GE Healthcare Camden Group Insights Blog

Building a Value Model for Population Health Management

Posted by Matthew Smith on Jun 16, 2017 10:40:18 AM

By Daniel J. Marino, MBA, MHA, Executive Vice President, GE Healthcare Camden Group

Most healthcare leaders understand the importance of managing the health of their patient populations. Building the tools for effective patient population management is key to improving outcomes while “bending the cost curve” in U.S. healthcare.

At the same time, executives are concerned about the cost of population health initiatives. What level of investment is needed to effect change? What is the right pace for transitioning from fee-for-service (FFS) to value-based payment? Finance leaders, in particular, are concerned about preserving margins during the transition.

How can a healthcare organization maintain profitability as spending increases on population health initiatives while FFS revenue decreases?The only way to answer these questions is to use a data-driven “value model” to predict and manage the total financial impact of the population health initiatives.

An ideal value model will accomplish three goals:

  1. Quantify the output of population health interventions, including shifts in utilization and changes in cost of care.
  2. Help identify population health investments that will move the organization forward while retaining margin.
  3. Allow finance leaders to support value-based contracting with predictions of costs and the quality of outcomes.

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Value Model, Population Health

Topics: Value-Based Care, Population Health, Value-Based Contracting, Daniel J. Marino, Value Model

Top 10 Reasons to Integrate Your Inpatient Case Management with Your Population Health Initiatives

Posted by Matthew Smith on May 30, 2017 10:42:24 AM

By Mark Krivopal, MD, MBA, Vice President, & Tara Tesch, MHSA, Senior Manager, GE Healthcare Camden Group

Most hospitals understand the importance of inpatient case management. Yet, when asked how care managers are coordinating care for the inpatient population, most responses are focused on discharge planning tactics or utilization management strategies. The patient’s care is not truly being managed – just their length of stay (“LOS”), inpatient progress, and planning for discharge to avoid a readmission.

As the focus on value-based care is increasing, and more care is shifting into the ambulatory space while the U.S. population continues to age, a higher proportion of vulnerable ambulatory patients find themselves in need of holistic supportive care. Health systems are realizing the importance of ambulatory care management as a crucial foundation to managing populations across the care continuum by delivering high quality and patient-centric care while keeping in check avoidable costs. High performing organizations have implemented integrated care management programs focused on managing patients across care settings that include deciphering patients’ various medications, coordinating the many care directives from multiple providers, ensuring safe transitions of care from a post-acute care setting to the home, and helping patients with transportation difficulties or other social barriers to seeking care at the right time and at the right place.

The challenge though, is that many organizations are still thinking about delivering care within silos rather than integrating and aligning the initiatives within a patient-centric care delivery model. Outlined below are 10 reasons you should consider integrating your care management across the care continuum to support your population health initiatives.

1. Integrated care management addresses inefficiencies in managing the high risk populations and addresses LOS challenges and shifts in utilization to support the most effective care resource model.

The shift to value-based care delivery and the strengthened incentives for advancing value-based reimbursement will lead health systems and providers to renew their focus on adopting care models to support management of high-risk, high-cost patients, complex, and chronic care patients, in addition to disease-specific management programs. This will require new approaches to expanding patient access to lower cost sites of care and providing patients a more effective and simpler approach to navigating their care. The integrated care management model supports organizations and providers in developing innovative models (see graphic below) focused on reducing inefficiencies, managing medical spend, and improving patient access. Integration of targeted, evidence-based programs such as post-discharge transitions, complex care management, disease-specific, and episodic care pathways, as well as proactively connecting patients with behavioral health needs to appropriate care management and community services are just some of the strategies that have proven success.

For full-size image, click here.


2. Duplication of care management services causes competing priorities and operational inefficiencies and redundant costs.

An integrated care management model provides a seamless patient experience across the continuum of care when there exists one aligned team to care for the patient. For organizations to achieve an integrated care management model requires not only effective communication channels and standardized care processes, but the analytics and information technology systems to support these care processes. Duplication typically occurs because barriers in technology and lack of standardization of workflow processes limit the ability of care managers to share information as the patient moves across different sites of care. Due to the limitation in electronically aggregating the necessary clinical information, care managers are not able to coordinate their efforts and spend significant time manually gathering information from providers. As a result, time is spent on manual documentation and patient management that could be automated, and more staff is typically added to ensure such information is captured, verified, and reported. The development and implementation of a shared care plan (and tools that will house the care plan) that follows the patient and is accessible by the care team, along with electronically aggregating important clinical information, are key requirements to reduce staff duplication, inefficiencies, and redundant costs.

3. One quarter of patients consume three quarters of resources, many of whom are unmanaged and lack community-based resources.

Integrated care management and coordination is a person-centered, collaborative, and multi-disciplinary process that uses population based risk-stratification and evidence-based interventions to promote optimal outcomes in a value-driven environment. By incorporating tools that allow organizations to understand the health risk level of the populations served, organizations can build more prescribed programs to track and manage high risk (and typically high cost patients), and to help prevent potentially avoidable higher-acuity, higher cost care. As organizations become more proficient in understanding the risk factors of their populations, integrated care management programs will increasingly rely on partnerships and linkages with community-based services and organizations and community health workers to help coordinate care and meet patient needs — driving the most optimal results.

4. Integrated care management addresses suboptimal transitions across the care the continuum.

The most vulnerable time for the patient is when he/she leaves the acute care setting or transitions from a skilled nursing facility back into the community. Today more patients are transitioned out of acute and rehabilitation care settings earlier than even just a few years ago. This is because more services and treatments are deemed safe to be administered in an outpatient setting. Yet, many patients are limited in their ability to thrive when one considers social determinants of health such as ability to afford medications, transportation to providers, or simply required competency level to manage their health. These factors, although likely present before the admission, are not properly addressed as part of the traditional coordinated discharge treatment plan. As a result, providers only come across these social determinants when medical errors occur, important medications are erroneously discontinued, tests are not followed up, or patients end up back in the emergency department after being discharged. Implementing patient-centric integrated care management across the continuum of care that incorporates providers expanding their discharge care plan to include social determinant evaluations helps avoid “fumbled handoffs.”

