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Population Health Support Organizations Serve as New Infrastructures for Today's Population Health Needs

Posted by Matthew Smith on Aug 21, 2017 11:43:35 AM

By Graham Brown, MPH, CRC, Vice President, GE Healthcare Camden Group

With the transition to value-based payment, medical practices are aligning with accountable care organizations (ACOs) and clinically integrated networks (CINs) as a way for providers to remain in independent practice, while joining with like-minded clinicians to improve the experience, clinical and cost outcomes for their patients.

CINs and ACOs as enabling business structures to bring large groups of providers together to address the healthcare needs of a particular population in a given geography—usually via patients’ common health insurance coverage. As a CIN or ACO enters into a contractual relationship with a payer, such as the Centers for Medicare and Medicaid Services (CMS), a managed care plan or even directly with an employer, its providers seek to understand the collective disease burden, access issues and care needs of that population. Core competencies must be developed if these providers are going to be successful in managing the cost, quality and their patient’s experience of care.

A true population health support organization (PHSO) is an ideal fit in this dynamically evolving delivery landscape. It can serve as the operations backbone through which providers might develop and deploy new program resources meeting the needs of its patient population with scale and greater impact than working alone on such efforts.

Strategically, a PHSO aims to integrate providers, hospitals, payers and services across a continuum of patient care. The interoperability between each of the entities reduces fragmented patient care and serves as a bridge between healthcare silos.

A PHSO is a key platform for helping providers transition into the new world of medicine by providing infrastructure for physicians to reshape and drive patient-centered care and engagement via efficient management of patient populations. It is a sound structure for those starting and maintaining a CIN, or simply for those managing medical practices that are evolving to meet the demands of a future delivery system. Much like management service organizations (MSOs) of the past, a well-designed PHSO may also support physicians who wish to remain and thrive in private practice but still collaborate with other providers across a continuum.

Setting the Performance Management Foundation

The key differences of a traditional MSO versus a new-era PHSO relate to the breadth of capabilities that are focused on managing clinical and cost needs of a defined population. Historically, a MSO would deliver common business services designed to help provider practices with administrative burden or provide scale effect for managing overhead costs. As a result, the scope of a MSO’s service offerings would be narrow and cover offerings such as group purchasing, credentialing, office management or centralized billing services.
The additional objectives of a PHSO are three-fold:

  1. Support physicians in quality improvement;
  2. Offer sound financial management; and
  3. Develop the infrastructure needed for population health.

These include moving the needle on quality measures and outcome performance, controlling total cost of care and providing improved patient access to medical care.

The goal is to improve patient loyalty and experience, ultimately keeping patients in an organized system of care. A PHSO also acts as an aggregator of key patient and administrative data so it might become the conduit for a transfer of knowledge critical to success in managing the health of populations.

Quality improvement initiatives must be grounded in a firm understanding of current performance by providers related to the key measures negotiated with managed care payers in a performance contract. Contracts that use shared savings, pay for performance, partial or capitated risk related to utilization and cost targets reward physicians and other providers only when specific measures can be calculated and action can be taken en-masse to have a positive impact on those measures.

Aggregating care delivery data across a network of participating providers is critical. A foundational capability of a PHSO must be deploying the information technology and analytics systems required to determine how care is currently delivered across a network. IT solutions that integrate claims-based data provide the first level of visibility regarding missing or over-utilized services. Such data could bring to light missing services and identify patients with complex or polychronic conditions who may benefit from additional care management.

Patient-centered care needs to augment this view of historical services with a forward-looking perspective to inform an individual plan of care. Care plans which truly engage patients will consolidate to the best extent possible, a whole-person view of the patient’s situation, integrating medical record data, diagnostic results, medications, procedures and clinical interventions into a longitudinal record. Each provider involved in caring for a patient needs to be able to see what other care is being provided to a patient in different care settings, and document the services they provided the patient, therefore, playing their role in furthering the objectives of a care plan.

