‘The Future is Accountable Care,’ Population Health Management

March 04, 2016 - Effective population health management remains a key aspect of running a successful accountable care network. As part of a stronger population health management program, the primary care physician’s referral system must be efficient in order to ensure patient care remains well-coordinated among specialists, radiologists, and hospital staff.

One Accountable Care Network (ACN) called WellHealth Quality Care, has partnered with par8o, a referral management platform, in order to use a referral system within a patient-centered medical home setting managing the health of more than 17,000 members. The accountable care network offers a variety of different healthcare specialties including pediatrics, neurosurgery, primary care, and obstetrics, according to a company press release.

HealthPayerIntelligence.com sat down with Steve Keltie, President of Network Development and Marketing at WellHealth Quality Care, and Daniel Palestrant, MD, Founder and CEO of par8o, to hear more about how a successful referral system boosts population health management.

HealthPayerIntelligence.com: In what ways does a referral system enable you to improve the health of your patient population?

Steve Keltie: “Basically, par8o helps us get our patients and the members of the health plan that we serve into the appropriate specialists in a timely manner. That information is shared in real-time with the referring physician, which completes a well-coordinated experience for the patient. That leads to better adherence to care plans among other things.”

“If a patient has a better patient experience, they’re going to be more compliant with their treatment plans and more educated on the healthcare delivery system as a whole. They’re going to actually value their healthcare and these are areas that the industry has really struggled with.”

“Implementing par8o has helped us by bringing value to the patients and value to the doctors. Across the board, it makes a more efficient and engaged system, which clearly improves the quality of healthcare.”

HealthPayerIntelligence.com: How important is coordination and data sharing to population health management and accountable care?

Steve Keltie: “Coordination and data sharing, as we were talking about before, is everything. You can’t accomplish accountable care and you can’t accomplish a well-run system any longer without close coordination between all of the parties involved. I don’t mean just the patient and the primary care physician, but the specialists and the network and the payer group and the healthcare advocates.”

“Having all of these coordinated and actually working together in real-time and the data that backs all that up, is critical to our success. We can’t do what we need to do without that.”

“This is why years ago, our industry started implementing things that today we would call accountable care programs, but we could really just only scratch the surface. Medical stop loss facilities and TPAs and more sophisticated entities were putting narrow, high-performing, pay-for-performance type programs in place, but they were only doing it treatment type to treatment type and specialty to specialty.It was difficult to do it across the board and that’s because we didn’t have the data that allowed for good, close coordination. Now we do.”

Daniel Palestrant: “I think that what WellHealth is doing very effectively here is starting to get a community – in fact, a whole metropolitan area of the broader Las Vegas area – to stop acting like individual providers and start acting more and more like an Accountable Care Network. This is so there is a care delivery system so patients don’t fall through the cracks and there aren’t missed opportunities to provide the best possible care.”

“What I like to tell both my colleagues and patients, if you’ve got a patient who’s had an initial diagnosis for diabetes or hypertension, the disease is insipient – it’s a worthy foe. Just because the patient decides that they’re too busy, dealing with everyday challenges of life and that they can’t make it to the doctor, the disease doesn’t go away. The disease keeps pecking away at them.”

“Whether that’s hypertension or diabetes or cancer or whatever the case might be, we have the opportunity here to create a new level of care – call it accountable care where nobody falls through the cracks.”

“What makes referrals such a high impact moment is that referrals are occurring when there’s a change in diagnosis or escalation in care. By definition, it’s a moment when something very important happened and it’s critical that the patient has a successful transition toward the next step in their care.”

“Las Vegas has been a market that has a huge opportunity to be able to create that next level of accountability.”

“WellHealth is doing here is really bringing a superior product to the market both in terms of the kind of care it’s going to be able to deliver but also in terms of the value that it can provide to the community.”

HealthPayerIntelligence.com: What advice would you offer to accountable care organizations looking to improve their population health management and referral process?