5. Integrated care management helps providers meet increased expectations around quality, cost, productivity, and patient satisfaction, critical to population health management.

The pressures on and expectations of providers (particularly primary care physicians) are immense. Physicians themselves cannot (nor should they) assume that they can address quality of care, cost, and patient satisfaction on their own. An integrated care management approach provides support to primary care practices by managing these increased expectations and helps the entire risk-bearing organization achieve success. The key is to redesign the care model to incorporate a physician-led and team-driven best practice approach. This should include integrated care plans, coordinated protocols, and outcome tracking. Providers benefit from pre-visit planning to identify complex, chronic, and high risk patients, making practice operations run more efficiently. This, in turn, leads to a more focused care plan, better managed patient flow within the practice, enhanced patient and provider satisfaction, and more coordinated overall care. By incorporating a care model that includes a significant preparatory assessment, chart reviews, and checklists to ensure preventative screening is performed and documented, providers are well-positioned to enhance the quality of care delivered and see real results within their quality performance outcomes. Those organizations that embrace an integrated care management approach find themselves better positioned to meet ever increasing demands on their expertise, time, and resources, and are better able to maximize opportunities within a value-driven healthcare world.

6. Overlap and lack of clarity in roles and responsibilities create staff dissatisfaction that can be ameliorated with integrated care management.

Over the last several years, many healthcare systems have invested substantial resources and efforts into deploying and retraining inpatient case managers to address preventable hospital LOS. As these organizations take on financial risk by participating in value-based contracting, they embed care managers in the primary care physicians’ offices to assist with managing complex patients, help with their social and behavioral needs, and improve communication around transitions of care. However, some providers are not as satisfied with this approach as one might expect. There is significant role confusion and frustration among various healthcare professionals, resulting in multiple calls to patients, for example, from home health, the care manager assigned to them by their payer, a hospital social worker, and an ambulatory care manager. Physicians are then also confused as they receive mixed messages from various care managers, which is exacerbated by lack of clarity around who they should contact in order to address some of the issues. Is it the responsibility of the hospital discharge planner to communicate important information to the ambulatory care manager, or is the ambulatory care manager responsible for contacting the hospital to get this information? Who is truly empowered and accountable for care managing the patient along the entire continuum? This can all be resolved by a single, clearly identified integrated care manager who has the responsibility to work on the patient’s behalf and serve as the single source of truth for the patient and all treating providers. Clarity around care managers’ role designation and empowerment will increase overall provider satisfaction and significantly enhance quality of care delivered to patients.

7. Integrated care management helps improve patient engagement and activation in their care.

Organizations are frequently struggling with getting patients to engage in their health in a proactive way. For many patients, active engagement in creating (and understanding) their care plan is a key to improving their health outcomes and conditions. Education and engagement with the caregivers as well as the patient is an important element in ensuring proper activation of the care plan. The integrated care manager’s care plan should include education and clear instructions to not only the patient but to care giver to ensure a common thread is formed along the complex continuum of care that bridges factors affecting patient motivation, care compliance, and the ability to activate a safe, cost-efficient, and truly patient-centric model of care.

8. Fragmented and uncoordinated care creates a poor patient experience and confusion.

When patients are battling a healthcare issue, the last thing they or their families/caregivers are thinking about is how to navigate the healthcare system. Yet, healthcare providers often overlook the basic coordination needs of patients beyond the actual treatment provided. Integrated care management is designed to ensure a positive experience for the patient and improve satisfaction in how care is provided by understanding the patient’s journey across the care continuum. Thoughtful, coordinated, and patient-centric design ensures patients remain the focus in defining processes for warm handoffs between providers and care settings, eliminating the need for the patients to repeat information or fill out duplicate forms. It provides added clarity in roles of contact with the patient, ensuring the patient/caregiver has one person to contact with questions or for support, and influences how patient materials are created and deployed (e.g., use of pictures and graphics in teaching self-care concepts, use of lay terminology rather than clinical jargon, use of teach-back and follow-up demonstrations, etc.) to reduce confusion and provide a trusted resource for patients and caregivers to access.

9. Implementing optimal integrated care management across the continuum requires support from an analytics strategy, which aligns with population health initiatives.

As organizations continue to expand their systems of clinically integrated care, building an analytics strategy that connects data from disparate IT systems will create opportunity to allow providers to act more quickly on the information. The ability to effectively aggregate data and translate that data into actionable information available at the right time, and at the point of care, should be an ever-striving goal of organizations and the foundation for effective care management. Successful integrated care management uses real time data that is turned into actionable information allowing care managers to quickly identify high risk patients and apply interventions. Gathering the right data and analyzing it correctly requires a combination of skills involving clinical knowledge, medical informatics, and technology capabilities. The analytic strategy begins with creating a culture of transparency requiring diligence in making information accessible, accurate, and easily transferrable to providers within their clinical workflow.

10. Health systems are missing opportunities to partner with payers in redesigning care delivery.

The adoption of an integrated approach to care management that is aligned with health system contracting and population health initiatives provides new revenue opportunities, when implemented successfully. By demonstrating the organization’s ability to deliver high quality, affordable care to various populations, health systems can leverage their value-based performance outcomes to engage in innovative contractual arrangements with employers and payers that align incentives across the system. Since investing in new care models and integrated care management program can be costly, it is most effective when both the providers and payers share in the investment costs and are appropriately aligned on the potential outcomes and medical cost savings. Some of this share investment occurs through innovative provider-payer partnership arrangements where the payer pays providers care coordination fees or reimbursement that is directly tied to care management services across the continuum. This will require a shared philosophy of managing care between the payer and provider as well as integrated approaches around data sharing, alignment in clinical protocols, and resource collaboration. In addition, the coordination of the care management network staff and providers aimed at promoting, maintaining, and/or restoring health will ensure a patient-centric model of care that truly spans the care continuum.