Sound financial management of healthcare resources should be placed in the hands of clinicians; the historical adage regarding the power of the pen (i.e., a physician’s ability to prescribe, order services or procedures) is just as true and important today if healthcare costs are to be managed effectively.

The backbone of core services that a provider needs to manage healthcare costs must be informed by a holistic view of the cost associated with an individual’s care. In this context, the role of the PHSO is to present to the provider, at the point of care, key data elements to help ensure the best clinical decision is made for a patient, in the most cost-effective manner. A PHSO fills this role by pulling together data on care provided, aligning those elements to the patient’s care plan and then giving providers and patients relevant cost information to help support making the right decision.

Common examples of where integrating cost and clinical data points are essential if a provider hopes to serve the best interest of a patient and performance expectations of value-based contracting. They include forecasting an appropriate length of stay, understanding the appropriateness of prescribing a generic drug, preventing duplicative and expensiver diagnostic tests or directing a patient to a lower cost site of care, such as an ambulatory surgery or urgent care center.

The infrastructure developed through a PHSO should reflect current capability gaps of the providers to be served. The assessment of provider needs and existing methods to manage and report upon clinical and cost performance at network/ population and provider/patient levels serves as a baseline around which new common services should be developed.

In some organizations, understanding and providing visibility to the variability of how care is provided within a network now might be the most valuable information. For other organizations, the ability to stratify a population to identify those most in need of care management and care coordination might provide the best return. The unique needs of provider practices, hospitals and patients served by a network have to be the basis around which a PHSO’s infrastructure, staff, expertise, programs and technologies are scoped and designed over time.

The strategic vision for the infrastructure services should have a multi-year implementation and scalability plan to ensure financial investments are spread out and are prioritized based on goals of the network and its timing for moving into value-based payments for population health management.

PHSO vs. MSO

The PHSO is a vehicle to connect all the dots for a transformation from the old fee-for-service to the new value-based payment models. There are many benefits to organizing and operating a PHSO to support this transition, including:

  • Integrating physicians with an organized delivery system of care, which supports ACO and CIN initiatives.
  • Creating a mechanism to aggregate a holistic view of care provided to a patient across a continuum of care and integrating that view for all providers involved in a patient’s care
  • Coordinating the care management services across a continuum and managing transitions of care between settings.
  • Providing a contracting vehicle that allows and supports providers to assume risk and manage it effectively.
  • Being the collaborative forum for clinicians to develop care pathways, protocols and patient-centered care management programs to bring role clarity and coordination to the many individuals who might be involved in a patient’s care.
  • Enhancing system interoperability to exchange and share data among providers to support care delivery,
  • Improving financial performance and managing the complexities of practice management.
  • Ensuring compliance with CMS programs, such as MACRA, and avoiding payment reductions.
  • Supporting consumerism by creating a unified brand focused on consumer experience and loyalty.
  •  Managing revenue cycle and coding processes (i.e., diagnosis coding, chronic care management requirements, hierarchical condition categories/risk adjustment factor to support value-based contracts.
  • Providing education to physicians—both employed and independent—on topics, such as industry trends, leadership and care redesign.

Whether physicians are employed or independent, a PHSO can support them equally while providing a vehicle for improved operational and financial performance.

Where to Begin

Systems should begin by assessing their employed medical groups and conducting outreach to independent, affiliated practices to determine needs, timing of a value-based transition and identification of gaps. An existing CIN, ACO or MSO could evolve to become a PHSO.

The key to success is either designing a new or adapting an existing organization to fill identified gaps of support services necessary for success under changing reimbursement and care delivery models.

Lastly, a PHSO can be used to gain new relationships while strengthening existing ones with physicians. These partnerships will allow organizations to ultimately improve the health of populations they manage through joint investment in common infrastructure, technologies and staff resources.

The healthcare delivery system and corresponding reimbursement models are undergoing significant change that is unlikely to slow down. The old ways to practice medicine will no longer work in the world of a value-based payment system. A transformation of current practice structure, business strategy and partnerships along a continuum of care will play key roles in achieving success in the new healthcare delivery model.

