Becker's Hospital Review

Q: Are your physicians engaged in your fee-for-value agreements? MM: Absolutely. We have two commercial ACOs. We're also pursuing a San Francisco Bay Area-wide network that will take capitation from the health plans that involve a fee-for-val- ue product. VJ: I don't think we have one fee-for-value agreement where the physicians are not en- gaged. You have to have physicians engaged. They're the ones who are going to determine whether you hit those targets or not. We need to get their buy-in on provider goal metrics and the protocols for success. RKM: Up until a couple months ago, we've asked our physicians to care for patients in a payer-blind way, which means they shouldn't let patients' payer/plan have any influence on the care or treatment they provide. Now we want our physicians to be payer agnostic, which means we do want the clini- cians to understand the payer/plan the patient is covered under. The providers should be aware of the exact plan the patient is covered by because there could be extra services avail- able with a certain plan that could enhance the care experience and/or help with treatment adherence. We want to make sure the patients can take full advantage of the services, and oftentimes that happens via the physician. Q: How do you know when your orga- nization is ready to assume more risk- based agreements? MM: You're ready when you have organized physician leadership committed to working in a risk-based environment, especially at the PCP level. You have to have the infrastructure to support them in areas like disease and case management, ambulatory case managers and quality. If you assume risk-based agreements, you have to build the infrastructure for the phy- sician — especially in primary care — to operate in a different way. VJ: The key is to understand your market. How do you know when the market is ready to assume more risk-based contracting? If the market is ready for it, the organization needs to make sure they're ready for it. You can't say you're doing it if the market's not there. Once the market's ready, hospital provid- ers need to strategically plan with the payers and physician organizations to get the infra- structure in place to be ready to take risk. You need a lot of information technology because you have to share information as close to real time as you can across all providers. IT is a big part of it, as is the establishment of a strong physician network. You also need the right incentives in place for physicians to be able to manage the patient population, and you must have the right post-acute strategy as well. It's a lot of blocking and tackling. Over time, if you do a couple of these [things] and you're successful, then you're ready to go further. RKM: Our prior experiences with various government demonstration projects and the Pioneer ACO provided real life experienc- es with various types of risk formulas and attribution models. Therefore, we've gotten pretty experienced with a variety of payment models — governmental and commercial — and understanding when we're ready to take on more or a new type of risk and what our risk tolerance is. This does not mean we have not been challenged by the methodology differences that may inherently have put us at a disadvan- tage when compared to our benchmark peers, but we went into these risk arrangements with our eyes wide open. Knowing our organiza- tion's risk tolerance lets us enter these types of arrangements with confidence, understand- ing our participation is helping influence the design of future models. As risk threshold levels significantly increase, we are performing more in-depth assessments of our operational preparedness to be successful because larger economic impacts are at stake. Q: What are you doing to prepare your organization for increased risk? MM: John Muir Health has a medical founda- tion, which is the employment vehicle for phy- sicians in California. We are using the medical foundation in conjunction with the oversight of a group of key physicians to develop all the workflow processes and how we leverage the IT system. We have to change the care models and allow the physicians with a team to care for patients that have complications such as diabetes and congestive heart failure. The physicians can't do that by themselves — they need a structure. All of this is hard and rewarding work, because it's cultural change. You can't lose sight of the fact that you're asking people to change their behavior. It's hard and people feel threatened by it, so you need to be respectful of everyone. Everyone needs to feel like a partner in the process. Most importantly, we can't do things to people; we have to do things with people. VJ: Although only 5 to 10 percent of our busi- ness is risk-based or fee-for-value, we spend 25 to 30 percent of our time working on it. We have a senior vice president of population health at Detroit Medical Center. It's his job to manage our risk, develop new platforms for financial risk and look at entering risk-based contracts. Physician network development and alignment is also a big focus. We also are leveraging the small (but growing) insurance company we own. More and more, you're going to see providers en- tering the insurance market. If you're assigned a population, you're responsible for those people. If we can be responsible, we can have a fully integrated solution we can offer directly to employers. As insurance companies move into the provider space, more providers move into the insurance space, which is natural when you're moving into population health. At some point, we would like patients thinking provider networks are a more important decision than which insurance company they use. Providers are best suited to manage care and create value for the health we provide. RKM: Aside from continuing to advance our understanding of methodologies and perfor- mance measurements, we've been doing a lot in the last 18 to 24 months. In the infrastructure and foundation space, we've recently moved our organization to an Epic-based billing, scheduling and registration platform that seamlessly integrates with our Epic EMR. Now we have the whole revenue cy- cle on an integrated platform, and think that'll bode well for us as we advance toward more sophisticated payment models. Also in the last 24 months, we've affiliated with three other health systems and plan to bring them onto this new integrated platform over time. We've also made some investments in enhanced analytics and created an Analytics Institute that brings all of our analytic tools and team members together. Working in concert with [Hanover, N.H.-based] Dartmouth College, we have much experience with big data. Now it is time to turn big data into actionable data that can be used to benefit our patients in real time. We're also looking at modifying our physi- cian incentive compensation model, which will be coming up in the next year. We just developed a provider/pay- er-owned population health management company. We have a variety of affiliated and unaffiliated health systems in our region that are working with one payer to provide services and products that advance the health of our region. The last thing we're working on is trying to understand how to use advanced automated tools to assist the clinical team. We want to make sure the clinical record of each patient is complete and the treatment plan encompasses all relevant health factors. We are not ready as a health system to have full capitation, but we are getting pre- pared for that. Over time, we feel that the clos- er we are to assuming more risk and achieving an 80 percent risk profile. Fundamentally, we feel we the closer we are to fee-for-value, the more funds will be available to improve health. n Sponsored by: Conifer Health Solutions is a healthcare services company helping more than 800 clients strengthen their financial and clinical performance, transition to value-based care and enhance the consumer and patient healthcare experience, with the goal of improving quality and access to healthcare, while controlling costs. Conifer Health has more than 24 million patient interactions across all service lines, manages more than $26 billion in patient revenue and $20 billion in medically managed spend. Conifer Health also provides technology and health management services to support care management for more than 5.5 million lives, annually. For more infor- mation, visit coniferhealth.com or follow @coniferhealth on Twitter. Executive Roundtable 32

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