By creating a focused approach around integrated care management operations and breaking down communication barriers, organizations and providers can fundamentally transform how to deliver patient-centric care management in an integrated fashion to achieve the most optimal results possible. Well designed and properly executed integrated care management is of foundational importance for any organization aiming to achieve success within their value-based contracts. Successful implementation of an integrated care management model will empower patients and their care givers to navigate through our complex healthcare systems that lead to better quality outcomes, reduced avoidable medical costs, and improved patient and provider experience.

krivopal_M-963748-edited.jpgDr. Krivopal is a vice president with GEHC Camden Group and an accomplished senior physician-executive with 19 years of healthcare experience across the continuum of care. Dr. Krivopal is responsible for developing and leading innovative, value-based programs addressing client needs in healthcare organizations, hospitals, and physician practices focusing on transformational system integration strategies, service line optimization, throughput and clinical leadership development. He may be reached at


Tesch_T_headshot.pngMs. Tesch is a senior manager with GE Healthcare Camden Group with more than 18 years of experience as a healthcare leader and strategist. Ms. Tesch specializes in value-based care delivery strategic planning, CIN development and implementation for commercial, Medicare, and Medicaid populations, health information technology data governance and analytics strategy, as well as care management strategy, design, and implementation. She may be reached at

Topics: Population Health, Care Management, Tara Tesch, Mark Krivopal

Five Focus Areas for Medical Groups in 2017

Posted by Matthew Smith on Jan 26, 2017 12:59:09 PM

For medical groups, the last few years have been tumultuous with the shift to value-based care. In 2017, medical groups will continue to experience change on all fronts, including payment, care delivery, and interaction and communication with patients. Medical groups must contend with new payment models, fierce competition in their markets, increased regulatory requirements, clinical advances, digital and information technology changes, and population health management implementation.

In response to these shifts, medical groups should focus on five key areas to position themselves for the future. As Socrates said, “The secret of change is to focus all of your energy not on fighting the old but on building the new.” And that is what medical groups need to do in 2017: build the new by transforming the old ways of practice management.

To read this article in its entirely, please click the button below to be taken directly to the HFMA website.

Medical Groups, 2017 Trends

Topics: Population Health, Medical Groups, Patient Access, Trends, Medical Group Transformation

Infographic: Population Health and Children's Hospitals

Posted by Matthew Smith on May 25, 2016 9:05:23 AM

The Children's Hospital Association ("CHA") collected data from a series of iterative population health surveys to provide members with timely, relevant benchmarking data and inform their shared planning. Findings from the first CHA survey offer a high-level overview of children’s hospitals engagement in population health. Seventy-three of 207 members invited to participate responded, yielding a response rate of 35%. This data collection is part of a larger CHA effort to support children’s hospitals in balancing the dual roles of healthcare delivery and creating child health.

Key takeways include:

  • More than two-thirds of respondents consider population health a top priority.
  • 95% of participants agree that Population health is aligned with their children’s hospital mission.
  • 68% of participants agree that population health is a top priority of their children’s hospital.
  • 63% of participants agree that financial resources are available for population health at their children's hopital.
  • Only 34% of particpating children's hospitals have reliable data to measure identified target population health outcomes.survey_results_Page_1.png



Topics: Population Health, Children's Hospital Association, Children's Hospitals

9 Ways to 'Activate' Patient Engagement

Posted by Matthew Smith on Apr 18, 2016 10:53:06 AM

New payment models reward healthcare systems and providers for improving the health of populations. Providers are understandably concerned about the extent to which they can succeed in such models because so much of patient health is beyond their personal control.

Seventy-five percent of our health dollar is spent on chronic conditions that have everything to do with the choices made by patients, notably diabetes and degenerative joint disease as they relate to obesity. Therefore, engaging patients in the management of their own health is vital to achieving population health improvement.

At a recent national health conference I attended, the speaker asked the audience, “What is the least utilized resource in the American healthcare system?” After a few seconds of silence, as thousands scratched their heads for the answer, the speaker called out, “The Patient!”

Accountable systems and providers will increasingly need to learn how to empower and “activate” patients, rather than encouraging their dependence on the system to provide cures. Similarly, providers and care managers will need to reach out proactively to patients, rather than passively waiting for patients to seek care.

Here are nine key approaches to patient “activation:"

1. Charge Patients with the Primary Responsibility for their Own Care

Some patients have never been encouraged to think of their disease as their personal responsibility. Remind them there are some things they can do for themselves that no one else can do for them. For instance, no amount of insulin or other diabetic medication will overcome the effects of excessive eating.

2. Encourage Patients to Monitor their Own Conditions

Provide glucometers and blood pressure devices and ask patients to log their daily readings and progress. Let them know that you expect them to bring their logs (or devices that store results) to visits so you can monitor their progress. Teach them how to adjust their diets or medication to respond to their daily readings.

3. Encourage Use of a Patient Portal If You Have One (And Agitate Your System to Invest in Portal Technology if it Has Not Already Done So)

Make the procedure for signing up for the portal easy and understandable for the patient. Show them how to use the portal to check their own lab results or request appointments. Let them know that you want them to regularly use the portal so it can become a reliable channel of communication between you and them.

4. Plug your Patients Into Community and National Support Groups for their Condition

The local park district may hold free exercise classes, for instance. Many communities have free smoking cessation clinics. National organizations representing almost every major disease have websites that provide educational support materials and may introduce patients to local support groups for their condition.