PHSO, Population Health


BrownG.jpgMr. Brown is a vice president with GE Healthcare Camden Group and has over 25 years of experience in the areas of payer negotiations, program administration, and change management with healthcare provider, payer, government, and human service clients. He is an experienced leader in business planning and implementation for clinical integration and accountable care organization development across the U.S. He may be reached at [email protected].

 

 

Topics: Graham Brown, PHSO

Population Health 2.0: Activate Your Strategy Through a PHSO

Posted by Matthew Smith on Aug 18, 2016 11:12:27 AM

By Graham Brown, MPH, CRC, Vice President, GE Healthcare Camden Group

With the transition to value-based payment, medical practices are aligning with Accountable Care Organizations (“ACOs”) and clinically integrated networks (“CINs”). These enabling business structures, with the new payment models, require a new level of support to medical practices. A true Population Health Support Organization (“PHSO”) is the perfect fit in a dynamically evolving delivery landscape.

Strategically, a PHSO aims to integrate providers, hospitals, payers, and services across the continuum of patient care. The interoperability between each of the entities reduces fragmented patient care and serves as the bridge between healthcare silos. A PHSO is the key platform to help providers transition into the new world of medicine by providing infrastructure for physicians to reshape and drive patient-centered care and engagement via efficient management of patient populations. It is a sound structure for those starting and maintaining a CIN, or simply for those managing medical practices that are evolving to meet the demands of the future delivery system. Much like Management Service Organizations (“MSOs”) of the past, a well-designed PHSO may also support physicians who wish to remain and thrive in private practice but still collaborate with other providers across the continuum.

Setting the Objectives

The objectives of a PHSO are three-fold: support physicians in sound financial management, quality improvement, and infrastructure needed for population health. These include moving the needle on quality measures and outcome performance, controlling total cost of care, and providing improved patient access to medical care. The goal is to improve patient loyalty and experience, ultimately keeping patients in the organized system of care. The PHSO also acts as an aggregator of key patient and administrative data; so it may become the conduit for the transfer of knowledge critical to success in managing the health of populations.

PHSO vs. MSO

So how is the PHSO of tomorrow different from the MSO of the past? The PHSO is a vehicle to connect all the dots for the transformation from the old fee-for-service to the new value-based payment models. There are many benefits to organizing and operating a PHSO to support physicians’ transition to value-based care delivery, including:

  • Integrating physicians with the organized delivery system of care, which supports ACO and CIN initiatives
  • Providing a contracting vehicle that allows and supports providers to assume risk and manage it effectively.
  • Coordinating the care management services across the continuum and managing transitions of care from one setting to another
  • Enhancing system interoperability to exchange and share data among the providers to support care delivery
  • Improving financial performance and managing the complexities of practice management
  • Ensuring compliance with CMS programs, such as MACRA, and avoiding payment reductions
  • Supporting consumerism by creating a unified brand focused on consumer experience and loyalty
  • Managing the revenue cycle and coding processes (i.e., diagnosis coding, chronic care management requirements, Hierarchical Condition Categories ("HCC")/Risk Adjustment Factor ("RAF) to support value-based contracts
  • Providing education to physicians—both employed and independent—on topics such as industry trends, leadership, care redesign, etc.

Whether physicians are employed or independent, the PHSO can support them equally while providing a vehicle for improved operational and financial performance.  

Where to Begin

Systems should begin by assessing their employed medical groups and conducting outreach to independent, affiliated medical groups to determine needs, timing of the value-based transition, and identify the gaps. These become the starting points for core PHSO services. An existing CIN, ACO, or MSO could evolve to become the PHSO. The key to success is either designing a new or adapting an existing organization to fill the identified gaps of support services needed to be successful under changing reimbursement and care delivery models. Lastly, the PHSO can be used to gain new relationships while strengthening existing relationships with physicians. These partnerships will allow the collective organizations to ultimately improve the health of the populations they manage.

