By Daniel J. Durand, M.D.
Vice President of Clinical Strategy
LifeBridge Health System
Tiffany E. Wandy, M.P.H., M.B.A.
LifeBridge Health Clinically Integrated Network
Pothik Chatterjee, M.B.A.
Executive Director of Innovation
LifeBridge Health System
Nearly a decade after the passage of the Affordable Care Act, the U.S. continues to lead the world with over $3 trillion in annual healthcare spending, while American population health outcomes continue to lag behind those of other industrialized nations. At the same time, the healthcare industry is slowly evolving from a fee-for-service model towards value-based care, where providers are paid for the population health outcomes they produce rather than the services they provide. In this era of “Accountable Care Organizations” (ACOs), payors and providers have a novel opportunity to work together to share data to address clinical variation and cost drivers within populations.
Examples of innovative payor-provider collaborations include CareFirst BlueCross BlueShield’s patient-centered medical home (PCMH) model, in which primary care physicians (PCPs) are incentivized financially to engage with proprietary business intelligence tools that show them cost and utilization data on their patient panel. This allows PCPs to autonomously sift through data and derive novel insights about their patient populations*. PCPs are able to discover which patients are seeing numerous specialists of which they were not aware, who is utilizing the ER, when they are doing it, and for what diagnoses, etc. While some of this utilization is necessary or driven by factors beyond physician control, much of it can be prevented by taking action at the level of primary care (e.g. extending office hours, engaging patients on when urgent care may be a better option than the ER, etc.).
These rich data feeds and novel insights have made for a successful program. According to one independent assessment, CareFirst has saved nearly $1.2 billion since 2011 by implementing its unique PCMH model across ninety percent of its contracted providers in the mid-Atlantic region. The program has also achieved regional scale, involving over 4000 PCPs and NPs managing one million patients. At LifeBridge Health, we often begin engaging our PCPs on value-based initiatives by relating our goals to those of the CareFirst PCMH program, because the latter has achieved formidable mindshare amongst PCPs based on its deep local market penetration and strong financial incentives for PCPs.
UnitedHealth Group’s Optum provides another model for payor-provider collaboration. Optum leases select payor capabilities to providers in the form of consulting services and proprietary IT tools. At LifeBridge Health, we use tools created by Optum’s Advisory Board subsidiary to transform raw claims feeds from select populations into physician-facing cost and utilization dashboards. We then use in-house teams to engage physicians on the data throughout our clinically integrated network (CIN). Whenever possible, we schedule our CIN data review meetings on the same day as the CareFirst PCMH meetings so that our physicians can see common trends between the CareFirst and CIN data and prioritize which patients and processes need the most attention. Empowered by this strategy, the physicians within LifeBridge Health ACO, LLC have enjoyed significant success in the Medicare ACO program and have achieved shared savings all three years of our initial 3-year MSSP contract.
We also make use of Optum’s actuarial modeling experience to help project the financial performance of our value-based contracts, as well as contemplate new revenue strategies under consideration. For example, we recently used Optum’s actuary service to help us understand whether billing for care management services might adversely impact our chance at success in certain value-based contracts. The Optum examples illustrate a trend that would have been hard to imagine in decades past – a provider organization sourcing analytics from a major payor subsidiary. This type of collaboration is becoming more common throughout the industry, which has contributed to UnitedHealth Group’s year-over-year growth of 8.2% since acquiring Optum in 2011.
In terms of specific emerging technologies, blockchain has emerged as an exciting new technology that may help bridge the operational divide between payors and providers. Blockchain application allows for increased transparency to align providers, patients and payors and reduce administrative burden. Companies like Virence Health, former GE Healthcare value-based care solutions group, offer solutions that foster better communication of key clinical information between payors and providers to support the adoption of value-based care. According to Virence Health’s Senior Director of Architecture, Robert Maddison, “Blockchain that focuses on auto-adjudication of high volume, low value claims represents a good starting point.” Implementation includes the creation of an initial claims asset on the blockchain once the appointment is scheduled. Payors would then be notified when patient appointments are scheduled and providers engaged on any documentation gaps that need to be addressed. This process can also offload more routine claim adjudication, allowing payors and providers to focus on complex cases. Finally, Maddison adds, “Providing patients with a simplified, consistent view of the payment they are responsible for will also minimize post claim inquiries.” At LifeBridge, we are still in the early stages of exploring blockchain as a potential solution to improve the efficiency of claims auto-adjudication as well as the provider credentialing process.
In summary, at LifeBridge Health we are sourcing select analytics tools and services from payor organizations that have access to larger amounts of data, distinct talent pools, and greater financial resources to devote to the capital-intensive process of research and development. We recognize and respect the decades of experience that our payor partners have in understanding and controlling the total cost of care. Rather than make duplicative investments, we are focused on creating a best-of-breed model of healthcare delivery that leverages payor analytics alongside the deep level of engagement, trust, and brand recognition that patients and providers have in LifeBridge as a health system. While this integration has required an ongoing shift in our mindset and culture, we firmly believe that our willingness to engage in “payvider innovation” will help us find new ways to improve patient outcomes and continue to excel as a national leader in value-based care.
*A primary care provider’s patient population is comprised of individuals who have either affirmatively selected that provider or who have had a visit with that provider in the last 18 months.
Dr. Daniel J Durand (“Dan”) is a physician executive with deep expertise in value-based care. He has served multinational corporations, ACOs, healthcare startups, provider-owned health plans, government agencies, and top-ranked academic institutions.
Dan began his career on the radiology faculty at The Johns Hopkins Hospital before working as an Associate with McKinsey & Company advising hospitals and health systems on post-ACA Strategy and Operations. He then joined the Executive Leadership Team at Evolent Health, where he served as the first Vice President of Clinical Transformation and helped grow revenues from $8M to over $118M en route to a successful IPO on the New York Stock Exchange.
Dan then served as the first Director of Accountable Care for Johns Hopkins before taking his current role as Chair of Radiology and Vice President of Clinical Strategy for LifeBridge Health System, where he has led the LifeBridge Health Clinically Integrated Network to become one of the most successful ACOs in the country.