5. Consider Group Visits

Group visits have several advantages that accrue to the providers (it saves time and enhances revenue) but one of the best outcomes of group visits is that they greatly increase patient engagement. Patients with chronic conditions gain significant emotional support and encouragement from interacting with other people “like them” who share their condition. Social support is one of the most powerful motivators of behavior. Group visits produce surprising improvements in the health of their members.

6. Pull Patients into the Electronic Health Records ("EHR") Screen in the Exam Room

EHRs threaten direct eye contact of health professionals with their patients. Savvy providers have learned to turn this liability into an asset by bringing the patient “into” the EHR as they work, showing them computer-generated charts, for instance, that trend their blood pressure or blood sugar, or to have the patient verify their medications and doses. The EHR becomes an engagement tool, and patient trust is enhanced when they realize the provider is not hiding information from them.

7. Use In-Office Instructional Videos

Some practices run motivational or educational videos in their waiting rooms or have a learning room with a library of instructional videos on a variety of health-related subjects. A well-organized file of printed educational materials is a low-tech way to achieve the same ends. The more information patients can absorb about their conditions, the more engaged they will be with their self-care.

8. Create an Interactive Website

Numerous providers have created their own webpage or blog and write about topics related to the health of their patients. These providers found that this strategy increased the engagement of their patients and generated new business.

9. Convey an Openness to Questions and Support Initiative

Consider the factors that might harm patient engagement and work to reduce them. Be there to support and respond to patients when they attempt engagement. This requires a positive response when the patient asks about their condition and how to improve it. Old-fashioned paternalism, which thwarts patient questioning, kills patient engagement. Patients respond to praise for even modest health improvements they achieve. 

GE Healthcare Camden Group and Prophet recently hosted a webinar discussing their new patient experience study which was conducted to understand the consumer healthcare experience by assessing the gap between patient and providers’ expectations and perceptions. To view this webinar on-demand or stream it to your device, please click the button below.

Webinar, Patient Experience, Patient Satisfaction

Topics: Population Health, Patient Engagement, Patient Activation

MSSP and NGACO Application Windows Quickly Approaching

Posted by Matthew Smith on Apr 6, 2016 11:50:17 AM

CMS recently launched the first step of the application process for its Next Generation ACO (“NGACO”) Model, and next month opens the window to apply for the Medicare Shared Saving Program (“MSSP”) Initiative. The NGACO, CMS’ newest two-sided risk model, accepted 21 organizations for 2016. The MSSP, which also added enhanced risk-based options in 2016, had 100 new ACO participants this year, bringing the total to 434 ACOs at the start of the year. These numbers reinforce CMS’ stated goal to move 30 percent of traditional Medicare fee-for-service payments into alternative value-based payment models by 2016, and 50 percent by 2018.

MSSP: Zero Downside Risk

The MSSP Model was introduced in 2012 as a key component of the Medicare delivery system reform initiatives found in the Affordable Care Act and a new approach in the delivery of health care intended to facilitate coordination among providers to improve the quality of care. Among the primary attractions of the MSSP was the option to participate with zero downside risk, meaning if organizations outspent their target expenditures, they would not be liable to repay the difference to CMS. Through Track 1 there existed only upside, or the ability to share in any savings generated, an appeal that the MSSP Model maintains to this day. This allows organizations to dip their toes in the accountable, value-based waters and develop the infrastructure necessary for future success while still participating in a fee-for-service environment today. And the participating organizations have largely voiced their approval of the program – more than two-thirds renewed their participation when their initial agreement ended in December.

NGACO: Higher Risk/Higher Rewards

While the MSSP Model was the right first step for many organizations beginning their journey towards value-based care, it was in many ways insufficient for more advanced organizations experienced in care management and risk-based contracting. Thus the Next Generation ACO model was born, providing a higher-risk, higher-reward alternative to the MSSP, while simultaneously responding to and improving upon its oft-maligned and challenged predecessor, the Pioneer Model, with a refined attribution process and enhanced benchmarking methodologies. Now organizations can select between two risk options from 80 to 85 percent on the shared savings option all the way to a full-risk opportunity. Now if organizations overspend their benchmark expenditures, they will have to cut CMS a check at the end of the year. This may seem daunting, but many organizations view this as the natural programmatic evolution and that the increased skin in the game can be the push their organization might need to really enact the necessary transformation. In fact, seven of the new NGACO participants came from the MSSP program, demonstrating the interest of existing program participants to advance their risk exposure and opportunity based on their work and success to date.

The NGACO, with its enhanced risk profile, is obviously not for everyone, which explains why only 21 were accepted in the past cycle. As stated above, the NGACO was effectively developed for those organizations with experience in commercial ACOs or with value-based contracts, or that had experienced success in the MSSP and had outgrown the less-lucrative risk arrangement. Accordingly, in addition to the seven MSSP converts to the NGACO program, eight made the transition from the similarly two-sided, but less favorable Pioneer model.

Deadlines Approaching

The good news for organizations wanting to prepare for a value-based future is that the 2017 application windows for both programs are upon us. Organizations contemplating their fit in either initiative can apply for one or both, but need to submit their Notice/Letter of Intent by the respective deadlines to be considered. These submissions are non-binding, so we encourage organizations at all considering participation to file one and then assess their options in the next few months. One caveat is that while organizations can simultaneously apply for both models, they will ultimately only be able to participate in one of the two initiatives.

The NGACO Letter-of-Intent is due May 2, with the MSSP Notice-of-Intent due May 31. Additional key milestones for both models can be found below:


With the continuous innovations of both payment and delivery models, CMS is maintaining its commitment to the transformative shift to value-based care. While that momentum is undeniable, not all organizations are necessarily ready for that transition just yet, particularly in the riskier models. We recommend undergoing a comprehensive (and candid) self and market assessment of your organization’s present situation and evolution in what GEHC Camden Group considers the eight core domains essential for clinical transformation to successfully thrive in a value-based world. A commitment must be demonstrated in the below key operational competencies in order to achieve success in the changing landscape.