The healthcare delivery system and corresponding reimbursement models are undergoing significant change…which is unlikely to slow down. The old ways to practice medicine will no longer work in the world of a value-based payment system. A transformation of current practice structure, business strategy, and partnerships along the continuum of care will play key roles for success in the new healthcare world.

 Population Health Support Organizations, PHSO


BrownG-470185-edited.jpgMr. Brown is a vice president and clinical integration practice leader with GE Healthcare Camden Group and has over 25 years of experience in the areas of payer negotiations, program administration, and change management with healthcare provider, payer, government, and human service clients. He is an experienced leader in business planning and implementation for clinical integration and accountable care organization development across the U.S. He may be reached at [email protected].

 

Topics: ACO, CIN, Graham Brown, Population Health Support Organization, PHSO

Strength In Numbers: Super Clinically Integrated Networks Built to Improve Healthcare Value

Posted by Matthew Smith on Mar 22, 2016 2:27:39 PM

Graham A. Brown, MPH, CRC, Vice President, and Marc Mertz, MHA, FACMPE, Vice President, GE Healthcare Camden Group

As organizations assess their capabilities, resources, and infrastructure to succeed in evolving value-based reimbursement structures, many health systems have begun to partner with other health systems in a manner that allows organizational independence but fosters collaboration in areas where synergies may exist, specifically around population health management.

The creation of super clinically integrated networks ("SCINs") reflects this trend. For some, these SCINs are merely a stepping stone to full integration or merger, but to most, these affiliations are viewed as a vehicle to strengthen each of the independent members by collectively joining forces to improve healthcare value.

These SCINs could have significant strategic potential if they are able to organize appropriately, prioritize initiatives, and advance to the level of jointly assuming risk, developing effective care models, and positioning the members as an attractive option to healthcare purchasers.

Often, SCINs embark on relatively low risk activities at the outset such as optimizing the supply chain, sharing services and overhead, sharing clinical knowledge around best practices, and improving patient access (particularly when organizations are in different markets).

While these may be reasonable starting points that help to garner trust and build momentum, they will not be solid long-term strategies on their own to support sustainability of the SCIN or lead to return on investment for its members.

Establishing goals and objectives of the SCIN at the outset with cohesive strategy formulation and buy-in, as well as ensuring that it is properly resourced, will be integral to their success.

As mentioned, most SCINs that have been formed have a goal of developing joint population health management infrastructure. Defining exactly what this means and responsibilities of the SCIN versus responsibilities of each individual member is a key initial step.

Certainly, there is extensive cost associated with developing the proper infrastructure to support population health. Thus, the economic opportunities to the SCIN should be evident when compared to resourcing population health initiatives as individual organizations.

Ultimately, as the population health infrastructure is built and care model effectuated, there are many opportunities to better manage care and impact overall value. Many SCINs endeavor to offer an attractive, efficient delivery network to self-funded employers via direct to employer contracting; and this activity often begins with their own collective employee health benefits programs. More advanced SCINs progress to joint payer contracting but will need to have achieved clinical and/or financial integration to an acceptable level.

Shifting of financial risk from major payers to the SCIN through a plan-to-plan type arrangement or global capitation are other alternatives as the SCIN evolves and is better equipped to manage risk. Further, the individual exchange marketplaces and Small Business Health Options Program (“SHOP”) allow these advanced delivery networks to access individuals and small groups in an efficient manner and compete more quickly with larger carriers.

Depending on the overall goals, objectives, market characteristics, and current capabilities of each individual member and the SCIN, a provider sponsored health plan may be another opportunity to consider. Between 2012 and 2015, 54 percent of the new Medicare Advantage plan entrants were provider owned.

There is great risk in starting a health plan, but sharing this risk across organizations in the SCIN could be a mechanism to diffuse risk and share collective resources. Additionally, the mere scale in size of the SCIN provides a larger pool of lives than any individual system would have on its own. While the task seem to daunting, particularly at a time when the healthcare system is changing rapidly, embarking on these initiatives collectively may prove to be the best strategy.