Steve Keltie: “I think, again, I would say that none of this happens without good data sharing. It’s impossible to influence physician behavior and referral management processes without data. Otherwise, you’re just another managed care or similar organization going to a provider, asking them to do something different, and not being able to provide them the information that backs that request up.”

“A system like this provides you the functionality and the data to be able to move those conversations forward with providers. The number one piece of advice, as simple as it is, is to implement something like this. If it’s not par8o, it had better be something very similar. Give your network management teams the tools they need to better do their jobs and give the doctors the information they need to make better referral decisions.”

Daniel Palestrant: “The one thing I might add is that people tend to think of healthcare as a large, monolithic entity and if you notice, each doctor’s office is its own sort of universe – different workflows, different people in different roles. The one thing that WellHealth and par8o has taken great care to be able to do with this deployment is to try to be as flexible and adaptable as possible.”

“Among this variation that you might see is small offices with one or two providers all the way to large, multi-specialty groups. The WellHealth and par8o deployment in Las Vegas will encompass the full spectrum from the smallest offices all the way to the largest groups here in the city. And flexibility is really critical in this setting.”

HealthPayerIntelligence.com: Where do you see the future of population health management and accountable care moving for the payer community? How will provider reimbursement change?

Steve Keltie: “Our use of par8o isn’t just related to network management. It’s also a very valuable tool for our healthcare advocates who work very closely with patients to get them the proper, timely care that they need. Not only can the patient be referred to a specialist that they need to see, but they can just as easily be referred into one of our population health management programs such as our diabetic, high risk pregnancy, COPD, and asthma programs.”

“Again, just like going from a primary care doctor to a specialist, that data par8o provides helps us make sure that connection is actually made. WellHealth operates several different networks and par8o allows us to be nimble and customize the networks to meet the needs of each payer group.”

“Some payer groups want a traditional PPO, some of them want a fully accountable care pay-for-performance type program, and some of them want a mix between the two. We’re able to be nimble and provide all of those things. We offer several different networks.”

“If we don’t do that carefully, it can also be confusing. We can’t have providers and their office staff getting mixed up about where to send referrals. The system helps us keep this all simple. It clearly shows providers where each patient needs to go for a  referral. We’ve got five different networks for six different payer groups, and shows that to the provider—making it very easy for them to use.”

“I think that kind of functionality is going to be what allows our network to conform to the different needs of the payer groups. The old relationship between a payer group and a provider network just being names on a page needs to be in the past.”

“The payers need a truly engaged relationship with their providers. Population health management programs deliver good care to the patients and they make sure our high-risk patients are getting into the specialized programs that they need to, but pay-for-performance models allow for more improvement beyond the traditional fee-for-service PPO.”

“This is what allows us to allow for true engagement with the provider. We’re not just asking them to change their utilization pattern. Since it’s in the best interest of the payer group, we can also show that it’s in the best interest of the provider.”

“It’s very difficult to have a discussion with a provider about managing the medical loss ratio or managing their claims when you pay them only per claim. The more population health management we do and the more pay-for-performance accountable care programs we do, we fulfill this accountable care model. What’s the future look like? The future is accountable care.”

“As quickly as we can get away from the normal, generic, wide-open fee-for-service PPO panels, the better.”

Daniel Palestrant: “A challenge that a lot of payers and organizations now face around population health is one of reconciling timelines. Population health and the benefits from good value-based care is really measured in years.”

“Improvements in hypertension and glycemic control – the data shows very clearly that it will have a positive impact on patient outcomes, but that usually takes years to benefit the patient and ultimately benefit the overall cost.”

“That said, MLRs and costs by most health systems are measured over months and quarters. What I am starting to see payers recognize is that they need to do both. They need to be able to manage through good population health and yet, in the near term, be able to help control costs.”

“The most valuable and the most impactful way for these organizations to be able to do that is to influence site of care selection. When a patient is referred, they’re referred to a location or to a facility that’s both in network, high quality, and has a cost that isn’t going to be out of bounds of what either the patient or the plan is able to pay.”

“Again, referrals and, in particular, what WellHealth has done with par8o are an excellent example of our ability to serve both those goals simultaneously.”