CMS has reiterated its commitment to population health with its ongoing development and support of these accountable initiatives. Even more encouraging, CMS has demonstrated a willingness to adapt and improve to encourage participation and collaboration. The strongest healthcare organizations tend to be the ones that are proactive rather than reactive. For organizations that can see what’s coming down the tracks, there may be no better time than now to begin preparing for a value-based future.

Next Generation ACO

Topics: ACO, MSSP, Population Health, CMS, Next Generation ACO Model, MSSP ACO, NGACO

10 Myths of Population Health and Clinical Transformation

Posted by Matthew Smith on Mar 1, 2016 11:40:34 AM

It is a confusing time in United States healthcare. Healthcare organizations are faced with the new reality of value-based care and are identifying the necessary steps for success in an evolving healthcareenvironment. For many, this transformation is difficult, and fear of this change may hinder progress. However, at present, a lack of true understanding of the care processes, tools, and consequences of this transformative shift persists in the healthcare community, and with the public at large. The delivery and consumption of care is rapidly changing for both provider and patient, and not everyone is on the same page. Below are ten myths associated with clinical transformation and its ability to position an organization for success in a value-based world, along with the realities with which providers and organizations must face.

Myth #1:  The best care (or better care) is provided in hospitals.

RealityFor many years, the United States healthcare system has been very hospital-centric. Patients who were sick were directed to go to the Emergency Room or the hospital to get better, and physicians were paid handsomely for services provided in the hospital setting. This cycle has engrained within Americans (and within many physicians) that the hospital is the setting for receiving the highest quality of care. Patients will often even ask to be admitted to the hospital because they believe superior care will be provided there. Today, the healthcare system has begun to shift to improve and increase the suite of outpatient healthcare services to include ambulatory surgery centers, urgent care centers, retail clinics, even home-based care. The hospital is no longer the only place to go to receive care and, in fact, the best interventions will keep patients safely in their homes and out of the hospital altogether.

Myth #2:  All organizations should be negotiating value-based payment contracts.

Reality:  While value-based payments are a driver for clinical transformation, organizations should move at the pace of their market (and their own capabilities). Each market across the county differs in its pace in the shift from a volume to value-based environment. Organizations who are maintaining success in a primarily fee-for-service environment may not be ready for an immediate switch to value-based payments. Instead, these organizations should begin undertaking efforts to prepare for an eventual change to value-based contracting through improved medical management efforts and regular analysis on clinical outcomes and cost of care. This transition for some has had to be rapid, given the speed with which the market had adopted value-based payments. However, for many others who are not yet positioned for success in a value-based market, this transition should be gradual as the organization begins to develop the necessary capabilities; in a volume-based environment, these changes can still have positive outcomes through a focus on treating patients in appropriate care settings, thereby increasing capacity and access. Therefore, the focus for all organizations should be developing and implementing the clinical care model that is in sync with its payer contracting strategy.

Myth #3: Interoperability among information technology (“IT”) systems results in clinical integration.

Reality: As healthcare organizations begin to explore the clinical transformation needed to achieve clinical integration, the number one barrier frequently identified is the lack of interoperability among the health IT systems. Often, organizations may decide a complete IT overhaul is necessary (very costly) or that clinical integration is simply not possible and withdraw from the effort. However, highly integrated IT systems do not magically result in clinical integration. IT systems lack the clinical judgment that is necessary to provide high-quality, patient-centric care. IT systems cannot identify population health objectives and goals and design interdisciplinary medical management programs that aim to meet population health goals. It is the aligned vision for improving health outcomes among all care team members that results in clinical integration; IT systems can simply enable this type of care through real-time alerts, evidence-based clinical pathways, and historical and predictive trending of clinical data and notes. Interoperability should be viewed as a means, not as a deal breaker in its absence.

Myth #4:  Electronic Medical Records (“EMRs”) make physicians lives easier and provide better patient care.

Reality: Advances in technology have provided innumerous innovations to the majority of industries and society in general. While healthcare has been an undeniable benefactor, it is widely assumed that because electronic tools have made the public’s lives significantly easier, healthcare providers have experienced the same benefits and welcome all advancements. Healthcare IT, including EMRs, can provide the care team (e.g., the physician, medical assistant, nurse, social worker, or other care coordinator), with a wealth of knowledge about each patient. Tools exist that track and trend lab results, maintain and update a singular care plan, and provide point-of-care alerts to close gaps in care. Many organizations rely heavily on the information provided through these tools to provide patient-centered, high-quality care. However, it is not the information contained within these tools that has enhanced patient care; instead, it is the care processes and workflows that have been developed to ensure this information is meaningful and utilized that has enhanced care. Without clear care protocols or actionable reports, physicians can be frustrated by the vast amount of information presented to them and the myriad of tasks they must complete within multiple IT systems. Too much data contained in a myriad of health IT systems can actually result in less coordinated care between physicians and across care settings. It is the integration of this information, in a succinct form, into clearly defined care processes that enables the delivery of high-quality patient care and allows the technology to ease the burden on the provider, rather than add to it.

Myth #5: Population health management requires significant IT capital and increased staffing.

Reality: Additional capital to support informatics and staffing are a luxury and can improve efficiency and effectiveness of care management initiatives, but they are in no way a necessity for population health management. Population health management begins with a cultural transformation within the organization that is centered on a dedication to providing high-quality, patient-centric care. A clinical transformation subsequently occurs that leads to the development and establishment of refined clinical pathways and processes and often the redeployment of staff. IT tools can assist with these processes, but they should not drive the clinical transformation that needs to occur within the care teams. Similarly, the role of support staff (e.g., care managers, social workers, health coaches) does not actually increase; instead roles are assessed and redefined, as necessary, to ensure staff resources are deployed in a manner that is targeted to meets the needs of the population and the associated intervention. Too often organizations making this transition attempt to run before they can walk.