There is significant opportunity for super clinical integrated networks to chart their own path and truly transform the delivery system in a positive manner. However, coordinating efforts across multiple large organizations that remain independent is not without its challenges.

Starting with the basics is a reasonable first step so long as there is a well thought out strategy and plan to more fully develop the organization to its potential.

Each individual organization will have its separate priorities. Determining how the SCIN moves forward as “one” while supporting the independence and priorities of the individual organizations will be key to their success.

An effectively designed governance structure of the SCIN that includes the chief executive officer of each member, along with one other key leadership position, is recommended. This will allow nimbleness of the SCIN in decision-making, but will also foster effective communication and alignment of strategies.

Those organizations that can pull it all together could easily set themselves apart and have significant strategic advantage in their respective market(s). Developing a detailed strategic framework for the SCIN that all parties support and holding each other accountable will serve as a foundation of success for these organizations.


BrownG.jpgMr. Brown is a vice president and clinical integration practice leader with GE Healthcare Camden Group and has over 25 years of experience in the areas of payer negotiations, program administration, and change management with healthcare provider, payer, government, and human service clients. He is an experienced leader in business planning and implementation for clinical integration and accountable care organization development across the U.S. He may be reached at [email protected].

 

MertzM.jpgMr. Mertz is a vice president with GE Healthcare Camden Group and has 18 years of healthcare management experience. He has 15 years of experience in medical group development and management, physician-hospital alignment strategies, physician practice operational improvement, practice mergers and acquisitions, medical group governance and organizational design, clinical integration, and physician compensation plan design. He may be reached at [email protected].    

 

This article was originally published by Modern Healthcare Executive, November 27, 2015

Topics: CIN, Clinically Integrated Networks, Clinically Integrated Network, Marc Mertz, Graham Brown, Super CIN

Super Clinically Integrated Networks Offer Unique Opportunities

Posted by Matthew Smith on Dec 8, 2015 2:09:45 PM

By Graham Brown, MPH, Vice President and Clinical Integration Practice Leader; Marc Mertz, MHA, FACMPE, Vice President and Physician Services Practice Leader, GE Healthcare Camden Group

As organizations assess their capabilities, resources, and infrastructure to succeed in evolving value-based reimbursement structures, many health systems have begun to partner with other health systems in a manner that allows organizational independence but fosters collaboration in areas where synergies may exist, specifically around population health management.

The creation of super clinically integrated networks ("SCINs") reflects this trend. For some, these SCINs are merely a stepping stone to full integration or merger, but to most, these affiliations are viewed as a vehicle to strengthen each of the independent members by collectively joining forces to improve healthcare value.

These SCINs could have significant strategic potential if they are able to organize appropriately, prioritize initiatives, and advance to the level of jointly assuming risk, developing effective care models, and positioning the members as an attractive option to healthcare purchasers.

Often, SCINs embark on relatively low risk activities at the outset such as optimizing the supply chain, sharing services and overhead, sharing clinical knowledge around best practices, and improving patient access (particularly when organizations are in different markets).

While these may be reasonable starting points that help to garner trust and build momentum, they will not be solid long-term strategies on their own to support sustainability of the SCIN or lead to return on investment for its members.

Establishing goals and objectives of the SCIN at the outset with cohesive strategy formulation and buy-in, as well as ensuring that it is properly resourced, will be integral to their success.

As mentioned, most SCINs that have been formed have a goal of developing joint population health management infrastructure. Defining exactly what this means and responsibilities of the SCIN versus responsibilities of each individual member is a key initial step.

Certainly, there is extensive cost associated with developing the proper infrastructure to support population health. Thus, the economic opportunities to the SCIN should be evident when compared to resourcing population health initiatives as individual organizations.

