Pennsylvania-Based Health Plan Engages with its Providers through an Analytics Platform

Independence Blue Cross and Abington Health have are collaborating on an initiative that could transform the reimbursement landscape of southeast Pennsylvania

Earlier this spring, Abington Health, a two-hospital integrated health system based in Abington, just north of Philadelphia, and the Philadelphia-based Independence Blue Cross, the largest health plan in southeast Pennsylvania, announced the creation of an accountable care initiative.

Abington Health is one of the first organizations to partner with Independence Blue Cross (IBC) since the insurer announced the creation of its accountable care payment model, called the Integrated provider Performance Incentive Plan, which “rewards doctors and hospitals for delivering higher-quality, better-coordinated, more efficient care,” according to the press release issued to announce the partnership.

For their technology platform, the insurer and provider are leveraging the cloud-based Accountable Delivery System Platform from the St. Louis-based Lumeris, which describes itself as “an accountable care delivery innovation company offering health systems, payers, and providers operations, technology and consulting services.”

Lumeris’s work in this area began through the servicing of the needs of a Medicare Advantage plan in St. Louis beginning in 2006, according to Lumeris executives. With regard to this particular initiative, IBC and Abington were scheduled to go live with the Lumeris solution sometime early May.

Meanwhile, not long after the announcement of the IBC-Abington Health accountable care initiative, HCI Editor-in-Chief Mark Hagland spoke with Doug Chaet, senior vice president, contracting provider network, and Somesh Nigam, senior vice president and chief informatics officer, both of Independence Blue Cross, to learn their perspectives on their organization’s outreach to providers around the accountable care organization [ACO] concept. Below are excerpts from that interview.

What has been your overall accountable care strategy with regard to providers in your market?

Doug Chaet: A couple of years ago, we decided that we needed to be progressive in terms of engaging the providers to a greater degree, because we happen to be in a market where utilization is typically among the top three healthcare markets in the country. And once we determined why that is—and one of the reasons was because of lack of care coordination, and a second was the siloing of information—we put together our own accountable care payment model.

We actually did that in late 2009, even before the ACA [the Affordable Care Act] was passed. And we shared it with the health systems in our market, and began to incorporate this payment model really into everybody’s renewals. And not just those of hospitals; physicians, too. We required that if a health system wanted to participate in this model, they had to bring their doctors along as well. And it couldn’t just be the primary care physicians and not the specialists. And it was a tall order.

Step one was to develop a model that would be effective and have a good chance of being accepted by the providers. Step two was to incorporate the provisions into the contracts, which took a while, because we deal with about 40 hospitals and 25,000 providers in this model. And step three was to be successful, because it is a shared-savings model, and if they benefit, so do we. And now, three years later, the good news is that we have successfully embedded that accountable care model into about 80 percent of all of our contracts, which is exceptional.

The challenge at this point is to enable the providers, so that they can prosper, and actually succeed in this environment. And for the most part, this is new for them, and it represents a change in how they practice. And one of the things that you have to do, if you’re going to incent the providers to be more thoughtful with respect to whom they refer to; to really engage them to agree that they, as PCPs need to be quarterbacks over patients’ care—we’re asking them to spend more time on the front end, be more thoughtful, and look at more data, so that at the end of the day, they’ll be more successful under this model.

And to do that, you have to provide them with tools that they haven’t had access to in the past. And we looked at a number of tools out there, and to partner with Lumeris, because we thought they might be a good fit. Part of the problem, from a data standpoint, part of the historical problem is that, as a claims payer, we have a wealth of claims information, but we don’t have access to clinical information; whereas the doctors have access to their electronic health record [EHR] data, but don’t have access to the claims data. So what we were trying to do by partnering with Lumeris was to pair the EHR and claims data.

Somesh Nigam: We totally realized even a few years ago when these accountable care models were established, that we would have to provide doctors with appropriate reports and data, and we do. We send them quarterly reports; they have access to a portal, where they can go in and look at the care of individual patients. But these are all point systems, and doctors are busy. But they didn’t have the opportunity to see all of the information and data, integrated, at the time they’re seeing the patient. And we needed it at the point of care. That, I think, is the game-changer. As an insurer, we’re the only ones with a 360-degree view of the patient, from a claims perspective.

How did you get the clinicians to trust you on the data?

Chaet: We started with the employed physicians in the health system, and Lumeris did a demo. The doctors and the hospital were already engaged, having agreed to participate in the ACO model. So the only question was, would they be open to this technological support. And this particular hospital employs about one-third of its medical staff. This is Abington Health, two hospitals. And they have a large private practice community as well.

What did you want Lumeris to build for you?

Nigam: The starting point was a really innovative physician desktop, which allows the physician to have a 360-degree view of the patient. They can look at the patient who walks in, look at their prior medical history; is able to look at prior laboratory results; any prior hospitalization; any prior interactions with other doctors in our network. We even provide them with risk assessment tools. And in addition, we also provide care gaps—if they’re complex diabetics and haven’t had their a1c test on time, we’ll flash that; if they’re a congestive heart failure patient and have been having problems managing their weight or fluid balance, for example, we’ll give them that. So the idea is that it’s not a set of complex, difficult-to-read reports, it’s that patient-centric view that is not only alerting you to the latest information, but that is also guiding you.

Chaet: It’s sort of like figuring out the home page of your bank’s website; it’s intuitive.

Nigam: Obviously, we all cherish something like an Apple-like interface or banking-like interface. But anyone who’s worked with a traditional EHR knows that that tends not to be the case. But the intuitive interface is obviously the key.

What lessons have been learned so far, in the run-up to the go-live that you expect to occur in May?

Chaet: You actually touched on this earlier, but physician engagement is the key. And in fact, I would tell you that, from an accountable care concept standpoint, physician engagement is the key, because the doctors are the only ones who have the ability to transform the way care is delivered. So they have to be engaged and excited about it, and to do this right, they need to embed and incorporate this into their routines; it can’t just be about five patients a day. And one advantage we have is that we are the largest payer in this market, so anything they do with us will be meaningful. So if you were a much smaller player in this market, even if you had a good product, the likelihood of their embracing it would be much smaller. And it requires not just giving them the tools, but also training them on the tools. Yes, you need a good product; you need a good incentive program that rewards them appropriately; but they have to be incented and excited to do this.

Nigam: I would absolutely agree with Doug; it really is a big change management challenge. The technology challenges are many, but they’re doable. Once you figure out how to create a platform and how to arrange the data feeds and the interoperability, and work out the algorithms, you can work those out; those are surmountable challenges. But the key will be usability and physician workflow, and physician use at the point of care, and outreach to patients who need to be reached out to.

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Healthcare Informatics
April 22nd, 2013