Myth #6: Clinical integration results in mass layoffs of staff.

Reality:  The Triple Aim® consists of three components: improved health outcomes, improved patient experience, and reduced overall cost of care. While it is imperative that all three of these tenets are taken into consideration for successful clinical transformation, providers frequently focus on the latter and associate it with cost and workforce reductions. Often, organizations are not over-staffed for population health management; instead, staff members are simply not working to the top of their license and are not always providing care to the right cohort of patients, at the right point in time, with the right care interventions to meet the patient’s needs. A reduction in staff will only increase the volume strain all staff is already experiencing. Instead, an assessment and redesign of clinical protocols should inform the medical management staffing. A re-deployment of staff may be necessary to ensure staffing levels are congruent with the acuity of the patient population, and additional training may become necessary to ensure all staff members are able to perform effectively and efficiently in new roles. In many cases, rightsizing can be replaced by adhering to clinical protocols and reallocating existing workforces.

Myth #7: Buying services that span the continuum is the only way to achieve clinical integration.

Reality:  The desire to purchase services that span the continuum stems from a need to be able to share clinical information, conduct warm handoffs between care settings, and keep healthcare costs and revenue under a single umbrella. However, just because an organization may own these services does not mean that these services are the highest quality, nor even utilized by other providers in the continuum. What is most important when developing a clinical integration model is the provision of high-quality, patient-centric care across the continuum. Services do not need to be owned to meet this obligation. Organizations should be looking, instead, to develop formal relationships with the most high-quality and value-based healthcare service providers. Referrers should have access to cost and quality metrics for all partner organizations and should utilize these results to drive care to the most appropriate providers. Preferred networks should be developed to enable care model development in conjunction with these partner organizations, all with the intent to provide patients with coordinated, seamless care transitions across care settings and, when appropriate, back to their home. There are several ways to achieve tightly aligned networks – organizations should be judicious when deciding if ownership over all components is the right strategy for them.

Myth #8: Maintaining universal physician satisfaction is a critical success factor for population health management.

Reality:  Physicians are critical to cultural and clinical transformation – this is an undeniable truth. However, not all physicians are well-educated about or in favor of clinical transformation to position them for success in population health. Some may be nearing the end of their careers, and this change may present a large burden. Placating to physician needs and preferences will not always bring about successful and unified change within an organization. Instead, try performance transparency. Initially, this may cause some discomfort among physicians; however, no physician wants to be the poorest performer, and this tactic may bring about the most rapid change in behavior. The enforcement of remedial action plans for physicians who do not follow established evidence-based protocols may also not be welcomed by all physicians, but will ultimately ensure that high-quality care is provided. While physician engagement is a critical element for success in population health management, it must be a mutual effort. Organizations that make the successful voyage to population health management need to weed out those vocally not on board, as well as those refusing to row in the same direction in their practices.

Myth #9: Patient satisfaction is the same as optimizing the patient experience.

Reality:  Despite what physicians may think, patients aren’t really rating physicians on whether they “always communicated well with them” or “always controlled their pain well.” The truth is that patient satisfaction has many components. Ultimately, patients are rating physicians on factors such as whether they got better and had timely access, which can ignore critical aspects such as the cost and appropriateness of care being provided. One prominent study contended that patients who reported being most satisfied with their physicians had higher healthcare and prescription costs and were more likely to be hospitalized than less satisfied patients. Could physicians who have patient satisfaction scores tied to their compensation be less likely to advocate against unnecessary requested treatments or less likely to raise concerns about lifestyle and behavioral modification issues?  Or could there be a correlation between high patient satisfaction scores and providers who actively tackle the hard-to-discuss issues the best? More research – and specifically innovative research – is necessary. Further complicating this issue is the new trend towards Yelp-style online public reviews influencing local perceptions of healthcare providers. As with any crowd-sourced review product, an issue arises when the public tends to only be inclined to offer their opinions when the service is exceptional, or the experience was considered an unpleasant one. Managing digital perceptions is yet another responsibility that consumer advancements and innovations have required of providers.

Myth #10:  Patient satisfaction will increase if physicians spend more time with each patient.

Reality: Patient satisfaction is about much more than the length of an appointment. Ultimately, patients are concerned about receiving personal, high-quality care at the time they need it. A patient will be satisfied with their care if they feel they can access it when they need it; for example, when a patient is able to schedule an appointment on the day and at the time they wish to see their physician or other provider and if their wait time is minimal.  Or, when a patient contacts their physician via a patient portal and receives a timely response. Furthermore, the patient wants to feel as though their physician is utilizing the appointment time to truly discuss their care, rather than reviewing old notes and labs and consistently typing on a computer; patients respond very positively to eye contact and listening skills as indicators that a physician is interested in a patient. A medical assistant or other office support staff can greatly assist physicians prepare for their appointments so that patients feel as though they are receiving the physician’s full attention, thereby bolstering the patient’s satisfaction with their visit.

Topics: Clinical Integration, Population Health, Regional Clinical Integration Networks, Clinical Transformation

Moving from Utilization Management / Referral Authorizations to True Population Health Management

Posted by Matthew Smith on Feb 9, 2016 4:28:16 PM

Historically, many organizations managing care in a risk-bearing structure such as independent practice associations, medical groups, or related enabling entities such as management services organizations have primarily concentrated on utilization management, referral authorization, and claims processing, with attention to cost containment and ensuring all compliance standards are met. These functions have served as an "operational core," focused on getting the job done and meeting necessary requirements.

As they evolve, these organizations realize that simply "getting it done" will not suffice; they need to increase the focus on the clinical delivery process in order to affect the health outcomes of their populations.

To read this article in its entirety, please click the button below to immediately access CAPG Health.

