until you've been successful—at least after the first year you've demonstrated that things are working and that they're [generating] shared savings," he says. "So we're still in the process of sorting out how we'll make sure this infrastructure is utilized actively."
Detailing the financial incentives, Robertson says the primary care physicians who participate in the patient-centered medical homes receive additional compensation, such as a monthly retainer or hourly incentive to compensate them for the additional time that is necessary to care for the high-risk patients in the PCMH.
Recent headlines have highlighted some fallout from the Pioneer ACO program. Fifteen charter members dropped out of the program after finding inadequate return on investment or improvement from their ACO initiative. To Robertson, this just highlights the importance of population health analytics in achieving ACO success. Had Adventist focused on no-risk or low-risk populations, it might not have achieved nearly the cost savings it had with its own proof of concept by targeting the high-risk pool of its self-insured employee-based covered lives, he says.
Now Adventist is forming an ACO for Medicare populations based on this same set of tools to track high-risk members of those populations. As time goes on, commercial-payer populations are also in Adventist's sights. "We have a couple of pilots, like an apartment building that has a very large population of higher-risk individuals that we're providing those types of services to, and it's interesting to see when you focus on it what you achieve in terms of reduced consumption of healthcare services and increased health status," Robertson says.
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