Ultimately, as the population health infrastructure is built and care model effectuated, there are many opportunities to better manage care and impact overall value. Many SCINs endeavor to offer an attractive, efficient delivery network to self-funded employers via direct to employer contracting; and this activity often begins with their own collective employee health benefits programs. More advanced SCINs progress to joint payer contracting but will need to have achieved clinical and/or financial integration to an acceptable level.

Shifting of financial risk from major payers to the SCIN through a plan-to-plan type arrangement or global capitation are other alternatives as the SCIN evolves and is better equipped to manage risk. Further, the individual exchange marketplaces and Small Business Health Options Program (“SHOP”) allow these advanced delivery networks to access individuals and small groups in an efficient manner and compete more quickly with larger carriers.

Depending on the overall goals, objectives, market characteristics, and current capabilities of each individual member and the SCIN, a provider sponsored health plan may be another opportunity to consider. Between 2012 and 2015, 54 percent of the new Medicare Advantage plan entrants were provider owned.

There is great risk in starting a health plan, but sharing this risk across organizations in the SCIN could be a mechanism to diffuse risk and share collective resources. Additionally, the mere scale in size of the SCIN provides a larger pool of lives than any individual system would have on its own. While the task seem to daunting, particularly at a time when the healthcare system is changing rapidly, embarking on these initiatives collectively may prove to be the best strategy.

There is significant opportunity for super clinical integrated networks to chart their own path and truly transform the delivery system in a positive manner. However, coordinating efforts across multiple large organizations that remain independent is not without its challenges.

Starting with the basics is a reasonable first step so long as there is a well thought out strategy and plan to more fully develop the organization to its potential.

Each individual organization will have its separate priorities. Determining how the SCIN moves forward as “one” while supporting the independence and priorities of the individual organizations will be key to their success.

An effectively designed governance structure of the SCIN that includes the chief executive officer of each member, along with one other key leadership position, is recommended. This will allow nimbleness of the SCIN in decision-making, but will also foster effective communication and alignment of strategies.

Those organizations that can pull it all together could easily set themselves apart and have significant strategic advantage in their respective market(s). Developing a detailed strategic framework for the SCIN that all parties support and holding each other accountable will serve as a foundation of success for these organizations.

This article was originally published by Modern Healthcare Executive, November 27, 2015


Mr. Brown is a vice president and clinical integration practice leader with GE Healthcare Camden Group and has over 25 years of experience in the areas of payer negotiations, program administration, and change management with healthcare provider, payer, government, and human service clients. He is an experienced leader in business planning and implementation for clinical integration and accountable care organization development across the U.S. He may be reached at gbro[email protected] or 585-512-3905.

 

mertz_headshot.pngMr. Mertz is a vice president with GE Healthcare Camden Group and has 18 years of healthcare management experience. He has 15 years of experience in medical group development and management, physician-hospital alignment strategies, physician practice operational improvement, practice mergers and acquisitions, medical group governance and organizational design, clinical integration, and physician compensation plan design. He may be reached at [email protected] or 310-320-3990.    

 

Topics: CIN, Clinically Integrated Networks, Clinically Integrated Network, Marc Mertz, Graham Brown, Super CIN

New White Paper: "Building an Integrated Delivery Network?"

Posted by Matthew Smith on May 1, 2015 11:28:20 AM

A consistent trend has been emerging of medical groups continuing to consolidate and/or collaborate in new ways. Balancing the desire to operate independently, while taking advantage of the infrastructure and systems available through alignment with integrated networks has made network participation a necessity – rather than an option – for most physicians.

This need on behalf of physicians, coupled with the requirement for health systems and managed care payers to provide a robust scope of clinical services across a targeted geography, has driven the formation of many integrated delivery networks (“IDNs”) across the healthcare delivery system.

The latest white paper from GE Healthcare Camden Group titled, “Building an Integrated Delivery Network? Start Here…” focuses factors to consider in evaluating provider groups for a delivery network.

To download the white paper, please click the button below.

Integrated Deliver Network, White Paper, The Camden Group

Topics: Clinical Integration, Integrated Delivery Network, Graham Brown, White Paper

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