 Population Health

Topics: Population Health, Risk-Based Contracting, Healthcare Analytics

Asked and Answered: Frequently Asked Questions by Physicians About Clinically Integrated Networks

Posted by Matthew Smith on Sep 21, 2015 3:35:11 PM

By Daniel J. Marino, MBA, MHA, Executive Vice President, GE Healthcare Camden Group

While clinical integration development continues to build momentum, many questions still remain. The following questions and answers will help communicate the value of clinical integration and clinically integrated networks ("CINs") to your physicians. If you're a physician, these questions and answers should help you with some recurring and nagging issues.

What is clinical integration?

Clinical integration is an effort among physicians, often in collaboration with a hospital or health system, to develop active and ongoing clinical initiatives focused on delivering quality, performance, efficiency and value to the patient.

What’s driving the movement toward clinical integration?

In the years ahead, physicians and hospitals must partner more closely than ever before to ensure that the community receives the highest quality and value. As we move from today’s fee-for-service reimbursement models to new performance- and value-based pay models, CINs enable healthcare providers to join together to enhance the health of a community. These networks bring value to patients, payers, and physicians by improving transitions of care, coordinating chronic disease management, and managing the health of a population.

What does a CIN do?

A CIN helps physicians align with the hospital to coordinate care across caregivers, focus on quality and performance, and prepare for new, incentive-based compensation programs in addition to the base compensation they already receive. The network will develop new payment systems and methods that focus on achieving quality, efficiency, cost-management measures, and enhancing value.

What is the purpose of the CIN?

The principal purpose is to enhance the quality and efficiency of patient care services provided by the participating providers to the community. A CIN with participating providers works together to develop clinical performance standards and protocols for the network. These will form the basis for the network to negotiate contracts with payers for performance incentive programs.

How is it structured?

The CIN is a wholly owned subsidiary of the health system managed by its own Board of Directors, with community physicians and hospital members. Physicians willing to participate in a meaningful way have the opportunity to be involved in the organizational committees that drive the network.

What are the benefits of joining?

For physicians, the network offers the opportunity to:

  • Become available as a preferred network provider to members
  • Use care management resources provided by the CIN
  • Identify and measure best practices
  • Improve outcomes for patients
  • Receive financial rewards for value-based outcomes and achievements

The goal of the CIN is to provide an exemplary patient experience and improve the health of individuals in our community in a continuum of care that is focused on quality, performance, efficiency, and value. This serves as the platform that will determine financial incentives for physicians.

Who can join?

To ensure the best value for patients and payers, the CIN welcomes physicians who want to be accountable and raise the quality of care. These physicians can be:

  • Independent community physicians who seek clinical and quality alignment
  • Physicians employed by a health system
  • Physicians who contract with the hospital to provide services in specialties such as emergency medicine, anesthesiology, and pathology

Do physicians join as individuals, or do all the physicians in a practice need to join?

For independent physicians, a delegated representative from a group practice may sign the participation agreement and code of conduct on behalf of the practice to enroll all providers. However, in most instances, each individual physician in the group will need to complete a short application packet. Physicians employed by the health system will be enrolled with other members of their practice groups.

Will members be required to refer enrolled patients to other network members?

In-network referrals allow for the efficient accumulation and reporting of data, promote coordination and continuity of care and ensure adherence to evidence-based medicine.

What type of data is monitored?

Network leaders and physician advisory committees will determine details on clinical initiatives and data to be monitored and reported. Collected data likely will be similar to that being measured for Medicare programs, such as the Physician Quality Reporting System.

How will clinicians submit data to the network?

Providers will submit clinical and claims data on a timely basis to a secure, web-based platform that is HIPAA compliant and password protected. The web-based platform enables physicians to conveniently and easily submit data from any device with internet access.

What is the difference between a CIN and an Accountable Care Organization ("ACO")?

According to the Centers for Medicare and Medicaid Services, an ACO is accountable specifically for Medicare beneficiaries. It is an organization of healthcare providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries enrolled in the traditional fee-for-service program who are assigned to the ACO. Similarly, a CIN is an alignment model, coordinating care across affiliated caregivers and developing contracts with payers to improve quality while controlling growth in total cost of care, including value-based contracting initiatives with commercial payers and Medicare.

Clinical Integration Networks, CIN, Daniel J. Marino

Daniel J. Marino, The Camden Group, Clinically Integrated NetworksMr. Marino is an executive vice president with GE Healthcare Camden Group with more than 25 years of experience in the healthcare field. Mr. Marino specializes in shaping strategic initiatives for healthcare organizations and senior healthcare leaders in key areas such as population health management, clinical integration, physician alignment, and health information technology. He may be reached at



Topics: Population Health, Clinically Integrated Care, Clinically Integrated Networks, Clinically Integrated Network, Daniel J. Marino

7 Ways to Achieve Clinical Integration Through Strategic Physician Engagement

Posted by Matthew Smith on Aug 19, 2015 12:11:58 PM

New payment models make it more important than ever for hospitals to collaborate with physicians. From readmission penalties to bundled payments to Accountable Care Organizations ("ACOs"), providers have a growing economic incentive to pool resources, share information, coordinate care and services, and cooperate on quality improvement. 

But while the incentives are strong, the obstacles to clinical integration are daunting. Hospital-physician collaboration is operationally complex. Although physician employment can smooth out some of the bumps, practice acquisition is expensive. While a handful of large health systems have devoted extensive resources to launching clinical integration initiatives, most smaller organizations are still sorting out their options.

How can hospitals integrate with physicians without creating political and financial problems? The solution is to focus on building mutually beneficial relationships and use existing resources wisely.

The following practical approach will help healthcare leaders achieve clinical integration by engaging physicians, strategizing collaborative programs and making targeted investments.

