Becker's Hospital Review

32 Clinical Integration & ACOs B ased on extensive client work and research, this article describes the journey towards population health — cutting through the hype and buzzwords to offer practical advice. The health system described in this article ("Integer Health") and its leader ("Martha") are based on several health systems and executives Strategy& has supported recently in a transition towards population health. Inside mission control Martha, president of Integer Health, a 10-hospital system in the Midwest, used to have a routine. She would start every morning with a large coffee and a report showing her bed census, discharges and the utilization of her operat- ing rooms. This routine has now been upended. Martha now begins her day by walking into her population health command center. The "command center" is a repurposed conference room with several desks and big-screen monitors. Large-scale maps, timelines and dashboards change in real time; seated around the table are experts in care management, network configuration, predictive modeling and contracting. The experts and analysts in the room greet Martha with updates on performance against a range of clinical, operational and financial targets – giving her not only a look into the past but a sense for what is coming today, this month, this quarter and next year. For example, a change in ground-level ozone tells her to anticipate a spike in asthma-related ED visits today – and prepare accordingly. There is also plenty of fresh coffee — at least this part of the routine has not changed. Over the past several years, Martha has seen Integer go through a quiet transfor- mation. Without too many ribbon-cuttings and press releases, the health system now derives nearly a third of its revenue from population-based contracts. While other systems still talk about it, Martha has been able to take Integer down the population health path without taking her eyes off the operations, by integrating the system's physician partners into the plan, and without taking a financial hit — a major consideration in an industry in which, for many players, "no margin" equals "no mission." Martha is also comforted when she looks at the timeline on the wall of the control center — it tells her where Integer Health is headed next and calls out the things to watch out for along the way. Getting there Integer's journey began approximately four years ago, independently of the Patient Protection and Affordable Care Act or other reform efforts, and it began by looking in rather than out. As a large employer, Integer was spend- ing $200 million per year on its own healthcare costs. The system took three straightforward steps: It asked the employees to actively engage in their own healthcare (beginning with a health risk assessment), created a benefit plan and clinically integrated network that delivered the vast majority of care in- network, and created the first of many chronic care programs. The initial chronic care focus was on low back pain — a major source of clinical, productivity and disability costs. That year was the first year Integer's healthcare costs did not go up. A year later, the system had clear indications of improvement — measurably lower utilization and cost, fewer days missed and fewer incidences of re-injury. With hard results in hand, Martha was able to approach the system's payer partners — the local Blue Cross, a new Medicare Advantage plan and the teachers' union trust. The proposal was simple. In year 1, the system would treat these populations on a fee-for-service basis, at a discount using the tools it created for its own employees. If there were savings derived from the strategy, Integer and the payers would share those savings (similar to a CMS model). At the end of year 1, based on the data, Integer and the payers would agree to an appropriate global budget, with Integer committing to a per-member per-month rate for three years and promising a measurable im- provement in member health. The shift from shared savings to a global budget was not a comfortable one, but Integer had built in some safety net for itself based on a good under- standing of the conditions that drove most of the variability in cost — and its internal experience of managing those conditions. Integer ended up hiring several actuaries to analyze the utilization data, make projections based on health risk assessments, and help the system determine the necessary amount of reinsurance to buy to cover exposure to catastrophic, multimillion-dollar cases. Integer also contracted with a local third party administrator to process the claims. After year 1, the claims would no longer need to be sent, but they would still be a useful internal tool to track utilization. As time went on, Integer found new ways to improve care and its bottom line. It worked with physicians to create better access through a system of primary care medical homes. It instituted the first steps of virtual health with e-visits and the first steps of mobile health. It created a fully integrated care manage- ment unit that follows customers through the total journey of healthcare. A Practical Approach to Population Health: Report From the Front-Lines of Healthcare Transformation By Igor Belokrinitsky, Ted Schwab and Minoo Javanmardian with Strategy&

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