1. Understand Physician Motivation

Convincing physicians to collaborate more closely with a hospital can be challenging. Physicians are trained as autonomous decision makers. Perfectionism and the need for control can make it difficult to weave physicians into an integrated organization. But there is a positive side to the medical personality: No doctor wants to be an outlier.

Engage physicians by presenting data on their patient outcomes. Most physicians will discover at least a few areas in which their performance falls short of their peers.

Talk to doctors about their patients’ flu vaccination rates, medication reconciliation rates, performance on diabetes control measures, etc. This is easiest for hospitals that have access to physician claims data through a physician-hospital organization ("PHO") or that offer physicians a subsidized electronic medical record ("EMR") with built-in Clinical Quality Measure ("CQM") templates that facilitate reporting.

Most physicians do not track and evaluate their own performance, let alone measure their performance against peers. Relevant patient statistics will earn physicians’ attention and generate interest in working more closely with hospital staff to improve outcomes.

It is also important to educate physicians on the evolving healthcare market. Explain how payers are creating incentives for clinical integration though bundled or global payments and per patient/per month care coordination fees. As physicians become more aware of these payment trends, many will embrace the opportunity to increase their salary by partnering with the hospital.

2. Create True Physician Governance

To gain the most under new payment models, physicians and hospitals have to play nice in the sandbox. The key is establishing a governance body that allows physicians to guide the development of care strategies and clinical protocols. Physician-led governance will create physician awareness and support for clinical integration initiatives and make a positive impact on the overall success of the program. Make sure the clinical integration governance committee includes physicians from solo practices and small partnerships as well as large groups. Include representatives from a range of specialties.

Most important, the governance body should include physicians who are critical or even negative about the clinical integration initiative. Often these “difficult” physicians simply want to be heard and provide their input. Making these physicians feel included will go a long way toward smoothing the transition to integration.

3. Focus on Quality, Not Finances

Physicians are concerned about productivity and payment, but concentrating exclusively on financial metrics will disenchant many providers. Focus instead on clinical quality and performance improvement. After all, this is the main reason physicians entered medicine — to provide quality care to the patients they serve.

The clinical integration committee should establish quality benchmarks and treatment protocols that define performance standards. Benchmarks can be based on evidence-based standards and care plans developed by national quality organizations and disease associations. Micromanaging clinical decisions will be unpopular, so care protocols should be broad guidelines that allow room for individual judgment.

To choose initial improvement goals, review admission and inpatient reports to identify areas of low quality and high cost. For which conditions does the hospital see the greatest number of admissions? Which conditions have the longest length of stay? Physicians using an EMR may be able to report on certain quality measures. For example, what is the percentage of hypertensive patients with adequate blood pressure control? How many heart disease patients have an up-to-date lipid profile?

Begin the clinical integration outreach with physicians in specialties linked to poorer outcomes and higher costs. Another logical starting point is primary care. Family practice physicians and internists often have the greatest impact on chronic disease management.

4. Concentrate on Care Coordination

One of the biggest opportunities in clinical integration is better coordination of care. Focus on high- and medium-risk patients who are responsible for the highest costs or who will likely increase costs in the near future. Target care transitions between the hospital and admitting specialists or primary care physicians. Involve physical therapy, home health providers and long-term care facilities in clinical coordination planning.

Physicians need to ensure that discharged patients complete follow-up visits. The hospital can assist by sponsoring a care coordination team for the entire organization to help manage follow-up appointments, referrals and home health services. To help guide care coordination, stratify hospital discharges by risk of readmission, complication or care plan non-compliance.

5. Use Technology to Get Providers Talking

Clinical integration is nearly impossible without an EMR system, but many medical practices are not far along in EMR adoption. Most practices cite expense as the main obstacle.

To overcome the cost hurdle, consider subsidizing EMR systems for practices that agree to join the integrated organization. Relaxation of the Stark laws allows hospitals to subsidize as much as 85 percent of the purchase and support costs of an EMR system. Subsidy agreements can require physicians to report quality measures and meet quality performance thresholds.

However, do not expect physicians to acquire the same EMR system as the hospital. Many small practices can do very well with free and low-cost alternative systems. The hospital should build interfaces for exchanging information with the EMR systems used by the majority of integrated physicians.

Many physicians who have implemented EMRs have participated in the Medicare and Medicaid EHR Incentive Program. As part of demonstrating Meaningful Use under the program, these physicians have already begun tracking clinical quality measures. Clinically integrated organizations should use the EMR to create aggregated quality reports and share them with physicians. Weekly or monthly reports can track disease management data such as HbA1c levels, cholesterol, blood pressure and preventive screenings. Giving physicians the chance to view quality performance metrics will engage both their competitive personalities and their collaborative spirit.

6. Build Financial Incentives

Clinical integration will require physicians to invest time and money into patient education, technology and additional staff. The problem is that methods of compensating providers for care coordination are still being developed and tested by payers. Given the costs being shouldered by physicians, financial incentives are critical.

Regardless of how incentives are distributed, hospital leaders should reward physicians either for controlling costs, achieving quality benchmarks or both. Focus on achieving care management quality metrics early on, since reduced costs tend to follow well-managed patients. Establish and re-assess these performance targets annually.

One important note: Make sure primary care physicians get a piece of the pie. Although surgical specialists might be responsible for most of the hospital’s costs and revenue, primary care doctors have the most frequent patient contact and are also responsible for most of the work of chronic disease management.

7. Invest Early for Healthy Returns

Even hospitals without the resources of a large medical system can achieve clinical integration by focusing on strategic investment and engaging community physicians through quality improvement. Hospital leaders need to allow physicians to establish the quality benchmarks and evidence-based protocols for the organization’s costliest conditions. Leaders can then concentrate on linking doctors through technology, assisting with care coordination, and negotiating with payers on bundled payments or pay-for-performance incentives.

Topics: Clinical Integration, Population Health, Physician Engagement, Governance, Care Coordination

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